PHINMA UNIVERSITY OF PANGASINAN
COLLEGE OF ALLIED HEALTH SCIENCES
Student Nurse: DELOS SANTOS, JULIA RAE D. Block: 4BSN1
FDAR
Date and Time FOCUS
August 1, 2023 a.) Hemoglobin of 60g/L
3:00-11:00 pm b.) BT 2 units of PRBC
c.) With blood transfusion reaction
DATA
Objective:
- Increase in body temperature
- Flushed skin
- Chills
ACTION
- Stopped the transfusion.
- Started IV line of PNSS.
Monitored vital signs every 5 minutes.
- Notified the physician immediately.
- Obtained urine specimen and sent to laboratory.
- Administered antipyretics as ordered.
- Explained the situation to the watcher.
RESPONSE
Patient maintained body temperature within normal limits
as evidenced by stable vital signs and the absence of
chills.
Date and Time FOCUS
August 1, 2023 Anxiety to upcoming surgery
3:00 – 11:00 pm
DATA
Subjective:
Patient verbalized “Nurse, kinakanahan ako baka may
masamang mangyari habang inooperahan ako
mamaya.”
Objective:
- Restlessness
- BP: 130/70
PR: 108 RR: 19
ACTION
- Assessed the level of anxiety.
- Assessed the patient’s understanding of the impending
surgery.
- Used simple language and brief statements in
explaining the procedure to the patient.
- Encouraged the patient to express anxious feelings.
- Implemented nonpharmacologic measures.
(therapeutic touch and music)
RESPONSE
Patient demonstrated techniques to control anxiety
Patient demonstrated decreased distress.
Date and Time FOCUS
August 1, 2023 Diarrhea
3:00 – 11:00 pm
DATA
Subjective:
“Masakit po ang tiyan ko at limang araw nang basa ang
tae ko tsaka apat hanggang limang beses ako
magbawas. Pag nautot din ako minsan may sumasama.”
Objective:
- BP: 100/70 PR: 113 T: 37.8°C RR: 17
- Pale and dry skin
- Borborygmi in the stomach
- Weak in appearance
ACTION
- Assessed onset and pattern of diarrhea.
- Obtained a stool culture.
- Assessed bowel sounds.
- Started IV Fluids
- Monitored electrolyte imbalances.
- Educated on diet changes to prevent diarrhea
such as bland diet with low fiber and discussed
foods to avoid such as oily, fresh foods, and
caffeine.
- Encouraged a liquid diet.
- Administered antidiarrheals as prescribed.
RESPONSE
Patient reported experiencing less than three loose
stools per day.
Patient reported relief from abdominal pain, gas, or
cramping.
Date and Time FOCUS
August 1, 2023 Sleep Disturbance related to nasal irritation secondary to
3:00-11:00pm allergic rhinitis.
DATA
Subjective:
3:18 pm “Pumunta na ako dito sa ospital kasi madalas na yung
pagbahing ko to the point na nagigising ako sa madaling
araw nang ilang beses tsaka feeling ko palagi barado
yung ilong ko tsaka makati yung lalamunan ko kapag
nasa labas ako.”
Objective:
- Weakness
- Presence of postnasal drip
- Constant sneezing
- Red, puffy, watery eyes with dark circles
- Test results: allergies to pollens and dust
- BP: 140/80
ACTION
- Recognized the varieties of allergens that may
affect the patient. Identify the presence of such in
the patient’s environment.
- Assessed the patient’s history for allergies and
previous instances of allergic rhinitis.
- Suggested adherence and follow through with a
cleaning routine to minimize the vulnerability of
acquiring dust mites.
- Instructed the patient to follow and administer the
prescribed at-home medication.
- Encouraged the significant use of nasal sprays
and educated the patient on their proper usage.
RESPONSE
Has reported comfort and ease of breathing after 8
hours.
Has reported a good daytime nap.
FOCUS
Date and Time
Constipation
August 1, 2023
3:00 – 11:00 pm
DATA
Subjective:
“Hindi na ako madalas dumumi nitong mga nakaraang
araw.”
Objective:
- Abdominal cramping
- Appears bloated
- Decreased bowel sounds
ACTION
- Encouraged the patient to increase fluid intake of
1.5 to 2 L/day as tolerated.
- Advised the patient to eat high-fiber foods.
- Provided laxatives and discussed use of stool
softeners and mild stimulants.
- Encouraged exercises to increase peristalsis.
- Initiated regular schedule for defecation.
RESPONSE
Patient has experienced a normal bowel pattern;
maintained passage of soft, formed stool without
straining.
Patient is free from incontinence and stated relief from
discomfort.
