F-Dar, Focus Charting

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.---N. Nurse General Survey • 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.  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 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 > 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 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  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

F-Dar, Focus Charting

by Jay-D Man on Aug 06, 2009

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F-Dar, Focus Charting — Document Transcript

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