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3/7/20108:00pm
DataActionResponse
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 techniques >Kept patient comfortable and safe R:
Hyperthermia
Date/Hour Focus Progress Notes 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 doctors order>Encouraged adequate oral fluid intake >Encouraged adequate rest R: 10:00pm>Temperature decreased from 38.9 to 37.1 OC 5/20/20108:00pm Hyperthermia
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 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
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