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FDAR Charting

This document contains a patient chart for an 18-year-old female diagnosed with Non-Hodgkin's Lymphoma in the anterior mediastinum. The chart notes show that at 0800 the patient reported squeezing chest pain rated at 3/10 that was relieved to 1/10 with positioning, fluid intake, and breathing exercises. At 1200 the patient showed an increased respiratory rate and use of accessory muscles, which improved with positioning and relaxation techniques.

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210 views1 page

FDAR Charting

This document contains a patient chart for an 18-year-old female diagnosed with Non-Hodgkin's Lymphoma in the anterior mediastinum. The chart notes show that at 0800 the patient reported squeezing chest pain rated at 3/10 that was relieved to 1/10 with positioning, fluid intake, and breathing exercises. At 1200 the patient showed an increased respiratory rate and use of accessory muscles, which improved with positioning and relaxation techniques.

Uploaded by

kristineestrada.labanon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

COLLEGE OF NURSING

____________________________________________________________________________

Patient name: X Age: 18


Sex: Female Bed: 6
Civil Status: Single
Diagnosis: Non Hodgkin’s Lymphoma in anterior mediastinum.

FDAR CHARTING

Date & Time Focus Progress Note

11/ 20/2023 Pain D: Pt verbalized squeezing


0800 pain during cough in anterior
mediastinum, 3/10.
A: Assisted pt to maintain high
fowler's position as tolerated.
Encourage pt to increase fluid
intake to 3L per day. Educated
pt on proper coughing and
deep breathing techniques.
R: Pt expressed relief, rates
pain 1/10. ————————

K. L., S.N
BUCN Level IV - Group 7

1200 Ineffective Breathing D: Increased respiratory rate of


Pattern 25 bpm. Use of accessory
muscle to breathe. Presence of
unproductive cough.
A: Assisted pt in a high fowler's
position. Educated pt on
relaxing breathing exercises
and proper coughing
techniques.
R: Pt verbalizes relief in her
position and shows
improvement on her coughing
technique. RR is 18. ——

K. L., S.N
BUCN Level IV - Group 7

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