1.
FOCUS D - DATA A- ACTION R- RESPONSE
FEVER Temp – 38, skin warm to touch, flushed skin,
dry lips, irritable
Continuous TSB, increase fluid intake, expose skin, avoid
warm binding clothes and blanket, antipyretic medication as
ordered, comfort measures, cold compress applied to
forehead
Afebrile, temp – 37.5
Infiltration Swollen IV site, not flowing, cold to touch,
tenderness, pain at the site
Observed for signs of infiltration or phlebitis; Informed
nurse about patient’s status; Explained procedure to
patient/watcher. Assisted in removing IV device aseptically;
secured necessary materials. Assisted in reinsertion of IV
device aseptically. Placed patient in comfortable position.
Monitored for unusualities.
Seen patient comfortable; IV site free from
infiltration/infection and infusing well at ___.
Ineffective breathing pattern
Airway clearance altered
Risk for infection
Anxiety
Intubated, increase RR, cyanosis, nasal
flaring, retractions, restlessness,
apprehensions, wheezing, crackles,
productive cough, poor oral intake
Oxygen therapy, check placement and patency of ET,
suction secretions, comfortable positions, high backrest,
decrease stress/ calm environment, nebulize as ordered,
gentle chest/ back clapping after nebulization, adequate
hydration, observe iv site for infiltration, maintain NPO,
record I & O, provide rest and comfort, skin care, change
positions frequently.
No signs of complication; stable V/S, no
infections; normal temp., seen relaxed and at
ease, still intubated, still with productive
cough
For discharge
Discharge teaching
a. With may go home as ordered by
Dr._____; V/S stable.
b. With DAMA as ordered by Dr._____
Assessed patient’s condition, Allowed patient / watcher to
verbalize feelings and concerns regarding status, Informed
about discharge process, clearance given (NP) and
facilitated, followed up laboratory / diagnostic test results,
health teaching done, instructed home medications and care,
encouraged to come back for follow up on _____ , 10 am at
room 10.
(NP) nonPhilhealth
a. Patient went home accompanied/ carried/
cuddled by mother/father in good condition.
b. Patient still in; awaiting clearance.
c. Patient still in; to secure all lab results/ xray
result and awaiting clearance.
Laboratory / diagnostic work-up
With order of ________ by Dr. ______. Assessed patient’s condition, vital signs taken and recorded.
Informed watcher about work-up; explained procedure and
its importance. Encouraged expression of feelings and
concern. Lab/ Xray requested as ordered. Monitored for
unusualities. Followed up request.
a. Lab/ xray result in, referred to Dr. _____.
b. Still for lab / Xray once with available
funds.
c. Still for follow-up lab/ xray result.
Pain
Discomfort
With pain scale of _____; guarding position,
crying, irritable, poor appetite.
Explored probable cause of pain; encouraged to verbalize
feelings; determined factors that aggravate pain; encouraged
to perform relaxation techniques; informed the nurse
regarding status; provided comfort measures; promoted
calm and restful environment; administered pain medication
a. seen asleep and without further complaints.
b. still with pain with pain scale of ____.
Your name/ Myra P. Oka, RN/ ______
SN UZ/ CI UZ/ NOD