This document contains sample focus charting from a nurse's notes. It includes 3 entries with the date, focus, and progress notes in the DAR (Data, Action, Response) format. The focuses included pain, hyperthermia, and fatigue. The summaries provided nursing assessments, interventions, and the patient's response for each focus area in 3 sentences or less.
The Filipino registered nurse believes in the worth and dignity of each human being, recognizes the primary responsibility to preserve health at all cost.
The EINC initiative of the Philippine Department of Health- Non Communicable Diseases Prevention and Control-Family Health Office (DOH-NCDPC-FHO) and DOH Center for Health Promotions (NCHP), supported by the Joint Programme on Maternal and Neonatal Health (JPMNH), and being funded by AusAID, was piloted in 11 hospitals in the Philippines, and has yielded favorable results.
The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non-routine episiotomy, and active management of the third stage of labor (AMTSL).
For newborns, four core steps were recommended in a time bound sequence. A social marketing handle, “The First Embrace,” accompanied the initiative for practice change among health workers.
The Filipino registered nurse believes in the worth and dignity of each human being, recognizes the primary responsibility to preserve health at all cost.
The EINC initiative of the Philippine Department of Health- Non Communicable Diseases Prevention and Control-Family Health Office (DOH-NCDPC-FHO) and DOH Center for Health Promotions (NCHP), supported by the Joint Programme on Maternal and Neonatal Health (JPMNH), and being funded by AusAID, was piloted in 11 hospitals in the Philippines, and has yielded favorable results.
The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non-routine episiotomy, and active management of the third stage of labor (AMTSL).
For newborns, four core steps were recommended in a time bound sequence. A social marketing handle, “The First Embrace,” accompanied the initiative for practice change among health workers.
For those of you who want to get a head start on the chartsmart, these are the applicable slides. Also, Brenda has a sheet of "Descriptive Terms" that you will want for that project. She handed it out to a few people the other day who wanted to get a head start on the charting assignment.
This case was presented during an Ambulatory Care rotation at 7th Avenue Clinic with Dr. Norwood in July 2011. I was assignment was to write a detailed SOAP Note regarding the case, summarizing pertinent problems and pharmacy-related recommendations
Under the scrutiny of review, rehabilitation and nursing documentation must support skilled coverage criteria. This presentation covers skilled coverage criteria and documentation by rehabilitation professionals and nursing to support clinically appropriate levels of care.
1. Learn to define skilled coverage criteria.
2. Learn to define key elements of documentation.
3. Learn examples of rehabilitation and nursing documentation to support Medicare coverage criteria.
This student "cheat sheet" is designed to provide medical students with basic information regarding how to write a basic Subjective, Objective, Assessment & Plan (SOAP) Clinic Note. It also includes information on how to organize a presentation to an attending physician and how to write a basic prescription.
These guides are particularly designed for first and second-year medical students as an introduction to ambulatory care medicine and attempts to tie in the basic pathophysiology that is high-yield for USMLE Step 1.
Any and all feedback is very welcomed.
Newborn Care: Skills workshop Clinical notes and observationSaide OER Africa
Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents
Preoperative and postoperative Nursing care(ayoub ) for presentation Ayoub Abdul Majeed
Photo: Pre and post-operative care
During the perioperative period, specialised nursing care is needed during each phase of treatment. For nurses to give effective and competent care, they need to understand the full perioperative experience for the patient.
Perioperative refers to the three phases of surgery.
Preoperative stage
Intraoperative stage
Postoperative stage
Within these stages there are many different roles for nurses and different care needed for the patient dependent on which stage they are in.
As with any nursing care, the goal during these stages is to provide holistic and evidence-based care as well as support to the individual
Date PRE POST PRE POSTna na na na .docxedwardmarivel
Date PRE POST PRE POST
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Marked
*Notify surgeon/Reg n/a n/a n/a
n/a n/a
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n/a n/a n/a
2400 n/a n/a
2400 n/a n/a
n/a n/a
(circle) Top/Bottom/Partial denture n/a n/a n/a n/a
n/a n/a n/a n/a
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Pre-Operative Antibiotics: n/a n/a
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Bloods n/a
ECG n/a
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UR NUMBER 075486
Chelsea Bassett
Joelle Latham
Lisa Leanard
P
E
R
I-O
P
E
R
A
T
IV
E
C
H
E
C
K
L
IS
T
M
R
7
1
A
Chelsea bassett
Joelle Latham
Lisa Leonard
Signature:
Signature:
Signature:
Post- Operative check performed by:
Xray/Scans:
Patient reception check performed by:
Given and signed
Given and signed
Pre-Operative check performed by:
Medical Certificate
Follow up Appointments
Observations Checked
Discharge SummaryGraduated compression stockings insitu
(Circle) N/A / with Patient / With Doctor
VTE Prevention Anticoagulant
Investigations: FBC updated
Check/Wound/Drain tube
POST OP ONLY
Epidural Test Dose
Post Op Orders
Glasses
Hearing aids
Posthetic devices
Pacemaker insitu:
Seen by technician
Pre Op Prep: Skin Prep (Betadine)
Bariatric: (>120kg) - Notify Theatre
(obtain Hover mat prior to transfer to OT)
Cytotoxic Drugs Within 48 hours
Weight Recorded:
Anaes. Record
Fasting time: Food
Fluid(Document time)
Own teeth:
Pre-medication Ordered
Ordered
IV Therapy IV bung flushed
IV orders written
Clip
Bowel Prep
Identification Labels: Min of 20
Infectious State: Please state:
Theatre notified
History: (circle) Old New
Jewellery: (circle) Taped / Removed
Make-up/Nail Polish: Removed
Underwear: (circle) Disposable / Own
Female Sanitary Products:
NB:Please remove tampons Pad in situ
Personal items with patient:
Contact lenses
Procedure on consent form corresponds with
Theatre List
* Do not allow pt to leave holding bay
Side and site of surgery:
Not Marked
Allergies:
Wrist band
Patient Identifcation (check against
Notify surgeon/registrar Not completed
Consent form:
Admission form: Wrist band
Leg band
Patient/rep signature
Doctors signature
Comments: (e.g. Alerts, manual handling issues, Infections, Bariatric skin integ.)
PRE AND POST OPERATIVE CHECKLIST YES P NO O Not Applicable N/A
5/03/2018
DOCTOR John Smith
DATE OF BIRTH
ROBERTS
Darren
25 Happy Street
CAIRNS 4860
23/11/1968
SURNAME
FIRST NAME
ADDRESS
SIMULATED HOSPITAL
Name ROBERTS, Darren Lab ID
UR 075486 Request Date 04/03/2018
Age/Sex 50 years, Male Reported Date 05/03/2018
Test Normal Range Result
Na+ mmol/L 139
K+ mmol/L 4.5
CL- mmol/L 100
Bicarb mmol/L 25
Urea mmol/L 3.5
Creatinine mmol/L 65
Glucose mmol/L 5
Ca++ mmol/L 2.5
Mg++ mmol/L 0.78
CRP mg/L 0.2
Serum Fe µmmol/L 20
Transferrin µmmol/L 45
21- 29
3.0 - 8.0
14 - 32
40 - 260
0 - 5
Laboratory Report
2100045678
Biochemistry Results
2.25 - 2.65
.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ocular injury ppt Upendra pal optometrist upums saifai etawah
Fdar charting
1. SAMPLE DAR CHARTING
Date/Time Focus Nurse's Notes
31/5/2010 pre-operative care
F >Received asleep lying on bed with ongoing 5thIVF of PLRS iL+1 amp vit.b and vit.C x 16hoursat
150 cc level infusing well at the rightcephalic vein.
D>With intact and patent CTT at 5th left intercostalspace connected to thorabottle draining toyellowish
secretion. No signs of respiratorydistress. No compliants as of this moment.
A>Established rapport. Assessed for signs andsymptoms of respiratory
distress.Checked presence of dentures,nail polish, and jewelries.Dentures removed and handed
towatcher.Consent signed for Cholecystectomyattached to chart.Instructed on NPO.Oral
caredone. Shaving done. Skin prep done andclothing changed to O.R gown.Advised to dodeep
breathing exercises.Encouraged toverbalize feelings and concerns to upcoming procedure.
1:00 a.m >Above IVF consumed and replaced withthe 6thIVF of D5LRS 1L regulated to 28gtts/min.
R>Pt. was able to show readiness to upcomingoperation.Endorsed with an ongoing 6th IVF of D5LRS
iL x 28 gtts/min at 650 cc level andscheduled for cholecystectomy at 8 a.m
Date/Time Focus Nurse's Notes
31/5/2010 Focus:mild pain
>Received lying on bed with ongoing 1st IVF of PNSS iL+2 amps.vit B and vit.C x 16 at 360cclevel
infusing well at left metacarpal vein.
D>With O2 inhalation at 2-4 LPM via nasalcannula.Poor skin nturgor noted. "nasakit ti takebko karkaru
nu agkutikuti ak" as verbalized. Pain israted as 4/10 and is localized on the anterior chest.Characterized
as pricking pain.Facial grimaces andguarding behaviors noted when in pain.
A>Established rapport. Assessed pain level andcharacteristic.Assessed skin turgor. Cutaneous
stimulation done. Provided quiet and calm environment.Positioned to comfort.
Encouragedverbalization of feelings.
5:20pm >above IVF consumed and 2nd IVF of PNSS il x16 hours replaced.
R>Pt. verbalized that pain is reduced from 4/10to 2/10.
11:00pm >Endorsed with ongoing 2nd IVF of PNSS iLx16at 800 cc level
2. Date/Time Focus Nurse's Notes
5/31/2010Focus:elevated body >Received awake in a semi-fowler's position
7:00 am temperature with ongoing IVF of D5NSS il x8 at 950 cclevel infusing well at right cephalic vein arm.
D>with intact and patent IFC connected tourine bag draining to light yellow urine.
>"napudot ti riknak"as verbalized.With bodytemperature of 38.2oC per axilla.Withflushed face and
skin warm to touch.
A>Assessed patency of IFC.Assessed for signs of fever.TSB continuouslydone.Offered fluids
available at bedside.Removed extra clothings and blankets.Opened windows to enhance ventilation.
Emphasized importance of increasing fluidintake.Encouraged verbalization of feelingsand concerns.
2:30pm >Above IVF consumed and removed asordered.
R>Temperature lowered from 38.2oC to37oC
Focus Charting of F-DAR is intended to make the client and client concerns and strengths the
focus of care. It is a method of organizing health information in an individual’s record. Focus
Charting is a systematic approach to documentation.
Three columns are usually used in Focus Charting for documentation:
Date and Hour;
Focus and;
Progress Notes.
The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR
(third column).
Here is an example of a format of Focus Charting or F-DAR
Date/Hour Focus Progress Notes
3/7/20108:00pm Focus of care, this DataActionResponse
may be:
a nursing
diagnosis
a sign or a
3. symptom
an acute
change in
the
condition
behavior
The Data Category
The data category is like the assessment phase of the nursing process. It is in this category that
you would be writing your assessment cues like: vital signs, behaviors, and other observations
noticed from the patient. Both subjective and objective data are recorded in the data category.
The Action Category
The action category reflects the planning and implementation phase of the nursing prosess and
includes immediate and future nursing actions. It may also include any changes to the plan of
care.
The Response Category
The response category reflects the evaluation phase of the nursing process and describes the
client’s response to any nursing and medical care.
Focus Charting Samples
Listed below are sample focus charting for different problems.
Pain
The focus of this problem is pain. Notice the way the D,A,R were written.
Date/Hour Focus Progress Notes
5/20/20108:00pm 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
irritableA:>Administered
Celecoxib 200mg IV
>Encouraged deep breathing
exercises and relaxation
4. techniques
>Kept patient comfortable
and safe
R:
>Patient reports pain was
relieved
Hyperthermia
Date/Hour Focus Progress Notes
5/20/20108:00pm Hyperthermia D:>Temperature of 38.9 OC
via axilla>Skin is flushed and
warm to touchA:>Tepid
Sponge Bath (TSB)
done7:30pm>Administered
250mg IV Paracetamol as per
doctor’s order>Encouraged
adequate oral fluid intake
>Encouraged adequate rest
R:
10:00pm>Temperature
decreased from 38.9 to 37.1
O
C
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
5. 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