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Kahong, Fatima Nashriya W. BSN 1-B Focus, Data, Action, and Response (Fdar) Charting

The nurse received a patient complaining of an elevated body temperature, pale skin, trembling, and feeling hot and cold. The nurse assessed the patient and found a temperature of 39.1 degrees Celsius, pulse of 84 beats per minute, respiration of 25 breaths per minute, and blood pressure of 120/80 mmHg. The nurse administered a tepid sponge bath, applied a cold towel to the forehead, gave paracetamol intravenously per the doctor's order, encouraged fluid intake, and provided a calm environment. The patient reported feeling less hot and cold with an improved temperature of 36.5 degrees Celsius.

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2K views1 page

Kahong, Fatima Nashriya W. BSN 1-B Focus, Data, Action, and Response (Fdar) Charting

The nurse received a patient complaining of an elevated body temperature, pale skin, trembling, and feeling hot and cold. The nurse assessed the patient and found a temperature of 39.1 degrees Celsius, pulse of 84 beats per minute, respiration of 25 breaths per minute, and blood pressure of 120/80 mmHg. The nurse administered a tepid sponge bath, applied a cold towel to the forehead, gave paracetamol intravenously per the doctor's order, encouraged fluid intake, and provided a calm environment. The patient reported feeling less hot and cold with an improved temperature of 36.5 degrees Celsius.

Uploaded by

Nashriya Kahong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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KAHONG, FATIMA NASHRIYA W.

BSN 1-B
FOCUS, DATA, ACTION, AND RESPONSE (FDAR) CHARTING
SHIFT or DATE TIME FOCUS PROGRESS NOTES

MAY 27, 2022 3:00 PM Received patient seated, awake,


pale, responsive with trembling
3:15 PM body ______________________
D – “Ang init po ng katawan ko,
3:30 PM ELAVATED BODY TEMPERATURE at nilalamig po ako” as verbalized
by the patient. With flushed
cheeks and skin and warm to
touch. Temperature 39.1 degree
Celsius via axilla, pulse 84 beats
per minute, respiration 25
breathes per minute, blood
pressure 120 over 80
mmHg_____________________
A – Perform tepid sponge bath,
applied soaked small towel with
alcohol and water to forehead,
administered Paracetamol
250mg intravenously as per
doctor`s advised. Encouraged
adequate oral fluids intake,
provide calm and clean
4:00 PM
environment to keep patient
comfortable_______________
R – “Medjo nabawasan na po
yung lamig na nararamdaman ko
at bumuti buti na at hindi na po
ganon ka init yung pakiramdam
ko” as verbalized by the patient.
Temperature decreased to 36.5
degree
Celsius--------------------------
Kahong, Fatima Nashriya W. SN

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