Fill Fdar Charting Question & Answer Guide (With Explanation)

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Structure your response with introduction, analysis, and conclusion.

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Original Question

Fill out the FDAR Charting template with the correct entries based on the specific case. You are expected to create one (1) FDAR Charting and (1) SOAPIE documentation per case scenario. CASE 01: A Patient in Pain Mr. C is a 47-year old male who is 1 day post-surgery of the abdomen (exploratory laparotomy). Upon doing your nursing rounds at 8:00 am (AM shift), you noted that Mr. C looks irritable. He seems fidgety and is restless on bed. He also grimaces from time to time especially when he tries to guard is incision site. Mr. C: “This wound right here (points at incision site) is making me uncomfortable! It does not let me sleep at night! Nurse: “I definitely understand what you are feeling right now. But I’m here to help you out. From a scale of 1 to 10, 1 being no pain, 10 with the most pain, can you rate it for me, please?” Mr. C: “It’s definitely an 8 out of 10! The pain is also sharp, like a cut of a knife.” There is a PRN order of celecoxib 200 mg IV, and as a nurse, you gave this to Mr. C to relieve his pain. Nurse: “Mr. C, I gave you a pain medication to ease the discomfort you’re feeling right now. In addition, you may want to do deep breathing exercises. That’ll ease the pain. Here, let me show you. (Nurse demonstrates deep breathing exercises.) ” Mr. C: “Alright, but as of now the pain is still there though.” Nurse: “What activities do you usually enjoy? Maybe that will help you relax and be distracted of the pain you’re feeling right now.” Mr. C: “Well, I like meditating. I also enjoy talking to my friends over the phone.” Nurse: “That’s great! You may want to do that as your relaxation techniques, that’ll help you in relieving the discomfort.” Mr. C: “Thanks for all your help.” After an hour, you went back and reassessed Mr. C if he still feels any pain. Mr. C responded that the pain is now more tolerable and is rated at 3 out of 10. CASE 02: A Patient with Fever Ms. J is a 23 year old female client admitted for a suspect urinary tract infection. Upon your rounds at the ward at 7:00 PM (PM Shift), you see Ms. J with flushed skin. You immediately went to her and tried to touch her neck. She is warm to touch. You got her temperature with a reading of 38.9 C via axilla. Ms. J: “I don’t really feel well at all.” Nurse: “Don’t worry Ms. J, I am here to assist you in alleviating your discomfort. I’ll just get some water your you to use in your tepid sponge bath. You may want to have somebody to assist you or I can do it myself, if that’s okay with you?” Ms. J: “That’s fine, I can do it by myself.” (Ms. J started doing tepid sponge bath.) 30 minutes after her bath, you rechecked her temperature with a reading of 38.7 C via axilla. She has a PRN order of Paracetamol 300 mg IV for fever more that 38.0 C. You administered this medication to her. Nurse: “Ms. J, since your temperature did not subside after the sponge bath, I gave you a medication called paracetamol IV that’ll help lower down your temperature.” Ms. J: “Thanks a lot! What can I do to hasten the lowering down of my body heat?” Nurse: “Well, you might want to increase your oral fluid intake to regulate body heat. You also need a lot of rest to ensure recovery.” After 30 minutes, you went back and reassessed Ms. J. Her temperature is now 37.1 and is on bed, at rest. Criteria Grading Scale 1. FOCUS 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 2. DATA 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 3. ACTION 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 4. RESPONSE 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 5. Subjective Data 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 6. Objective Data 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 7. Assessment 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 8. Plan 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 9. Intervention 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement 10. Evaluation 5 Excellent 3 Good 2 Satisfactory 1 Needs Improvement

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