F-DAR for Pain

The focus of this problem is pain. Notice the way how the D, A, and R are
written.
Date/Hour

Focus

Progress Notes

5/20/201
08:00pm

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 irritable

Administered Celecoxib 200mg

IV
Encouraged deep breathing

exercises and relaxation

techniques
Kept patient comfortable and

A:

safe
R:

Patient reports pain was

relieved

F-DAR for Hyperthermia

Date/Hour

Focus

Progress Notes

5/20/2010

Hyperthermia

D:

Temperature of 38.9 OC via

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

Alert and oriented to person, place and time. Skin pink, warm and dry.
Repirations regular and unlabored. (Or, crackles auscultated in RLL with
deep breath--productive coughing of green colored sputum upon deep
inspiration) No cough noted. Continuous O2 at 2L/min by nasal cannula.
Abdomen rounded and soft with active bowel sounds auscultated in all four
abdominal quadrants. No pain to mild palpation of abdomen. (Or, no bowel
sounds auscultated in any quadrant of abdomen after one full minute of
listening at each quadrant.) Foley catheter patent with clear yellow urine
draining. IV intact and patent in anterior aspect of left lower forearm with
1000cc D5W infusing at 100cc/hr by gravity drip (we didn't use pumps in
those days, but if we did I always mentioned that a pump was in use). No
pain, redness, or swelling at or above IV site. No calf tenderness. No pedal
edema. Knee high TED hose in place bilaterally. Side rails up. Call light in
reach

- In from Emergency Room via stretcher, unconscious and incoherent accompanied by

relative.
- Placed on bed on moderate high bed rest position.
- Admitted a 67 y/o male, married, with the chief complaint of
loss of consciousness> prior to admission.
- with ongoing
IVF's of the ff:
- Main Line: Plain NSS 1L @ 900cc level regulated @ 25gtts/min
- Side Drip 1 : D5W 250cc + 1 ampule Dopamine @ 200cc level
- Side Drip 2 : D5W 250cc + 1 ampule Dobutamine @ 200 cc level regulated
@
40gtts/min
- consent for admission signed by the relatives
- still with:
- endotracheal tube connected to ambu-bag to oxygen tanks @ 10LPM
- nasogastric tube closed and intact for feeding purpose
- foley catheter connected to urine bag draining into yellowish output potent
and
intact
- still for the following labs:
- FBS, lipid profile, SGOPT, SGPT
- cranial CT scan once with funds, relative informed
- urinalysis
- manual ambubagging continuously done by the watcher
- suctioning done
- advised watcher to secure oral and IV meds
- closely watched and attended.
F -vomiting
D -patient states is unable to keep anything down for 24 hours and is just
throwing up "yellow stuff".Color...pale,skin warm and dry, mucous
membranes dry, tugor fair HR120, B/P 104/56, RR 22
A -IV started 0.9NS #20angio LAC bolus given of 500 cc's Compazine 10mg
IV slowly.
1300
R - patient states feels less nauseated, no vomiting. HR 84, B/P 110/56,
RR18 urine obtained.

AbdominalPain
D
-Patient verbalized

sakit gyod akong tiyan

,
painscale 8 out of 10, facial grimacing, guarding behavior,irritable, Temperature 37.4
0
C, pulse 70 beats perminute, respiration 18 breaths per minute
A
-Administered Hyoscine N-butyl bromide 20 mgIntravenously as per
doctors
order, encouraged anddemonstrated deep breathing exercises, placed insemi
Fowlers position with side rails up and locked.
R
-Patient reports pain was relieved. Pain scale 5/10.
Elevated
BodyTemperature
D
Init akong lawas

as verbalized. With flushed skin

and warm to touch, Temperature 38. 9
0
C via axilla,pulse 80 beats per minute, respiration 24 breathsper minute,
blood pressure 120/80.-----------------

A
-Performed tepid sponge bath, applied ice cap onforehead, administered
Paracetamol 250mgintravenously as per
doctors
order. Encouragedadequate oral fluids intake, provided calmenvironment
to keep patient comfortable.
R
Gipaningot na ko
,
as verbalized, temperature
decreased to 37.