Nothing Special   »   [go: up one dir, main page]
Scribd Logo
Upload

Welcome to Scribd!

  • 4 views

    FDAR Sample

    Uploaded by

    krystle

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    FDAR Sample

    Uploaded by

    krystle
    4 views2 pages

    Original Title

    FDAR-Sample

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    4 views2 pages

    FDAR Sample

    Uploaded by

    krystle

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    FDAR Sample

    From the NCP you submitted on Module 3: Nursing as a Science, create a chart entry using the
    same scenario:
    Mr. P, a 73-year old male client diagnosed with chronic obstructive pulmonary disease is
    admitted in Room 321, under the service of a pulmonologist, Dr. Leonardo Lumanlan, due to
    difficulty of breathing. As you approach him, you notice that he sits on a tripod position,
    diaphoretic, and uses his accessory muscles to breath. He further tells you “Mejo hirap ulit ako
    huminga, Neng”. You take his vital signs and got the following: T: 36.5C, PR: 118 bpm, RR: 26
    cpm, BP: 130/90 mmHg.
    Upon chart rounds, you read the doctor’s order:

     May administer .5 lpm of oxygen via nasal cannula.


     Nebulize with Salbutamol PRN for episodes of DOB.

    Name of Patient: Mr. P Age: 73 Sex: Male Room # 321

    Initial Diagnosis: COPD Attending Physician: Dr. Leonardo Lumanlan

    Nurses’ Notes

    Date and Time Focus Progress Notes


    3/4/2024 Ineffective breathing pattern D: Received the patient on tripod position,
    2:41 PM c diaphoresis, uses accessory muscles
    in breathing, and verbalizes difficulty of
    breathing; c vital signs taken and
    recorded as follows: T: 36.5C,
    PR: 118 bpm, RR: 26 cpm, BP: 130/90 mmHg
    A: Loosened tight clothing.
    Elevated the head of bead.
    Hooked to pulse oximeter; SpO2: 89%
    Assisted in the use of relaxation
    techniques such as practicing pursed lip
    breathing.
    Monitored breath sounds via auscultation.
    2:45PM Administered .5lpm of oxygen via nasal
    cannula
    2:47PM Facilitated nebulization of Salbutamol as
    ordered.
    Referred to attending physician.
    3:15 PM R: Patient is able to sit upright on the bed
    without his arms as support, s diaphoresis
    and use of accessory muscles, verbalizes
    relief from difficulty of breathing, c vital
    signs as follows: T: 36.5C,
    PR: 115 bpm, RR: 20 cpm, BP: 120/80 mmHg,
    SpO2: 94%
    ---------------Precious Jean M. Marquez, RN

    You might also like