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Fdar Charting - Wadingan

A 65-year-old woman was admitted to the hospital with elevated blood pressure and symptoms of nausea, vomiting, cold clammy skin, shortness of breath, headache, and neck pain. She has a family history of hypertension, asthma, and cardiac problems, and two years prior had undergone gallstone surgery. The nurse monitored her vital signs, performed deep breathing exercises, and provided health education, and her vital signs stabilized.

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Skai Jeon
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2K views1 page

Fdar Charting - Wadingan

A 65-year-old woman was admitted to the hospital with elevated blood pressure and symptoms of nausea, vomiting, cold clammy skin, shortness of breath, headache, and neck pain. She has a family history of hypertension, asthma, and cardiac problems, and two years prior had undergone gallstone surgery. The nurse monitored her vital signs, performed deep breathing exercises, and provided health education, and her vital signs stabilized.

Uploaded by

Skai Jeon
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
  • Medical Documentation: Documents the medical case of a 65-year-old patient, detailing her symptoms, background, and the outlined healthcare response plan.

WADINGAN, Shiekey B.

14 March 2020
Funda-RLE (NAE)

Scene: A mother 65 y/o Fedeline Dan was admitted in the hospital due to elevated blood pressure.
She is manifesting nausea and vomiting, cold clammy skin, shortness of breath, headache and nape
pain. She lives on Gibraltar, Baguio City. Family history diseases are hypertension, asthma and
cardiac problems. Two years ago, she was admitted at the same hospital and undergone operation
due to gall stone.

Documentation

PATIENT’S PROFILE:
Name: Fedeline Dan
Age: 65 years old.
Sex: Female
Address: Gibraltar, Baguio City
Other data:
Subjective data: nausea, shortness of breath, headache and nape pain; family history
diseases: hypertension, asthma and cardiac problems
Objective data: nausea and cold clammy skin. Patient also undergone gall stone
operation two years ago.

FDAR CHARTING
DATE/TIME FOCUS DATA, ACTION AND RESPONSE
DATA:
 She is manifesting nausea and vomiting, cold
clammy skin, shortness of breath, headache
and nape pain.
 Family history diseases includes hypertension,
*not Elevated blood asthma and cardiac problems
indicated/given pressure  Undergone gall stone operation (2 years ago)
*
ACTION:
 Performed deep breathing to the patient at a
semi-fowler’s position.
 Monitored vital signs
 Offered health education and promotion

RESPONSE
 Vital signs are stable (body temperature, pulse
rate, respiration rate, and blood pressure).

WADINGAN, Shiekey B. 14 March 2020 Funda-RLE (NAE) Scene: A mother 65 y/o Fedeline Dan was admitted in the hospital due to el

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