DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program

FDAR CHARTING

Name of Patient: Patient Z Date of Admission: January 15, 2023 Room: 401a Age: 42-year-old
Sex: F Civil Status: Married Chief Complaint: Irregular contraction coupled with lower back pain Attending Physician: Dr. Ran

DATE & TIME FOCUS PROGRESS NOTES (DAR)

January 15, 2023 Data:
@8:00 AM
• “Nag-anha ko unta karon diri kay para magpa-prental lang, pero nalipong man ko
Hypertension atong paingon ko diri uy mao naka desisyon ko magpa-admit nalang. Nagkaon man
ko bag-o ko nigawas sa balay para magpa-check-up. Dili hinoun kayo daghan ako
nakaon, mga half bowl of cereals ug isa ka baso na orange juice lang. Wala ko
kabalo ngano nalipong jud ko.” As verbalized by the client.
• BP: 130/80 mmHg

Action:

• Assessed VS, Monitor BP.

• Provide calm, restful surroundings, minimize environmental activity and noise.
8:30 AM • Encouraged deep breathings.
• Educate stress management.
• Educate family to not give any stress to the client.
• Teach relaxation techniques, guided imagery, and distractions.
• Administer medication as per doctor’s order.
o Monitor response to medication that control BP.

Response:

• Know how to cope up with stress.

2:30 PM • Participate in activities that help to reduced blood pressure and cardiac workload.
• Family doesn’t talk manageable problem and events that can cause stress to the
client.
• Improve cardiac output as evidenced by a Blood Pressure of 120/80 mmHg.

GOAL PARTIALLY MET

ANGELICA CONTRERAS, SN