1

ICU FDAR CHARTING SAMPLE

FOCUS: Diagnostic Procedure D: For whole abdominal ultrasound

A: -Maintained patient in comfortable position
- Instructed to remain on nothing per Orem
- Instructed ultrasound department for transfer
R: Awaiting results

FOCUS: Altered comfort D: with epigastric pain, with pain scale 7/10, (+)
nausea and vomiting.
A: -Maintained patient in comfortable position
-Encouraged to perform deep breathing
exercise and relaxation technique.
- Encourage to perform deep breathing
exercise and relaxation technique.
- IV fluids regulated as order.
- Due medications given
- Advised to notify nurse on duty for
progression of pain.
R: No progression of pain reported, Patient well
rested.

FOCUS: Fluid volume excess (Edema) D: with edematous upper and lower extremities
A: - Instructed to limit oral fluid intake to 1 liter
per day.
- Instructed to elevate both legs with pillow
- Regulated IVF fluids as order.
- Monitored Intake and output strictly
- weight patient daily
- Promoted adequate rest period.
R: Patient verbalize understanding.

FOCUS: Risk for elevated blood pressure D: with diagnosis of HPN II, Latest BP 120/80
mmHg
A:- Low salt,Low fat diet instructed as order
- due medication given as order.
- Advised patient to notify nurse on duty for any
untoward signs and symptoms if
manifested.
R: Verbalize understanding.

FOCUS: Risk for Fall (Dizziness) D: ‘’ Medyo nahihilo lang po ako as verbalized by
the patient.
A: - Padded both side rails up
- Bed is place on its lower position
- Advised patient to call Nurse on Duty for
assistance if giong to the bathroom.
- Advised patient to make room well lighted
Especially when giong to bathroom.
R: Patient is stable, No episodes fall, Patient
safely secured.
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ICU FDAR CHARTING SAMPLE
FOCUS: Constipation D:- “ Sir 3 days nako wala dumi’ as verbalized by
the patient.
- stomach distented.
- hypoactive bowel sound upon auscultation
noted.
- (+) irritable.
A:- Administered Suppository as order and
provide privacy.
- Advised patient to increased fluid intake.
- Advised patient to eat foods high in fiber like
green leafy vegetables and fruits.
- Encourage patient mobility.
R: Patient able to defecate and felt comfortable.

FOCUS: Anxiety related to scheduled of surgery D: Received patient with IVF of D5LR 500 ml at
KVO rate infusing well at left cephalic vein.
- ‘’ Natatakot ako sa operasyon’’ as verbalized by
the patient.
- Ask question repeatedly regarding surgery
- (+) cold clamy skin, (+) looks worried, (+) pale
looking.
A: -Advised patient family member to stay with
the patient.
-Referred to AP for the re-explanation of the
surgical procedure.
-Encourage to verbalize feelings.
- Consent signed by the patient and assisted by
the AP during rounds.
-Provide peri operative health teachings
- allowed to ask question and answers provided.
R: ‘’ Na intidihan ko na ang opersyon at hindi na
ako natatakot as verbalized by the patient,
appears relaxed and skin warm to touch.

FOCUS: Receiving Assessment D: Received Patient lying in bed, response alert

and coherent with IVF attached at Left Arm of
PNSS 1L at 20 gtts/min with the following Vital
signs: BP 90/60 mmHg, PR 141 bpm, RR 29 cpm
Temp: 36.1 C ,O2 sat: 93%.
FOCUS: Ineffective breathing Pattern D: Upon Assessment patient displayed a
respiratory rate 28 cpm.
A: - Identified patient and assessed overall status
of the patient.
- Established rapport with the patient.
- Auscultated chest to evaluate presence
character of breath sound and secretion.
- Noted rate and depth of respiration.
- Encourage slower deeper respiration and use of
pursed lip technique.
- Monitor pulse oximetry as indicated.
- Maintain calm attitude while dealing with
patient and relative to limit level of anxiety.
- Assisted client in the use of relaxation
technique.
-Instructed patient to drink fluids frequently
R: Patient verbalized understanding or awareness
of current condition, Patient established a lower
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ICU FDAR CHARTING SAMPLE
respiratory rate of 21 cpm.

FOCUS: Fluid Volume Excess (Edema) D:Swelling of Upper extremities noted non
pitting, latest albumin level 1.98 g/dl dated at
August 3 2015.
A:- Monitor Intake and Output strictly
- Intravenous fluid regulated 50 cc/hr
- Administered Human Albumin 20% as
ordered
- Monitor for signs and symptoms pulmonary
congestion and progression of edema.
-added prosure and egg whites to feeding as
ordered.
R: Still with swelling of upper extremities, noted
clear breath sound upon auscultation with No
signs of pulmonary congestion.

FOCUS: Acute Pain D: - Patient reports of sharp pain in the

abdominal incisions area with pain scale 8 out of
10 scale.
- (+) Facial grimace, (+) Guarding behavior
- Patient is restless and irritable.
A: - Administered Celecoxib 200 mg/tab P.O as
order.
- Encourage deep breathing exercise and
relaxation technique.
R: Patient reports pain was relieved.

FOCUS: Risk for infection D: with incision site in front of the left ear
extending down and around the ear and into the
neck approximately 6 inches length with dressing
Jackson Pratt drain in the left neck bellow ear
secured in place with suture.
A:- Assessed the incision site for signs of
infection.
- Emptied Jackson Pratt drain and maintain on
negative pressure.
- Instructed the patient not touch the incision
site.
- taught signs and symptoms of infection.
R: No swelling or bleeding, bluish discoloration
left ear noted. JP drained 20 ml bloody drainage,
Patient stated understanding of teaching given.

FOCUS: Risk for infection related to presences of D: Presence of incision on Right mid lateral
episiotomy perineum.
A: - Educate and demonstrate proper perineal
care.
- Applying warm compress on the affected area
and changing perineal pads frequently.
R: Patient is able to verbalize and demonstrate
the nursing technique to prevent infection.
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ICU FDAR CHARTING SAMPLE
FOCUS: Decreased of level of consciousness D: GCS 3, No eye opening No verbal response,
Anisocoric Pupil with temperature 39 C.
A: - Monitor Neurologic Status and Vital signs
Closely.
- AP and ROD was notified
- Head of the bed at 30 degrees angle elevation.
- Maintained the body of the patient on neutral
position.
R: Closely monitored for further deterioration of
neurologic status.

FOCUS: ASYSTOLE D: Pulse and BP unappreciated, No Spontaneous

Breathing with oxygen saturation 89%, Fixed
dilated pupils 8 mm, Ventricular fibrilation noted
on the cardiac monitor.
A- High Quality CPR done.
- AP, ROD seen and examined the
patient,significant others were appraised of
patient condition, ventilation via bag mask at
10Lpm,defibrilation at 36 joules done by Dr. Cruz,
MROD,Epinephrine 1mg given 3min interval for 3
doses, flushed with 20cc normal saline and arm
raised thereafter, monitored for return of
spontaneous circulation.
D: Flatline tracing on the monitor, pulse
unappreciated, patient family opted to stop
resuscitation measure.
A:- Waiver for DNR and refusal for emergency
medications secured and sign by the patient wife.
- Rhythm stip taken.
R: Pronounced clinically Dead by AP,ROD; Post
mortem care done; Brought to the morgue by
Nursing Aide on duty.

FOCUS: Nausea and Vomiting D: Patient complaining of vomiting four times per
day, feeling dizzy and weak; states that she is
nauseated especially in the morning.
A:-Monitor and Record Vital signs every 4 hrs.
- Assessed skin turgor.
- Assessed the color and amount of urine.
- Provide clean and peaceful environment.
- Avioded offending odors.
R: The patient reported that there no occurrence
of vomiting and feeling nauseated.

FOCUS: Impaired verbal communication related D: slurred spattering speech and difficulty of
to brain injury as evidenced by slurred spattering speaking.
speech and difficulty of speaking. A: -Assess ability to understand picture and
written words.
- Place important objects on reach.
- Teach patient to use assistive device.
- Teach family how to correctly use assistive
device.
- Reffered patient to speech language therapist
as order.
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ICU FDAR CHARTING SAMPLE

R: Patient is able to express self with devices ,

Patient correctly demonstrate use of devices.
Patient is able to successfully communicate with
all family members.

FOCUS: FATIGUE D: Patient complaining of feeling dizzy and body

weakness.
A- Monitor vital signs and record.
- Determine the presence degree of sleep
disturbances.
- Asked the client to rate fatigue and its effect on
the ability to participate in desired activities.
- Monitor Client food intake and nutritional
status.
R: The patient verbalized reduction of fatigue as
evidenced by reports of increased of energy and
ability to perform desired activities.

FOCUS: IV out D: with swelling noted on the IV site and Pain IV

site noted
A:- Removed IV line aseptically
- Informed AP of IV line not inserted.
- Carried out doctors order to may not reinsert
for the mean time.
R: Patient refused for reinsertion.

FOCUS: Change IV site and set D: Seen previous IV site with redness and
swelling.
A:- Seen and examined by AP.
- Verbal order of change IV site
- Removed previous IV site aseptically
- Re inserted IV cannula G.20 at Right Basilic vein.
- Regulate IVF as order.
- Due medication given as order.
- Monitor patient from time to time.
- Advised to notify nurse on duty to report any
untoward sign and symptoms if manifested.
R: Patient IV line intact and infusing well.
FOCUS: Pain at IV site D: - ‘’ Masakit ang pinalagyan ng IV catheter ko”
as verbalized.
- Checked IV site, found beginning signs of
infiltration.
A:- Removed IV catheter and change the whole
system.
-Reinserted the new set of IV catheter aseptically
into the distal portion of basilic vein on the left
arm.
- Splint applied on the IV site.
- Advised to call Nurse on duty for any
progression of pain.
R: “ Wala na sakit ang kamay ko” as verbalized by
the patient.
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ICU FDAR CHARTING SAMPLE
FOCUS: IV reinsertion D: IV site swelling noted
A: - Prepared necessary materials for IV catheter
insertion.
- Re inserted IV cannula aseptically.
- Secured IV site with dressing.
- Regulated IVF as order.
R: Re-change IV site properly.

FOCUS: Cardio Pulmonary Arrest D: (+) unresponsiveness, (+) breathlessness,

(+) cyanosis, BP/RR not appreciated
A:- Placed flat on the bed at 9: 31 AM
- O2 administered @ 10 L/min thru ambubag.
- AP infrormed Code Blue activated
- STAT intubation done by AP.
- Placement Checked.
- Hooked to cardiac monitor asytole noted.
- ATSO4 1amp given IV as order.
- Present IVF shifted PNSS 1L to rub fast drip.
- Started Dopamine drip at 15 mcgtts/min.
R: 09:37 AM @ Sinus Tachycardia noted in the
cardiac monitor HR= 120 bpm, BP=90/60 mmHG
A:- CPR discontinued.
- continuous ambubaging rendered at 12 L/min.
- suction at intervals obtained, thick yellowish
phlegm approximately 100 cc.
-NGT inserted aseptically, per left nostril by AP.
- Foley cath Fr. 16 inserted, connected to urine
bag voided 100 cc dark yellow urine.
R:-7:35AM Vital signs, Stable responsive to
suctioning and painful stimulation, Pupil reactive
to light.
- Transported to ICU per stretcher assisted by the
Nurse and AP.

FOCUS: Chest pain D:- ‘’Masakit ang dibdib ko as verbalized by the

patient.Holding chest with facial grimace.
- (+) restless, Pain scale 6/10 on claimed.
A:- Assisted at comfortable position at 7:30 Am
- Encourage to remain on bed.
- Encourage to do deep breathing exercise.
- Informed AP seen and examined with orders
made and carried out.
- Continuously monitoring for any progression of
pain.
R:-‘’Nabawasan ang sakit ng dibdib ko as stated
by the patient.
- resting on bed with out facial grimace.
-Pain scale 2/10 on claimed.
- BP= 140/90 mmHg RR=20 cpm PR=102 bpm
T=37.3 C
- will continuously monitor for recurrence
progress of chest pain.
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ICU FDAR CHARTING SAMPLE

FOCUS: Altered comfort due to pain in the D: ‘’Medyo masakit ang balikat ko’’ as stated by
shoulder. the patient.
A: Position Patient on his comfort.
- Provide diversional activities
- Advised to notify nurse on duty for progression
of pain.
R: Patient stated that the pain was decreased.

FOCUS: Risk for fall D: ‘’Medyo Nahihilo lang po’’ as stated by the
patient.
A:-Encourage verbalization of health concern.
-Position Patient in comfortable position.
-Bed is place on its lowest position.
-Advised to call NOD for assistance.
-Advised to make room well lighted especially
when going to bathroom.
- Advised the patient to report to Nurse on duty
for any untoward signs and symptoms.
R: Patient stable, No episode of fall, Patient safely
secured.

FOCUS: For discharges D: with doctors order 04/15/2021

A:-Advised to secure all pertinent document
regarding discharge.
- discharges instruction explained.
- Instructed home medication.
R: Discharged in the pair condition per
wheelchair accompanied by the relative with
latest Vital signs of BP=120/80mmHG, PR=84
bpm, RR=20 cpm, T=36.5 C, 02 sat=98%.

FOCUS: Discharge plan D: -Received patient awake sitting on bed.

-‘’I think might go home, because the doctor said
that should process my papers because I'm now
ok and ready to go home’’ as verbalized.
-normal vital signs,no distress or pain, appear to
be well.
A:- Educated about the medications dosage,
route effect and adverse effect.
- Encourage to drink medication in proper dosage
of time.
- Demonstrated the proper use of metered dose
inhaler to patient.
- Instructed Patients to report to their primary
healthcare provider the changes and
consistent ,prolonged period of dyspnea that are
unrelieved by medications.
- Instructed and encouraged to attend follow up
check- up after 2 weeks of discharge.
R:’’Yes I will go to my follow up check up two
weeks after my discharges’’ as verbalized by he
patient, also demonstrated the proper used of
inhalers.
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ICU FDAR CHARTING SAMPLE
FOCUS: Difficulty of Breathing D: -‘’ I cant breath and its going on for hours
now’’ as verbalized by the client.
- Dyspneic, wheezing, coughing, rapid irregular
heart rate, tachypnea, VS: BP 112/62 mmHg, RR
22cpm, HR 92 bpm irregular, temp 36.5 C, 87%.
A:-Assessed vital signs of the client.
- Monitor oxygen saturation.
- Auscultated lung fields.
- Positioned patient in a high fowlers.
- Administered oxygen theraphy as ordered
- Administered prescribed medications.
- Encourage patient to use relaxation technique.
R: ‘’I can now breath properly’’ as verbalized by
the patient.

FOCUS: Elevated body temperature D: -“Mainit ang pakiramdam ko” as verbalized by

the patient.
- with flushed skin and warm to touch.
- Temperature 38.9 C via axilla, pulse 80 beats
per minute, respiration 24 breaths per minute,
blood pressure 120/80 mmHg.
A:-Performed tepid sponge bath, applied ice cap
on forehead, Administered Paracetamol 250 mg
as per doctors order. Encourage adequate oral
fluids intake, Provide calm environment to keep
patient comfortable.
R:‘’Pinagpapawisan na ko’’ as verbalized,
temperature decresed to 37.2 C.

FOCUS: Abdominal pain D: Patient verbalized “masakit ang tiyan ko”,pain

scale 8 out of 10, facial grimacing, guarding
behavior irritable, Temperature 37.4 C Pulse 70
bpm respiration 18 cpm.
A:- Administered Hyoscine N-butyl bromide 20
mg Intravenously as per doctor order.
- Encourage and demonstrated deep breathing
exercise.
- Placed in Semi fowlers position with side rails up
and locked.
R: Patient reports pain was relieved. Pain scale
5/10.

FOCUS: Pain at IV site D:’’Masakit ang kinalalagyan ng swero ko’’ as

verbalized. IV site slightly swollen and with
redness noted.
A:- Checked IV site and found beginning of sign of
infiltration. Closed and removed IV aseptically,
change the whole system, reinserted the new set
aseptically into the diatal portion of basilic
vein,left arm anchored, splint applied, regulated
IVF as prescribed drops, Advised to call nurse for
any presence of pain.
R: ‘’Wala na sakit sa aking swero as verbalized by
the patient.
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ICU FDAR CHARTING SAMPLE
FOCUS: Admission D: Received patient awake and coherent with
compliant of left sided body weakness,GCS 14,
with ongoing intravenous fluid PNSS 1L x KVO
with side drip PNSS 90 CC+ 10 MG Nicardipine at
1 mg/hr.
A1:- Transferred patient to bed safely.
- kept both side rails up for safety.
- Oriented to room and hospital policies.
- attending physician informed.
- Initial Vital signs taken and recorded.
R- Well comprehended.

FOCUS: Elevated Blood Pressure D:- with blood pressure 180/90 mmHg.
A2:- Place on cool and quiet environment.
- Encourage deep breathing exercise.
- Place on moderate high back rest.
- Advise to decreased intake of salty and fatty
foods.
- Continoeus BP monitoring done
R: Blood pressure decreased 140/80 mmHG, For
FBS and lipid profile determination in AM

FOCUS: Increased blood sugar D: - Capillary Blood Glucose 180 mg/dl.

A:-Advice to decreased intake of food rich in
sugar.
- Advice to increased oral fluid intake.
- continued monitoring as order.
R: Blood sugar decreased to 120 mg/dl.
- For continuity of care.

FOCUS: Risk for aspiration D: with NGT fr 16 at left nares, intact and secured
with tape and IFC fr.12 connected to urine bag
draining well to clear yellow urine output.
A: - Place patient in moderate high back rest.
- Chest Physiotherapy done.
- Oral care done.
- Suction secretions as needed.
- Position to high back rest pre-feeding
- NGT patency checked,
- Due feedings given with aspiration precaution.
R: No incident of aspiration.

FOCUS: Risk for potential adverse reaction D: -with Hgb 75 mg/dl

(Blood Transfusion) - with Hct 0.20
- with doctors order 1u PRBC
A:- Placed patient on moderate high back rest.
- Secured consent for blood transfusion
- Informed patient regarding blood transfusion
procedure.
- Started BT with SN 123456 properly type and
cross match infusing well.
- Secured for any BT reaction
-Observed for BT reaction
R: Above BT ended, No noted blood transfusion
reaction.
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ICU FDAR CHARTING SAMPLE
FOCUS: Aspiration Precaution D: On diabetic diet with commercialized feeding
via nasogastric tube.
A:- Assessed patient condition.
- Maintain on moderate high back rest.
- Check patency and placement of nasogastric
tube by checking positive gurgling sound.
- Due feeding given as order.
- All needs attended.
- Keep monitored.
R: No aspiration noted.

FOCUS: PAIN/POST OPERATIVE PAIN D: ‘’ Masakit po ang sugat ko sa vebalized by the

patient. with pain scale 8/10, with facial grimace,
inability of moving from side to side, with cold
clammy perspiration, irritable and guarding
behavior, lack interest and avoid being disturbed.
4th day Post OP with surgical incision at Right
lower quadrant covered by dry intact dressing
and no signs of infection, Initial vital signs taken
T= 36.5 C, PR=80 bpm RR= 20 cpm BP= 120
mmHG.
A: - Establish rapport for proper coordination of
providing needed nursing care.
- Assessed level of pain as discomfort expressed
- Encourage patient to verbalize feelings about
pain.
- Place or assisted patient to be in comfortable
position
- checked doctor order
-Routine admission done
- Consent for operation secured
- Advised on NPO at midnight
- Laboratory examination facilitated such as CBC,
UA, Fecalysis and blood chemistry including
abdominal X-ray with barium enema.
- Prepared patient with surgical procedure.
- Monitor Vital signs and recorded every 2hrs
- Monitor for Flatus.
- Skin testing Cefuroxime, Metronidazole,
Parecoxib done
- Administer medication as order.
R: -Patient seen lying on bed response to pain is
tolerable and minimal at pain scale 3/10.
- Still for CBC, UA, FA, Blood Chemistry
- No Flatus noted during the shift.

FOCUS: Knowlegde deficit r/t diagnosis D: Pt states she does not understand what her
diagnosis means.
A:- Illness explained to patient according to her
level of understanding.
-Pt taught symptoms she may expect and why
she is having current symptoms.
- Treatment and procedure explained.
R: Pt verbalize better understanding of her
illness.
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ICU FDAR CHARTING SAMPLE
FOCUS: Anxiety D: Patient states ‘’ I'm a afraid of all this blood’’
A:- Emotional support provided
- Encouraged verbalization of health concern.
- Explanation given regarding treatment and
procedure.
- Family in to provide support.
R:Pt observed talking and laughing and family. Pt.
States she feels anxious.

FOCUS: Urinary Retention (Catheter Insertion) D:- Pt feels they are not emptying the bladder
despite the need to void frequently.
- Urinary output significantly declined in last 24
hrs. Last void 16 hrs ago.
A: -Palpate the bladder, distention noted and pt
unable to pass urine.
- Foley catheter inserted as order to relieved
urinary retention, 12 Fr 10 ml balloon to gravity.
R:-Patient verbalized no pain during insertion,
draining clear yellow urine, amount 1000 ml.

FOCUS: Risk for bleeding (dengue Fever) D: with latest Platelet count of 91 mg/dl.
A:- Advised to avoid dark colored foods.
- Advised to used soft bristle tooth brush.
- Encourage to increased oral fluid intake.
- IVF regulated accordingly.
- Advised to notify nurse on duty for any
untoward signs and symptoms that will
manifested.
R: No episode of bleeding noted.

FOCUS: Diagnostic Procedure D: For Chest CT scan with contrast

A: -Informed patient regarding the procedure.
-Secured consent for procedure.
- Secured latest result of serum creatinine.
- Informed radiology department regarding the
transfer.
- Transferred per wheelchair/stretcher
accompanied by NOD with orderly on duty.
R: Awaiting official results.

FOCUS: New born care D: asleep, attended by the mother, reactive and
responsive to tactile stimuli, On breastfeeding
with strict aspiration precaution, both band
check, not in distress.
D: term birth male
A: -Asessed baby condition.
- vital signs taken and recorded.
- Encourage mother to do breastfeeding with
strict aspiration precaution.
- daily cord care done.
- Kept baby well monitored.
R: - not in respiratory distress.
-New born care done
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ICU FDAR CHARTING SAMPLE
FOCUS: Immediate new born care D: Newly delivered an active babby boy NVSD in
Cephalic Presentation at 2:40 PM; vigorous cry
and active pull of extremities noted, bluish
extremities noted.
A: Thoroughly dried the babby from face to trunk
to extremities. rubbed the back gently to
stimulate cry. Removed wet and soiled linen.
Provided skin to skin contact for 90 mins. Place
identification tags on baby's legs. Covered the
head with bonnet. Clamp and cut the cord
aseptically after pulsation was no longer felt.
Initiated breastfeeding at 03:07 pm to 3;22 pm.
Brought baby’s to new born care area.
Oxytetracycline Polymyxin B sulfate applied in
both eyes, Injected Phytomenadione 0.1 ml IM at
right anterolateral aspect of the thigh. Injected
Hepatitis B 0.5 ml IM at left anterolateral aspect
of the thigh. BCG administered at the Right
deltiod. APGAR score noted. Anthropometric
measurements recorded. Vital signs taken
recorded q15 for the first hour and q30 for the
next hour and the q1hr until stable. Assisted
Pediatrician and determining Ballard score.
Monitor intake and output. For rooming in with
mother and kept thermoregulated at 36.5 to
37.5 C.
R: Baby is subjected for hearing screening and
new born screening at least 24 hrs of life has
passed, monitored for any unsualities.

FOCUS: Hyperthermia (Pedia) D:- Received patient alert, conscious, oriented to

time and place, ambulatory, unable to speak in
full sentences.
- With ongiong 1# Bottle PNSS 1L to run 40 ml/hr
infusing well at Right metacarpal vein.
- with O2 at 2 Lpm via nasal cannula.
- Audible wheezing was noted with no accessory
muscle used.
- Chest has increased in antereposterior (AP)
diameter.
- Heart sounds is regular with no murmrur.
- Vital signs were also taken on this time BP=
130/80 mmHg, PR= 103 bpm ,RR= 23 cpm
Temperature= 38 C o2 sat=97%.
A:- Rendered Tepid Sponge bath.
- Administered supplemental oxygen via nasal
cannula 3 lpm as order.
- Encourage patient to wear light clothing
- Maintained on bed rest
- Encourage to increased fluid intake to 1L per
day.
R: - ‘’lumamig na pakiramdam ko’’ as verbalized
by the patient
- Patient temperature was reduced 38.0 C to 37.1
C
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ICU FDAR CHARTING SAMPLE
FOCUS: Status Postpartum Assessment D: Into the OB ward per stretcher accompanied
( New born mother) by transport NA and Staff nurse, Fully conscious,
Cuddling her baby. With intact and patent D5LR
1L x 80ml/hr. Baby has good and fair sucking and
rooting reflex noted. Pateint complaint of vaginal
soreness and breast tenderness. Vital signs
obtained: RR= 40 cpm, HR= 80 bpm, T=36.5 C BP=
120/80 mmHg.
A: Vital signs monitoring every hour done.
Assessed for signs of bleeding.Assess the
location, consistency, height of the fundus
through palpation. Massaged the fundus gently
and placed the infant on the mothers breast to
stimulate contractions. Changed patient soiled
gown keep warm by providing enough blanket.
Provided comfort by offering a pillow to sit on for
vaginal soreness. Applied warm washcloth and
encourage breastfeeding frequently to relieved
breast tenderness. Taught relaxation technique
such as deep breathing exercise for discomfort.
Anticipated needs and attended them.
Reinforced proper breastfeeding technique.
Advice to increased fluid intake as tolerated and
diet rich with Vitamin C like orange and protein
like chicken for faster wound healing. Reiterated
front to back technique of washing the perineal
area and importance of maintaining the area
clean and dry as much as possible. Emphasized
importance of exclusive breastfeeding and
immunizations.
R: Verbalized the relief of discomfort. Able to nap
during the shift after breastfeeding the infant. No
signs of infection and hemorrhaging noted.

FOCUS: Hypotension D: Blood pressure of 90/40 mmHg and dizziness.

A: - Elevate the legs of the person by placing
pillow below the feet or if in a hospital setting
place the client in trendelenburg position.
- Provide well ventilation.
- Promote client safety.
- Promote client comfort.
R: Patient verbalized loss of dizziness, Patient BP
from 90/60 mmHg to 110/70 mmHG.

FOCUS: Nausea and Vomiting related to D: Patient states she feels nauseated, Vomited
anesthesia. 100 ml fluid at afternoon time.
A: Administered Metoclopramide (plasil) 10 mg
amp as order.
Provide relaxation technique.
R: Patient report no further nausea, no further
vomiting.
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ICU FDAR CHARTING SAMPLE
FOCUS: Ineffective airway clearance related to D: - ‘’Ubo siya ng ubo at nilulunok niya ang plema
mucous secretions, due to PCAP as nya’’ as verbalized by the patient mother.
manifested by crackles and retraction. - (+) Crackle sound, (+) Chest retraction, (+)
(Pedia) cough.
A: Establish rapport to patient and patient
relative. Assess patient condition. Monitor and
record vital signs. Assist patient to change
position every 30 min in upright position.
Encourage to increased fluid intake. Perform
chest physiotherapy after each nebulization.
Administered medication as order.
R: Patient mother able to demonstrate behavior
to improve airway as evidenced by verbalization,
‘’Kapag umuubo siya tatapikin yung likod niya
para maging maganda ang daloy ng paghinga
niya’’ as verbalized by the patient mother.

FOCUS: Elevated blood Pressure/Health teaching D: Blood Pressure 220/120 mmHG,

regarding diseased process A: Administered Nicardipine drip 10 mg in 100 ml
solution at 10 ml/hr,Increased 5 ml/hr every 15
mins.Head of bed elevated at 30 degrees angle;
Provide comfort measures and provided
opportunity for patient to rest; Health teaching
imparted to a client as to appropriate food
selection such as diet rich in fruit, vegetables, and
low fat diary foods diet. Advise patient to avoid
high saturated fat such as butter, cheese, egg and
cholesterol oil, fatty meats, egg yolks, whole
dairy products, shrimp, organ meat. Encouraged
gradual smoking cessation. Advise to adhere
medication regimen on Telmisartan 80 mg tablet
once a day to be taken at 6AM. Recommended to
exercise regularly and to eat lots of fresh fruit
and vegetables as whole grains, lean meats and
fish, and whole grains, low fat dairy products.
R: Pt BP gradually decreased to 120/80 mmHG;
verbalize understanding of the imparted health
teachings.
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FOCUS: Elevated blood Pressure D: ‘’Umiikot ang paligid ko’’ as verbalized by the
patient. Vital signs as follows BP= 160/90 mmHg
PR=88 bpm______________________________
A: Assessed Vital signs. Measured BP taken three
reading, 3 to 5 minutes a part while client is rest
then sitting, then standing for reassessment using
correct cuff size and accurate technique.
Recorded elevations in systolic and diastolic
reading. Auscultated heart tones and breath
sounds. Provided a calm, restful surroundings
minimize environmental activity and noise.
Planned activities to insert rest periods in
between activities. Provide comfort measure,
such as back and neck massage or elevation of
head. Instructed in relaxation technique, guided
imagery and distractions. Monitored response to
medication that control BP. Administered
medication as order.
R: Participated in activities that reduces BP and
cardiac workload. Improved Cardiac output as
evidenced by blood pressure of 140/90 mmHG.

FOCUS: Elevated blood pressure D: BP= 160/90 mmHG, PR= 82 bpm.

A: Monitored BP. Administered medication as per
doctors order. Provide calm and restful
surrounding. Provide comfort measure ( back and
neck massage, elevation of head). Educated
patient on stress management, deep brathing
exercise and relaxation technique. Monitored
response to medication to control blood
pressure.
R: Decreased blood pressure from 160/90 mmHG
To 120/80 mmHG.

F: Unstable blood glucose level related to lack of D: Received patient awake lying in bed with
adherence of diabetes management. ongoing IVF of PNSS 20 gtts/min infusing well at
(Hypoglycemia) the left hand. ‘’ parang sumasakit ang ulo ko’’ as
verbalized by the patient. Patient is cold clammy
with capillary refill within 2 seconds. CBG result
55 mg/dl. Urinary results reveals ketones in
urine. Fluid intake is approximately 1500 ml and
urine output of 700 ml during the 8 hour shift.
Initial vital signs BP= 100/60 mmHG, PR=88 bpm
RR=20cpm, O2sat 97%, Temp 36.7 C.
A: Assessed patient integumentary status.
Monitor vital signs and record. Monitored blood
glucose level. Monitor and record intake and
output. D50W given as order. Advice the patient
to report any signs and symptoms, encouraged to
eat 30 min after the insulin given. Reiterated the
Importance of drug compliance and healthy
eating habits. Advised patient to eat candy.
R: Blood glucose level is normal, 95 mg/dl. Not
any type of distress, skin warm to touch, not
diaphoretic.
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FOCUS: Acute Pain D: Received on bed with a chief complaint ‘’
Masakit po ang tiyan ko sir sa may bandang baba,
pati po yung pag ihi ko masakit tapos panay
panay. Pain scale 7/10 as verbalized. Restlessness
and irritable. Facial grimace and guarding
behavior noted in pain. BP= 150/90 mmHG,
RR=21 cpm.
A: Obtained baseline vital signs. Noted the level
of pain. Identified causative factor. Monitor I&O.
Assessed the abdomen and noted for rebound
and tenderness. Modified environment and
noise. Facilitated therapeutic touch and
destructing technique such as opening the
television for entertainment. Positioned and
comfort and raised side rails. Facilitated
therapeutic communication. Administered pain
reliever as order. Facilitated IVF therapy as
indicated. Encourage bed rest and avoid physical
activity. Encourage to increased oral fluid intake.
Maintain hygiene and sanitation of the penile
private part after urination.
R: was able to at lease manifest minimal comfort
and sleep. Pain scale 5/10 as verbalized by the
patient.

FOCUS: Impaired urinary Elimination (UTI) D: Received patient with a chief complaint of
‘’ Panay ang ihi ko pero konti lang lumalabas’’.
Vital sign T37.2 C BP 130/80 mmHg. Urinary
frequency and dysuria for 3 days.
A: Determined pathology of bladder dysfunction
related to medical diagnosis identified.
Determined the presences of pain nothing the
location, duration, intensity. Monitored the
patients vital signs. Monitored client usual daily
Fluid intake and note the condition of the skin,
mucous membrane and color of the urine;
Ascertained the clients previuos pattern of
elimination; Encourage fluid intake up to 1500-
2000 ml/day; Palpated the bladder every 4 hours.
Encourage to verbalize feelings of health concern
relating the condition. Emphasized not to hold
urine and assist in toileting routines. Educated to
perform hygienic practice after urination and
elimination, cleanse the gland penis and
perineum.
R: was able to increase output and verbalized
understanding of his conditions and adhered to
hygiene practice after urination.
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FOCUS: Impaired comfort D: -Pain in the abdomen.
- Increased fetal movement.
- Tense and rigid feeling of uterine contraction.
A: Established rapport. Made environmental
changes to improve the changes to improve the
patient comfort. Provide relaxation technique
that may decreased discomfort. Performed
healing touch if patient cannot any other for
stimulation, such as back rub or ROM. Used of
verbal exchange strategy along with listening and
empathy. Praised and supported the patient
whenever they are able to successfully use the
newly learned coping skills.
R: The patient was able to demonstrated and use
the coping mechanism when in distress. Showed
and verbalized improved in comfort. Patient was
able to maintain a desired level of comfort.

FOCUS: Labor Pain (Acute Pain) D: Complaints of labor pain, Patient verbalize
‘’ Para manganganak na yata ako’’. Pain scale
8/10, guarding behavior, facial grimacing.
A: Help patient to take the deep breath and
relaxation technique to release tension from the
muscle. Keep patient comfortable and safe.
Position the client into the supine lying position
to alleviate the pain. Evaluate the client
assessment of pain.
R: Client appears relaxed and resting between
contractions. Client reports pain was relieved or
controlled. Pain scale of 3/10 or bellow.

FOCUS: Labor and delivery. D: Strong regular contractions observed, profuse

perspiration noted, full cervical dilatation noted.
A: Inducted to delivery room. Mounted on the
delivery table. Positioned in lithotomy position.
Perineal preparation done. Aseptically placed
leggings and baby’s receiver on mother
abdomen, coached on how to bear down
properly.
R: With well contracted uterus and sight vaginal
bleeding and proceed with postpartum care.

FOCUS: Diarrhea related to irritable bowel D: 45 yr old patient with IVF of PNSS 1L at 4
disorder as evidence by lower abdominal pain gtts/min, 90 cc remaining. With chief complaint
and loose stools. of loose stools and lower abdominal cramping.
Latest Vital signs Temp: 37.4 C, HR: 106 bpm, RR:
16 cpm, BP: 130/80 mmHg.
A: Assessed patient general status, performed
bedside care,provided patient comfort.
Monitored and record vital signs. Monitored and
record Intake and output. Assessed pain score.
Observed and documented stool frequency,
characteristics, amount, and precipitating factors,
promoted bed rest, if indicated and provided
bedside commode. Restarted oral fluid intake
gradually. Discussed patient usual diet. Provided
opportunity to vent frustrations related to
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ICU FDAR CHARTING SAMPLE
diseased process. Administered medication as
indicated.
R: Patient was able to report reduction in
frequency of stools, returned to more normal
stool consistency, identified and avioded
contributing factors such as poor hygiene, eating
large amount of meat and fibers and drinking
poor quality water.

FOCUS: Risk for infection related to immature D: - Small for gestational age (1.2kg)
immune system (Premature Baby) - Preterm baby (30 weeks).
- Increased skin integrity.
- Elevated leukocytes.
- Depressed function of nuetrophils
- Birth asphyxia
A: Ensure multidisciplinary strict involvement in
hand hygiene and wear PPE. Use strict aseptic
technique when changing the surgical dressing or
working in IV line, tubes or drains. Change soiled
dressing promptly. Monitor for elevation of
temperature. Observed rate and characteristic of
respiration. Administer broad-spectrum antibiotic
(Ampicillin,Gentamicin) as indicated. Administer
immunization as indicated (BCG, Hepa B vaccine,
Vit K). monitor for signs of deterioration of
condition or failure to improve with therapy.
Review serial Chest X-ray. Place the patient in
protective isolation (NICU) if the patient at high
risk of infection. Monitor for laboratory studies,
CBC, WBC count fall or sudden change occur in
nuetrophils.
R: the baby was able to remain free of infection
as evidenced by:
- Normal vital signs especially temperature.
( Newborn vital signs was T: 36.8 C: PR: 122 bpm;
RR: 60cpm; BP: 60/40 mmHg).
- Absences of signs and symptoms of infection.
( Newborn don’t have signs and symptoms of
infection such as lethargy, bleeding, unstable
body temperature or heart rate, pallor, breathing
problems and low blood sugar)
- White blood cell count and differential will
almost reached the normal limits.
( WBC: 12x10^9/L; Neutrophils; 0.67 10^9/L;
Lymphocytes: 0.36 10^9/L; Eosinophils 0.06
10^9/L).
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FOCUS: Fluid volume deficit related to vomiting D: The patient verbalized ‘’I feel nauseous. I
and diarrhea. (Dehydration) already vomited thrice and I have defecated 5
times already ‘’ She also added ‘’I’m also very
thirsty and I feel like dehydrated.’’ Upon arriving
at the ER the patient defecated and vomited
once more. Her vital signs are Temp: 38.1 C; RR:
24 cpm; PR 110 bpm; BP: 90/60 mmHg. The
patient lab result revealed dark yellow urine and
high specific gravity. The patient capillary refill
last 4 seconds, hre lips were dry, has poor skin
turgor and diarrhea.
A: Started D5LR 1L to run 8 hrs. Provide patient
with water to drink as tolerated. Assessed the
color and amount of urine,skin turgor, capillary
refill and mucous membrane every hour. Monitor
and record vital signs every hour.
R: The patient verbalized ‘’I don’t feel nauseous
anymore’’. she also added ‘’I feel like I’d drink
more if it’s not just plain water. Vomitting was
stopped, temperature went down to 37.4 CC, RR
went down 19 cpm, BP went up to 110/80
mmHg, defecated once, urine output is 35 ml/hr,
urine color is yellow, has improved skin turgor,
lips were only a little dry and capillary refill time
is 3 seconds.

FOCUS: Body malaise and Right body weakness D: Received pt. Lying on bed; awake responsive &
coherent upon interaction, with IVF no.3 D5%NM
1L @ 25 gtts/min inserted at Right metacarpal
vein and with oxygen cannula @ 15L/min. Initial
Vital sign T=37.5 C; PR= 88 bpm;RR= 22 BP=
130/70 mmHg.
A: Morning care done. Diet served ate just
enough. Pt escorted to radiology unit for x-ray. X-
ray done. Patient place on bed with side rails up.
Due meds given as order. Seen and examined by
Dr. Dacudaw with orders carried out. Bedding's
are change. I&O measured. Health teachings
given to significant others such as assist pt. In
ROM as always,take medications on time as
prescribed, Always ask pt. For current date,time
and place. Turn pt. Side every hour.
R: Needs attended. Endorsed to NOD for
continuity of care.
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FOCUS: Urinary Incontinence D: -‘’ I always urge to pee but I feel embarrassed
that I can reach the toilet on time’’ as verbalized
by the patient.
-Urine Leakage
A:- Take note of duration, frequency and severity
of leakage episode and allevating and aggravating
factors.
- Place an appropriate, safe urinary receptacle
such as 3-in-1 commode.
- Advice the patient to minimize fluid
consumption two to three hours at bedtime and
to urinate right before bedtime.
- Educate patient about Kegel exercise.
- Place urinary catheter as order.
R: Patient verbalize decreased incontinence
episode.

F: Ineffective airway clearance r/treatained D: - Received patient conscious and coherent.

secretions AEB RR of 30 cpm, 90% O2 sat, Chest - Reports difficulty of clearing respiratory
X-ray results show bilateral lower lobe secretions.
pneumonia and lobar collapse of his right middle - Patient is on 2 L/min of oxygen via nasal
lobe. cannula.
- Chest X-ray revealed bilateral lobe pneumonia
and lobar collapse of his right middle lobe.
A: - Assess airway for patency.
- Auscultated lung for presences of normal or
adventitious breath sound, as in the following:
a) Decreased or absent of breath sound.
b) Whezzing.
c) Coarse crackles
- Assessed respiration's noted quality, rate,
pattern, depth, flaring of nostrils, dyspnea on
exertion, evidence of splinting, use of acessory
muscles, and position for breathing.
- Used pulse oximetry to monitor oxygen
saturation. Assess arterial blood gases (ABGs).
- Check for peak airway pressure and airway
resistances. If patient is on mechanical
ventilation.
- Coordinated with a respiratory therapist for
chest physiotherapy and nebulizer management
as indicated.
- Performed endotracheal/nasotracheal
suctioning as necessary especially if cough is
ineffective.
- Provided postural drainage, percussion and
vibration as ordered.
- Considered the need of humidifiers in home
care settings.
- Referred to the pulmonary clinical nurse
specialist, home health nurse or respiratory
therapist as indicated.
R: The patient was able to classify methods to
enhance secretions removal and was able to
maintain clear, open airways as evidence by
Normal rate and depth of respiration.
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ICU FDAR CHARTING SAMPLE
F: Difficulty of breathing D: ‘’ Nahihirapan po ako huminga as vrbalized by
the patient. Wheezing, coughing, rapid irregular
heart rate, tachypnea , latest vital sign BP:
120/80 mmHG, RR: 26 cpm, HR: 110 bpm, temp
36.7 C, Spo2 87%.
A: Assessed vital sign of the patient, Monitor
oxygen saturation, Auscultated lung fields,
positioned patient high fowlers position,
Administered oxygen therapy as ordered,
Administered medication as prescribed,
Encourage the patient to use relaxation
technique.
R: ‘’hindi na ako nahihirapan sa paghinga’’ as
verbalized by the patient. Latest RR 20 cpm,
O2sat 98%.

F: Cough D: Received awake sitting on bed with ongoing

oxygen therapy per nasal cannula at 2L/minute.
‘’ I have a cough and it’s already 2 weeks but ist
not going away’’ as verbalized by the patient.
With productive cough, thick gelatinous sputum,
dyspnea, wheezing.
A: -Auscultated lung for the presences of
adventitious breath sounds.
- Assess for cough efficacy and productivity.
- Assessed the amount, quality and color of
sputum.
- Monitor and record respiratory rate.
- Positioned the patient in semi fowlers position.
- Maintained humidified oxygen as prescribed.
- Administered medication as order.
- Encourage patient to increased fluid intake to 3
liters per day.
- Educated patient on coughing, deep breathing
and splinting techniques.
R: The patient has clear and open airways as
evidenced by normal breath sounds, normal rate
and depth of respiration's.

F: Hyperthermia D: - Patient verbalize ‘’ I have been so sick. It

must be flu.
- Temperature 38.5 C
- Flushed face, skin warm to touch.
A: - Tepid sponge bath done.
- Instructed patient to wear loose clothing.
- Instructed to let patient drink a lots of fluid.
- Provided opportunity for patient to rest.
- due med given.
- Administererd Paraceteamol 500 mg tab PRN as
order.
R: - Patient was able to rest.
- Patient temperature decreased to 37.4 C.
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ICU FDAR CHARTING SAMPLE
F: Vomiting /Risk for fluid volume deficit D: - Patient verbalize ‘’ I keep vomiting and have
not been able to keep anything down for the past
three days’’.
- Her skin is clammy and pale.
- Vomited twice within three hours.
- Report of red like blood vomitus.
A: - Provided an emesis basin within easy reach
of the patient.
- Assisted the patient in diagnostic testing
preparation.
- Maintain fluid balance in patients to prevent
risk for dehydration.
- Positioned the patient upright while eating and
for 1 to 2 hrs post meal.
- Administered anti emetics as prescribed.
- Keep room well-ventilated.
- Educated the patient to take prescribed
medication as ordered.
R: - ‘’ I feel like better now’’ as verbalized by the
patient.
- No report of vomiting after intervention.
- Patient is awake and alert when asked about his
feeling.
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F: Initial Assessment D: - Received a 69 year old female patient on left
side lying position.
- with best response of GCS 6 (E1V1M4)
27 - with anisocoric pupils, Right 2-3mm and Left 5-
ICU FDAR CHARTING SAMPLE
6mm.
- On mechanical ventilator with ET size 7.5 L21
with following set up: TV 360, PEEP 5, FiO2 50%,
BUR 20.
- with NGT F16, L65, patent and intact, inserted
on left nares.
- with dry lips mucosa and mucosa
- with OF of 1800/Kcal divided in 6 equal feeding,
and with 60 cc pre and post flushing.
- with ongoing IVF of PNSS 1L x 40cc/hr infusing
well in the right arm.
- with ongoing Nicardipine drip 10 mg in 90 cc
PNSS to run 14cc/hr infusing well, Maintain MAP
110-130, titrate by +/-2cc/hr.
- with IFC connected to urine bag, draining
adequate urine.
F: Risk for respiratory distress D: - CVA infarct LMCA with possible herniation
r/o hemorrhagic conversion, non covid, HCVD,
ARF Type 2, secondary to decreased CNS drive.
- with best response of GCS 6 (E1V1M4).
- with anisocoric pupils, Right 2-3 mmand Left 5-6
mm,sluggish.
- On mechanical ventilator with E.T size 7.5, L21
with the following set up. TV360,PEEP 5, Fio2
50%, BUR 20.
- with NGT F16, L65, patent and intact, inserted
on left nares.
- with OF of 1800/Kcal divided in 6 equal feeding,
and with 60 cc pre and post flushing.
- with ongoing IVF of PNSS 1L x 40cc/hr infusing
well in the right arm.
- with IFC connected to urine bag, draining
adequate urine.
A: - Assess patient condition
- Monitore VS and NVS hourly and recorded.
- Monitor intake and output accordingly.
- Assess level of conciousness hourly.
- Auscultated lung fields for breath sounds:
crackles and rhonchi.
- CBG monitoring Q6 done.
- Checked patency and placement of NGT prior to
feeding.
- Kept HOB elevated during and after feeding.
- watched for signs of aspiration during and after
feeding.
- Checked the patency of the IV line prior
medication administration.
- Nicardipine drip titrated accordingly.
- Na, K, BUN, Crea, Albumin done and relayed
to AP.
- Referred to Nephro service, Dr Chua
acknowledge.
- No target level of sodium as of now. Within
normal range of sodium level as per Dr. Galdo.
- turned patient side to side every 2hrs.
- Kept both side rails up for safety.
- Hooked bottle No # 2 PNSS 500 ml+ KCL 40
meqs at 50 cc/hr.
- used Glucobes as milk based for OF.
- rounds with Dr. Chua with orders maid and
carried out.
- Dr. Chua suggested to decreased 3% NaCl to
Q8H and hold furosemide, okay to carried out
order as per Dr. Galdo
- ECG done, awaiting officail results.
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