Date/Hour 5/20/2010 8:00pm

Focus Pain D:

Progress Notes

>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 >Kept patient comfortable and safe R: >Patient reports pain was relieved

Hyperthermia
Date/Hour 5/20/2010 Focus Hyperthermia D: >Temperature of 38.9 OC via Progress Notes

8:00pm

axilla >Skin is flushed and warm to touch A: >Tepid Sponge Bath (TSB) done 7:30pm>Administered 250mg IV Paracetamol as per doctors order >Encouraged adequate oral fluid intake >Encouraged adequate rest R: 10:00pm>Temperature decreased from 38.9 to 37.1 OC

Another Variation
This is DAR made by Jay-D Man of Slideshare.net. with some modifications made. This is a very good variation. 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 conditio

D: Pt. states she's nauseated. Vomited 100ml clear fluid at 2255 A: Given Compazine 1mg IV at 2300. R: Pt. reports no further nausea at 2335. No further vomiting. Focus: Risk for infection related to incision sites D: Incision site in front of left ear extending down and around the ear and into neck--approximately 6 inches in length--without dressing. Jackson-Pratt drain in left neck below ear secured in place with suture. A: Assess site and emptied drain. Taught patient S&S of infection. R: No swelling or bleeding; bluish discoloration below left ear noted. JP drained 20mL bloody drainage. Patient states understanding of teaching. Focus: Delayed surgical recovery D: Patient reported dizziness after trying to get OOB to use the bathroom. A: Assisted patient back in bed and with use of bedpan. Taught patient how to dangle legs and get OOB slowly. Also taught coughing and deep breathing exercises, turning in bed, and use of entiembolism stockings. R: Patient voided 200mL in bedpan. Did cough and deep breathing appropriately. Lungs clear bilaterally. Using antiembolism stockings. Focus: Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale. A: Given morphine 1mg IV at 2335. R: Patient reports pain as 1/10 at 2355.

5/22 0730--Alteration in comfort; burning on urination. D: Pt. reports passing urine frequently and in small amounts, c urgency and burning sensation during urination. Urine is cloudy and dark amber. A: Notified Dr. Roberts. UA and culture specimens collected, antibiotic therapy initiated. Instructed Pt. to increase fluid intake c water and cranbery juice. 1530 R: Pt. reports experiencing moderate relief from urgency and burning. I&O increased to 480 ml. Lungs clear. S. Jobs, RN__________
1. DEFINITIONS:
o

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.

o o

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

o o

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

o o

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

2. COMPONENTS OF A FOCUS NOTE:

o

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.

3.
o o

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.---N. Nurse

4. General Survey
o o o o o

Appearance of the patient, condition- when seeing the patient Any IVF or Medications attaches to the arms of the patient Current Vital Signs of the Patient Eg. Approached sitting on bed, awake, responsive, coherent with ease in respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @ 66 ugtts/min infusing well at the Right arm, with the following V/S: BP= 110/70 mmHG, PR= 100 bpm, RR= 26 cpm, T= 36.8 degree Celsius/axilla.

o o

Followed by F-DAR After writing the F-DAR , at the end of the shift write again your general observation/survey of the patient condition

5.
o o o o o o o o

F: Hyperthermia D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla > flushed skin and warm to touched A: 9:00am > Tepid sponge bath done > instructed SO to let patient wear loose clothing > instructed SO to provide blanket to patient when shiver > instructed SO to let patient drink lots of fluid

o o o o o o

> instructed SO to include in his diet foods rich in Vitamin C such as oranges > provided opportunity for patient to rest > due meds given R: 1:00pm > patient was able to rest > patient temperature decrease to T= 37.8 degree Celsius/axilla

6.
o o o o o o o o o o o o o o o o

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= 37.7 degree celsius/axilla F3: Fatigue D1: less movement noted with the verbalization of kapoy man ako lawas, kulangan ko ug katulog 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

7.
o

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

o o o o o o o o o o o o o o o

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

8.
o o o o o o o o

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

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