James Andre N.

Rendon
BSN1-A

Student 1 and 5; Student 9 (If there is)

Situation:
You have a 48-year-old male patient who comes in stating, “I feel like I can’t breathe.” Patients’
respiration are 28 breaths per minute and their heart rate is 115 beats per minute. The patient then
grabs his chest and says, “My chest hurts so bad, please help!” You ask the patient to rate the pain
on a scale from 0-10, 10 being the worst pain ever. The patient replies, “10, it hurts so badly!” You
then ask the patient to describe what the pain feels like, the patient reports that his pain feels like
pressure. Your patient then starts to become diaphoretic and pale. You take an EKG that shows
Sinus Tachycardia. The pulse oximeter shows 100% on room air and the patients’ blood pressure is
120/80 mmHg.
 NURSE’S NOTES (FDAR METHOD)

DATE TIME FOCUS NURSE’S NOTES (D.A.R. – DATA, ACTION, RESPONSE)

2/13/22 1100 Chest Pain D- “My chest hurts so bad, please help!” pain feels like pressure as
verbalized by the patient. Using the pain scale, the patient responded
10.

- PR 100 bpm, RR 28 bpm (+) diaphoretic, pale

- ECG shows Sinus Tachycardia. (+) HR 115 bpm.
1130 A- Checked vital signs every 15 mins while in distress.
- Checked signs of arrythmias
- Positioned in semi-fowlers.
- Encouraged patient to verbalize feelings about pain
- Administered a ventilator or oxygen mask to intake oxygen, as
prescribed.
- Administered medications as indicated.
- Administered electrocardiogram (ECG) for the rate, beat and
rhythm.
- Encouraged a calm and peaceful environment.
- Kept comfortable and rested.
1400 R- Decreased pain scale to 0 out of 10.
- Endorsed JAMES ANDRE RENDON, RN
LICENSE NUMBER: 000000
 NURSE’S NOTES (SOAP METHOD)

DATE TIME FOCUS NURSE’S NOTES (D.A.R. – DATA, ACTION, RESPONSE)

2/13/22 1100 Chest Pain S- “My chest hurts so bad, please help!” as verbalized by the patient.
- Pain feels like pressure.
O- S/P Vital signs taken: PR 100 bpm,
- EKG shows Sinus Tachycardia (+) HR 115 bpm.
- Pain scale verbalized by the rate of 10 out of 10.
- RR 28 bpm (+) diaphoretic and pale
A- Risk for decrease cardiac output related to chest pain
1130 P- Checked vital signs every 15 mins while in distress.
- Checked signs of arrythmias
- Attached to the cardiac monitor.
- Positioned to semi fowler’s position.
- Monitored for any untoward signs and symptoms.
- Checked to see whether the degree of consciousness has
changed.
1400 - The patient verbalized the pain by rating of 0 out of 10.
JAMES ANDRE RENDON, RN
LICENSE NUMBER: 000000
 NURSE’S NOTES (NARRATIVE METHOD)

DATE TIME FOCUS NURSE’S NOTES (D.A.R. – DATA, ACTION, RESPONSE)

2/13/22 1100 Chest Pain “My chest hurts so bad, please help!” pain feels like pressure as
verbalized by the patient. Using the pain scale, the patient responded
10.

- PR 100 bpm, RR 28 bpm (+) diaphoretic, pale

- ECG shows Sinus Tachycardia. (+) HR 115 bpm.
- Pain scale verbalized by the rate of 10 out of 10.
- Checked vital signs every 15 mins while in distress.
- Monitored for any untoward signs and symptoms.
- Positioned in semi-fowlers.
1200 - Administered a ventilator or a mask to intake oxygen.
- Encouraged a calm and peaceful environment.
- Kept comfortable and rested.
1300 - Seen and examined by Physician with orders noted and
- carried out.
1330 - Administered electrocardiogram (ECG) for the rate, beat and
rhythm.
- Administered medications as indicated.
- Decreased the pain rate by 0 out of 10.
- Patient emphasized the importance of regular check up to
monitor the health conditions or cardiac conditions to avoid
pain.
- Maintained adequate and will notified the physician before
discharge.
1400 - Endorsed JAMES ANDRE RENDON, RN
LICENSE NUMBER: 000000