Fundamentals of Nursing Practice FDAR

1st Semester - BSN1-N22G

Perpetual Help College of Manila ● FOCUS - identifies the content or purpose
Leigh Vesagas of the narrative entry and is separated from
the body of the notes in order to promote
FDAR (Focus, Data, Action, and Response) easy data retrieval and communication.
● DATA - is the subjective and/or objective
FOCUS CHARTING information supporting the stated focus or
describing the observation at the time of a
● Describes the patient's perspective and significant event.
focuses on documenting the patient's ● ACTION - describes the nursing
current status, progress towards goals and interventions (independent, basic and
response to interventions. perspective) past, present or future.
● RESPONSE - describes the patient
OBJECTIVES outcome/response to interventions or
describes how the care plan goals have
● To easily identify critical patient been attained.
issues/concerns in the progress notes.
● To facilitate communication among all FOCUS
disciplines.
● To improve time efficiency with ● To describe a patient's problem/focus/
documentation. concern from the care plan - when the
● To improve concise entries that would not purpose of the notes is to evaluate progress
duplicate patient information already toward the defined patient outcome from the
provided on flowsheet/ checklist. plan of care.

GENERAL GUIDELINES Examples:

★ Self care
● Focus charting must be Evident at least ★ Skin integrity
once every shift. ★ Activity tolerance
● Focus charting must be patient- oriented not
nursing task- oriented. ● To document an acute change in a patient's
● Indicate the date and time of entry on the condition - when there has been an event of
first column. new patient condition.
● Focus note written on the second column.
● Data, Action and Response on the third Examples:
column. ★ Respiratory distress
● Document only the patient's concern and / ★ Seizure
or plan of care. ★ Code blue (Hospital staff may call a code blue
● Document patient's status on admission, for if a patient goes into cardiac arrest, has
respiratory issues, or experiences any other
every transfer to/from another unit or
medical emergency.)
discharge.
● For eight hours shift, use blue or black ● To document a significant event or unusual
ink for morning and afternoon shift, red episode in patient care - when (a)
ink for night shift. responsibility for patient care changes from
● For twelve hours shift, use blue or black one department to another (b) a significant
ink for morning and red ink for night shift. treatment. Intervention took place.
Examples: unnecessary repetition.
★ Admission Pre-(specify procedure)
assessment DOCUMENTATION
★ Post-(specify procedure) assessment
★ Pre-transfer assessment DO's
★ Discharge planning ★ DO read what other providers have written
★ Discharge status before providing care and before charting.
★ Transfusion RBC ★ DO time and date all entries
★ PRN medication required ★ DO use flow sheet/checklist. Keep
information on flow sheet/checklist
DATA ★ current.
★ DO chart as you make observations.
● Statements contain objective and/or ★ DO draw a single line thru an error mark this
subjective information. entry a “ERROR” and sign your name.
● Action statement contains only nursing ★ DO use the next available line to chart.
interventions (basic, perspective, ★ DO document the patient's current status
independent) past, present or future. and response to medical care and
● Patient outcomes are evident in the treatments.
response statements. ★ DO write legibly. DO use standard chart
forms.
REMEMBER !! ★ DO use only approved abbreviations.
★ DO write your own observations and sign
● Data, Action, Response only contain over the printed name. Sign and initial every
information related to the focus, none of the entry.
information is extraneous (e.g.: asleep, ★ DO describe the patient's behavior.
watching TV, visited by family). ★ DO use direct patient quotes when
● Response statements are documented after appropriate.
PRN medications are administered. ★ DO be factual and complete. Record exactly
● DATA and ACTION are responded at one what happens to patient and care given
hour and RESPONSE is not added until
later, when the patient outcome is evident.
- DON'T's
★ DON'T begin charting until you check the
● Response is used alone to indicate a care name and identifying number on the
of plan wherein goal has been patient's chart on each page.
accomplished. ★ DON'T chart procedures or chart in
● DATA is used when the purpose of the note advance.
is to document assessment finding and ★ DON'T clutter notes with repetitive or
there is no flow sheet/checklist for that frequently changing data already charted on
purpose. the flow sheet/checklist
● ACTION AND RESPONSE are repeated ★ DON'T squeeze in a next entry or "leave
without additional data to show the space" for someone else who forgot to
sequence of decision making based on chart.
evaluating patient response to the initial ★ DON'T write in the margin.
intervention. ★ DON'T use meaningless words and
● Begin the charting with ACTION when the phrases. Such as "good day" or "no
patient's interaction begins with intervention complaints".
or when including date would be ★ DON'T use a notebook, paper or pencil.
★ DON'T make or sign an observation and
sign over entry for someone else.
★ DON'T change an entry because someone
told you to do so.
★ DON'T label a patient or show bias
★ DON'T try to cover up a mistake or accident
by inaccuracy or omission.
★ DON'T "white out" or erase an error.
★ DON'T throw away notes with an error on
Fundamentals of Nursing Practice ● Generally, is making a telephone referral
1st Semester - BSN1-N22G easy or difficult?
Perpetual Help College of Manila ● Do you get frustrated when receiving
Leigh Vesagas information about your patients/clients from
other staff?
ISBAR (Identify, Situation, Background, ● What have you experienced?
Assessment, and Request) ● If sometimes it is difficult, why?
● What information would you like when
receiving a referral or at handover?
ISBAR HELPS CLINICAL STAFF TO:
● People are busy and don't want more work!
It takes time and practice to plan a good
● Further develop their communication skills
handover of patient/client information
● Utilize these skills when making a telephone
● It can be difficult to summarize a complex
'referral'
case succinctly
● Utilize questioning / prompting skills when
● The person making the referral
receiving a telephone referral
○ is often asked about things they
● Use a standardized or common approach to
have already said
communication
○ may not get the help they were
● Adapted from SBAR, a tool developed by
expecting
the US Navy to improve communication
● The person receiving the referral may
● Why is improving our communication
○ interrupt mid-sentence
important?
○ make assumptions about the
○ Patient care is dependent on
capability of caller
effective communication including
telephone communication between
all staff involved in the care of the
ISBAR (Identify, Situation, Background,
patient. Assessment, and Request)
● Effective communication has become more
important as healthcare has become more I = IDENTIFY
complex, highly specialized and team-based
● Identify yourself - name, position, location
WHY DO WE NEED A STANDARD Identify the person you are talking to if not
already done
APPROACH TO VERBAL AND WRITTEN
● Identify the patient and unique ID number
COMMUNICATION?
Hello. My name is Jasmine Sass, I'm a Division 1
● It is a daily task RN working in Acute at UMHCS. Are you the
● It is rarely 'explicitly' taught Doctor on call today? ... I'm calling about a patient -
● Telephone referrals can be a source of Terry Jones –a 56 year old man in our Acute ward
frustration for both the 'giver' and the at present”
'receiver'
● Ineffective telephone communication can ● Why give your name?
compromise patient care ○ it is polite and professional to do so
● Why give your position?
SOME QUESTIONS FOR YOU TO THINK ○ helps the information receiver to
ABOUT..... know at what level to pitch their
response/advice
● How often do you make or receive a ● Why state where you are calling from?
telephone referral? ○ the information receiver may work at
multiple sites
 ● Why identify the person you are speaking ● Provide RELEVANT information only.
to? Deciding what is relevant is a skill that
○ to make sure it is the appropriate comes with experience.
person ● Don't forget 'less is often more'
● Why do you need their name? ○ You may get the message across
○ to document in the notes for future better with less Information
reference
● Why identify the patient - name, age, sex, ● Include aspects of history, examination,
location? investigations and management where
○ helps identify the patient and helps relevant.
the receiver to develop a mental ● The volume of information will depend on
picture of the patient the situation.
● LESS
S = SITUATION ○ If the receiver will see the patient
themselves shortly. No background
● Explanation of WHY you are calling may be quite appropriate in this
situation.
"I am calling you about a patient, Mr. Jones. He is a ○ If the receiver already knows the
56 year old man, 3 days post total knee patient.
replacement who has developed new atrial ● MORE
fibrillation with a blood pressure of 105/66. He looks ○ If you are wanting management
pale and feels unwell. I would like you to come and advice over the phone without the
assess this patient please” receiver seeing the patient.
○ The receiver can always fill any
● If urgent, make this clear at the start important gaps in your story by
asking questions.
Mr. Jones is a 56 year old man who is 3 days post
total knee replacement and is here for A = ASSESSMENT
rehabilitation. He has gone into atrial fibrillation. He
is stable at present with a blood pressure of 105/66 ● State what you think is going on. Give your
but he is normally hypertensive. He looks pale and interpretation of the situation.
feels unwell. I am concerned about him and would ● This is NOT about providing your diagnosis
appreciate it if you could come and help us stabilize of the patient - only a qualified medical
him" practitioner can do this.
● Don't leave the receiver to guess what you
● Stating the purpose of the call at the start of are thinking.
the conversation helps the receiver focus ○ Stating the obvious is helpful here
their attention appropriately when listening ○ Include your degree of certainty
to the story ○ Be objective

... the patient is febrile with a temperature of 39

B = BACKGROUND deg"

● Tell the story ● The patient has improved but I am

○ I'll tell you the story..." concerned they are still short of breath"
○ I'll give you the background ● The patient has rated their pain at 8/10
information..." despite 2.5 mg Morphine IV one hour ago"
R = REQUEST ● Have pen and paper on hand to write down
names, numbers and instructions, or use
● State what you want from the receiver the ISBAR documentation form
○ "We would be grateful for your
opinion regarding the need for REMEMBER, ISBAR CAN BE BRIEF
surgery”
○ "I need help urgently, are you able to ● I - “Hi, I'm Carol, an ANUM in Acute today"
come now? ...if not, who should I ● S - "I would like you to come and see a 21
call?” year old man who has had a significant skin
reaction to an IV antibiotic"
● Ask questions ● B - "He was admitted this morning for
○ "What would be the most treatment of an appendectomy wound
appropriate pain relief we can infection. He is a type 1 diabetic. He has
administer until you are able to come just had his first dose of Gentamicin,
and assess the patient?” Metronidazole and Ampicillin”
○ "What would you like me to do for ● A – “He is anxious and appears flushed with
the patient whilst waiting for you to an erythematous rash on his chest and
come in?" arms. His blood pressure is normal"
● R - "Are you able to see him urgently?"
ADDITIONAL POINTS ..... What would you like me to do in the
meantime?"
● What you say for Situation may be a
concise summary of what you say for RECEIVING A REFERRAL OR HANDOVER
Assessment and Request. This repetition is
helpful, as it emphasizes the key purpose of ● Don't forget you can help - you may need to
the referral, as well as why it is important help people stay on track - consider asking
they come NOW! the following questions
● Sometimes the receiver will lead the ● Are we using the ISBAR format?
conversation - you can still use ISBAR as a ● Can you give this to me in ISBAR format?
guide. ● Can you please identify .... patient's name,
● Don't forget, the receiver may not be familiar location?
with ISBAR. ● What is the Situation?
● Practice makes perfect - use the ISBAR ● What is the Background?
documentation form to help you organize ● What is your Assessment?
the information you are going to convey. ● What do you think needs to happen?

PREPARING FOR THE CALL Videos:

● Preparation is vital - use ISBAR to prepare https://www.youtube.com/watch?v=FV7FM-kFp6k -

● Make sure YOU are clear on the reason for ISBAR
referral before calling https://www.youtube.com/watch?v=Jt0MYij66jM -
● Write down your questions SBAR
● Document a written referral in the notes as
per the practice for
● formal referrals in your hospital or include in
nursing notes
● Gather relevant patient details, notes,
charts, ECGs, observations etc. before
making the call
Fundamentals of Nursing Practice ● Self regulatory, occur without conscious
1st Semester - BSN1-N22G thought, and usually function to correct
Perpetual Help College of Manila abnormal conditions.
Leigh Vesagas ● Short term & long term stress can threaten
the physiologic homeostasis & result in
STRESS AND ADAPTATION illness

STRESS TYPES OF PHYSIOLOGICAL HOMEOSTASIS

● "It is a condition in which the human system 1. Local Adaptation Response

responds to changes in its normal balanced 2. General Adaptation Response
state stress resulting from a change in the
environment,that is presided as a challenge, LOCAL ADAPTATION RESPONSE
a threat or a danger and can have both
negative and positive effects." 1. The Reflex Pain Response
- Pender and Parsons (2006) 2. The Inflammatory Response

STRESSOR THE 3 STAGES OF GENERAL ADAPTATION

SYNDROME
● "Stressor are themselves neither positive
nor negative but they can have positive and ● ALARM REACTION STAGE
negative effects as the person responds to
the changes." The alarm reaction stage of general adaptation
syndrome is the body’s initial response to stress.
ADAPTATION The sympathetic nervous system is activated by the
sudden release of hormones. You may better know
● "when person is in a threatening situation this stage as the fight-or-flight response.
immediate response occur.those response
are often involuntary,are called coping The sympathetic nervous system is a part of the
response. The change that takes place as a autonomic nervous system, which regulates the
result of the responses to a stressor is functions of your heart, stomach, bladder, and
adaptation." intestines, as well as your muscles. You are not
aware that this system is working because it
HOMEOSTASIS automatically responds to stimuli.

● "The various physiologic mechanisms within When the sympathetic nervous system is activated,
the body responses to internal changes to it stimulates the adrenal glands. The glands, in
maintain relative constancy in the internal turn, trigger the release of certain hormones,
environment is called homeostasis." including adrenaline and noradrenaline.

★ PHYSIOLOGIC HOMEOSTASIS The hormone release causes physical symptoms,

★ PSYCHOLOGICAL HOMEOSTASIS such as increased heart rate, breathing rate, and
blood pressure
PHYSIOLOGIC HOMEOSTASIS
Physical signs of being in the alarm response stage
● Autonomic nervous system & the endocrine include:
system primarily control homeostasis
mechanisms. ★ Dilated pupils
★ Increased heart rate
 ★ Rapid breathing ● EXHAUSTION STAGE
★ Trembling
Prolonged or chronic stress leads to the last stage
★ Pale or flushed skin
of general adaptation syndrome—exhaustion.
★ Heightened senses Enduring stressors without relief drains your
physical, emotional, and mental resources to the
According to Selye, most of the symptoms of the point where your body is no longer able to cope
alarm response stage disappear or are reversed in with stress.
the next stage (resistance), then reappear in the
final stage of exhaustion. Signs that you are in the exhaustion stage include:

● RESISTANCE STAGE ★ Fatigue

★ Burnout
The resistance stage of general adaptation ★ Decreased stress tolerance
syndrome is when your body tries to repair itself
after the initial shock of stress. If the stressful The physical effects of prolonged stress can
situation is no longer present and you can weaken your immune system and increase your
overcome the stress, your heart rate and blood risk of heart disease, high blood pressure, diabetes,
pressure will start to return to prestress levels and other chronic health conditions, including
during this stage. mental health disorders such as depression or
anxiety.
However, if the stressful situation continues for a
long time or if you do not resolve the stress, your In chronic stress situations, sufferers enter the
body will never receive a clear signal to return to exhaustion phase: emotional, physical and mental
normal functioning levels. This means it will resources suffer heavily, the body experiences
continue to secrete the stress hormones and 'adrenal exhaustion leading to decreased stress
your blood pressure will stay high. tolerance, progressive mental and physical
exhaustion, illness and collapse.
Prolonged levels of high stress can cause
disturbances in the immune, digestive, WHAT CAUSES GENERAL ADAPTATION
cardiovascular, sleep, and reproductive systems. SYNDROME
You might have symptoms such as:
● Any kind of stressor—both unpleasant and
★ Feelings of fear, anger, sadness, worry, rewarding, dangerous or thrilling—can
numbness, or frustration trigger general adaptation syndrome.
★ Irritability ● Selye discovered general adaptation
★ Changes in appetite, energy, desires, and syndrome after studying how the human
interests body reacted to physical stressors, such as
★ Stomach problems being exposed to cold temperatures or
★ Headaches physical overexertion.
★ Body pains or skin rashes ● It is now understood that many situations,
★ Sleeplessness or nightmares including those that cause psychological
★ Trouble concentrating or making decisions rather than physical stress, can cause GAS.

Prolonged stress that is not resolved leads to the Examples of stressors that can trigger GAS include:
third stage (exhaustion).
★ Daily stress (such as pressure at school,
work, or at home relating to your family)
 ★ A sudden change in your life (such as losing sexual behaviour and loss of sexual
a job, divorce, or illness) drive
★ Traumatic experiences (such as abuse, a ● JOINTS & MUSCLES
major accident, and war) ○ aches and pains, inflammation,
tension, lowered bone density
HOW STRESS AFFECTS THE BODY (propensity for osteoporosis),
tightness in the shoulders and back
● SKIN
○ skin problems like acne, psoriasis, PSYCHOLOGICAL HOMEOSTASIS
eczema, dermatitis, random
breakouts, and skin rashes Each person needs to feel loved & a sense of
● STOMACH belonging, to feel safe & secure & to have
○ can cause peptic ulcer disease, IBD self-esteem. When these needs are not met or a
(inflammatory bowel disease), IBS threat to need fulfillment occurs homeostatic
(irritable bowel syndrome), food measures in the form of coping or defense
allergies, stomach cramps, reflux, mechanisms help return the person to emotional
nausea and weight fluctuations balance.
● PANCREAS
○ results in elevated secretions of TYPES OF STRESS
insulin, which if chronic could lead to
diabetes, damaged arteries and Stress is a natural response to challenges or
obesity demands that individuals face in their daily lives,
● IMMUNE SYSTEM characterized by physical, emotional, and mental
○ suppressed effectiveness of the tension. It serves as a signal that the body and
immune system to battle and mind are responding to perceived threats or
recover from illness. Leads to high pressures, prompting people to take action to cope
levels of inflammation in the body, with or adapt to the situation.
which causes a variety of chronic
health conditions ● ACUTE STRESS
● HEAD ○ Acute stress is immediate,
○ issues with mood, anger, short-lived stress responses
depression, irritability, lack of energy, triggered by specific events or
concentration problems, anxiety and situations. Common scenarios that
panic attacks elicit acute stress include public
● HEART speaking, taking exams, or
○ increased blood pressure,fast heart encountering sudden challenges at
beat, increased risk of heart attack work or home. Acute stress is
and stroke, and higher cholesterol normal and can even be motivating,
● INTESTINES but prolonged exposure to acute
○ decreased nutrient absorption, stressors without effective coping
reduced metabolism, decreased skills can lead to negative health
enzymatic output, increased risk for effects.
inflammatory bowel diseases, ● CHRONIC STRESS
diabetes, and more ○ Chronic stress is persistent,
● REPRODUCTIVE SYSTEM long-term stress that results from
○ decreased testosterone and ongoing challenges, pressures, and
estradiol production leading to adversities in life. Common sources
reduced fertility. Dampening of of chronic stress include financial
issues, job dissatisfaction,
 relationship problems, or chronic NEGATIVE STRESS
health conditions. Chronic stress can
have detrimental effects on physical ● It is a contributory factor in minor conditions,
and mental health, increasing the such as headaches, digestive problems,
risk of cardiovascular disease, skin complaints, insomnia and ulcers.
depression, anxiety, and immune ● Excessive, prolonged and unrelieved stress
system dysfunction. can have a harmful effect on mental,
● EUSTRESS physical and spiritual health.
○ Eustress is beneficial or positive
stress that motivates and energizes TYPES OF STRESSOR
people to achieve goals, engage in
challenging activities, and adapt to 1. Physiological stressors
new experiences. Unlike distress,
which is harmful, eustress is ★ These stressors can come from pregnancy,
associated with feelings of injuries, or other physical health problems.
excitement, anticipation, and Sometimes they come unexpectedly, like if
fulfillment. Examples include starting we’re involved in a car accident or stem
a new job, planning a wedding, and from other health issues that we’ve been
preparing for a competition. Eustress facing.
can enhance resilience, promote
personal growth, and contribute to 2. Lifestyle stressors
overall well-being.
★ The choices we make dictate our lifestyles.
POSITIVE STRESS Some mean that we don’t get enough sleep
or manage our time correctly. Our work-life
● General adaptation syndrome is not only balance also plays a key role in our lifestyle
triggered by stressors that cause distress. It choices and our stressors.
can also be triggered by situations in which ★ A lifestyle stressor might be that our
the stressor is considered positive or demanding job forces us to order lots of
pleasant (known as eustress). takeouts, which might not properly fuel our
bodies.
★ For example, some people see the stress of
an upcoming exam as positive because it 3. Major life event stressors
helps them to stay motivated. Others might
enjoy the fear they feel while watching a ★ Life changes can be a huge source of stress
scary movie. while we adjust. These could be positive
sources of stress, like starting college,
*What seems like a threat to one person might be
having a child, or getting married
perceived as a positive challenge to someone else. Their
★ They can also be things that negatively
stress response to the same stimulus, therefore, will be
different. change our lives, like losing a loved one or
losing your job. Even major events like
● Stress can also have a positive effect, elections can cause stress.
spurring motivation and awareness,
providing the stimulation to cope with 4. Organizational stressors
challenging situations.
● Stress also provides the sense of urgency ★ Organizational means anything from our
and alertness needed for survival when schools, workplaces, or even clubs. Our
confronting threatening situations. stressors can stem from the people we work
 with at these organizations or the rules we FACTORS AFFECTING STRESS AND
have to follow. They can also be from ADAPTATION
pressure, like working for a good grade or
meeting a tight deadline at work. ● The Source of Stress
○ Developmental Stress
5. Financial stressors ○ Situational Stress
● Types of Stressor Experienced
★ Financial stress is a significant source of ○ Physiological Stressor
stress for people of all ages. One survey ○ Psychological Stressor
found that 50% of respondents were ● Personal Factors
stressed by simply talking about their
finances. Other financial stressors can PSYCHOLOGICAL STRESS ADAPTATION
come from taxes, thinking about unpaid
● Mind Body Interaction
bills, and unexpected expenses.
● Anxiety
● Coping Mechanisms
6. Social stressors
MIND BODY INTERACTION
★ Our social health is crucial for dealing with
stressors. Many studies have found that
● Humans react to threats of danger as if they
having solid support is important for our were physiologic threats of a person
physical and mental health. But a lack of perceiving the threat on an emotional level
social support or unhealthy social & the body prepares itself to either resist the
relationships can cause us stress and danger or to run away from it. Each person
damage our mental health. reacts in:
★ These stressors can stem from conflict with ○ Backache
people close to us or loneliness. ○ Constipation
○ Diarrhea
7. Environmental stressors ○ Dilated pupil
○ Dry mouth
★ Stressors that come from our environment ○ Headache nausea
are out of our control. We can encounter ○ Sleep disturbances
environmental stressors like excessive ● Mind-body interaction (MBI) refers to the
noise or traffic or things like natural holistic association and interactive process
disasters or war. between wisdom, thinking, belief, and
★ Sometimes we can manage them physiological reaction, which critically
ourselves, like dealing with loud noises, but affects health. The main goal of nursing is to
other times we don’t have control over maintain the mind and body in a healthy
things like hurricanes or tornadoes around state of well being.
us. ● The brain and body are connected through
neural pathways made up of
neurotransmitters, hormones and
EFFECTS OF THE STRESSOR chemicals. These pathways transmit signals
between the body and the brain to control
● Health and Illness our everyday functions, from breathing,
● Basic Human Need digestion and pain sensations to movement,
● Family reaction to illness thinking and feeling.
● You are physically affected (through body
sensations and functioning) by what goes
 on in your mind. For example, your heart helps a person identify & verbalize feelings
rate may increase when you experience associated with stress.
feelings of anxiety when you have to make
a speech in front of other people or when
you do something for the first time.

ANXIETY

● Anxiety is a feeling of fear, dread, and

uneasiness. It might cause you to sweat,
feel restless and tense, and have a rapid
heartbeat. It can be a normal reaction to
stress. For example, you might feel anxious
when faced with a difficult problem at work,
before taking a test, or before making an
important decision.
● Mental health disorders can only be
diagnosed by licensed health care
professionals.

COPING MECHANISMS

● Compensation
● Denial
● Displacement
● Introjection
● Projection
● Rationalization
● Reaction Formation
● Repression
● Sublimation
● Undoing

INTERVENTIONS TO REDUCE ANXIETY

a). Exercise:- Regular exercises help to maintain

physical & emotional health.

b). Rest and sleep:- Rest and sleep helps the body
to maintain homeostasis & restore energy levels.

c). Nutrition:- It plays an important role in

maintaining the body's homeostatic mechanisms &
in increasing resistance to stress. Obesity &
malnutrition are major stressors & greatly increase
the risk of illness.

d). Encouraging the use of a support system:-

Support system provides emotional support that