FDAR CHARTING

(Focus-Data-Action-Response)

Patient’s Age: 47 y.o. Sex: Male CC: High fever for 14 days, Right side chest pain for 14 days
Medical Diagnosis: Provincial Diagnosis: Pleural Effusion (Exudate Type)
Differential Diagnosis: Pneumonia, Pulmonary consolidation, Chronic lung abscess

Date, Time, and FOCUS PROGRESS NOTES

Shift

12/07/20 D- Upon assessment, cyanosis was observed;

VS includes: T - 101 F (38.3 C)/axillary; RR – 30
3PM- 11PM min, PR - 110 bpm; BP - 95/54 mmHg right hand,
supine position (+) mild dullness over the right
Airway chest (infra axillary), (+) bilateral vesicular breath
sounds, diminished in right side (infra axillary), no
additional sound, decreased tactile fremitus, and
asymmetrical chest expansion.-------------------------
A- Assessed the rate, rhythm and depth of
respiration; assessed cough productivity;
assessed patient’s hydration status; elevated
head of bed; changed position ever hour;
educated patient of deep breathing exercise;
demonstrated proper splinting of chest and
effective coughing while in upright position;
maintained oral fluid intake; instructed patient
how to use incentive
spirometer--------------------------------------------------------
R- Goal was met; patient exhibited a decreased
episode of coughing; patient’s respiration had
improved to 19 breaths/min.------------------LBD,
SN
 FDAR CHARTING
(Focus-Data-Action-Response)

Patient’s Age: 47 y.o. Sex: Male CC: High fever for 14 days, Right side chest pain for 14 days
Medical Diagnosis: Provincial Diagnosis: Pleural Effusion (Exudate Type)
Differential Diagnosis: Pneumonia, Pulmonary consolidation, Chronic lung abscess

Date, Time, and FOCUS PROGRESS NOTES

Shift
 12/07/20 D- Upon assessment, VS taken includes: T - an
increased above normal range to 101 F (38.3
3PM- 11PM C)/axillary; RR – 30 min, regular; PR - increased
pulse above normal range to 110 bpm; BP -
Hyperthermia decreased to 95/54 mmHg right hand, supine
position.-------------------------------------------------------
A- Monitored core temperature; tepid sponge
bath done to reduce body core temperature;
monitored BP; monitored heart rate and rhythm;
monitored respirations; encouraged patient oral
fluid intake; monitored urine output; reviewed lab
test results especially serum sodium level;
administered Paracetamol 650 mg tab PO as
ordered by the physician @ 6PM; adjusted room
temperature to patient’s tolerance; raised sideway
rails; provided high-calorie diet; encouraged
patient adequate rest, instructed SO to provide
blanket for the patient and let patient wear loose
clothing, health teach the SO how to measure the
patient’s temperature and the importance of
adequate oral fluid intake; instructed SO to use
damp towel to reduce body
temperature.--------------------------------
R- Goal was met; patient’s temperature
decreased from 38.3 C to 36.8 C; patient’s pulse
decreased from 110 bpm to 96 bpm; BP was
maintained within normal range; patient reports, “I
feel much better”; continuous monitoring of VS is
endorsed.----------------------------------------------------
---LBD, SN
 FDAR CHARTING
(Focus-Data-Action-Response)

Patient’s Age: 47 y.o. Sex: Male CC: High fever for 14 days, Right side chest pain for 14 days
Medical Diagnosis: Provincial Diagnosis: Pleural Effusion (Exudate Type)
Differential Diagnosis: Pneumonia, Pulmonary consolidation, Chronic lung abscess

Date, Time, and FOCUS PROGRESS NOTES

Shift

12/07/20 D- Patient reports right sided chest pain

described as sharp and stabbing, intensified by
3PM-11PM deep inspiration and episodes of dyspnea; Upon
assessment, findings taken includes: Lungs:
normal shape, (+) abdominal – thoracic type
respiration bilateral symmetrical chest movement,
Acute Pain (+) tenderness at right side chest. RR – 30 min,
regular, -------------------------------------------------------
A- performed pain assessment every time it
occur; monitored VS; educated deep breathing
exercises and relaxation techniques; provided
relief by diverting attention of watching television;
administered Paracetamol 650 mg tab PO to
maintain acceptable level of pain as ordered by
the physician @6PM; assisted the patient in
changing of position as a comfort measure;
evaluate the effectiveness of Paracetamol;
observed for facial grimace, moaning which are
indicators of pain; encouraged the patient of
adequate rest; discussed with the SO ways to
assist patient in pain
management.-----------------------------------------
R- Goal was met; patient’s displayed
improvement in mood; patient’s respiration had
improved to 19 breaths/min; difficulty of breathing
was relieved; patient reports, Patient reports,
“The pain is bearable compared to this morning.”;
pain assessment of the right sided chest is
endorsed.----------------------------------------------------
----LBD, SN