Sample Fdar

Date and time

Focus

20 Jan,2014 3:00Pm

3:30pm

Elevated Body Temperature

3:35pm

4:00pm 5:40pm 5:45pm

5:55pm

11:00pm

Impaired Skin integrity

Nurses note/ DAR Received patient on bed awake, weak, responsive with an IVF of D5lrx8h @ 200cc fluid level infusing via right metacar pal vein, with gunshot wound on left forearm supported by posterior mold cast and covered with elastic bandage.----------------------------------jf D.”Parang giniginaw man ako” as verbalized, patient covers sel f with blanket,Body temp of 37.7°c, skin warm to t ouch.----------jf A. Explained the need to do tepid sponge bath; provided tepid sponge bath advised wife to continue; Checked any ordered antipyretic medications and time last given; Encouraged to-----increase oral fluid intake---------------------------------------------------jf intake---------------------------------------------------jf -Rechecked body temperature with result o f 37.0°c-----------------jf pinkish D-with gunshot wound on left forearm; noted few pinkish discharges on wound dressing.----------------------------------------dressing.----------------------------------------- jf A. Assessed for moderate to severe wound pain, assessed for numbness on left digits; noted doctors order to do wound dressing BID; explained to patient the importance of wound dressing-----------------------------------------------------------------------jf -Provided wound dressing aseptically; Demonstrated proper hand hygiene and explained its importance; Advised not to touch or scratch the wound; wound; Advised to do range of motion exercises on left digits; Encouraged to include vitamin C and protein rich foods on meals. Provided teaching about the importance of ongoing antibiotics treatment compliance; Elevated side rails for safety---jf R- body temperature of 37.1°c, wound dressing intact, no other complaints noted, seen asleep with side rails up-------------------jf ( Signature)