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    cleahis cruz
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    The document is a focus-charting note from a nurse documenting the care of a patient over the first day of admission. It notes the patient's initial vital signs and symptoms of fever, loss of appetite, and sleeplessness. Throughout the day the nurse monitored the patient's vital signs, administered IV fluids and medications as ordered, and provided comfort measures like sponge baths. The patient's temperature decreased but they continued to feel unwell and only ate a small portion of their lunch.

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    The document is a focus-charting note from a nurse documenting the care of a patient over the first day of admission. It notes the patient's initial vital signs and symptoms of fever, loss of appetite, and sleeplessness. Throughout the day the nurse monitored the patient's vital signs, administered IV fluids and medications as ordered, and provided comfort measures like sponge baths. The patient's temperature decreased but they continued to feel unwell and only ate a small portion of their lunch.

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    147 views2 pages

    FDAR

    Uploaded by

    cleahis cruz
    The document is a focus-charting note from a nurse documenting the care of a patient over the first day of admission. It notes the patient's initial vital signs and symptoms of fever, loss of appetite, and sleeplessness. Throughout the day the nurse monitored the patient's vital signs, administered IV fluids and medications as ordered, and provided comfort measures like sponge baths. The patient's temperature decreased but they continued to feel unwell and only ate a small portion of their lunch.

    Copyright:

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

    Irish Queenie L.

    Malimban

    April 27, 2016

    1NUR3 | RLE 3

    Ms. Kathleen V. Chan

    Focus-charting (FDAR)

    Date/Hour

    Day 1

    Focus

    Progress Notes
    D:>
    Temperature of 39C
    Pulse Rate of 108
    beats/minute
    Respiration Rate of 20
    breaths per minute
    Blood Pressure of 120/80
    A:>
    Gave him routine admission
    care
    R:>

    D:>

    A:>

    Experiencing sleepless
    nights for the last 3 days.
    Has a loss of appetite
    Teary eyes
    Flushed face
    Skin warm to touch
    (+) rales
    (-) wheezes
    Monitored VS for every 4
    hours and record
    Administered IVF D5 NSS
    (Normal Saline Solution)
    for every 8 hours.
    Administered Paracetamol
    500 mg as per doctors
    order.
    Advised to increase the


    R:>

    intake of fluids and have


    small frequent feedings.
    Administered tepid sponge
    bath.
    Temperature decre
    Fluid intake increased to
    300cc
    The patient ate 20-30% of
    lunch served.
    The patient expressed
    malaise and the desire to
    sleep.

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