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    FDAR

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    ViolBernados
    The patient presented with sharp abdominal pain rated 8/10 following surgery. Celecoxib and relaxation techniques provided pain relief. Later, the patient experienced hyperthermia with a temperature of 38.9°C. Paracetamol and sponge baths decreased the temperature to 37.1°C by 10pm. Discharge instructions focused on medication administration, cleanliness, follow-up appointments, breathing exercises, nutrition, and spirituality.

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    FDAR

    Uploaded by

    ViolBernados
    15K views4 pages
    The patient presented with sharp abdominal pain rated 8/10 following surgery. Celecoxib and relaxation techniques provided pain relief. Later, the patient experienced hyperthermia with a temperature of 38.9°C. Paracetamol and sponge baths decreased the temperature to 37.1°C by 10pm. Discharge instructions focused on medication administration, cleanliness, follow-up appointments, breathing exercises, nutrition, and spirituality.

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    The patient presented with sharp abdominal pain rated 8/10 following surgery. Celecoxib and relaxation techniques provided pain relief. Later, the patient experienced hyperthermia with a temperature of 38.9°C. Paracetamol and sponge baths decreased the temperature to 37.1°C by 10pm. Discharge instructions focused on medication administration, cleanliness, follow-up appointments, breathing exercises, nutrition, and spirituality.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    15K views4 pages

    FDAR

    Uploaded by

    ViolBernados
    The patient presented with sharp abdominal pain rated 8/10 following surgery. Celecoxib and relaxation techniques provided pain relief. Later, the patient experienced hyperthermia with a temperature of 38.9°C. Paracetamol and sponge baths decreased the temperature to 37.1°C by 10pm. Discharge instructions focused on medication administration, cleanliness, follow-up appointments, breathing exercises, nutrition, and spirituality.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The key takeaways from the document are proper pain management, monitoring of vital signs, providing comfort measures to the patient, and discharge planning.

    On page 1, the patient reported sharp abdominal pain rated 8/10 on the pain scale, had a fever of 38.9°C, and had an increased respiratory rate of 24 breaths per minute with the use of accessory muscles.

    On page 2, nursing interventions done for the patient included a tepid sponge bath to reduce fever, encouraging adequate fluid intake and rest, providing a loose blanket and comfortable positioning in bed.

    Pain

    D:

    Reports of sharp pain on the abdominal


    incision area with a pain scale of 8 out of 10

    Facial grimacing

    Guarding behavior

    Restless and irritable

    A:

    Administered Celecoxib 200mg IV

    Encouraged deep breathing exercises and


    relaxation techniques

    5/20/20108:00pm

    Hyperthermia

    Kept patient comfortable and safe

    R:

    Patient reports pain was relieved

    D:

    Temperature of 38.9 OC via axilla

    Skin is flushed and warm to touch

    A:

    Tepid Sponge Bath (TSB) done7:30pm

    Administered 250mg IV Paracetamol as per


    doctors order

    Encouraged adequate oral fluid intake

    Encouraged adequate rest

    instructed SO to let patient wear loose


    clothing

    > instructed SO to provide blanket to


    patient when shiver

    > instructed SO to include in his diet


    foods rich in Vitamin C such as oranges R:

    10:00pm>Temperature decreased from 38.9 to


    O

    37.1 C

    F1: Ineffective Breathing Pattern


    D1: increase respiratory rate of 24 cpm
    D2: use of accessory muscle to breath
    D3: presence of nonproductive cough

    F2: Hyperthermia
    D1: skin warm and flush to touched
    D2: increased body temperature of T= 38.9 degree celsius/axilla
    F3: Fatigue
    D1: less movement noted
    A: 9:00am

    monitored v/s and charted

    regulated IVF and charted

    morning care done

    assessed patient needs and performed handwashing before handling the patient

    advised SO to always stay on patient bedside

    promote proper ventilation and a therapeutic environment

    elevated the head of the bed (moderate high back rest)

    provided comfort measures and provide opportunity for patient to rest

    due meds given

    9:30am

    tepid sponge bath done

    instructed SO to provide blanket and let patient wear loose clothing

    F4: Discharge Plan (12:00nn)


    D1: discharged order given by Dr.Name/Time

    M advised SO to give the ff. meds at the right time, dose, frequency and route

    E encouraged to maintain cleanliness of the house and surroundings

    T advised to go to follow-up consultations on the prescribed date

    H encouraged to do chest tapping to facilitate mobilization of secretion

    O observed for signs of super infections such as fever, black fury tongue and foul
    odor discharges

    D encouraged to eat fresh vegetables and fish

    S advised to continue praying to God and hear mass on Sunday

    2:00pm out of the room per wheelchair with improved condition

    Discharge plan for patient who undergo Surgery


    H Health Teachings
    A Anticipatory Guidance
    S Spirituality
    M Medications
    I Incision in Care

    N Nutrition
    E - Environment
    DEFINITIONS:

    Focus Charting - is a method for organizing health information in the individual's record. It is a
    systematic approach to documentation, using nursing terminology to describe individual's health status
    and nursing action.

    Focus a key word or diagnostic category from a nursing diagnosis or collaborative problem on the
    plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit
    a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital
    admission
    a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan,
    i.e. fever, constipation, hypertension, incontinence, lethargy
    an acute change in an individual's condition, i.e. respiratory distress, seizure, fever, discomfort a
    significant event in an individual's care, i.e. begin treatment regimen (oxygen), change in diet,
    catheterization
    a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self
    medication teaching plan, transition COMPONENTS OF A FOCUS NOTE:

    Data: Subjective and/or objective information supporting the stated focus or describing observations
    at the time of significant events.

    Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures
    initiated.

    Response: Description of individual's response to medical and/or nursing care. Statement that
    the Action Plan of Care outcomes have been attained or are progressing toward attainment.

    Example: Need: Comfort (or, Relief of pain)


    D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for
    pain now!" States pain is 9 on a scale of 10.
    A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to
    abdomen to help splint wound.
    R - Patient stated pain was "much better" 30 minutes later and rated it 3 on a scale of 10.

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