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FDAR Charting for Patient Discharge

The patient was experiencing sharp abdominal pain rated 8/10 with facial grimacing and guarding behavior. Celecoxib 200mg was administered intravenously, and deep breathing exercises and relaxation techniques were encouraged to keep the patient comfortable. The patient then reported that the pain was relieved. A separate patient was experiencing increased respiratory rate, use of accessory muscles to breathe, and nonproductive cough, indicating an ineffective breathing pattern. Oxygen was administered, suction was performed if needed, cough suppressant drugs were given, and relaxation breathing exercises were encouraged. The patient's breathing then continued normally. Another patient felt they were not emptying their bladder despite frequent urges to void, and urinary output had declined over 24 hours with the last void

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Charlayne Anne
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22K views2 pages

FDAR Charting for Patient Discharge

The patient was experiencing sharp abdominal pain rated 8/10 with facial grimacing and guarding behavior. Celecoxib 200mg was administered intravenously, and deep breathing exercises and relaxation techniques were encouraged to keep the patient comfortable. The patient then reported that the pain was relieved. A separate patient was experiencing increased respiratory rate, use of accessory muscles to breathe, and nonproductive cough, indicating an ineffective breathing pattern. Oxygen was administered, suction was performed if needed, cough suppressant drugs were given, and relaxation breathing exercises were encouraged. The patient's breathing then continued normally. Another patient felt they were not emptying their bladder despite frequent urges to void, and urinary output had declined over 24 hours with the last void

Uploaded by

Charlayne Anne
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Patient Care Report
  • Continued Patient Care Notes

Focus Pain

Data Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10 Facial grimacing Guarding behaviour Restless and irritable

Action Administered Celecoxib 200mg IV Encouraged deep breathing exercises and relaxation techniques Kept patient comfortable and safe

Response Patient reports pain was relieved

Focus Ineffective Breathing Pattern

Data Increase respiratory rate of 24 cpm use of accessory muscle to breath presence of nonproductive cough

Action Administer O2 Perform suction if there is a secretions Give cough suppressant drugs Encourage the patient to perform a relax breathing exercises

Response Patient shows a continues breathing and the respiratory rate normalize

Focus Urinary retention

Data Pt feels they are not emptying bladder despite the need to void more frequently. Urinary output significantly declined in last 24 hrs. Last void 16 hrs ago.

Action Palpated bladder, distension noted and pt unable to pass urine. Foley inserted as ordered to relieve urinary retention. 12Fr 10 mL balloon to gravity.

Response Pt indicated no pain during insertion. Draining clear yellow urine. 1000 mL out

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