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Charting

The patient presented with a fever of 39 degrees Celsius and complained of nose bleeding, nausea, headaches, and abdominal cramping. Over the course of two days, the patient was treated for hyperthermia, pain, nausea, and nose bleeding with medications, sponge baths, and other interventions. The treatments relieved the patient's symptoms and their condition improved.

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Kristine Olitin
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202 views

Charting

The patient presented with a fever of 39 degrees Celsius and complained of nose bleeding, nausea, headaches, and abdominal cramping. Over the course of two days, the patient was treated for hyperthermia, pain, nausea, and nose bleeding with medications, sponge baths, and other interventions. The treatments relieved the patient's symptoms and their condition improved.

Uploaded by

Kristine Olitin
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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FDAR Charting

A patient has a fever of 39 degrees Celsius and complained of nose bleeding, nausea, a 7/10 throbbing headache that was eased by painkillers,
and an 8/10 cramping stomachache. The patient also stated that she had been irritable for the past two days.

Date and Time Focus Data, Action, & Response


D: Temperature of 39oC via axilla, skin is flushed
and warm to touch
4/25/22 Hyperthermia A: - Tepid sponge bath (tsb) done
8:00 pm - 7:30 pm> administered 250mg IV paracetamol
as per doctor’s order
- encouraged adequate oral fluid intake
- encourage adequate rest
R: 10:00pm> temperature decreased from 39 to
37.1oC
D: - Reports of sharp pain on the abdominal area
with a pain scale of 8 out of 10
4/25/22 - restless and irritable
6:25 am Pain - Facial grimacing
A: - administered celecoxib 200mg IV
- keep patient comfortable and safe
- encouraged deep breathing exercises and
relaxation techniques
R: patient reports pain was relieved
D: unable to keep anything down for 24 hours
and is just throwing up “yellow stuff”. Color pale,
4/26/22 Nausea skin is warm and dry,
12:45 pm A: administered antiemetic
metoclopramide 10mg
R: patient states feels less nauseated, no
vomiting
D: suffering from nose bleeding
A: - Applied gentle suction to the nasal cavity to
remove excess blood & clots that block the
4/26/22 airway
6pm Nose bleeding - administered topical vasoconstrictive agents
- instructed the patient to use nasal saline spray
and antibiotic ointment and avoid strenuous
activities
R: pain was relieved and maintained a clear
airway as evidenced by arrest in nasal bleeding
Name: Kristine N. Olitin
Year & Block: 1-B

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