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Fdar Charting: Date, Time, and Shift Focus Progress Notes

The document summarizes a 67-year-old male patient's hospital visit for difficulty breathing over two days. Upon examination, the patient had few audible wheezes, clubbed fingers, and barrel chest. His vital signs and blood gases indicated respiratory distress. The nurse monitored the patient closely, administered nebulizer treatments and oxygen to improve his oxygen saturation. A chest x-ray revealed pneumothorax, so a chest tube was inserted after pain medication. The patient's condition improved with treatment.

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Blessyl Mae Estenzo
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352 views

Fdar Charting: Date, Time, and Shift Focus Progress Notes

The document summarizes a 67-year-old male patient's hospital visit for difficulty breathing over two days. Upon examination, the patient had few audible wheezes, clubbed fingers, and barrel chest. His vital signs and blood gases indicated respiratory distress. The nurse monitored the patient closely, administered nebulizer treatments and oxygen to improve his oxygen saturation. A chest x-ray revealed pneumothorax, so a chest tube was inserted after pain medication. The patient's condition improved with treatment.

Uploaded by

Blessyl Mae Estenzo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FDAR CHARTING

(Focus-Data-Action-Response)

Age: 67 Sex: Male CC:  Unrelieved difficulty of breathing and fatigue for two days at home
Medical Diagnosis: Ineffective airway clearance related to bronchospasm as evidenced by statements of difficulty
breathing, few audible wheezes and changes in respirations.

Date, Time, and FOCUS PROGRESS NOTES


Shift

D: difficulty in breathing; few audible wheezes is present; clubbed


fingers; barrel chest; VS: T: 99 F or 37.2 C; RR: 21 bpm ; PR: 105
bpm: BP: 132/78 mmHg; ABG’s: pH – 7.30, HCO3 – 28.4, PCO2 –
70, PO2 – 58
8:00-5:00 pm Difficulty Breathing

A: Monitored the patient’s ECG, SPO2, and vital signs every 5


minutes; Performed auscultation of the lungs; Patient was assisted
to semi-fowler’s position; administered Albuterol 2.5 mg in 3 mL
normal saline via nebulizer every 20 minutes x 3 doses as
prescribed; Administered oxygen via nasal cannula as ordered, to
maintain SPO2 greater than 90%; Physician ordered a chest x-ray
and the chest x-ray was done along with the administration of
Morphine 2 mg IV push before the insertion of chest tube, as
prescribed by the physician to relieve left-sided pneumothorax.

R: Patient’s condition improved as evidenced by an SPO2 greater


than 90%.

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