Scribd
Upload
7K views4 pages

Fdar 2

The patient was admitted with activity intolerance related to immobility from a leg injury. The nurse assisted the patient with gradual changes in position, passive range of motion exercises, and monitoring the incision site. Later, the patient showed impaired skin integrity with edema and an incision on the right thigh. The nurse assessed for infection signs, changed dressings, and taught self-care. Finally, the patient displayed altered comfort so the nurse provided comfort measures, exercises, assisted with care, and administered pain medication, resulting in increased comfort.

Uploaded by

Raidis Pangilinan
Copyright
© © All Rights Reserved
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
7K views4 pages

Fdar 2

The patient was admitted with activity intolerance related to immobility from a leg injury. The nurse assisted the patient with gradual changes in position, passive range of motion exercises, and monitoring the incision site. Later, the patient showed impaired skin integrity with edema and an incision on the right thigh. The nurse assessed for infection signs, changed dressings, and taught self-care. Finally, the patient displayed altered comfort so the nurse provided comfort measures, exercises, assisted with care, and administered pain medication, resulting in increased comfort.

Uploaded by

Raidis Pangilinan
Copyright
© © All Rights Reserved
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
  • Nursing Management: February 2, 2018
  • Nursing Management: February 8, 2018
  • Nursing Management: February 9, 2018

2.

NURSING MANAGEMENT (Actual FDAR)

February 2, 2018: Friday

F = Activity Intolerance related to immobility

D = Received patient on bed, lying on a supine position, awake, oriented to


time, place and person. Skin was warm to touch, pallor, weakness, with
dressing dry and intact covered with immobilizer on right thigh.

 Facial grimaces
 Inability to relax
 Irritability
 Prolonged immobility
 Needs support in moving
 Cannot be able to fully extend her right leg because pain will be
present
 With initial vital signs of the following: T=36.8°C, PR=64bpm,
RR=20bpm and BP=130/80mmHg

A=

 Assisted client in gradual changes in position.

 Assesed the physical activity level and mobility of the patient.

 Have the patient perform the activity more slowly, in a longer time with
more rest or pauses, or with assistance if necessary.

 Assisted with activities if needed.

 Encouraged client in doing Passive Range of Motion.

 Instructed patient to plan activities for times when they have the most
energy.

 Advised patient to monitor incision for pus and other signs and

symptoms.

 Advised patient to keep immobilizer to provide pressure on incision


site.
 Provides adequate rest and comfort measures.

R = The patient participated willingly on desired and necessary activities such


as PROM.
February 8, 2018: Thursday

F = Impaired Skin Integrity

D = Received patient on bed, lying on a supine position, awake, oriented to


time, place and person. Skin was warm to touch, CRT< 3seconds, weakness
with dressing dry and intact covered with immobilizer on right thigh.

 Facial grimaces
 Inability to relax
 Irritability
 Immobility
 Edema
 Disruption of the skin surfaces
 Incision site on right thigh with dressing dry and intact covered with
immobilizer.
 With initial vital signs of the following: T=36.6°C, PR=84bpm,
RR=19bpm and BP=140/100mmHg

A=

 Assessed skin for dryness.


 Assessed client for signs of infection like fever.
 Assessed Capillary Refill Test.
 Inspected incision every shift (REEDA).
 Advised patient to avoid having wounds d/t poor wound healing d/t
Diabetes by following a healthful balance diet and having regular
physical activity.
 Teached patient and SO self care hygienic practices.
 Teached patient on passive range of motion exercises.
 Administered antibiotics as prescribed
 Encouraged client to increase oral fluid intake.
 Changed and cleaned wound dressing.

R = The patient displayed timely wound healing and there were no signs of
infection.
February 9, 2018: Friday

F = Altered Comfort

D = Received patient on bed, lying on a supine position, awake, oriented to


time, place and person. Skin was warm to touch, CRT< 3seconds, weakness
with dressing dry and intact covered with immobilizer on right thigh.

 Facial grimaces
 Inability to relax
 Irritability
 Lethargic
 Confused
 With initial vital signs of the following: T=36 ° C, PR=80bpm,
RR=22bpm and BP=120/80mmHg

A=

 Provided comfort measures.


 Encouraged adequate rest periods.
 Emphasized proper hygiene.
 Encouraged client in doing Passive Range of Motion exercises.
 Encouraged Deep Breathing and Coughing exercise.
 Assisted in changing dressing.
 Assisted in self care activities.
 Maintained calm and quiet environment.
 Encouraged in early ambulation.
 Administered prescribed pain medication..

R = The patient verbalized an increased sense of comfort and understanding


of the treatment and other regimen measures.

You might also like