Focus Charting (FDAR)

QUESTION

Write 3 focus charting (FDAR) on the following scenerio. Lisa is a 74-year-old woman who presents to the ER with shortness of breath and fever. Lisa has a 10-year h of chronic bronchitis and 2 years ago she was also confirmed to have emphysema.

Currently Lisa has a 4 day h of a cold that has progressed to chest congestion and sinusitis. She also complains of a sore throat that makes swallowing difficult. She complains of a constant hacking cough and reports she coughs up a lot of thick, yellow stuff”. She states her chest is

“sore all the time and she has a stabbing pain of “8 out of 10” when she takes a deep breath or coughs.

Medical History

Lisa has a hx of frequent (2 to 3 times a year) respiratory infections requiring hospitalization.

Lisa was a 2 pack a day smoker until 2 years ago. She was also recently diagnosed with glaucoma. Lisa also has a hx of HTN and hyperlipidemia. She wears glasses.

Social History

Lisa is married and lives with her husband in a 2-bedroom condo. She retired from her job as librarian 9 years ago.

Initial impressions:

Lisa is diaphoretic and sitting upright leaning over her overbed table. Her breathing is labored and noisy. An IV was inserted in the ER (site – right dorsal hand, gauge – 20). An IV of NS is infusing at 100 mL/hr. The first dose of antibiotics was administered at 0400 in the ER. She has 02 at 6 L by face mask. She is not wearing her glasses. Her husband is pacing in her room and loudly insisting something be done for his wife as it is obvious she is in distress. Lab work has just come back.

Height 150 cm

Weight 61 kg

BP 146/90

HR 102

RR 28

Temp 39 degrees C

02 sats – 90% on 6 L 02 by facemask.

ANSWER

Focus Charting (FDAR)

Focus: Respiratory Symptoms and Infection

Data

Lisa presents with shortness of breath, fever, chest congestion, sinusitis, and a sore throat.
She has a constant hacking cough and reports coughing up thick, yellow sputum.
Lisa experiences chest soreness and stabbing pain of 8 out of 10 when taking deep breaths or coughing.
Lisa has a history of chronic bronchitis and emphysema.
She has a history of frequent respiratory infections requiring hospitalization.
Lisa was a heavy smoker until 2 years ago.

Action

Administered the first dose of antibiotics at 0400 in the ER to treat the suspected respiratory infection.
Initiated oxygen therapy at 6 L/min via face mask to improve oxygen saturation and alleviate respiratory distress.
Assessed respiratory status and monitored for any changes in respiratory effort.
Assisted Lisa in performing breathing exercises and provided comfort measures to alleviate chest soreness.

Response

Lisa’s respiratory symptoms and infection are being actively addressed through appropriate interventions.
Continued monitoring of vital signs, oxygen saturation, and response to treatment is essential.
Documented patient’s response to interventions and any changes in symptoms or condition.

Focus: Pain Management

Data

Lisa reports a stabbing pain level of 8 out of 10 when taking deep breaths or coughing.
Lisa experiences constant chest soreness.
Lisa has a history of chronic bronchitis and emphysema.

Action

Assessed and documented the characteristics and location of Lisa’s chest pain.
Administered prescribed pain medication as ordered to alleviate the chest pain and improve patient comfort.
Provided positioning techniques and breathing exercises to minimize pain during deep breaths or coughing.
Monitored and documented the effectiveness of pain management interventions.

Response

Evaluated the effectiveness of pain management interventions in reducing Lisa’s chest pain.
Documented patient’s response to pain medication and any changes in pain intensity or characteristics.
Collaborated with the healthcare team to adjust pain management strategies if necessary.

Focus: Patient Support and Education

Data

Lisa’s husband is visibly concerned and demanding immediate attention for his wife’s distress.
Lisa recently retired from her job as a librarian and has a history of hypertension, hyperlipidemia, and glaucoma.

Action

Engaged in therapeutic communication with Lisa and her husband, acknowledging their concerns and providing reassurance.
Educated Lisa and her husband about the current treatment plan, including the administration of antibiotics, oxygen therapy, and pain management.
Discussed the importance of smoking cessation and its impact on respiratory health.
Provided information on preventive measures to avoid respiratory infections, such as hand hygiene and avoiding crowded places during cold and flu seasons.
Offered emotional support and encouraged Lisa and her husband to express any further concerns or questions.

Response

Assessed the patient’s and her husband’s understanding of the provided information and addressed any additional questions or concerns.
Documented the education provided, patient’s and family’s response, and any modifications to the plan based on their needs.