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    Charting

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    Kristine Olitin
    The patient presented with a fever of 39 degrees Celsius and complained of nose bleeding, nausea, headaches, and abdominal cramping. Over the course of two days, the patient was treated for hyperthermia, pain, nausea, and nose bleeding with medications, sponge baths, and other interventions. The treatments relieved the patient's symptoms and their condition improved.

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    Charting

    Uploaded by

    Kristine Olitin
    91 views2 pages
    The patient presented with a fever of 39 degrees Celsius and complained of nose bleeding, nausea, headaches, and abdominal cramping. Over the course of two days, the patient was treated for hyperthermia, pain, nausea, and nose bleeding with medications, sponge baths, and other interventions. The treatments relieved the patient's symptoms and their condition improved.

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    The patient presented with a fever of 39 degrees Celsius and complained of nose bleeding, nausea, headaches, and abdominal cramping. Over the course of two days, the patient was treated for hyperthermia, pain, nausea, and nose bleeding with medications, sponge baths, and other interventions. The treatments relieved the patient's symptoms and their condition improved.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    91 views2 pages

    Charting

    Uploaded by

    Kristine Olitin
    The patient presented with a fever of 39 degrees Celsius and complained of nose bleeding, nausea, headaches, and abdominal cramping. Over the course of two days, the patient was treated for hyperthermia, pain, nausea, and nose bleeding with medications, sponge baths, and other interventions. The treatments relieved the patient's symptoms and their condition improved.

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    © All Rights Reserved
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    FDAR Charting

    A patient has a fever of 39 degrees Celsius and complained of nose bleeding, nausea, a 7/10 throbbing headache that was eased by painkillers,
    and an 8/10 cramping stomachache. The patient also stated that she had been irritable for the past two days.

    Date and Time Focus Data, Action, & Response


    D: Temperature of 39oC via axilla, skin is flushed
    and warm to touch
    4/25/22 Hyperthermia A: - Tepid sponge bath (tsb) done
    8:00 pm - 7:30 pm> administered 250mg IV paracetamol
    as per doctor’s order
    - encouraged adequate oral fluid intake
    - encourage adequate rest
    R: 10:00pm> temperature decreased from 39 to
    37.1oC
    D: - Reports of sharp pain on the abdominal area
    with a pain scale of 8 out of 10
    4/25/22 - restless and irritable
    6:25 am Pain - Facial grimacing
    A: - administered celecoxib 200mg IV
    - keep patient comfortable and safe
    - encouraged deep breathing exercises and
    relaxation techniques
    R: patient reports pain was relieved
    D: unable to keep anything down for 24 hours
    and is just throwing up “yellow stuff”. Color pale,
    4/26/22 Nausea skin is warm and dry,
    12:45 pm A: administered antiemetic
    metoclopramide 10mg
    R: patient states feels less nauseated, no
    vomiting
    D: suffering from nose bleeding
    A: - Applied gentle suction to the nasal cavity to
    remove excess blood & clots that block the
    4/26/22 airway
    6pm Nose bleeding - administered topical vasoconstrictive agents
    - instructed the patient to use nasal saline spray
    and antibiotic ointment and avoid strenuous
    activities
    R: pain was relieved and maintained a clear
    airway as evidenced by arrest in nasal bleeding
    Name: Kristine N. Olitin
    Year & Block: 1-B

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