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DEFINITIONS: Focus Charting - is a method for organizing health information in the individual's record.

It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action. Focus a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy an acute change in an individual's condition, i.e. respiratory distress, seizure, fever, discomfort a significant event in an individual's care, i.e. begin treatment regimen (oxygen), change in diet, catheterization a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self medication teaching plan, transition COMPONENTS OF A FOCUS NOTE: Data: Subjective and/or objective information supporting the stated focus or describing observations at the time of significant events. Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated. Response: Description of individual's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment. Example: Need: Comfort (or, Relief of pain) D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for pain now!" States pain is 9 on a scale of 10. A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to abdomen to help splint wound. R - Patient stated pain was "much better" 30 minutes later and rated it 3 on a scale of 10.---N. Nurse General Survey Appearance of the patient, condition- when seeing the patient Any IVF or Medications attaches to the arms of the patient Current Vital Signs of the Patient Eg. Approached sitting on bed, awake, responsive, coherent with ease in respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @

66 ugtts/min infusing well at the Right arm, with the following V/S: BP= 110/70 mmHG, PR= 100 bpm, RR= 26 cpm, T= 36.8 degree Celsius/axilla. Followed by F-DAR After writing the F-DAR , at the end of the shift write again your general observation/survey of the patient condition F: Hyperthermia D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla > flushed skin and warm to touched A: 9:00am > Tepid sponge bath done > instructed SO to let patient wear loose clothing > instructed SO to provide blanket to patient when shiver > instructed SO to let patient drink lots of fluid > instructed SO to include in his diet foods rich in Vitamin C such as oranges > provided opportunity for patient to rest > due meds given R: 1:00pm > patient was able to rest > patient temperature decrease to T= 37.8 degree Celsius/axilla F1: Ineffective Breathing Pattern D1: increase respiratory rate of 24 cpm D2: use of accessory muscle to breath D3: presence of nonproductive cough F2: Hyperthermia D1: skin warm and flush to touched D2: increased body temperature of T= 37.7 degree celsius/axilla F3: Fatigue D1: less movement noted with the verbalization of kapoy man ako lawas, kulangan ko ug katulog A: 9:00am monitored v/s and charted regulated IVF and charted morning care done assessed patient needs and performed handwashing before handling the patient advised SO to always stay on patient bedside promote proper ventilation and a therapeutic environment elevated the head of the bed (moderate high back rest) provided comfort measures and provide opportunity for patient to rest due meds given 9:30am tepid sponge bath done instructed SO to provide blanket and let patient wear loose clothing

F4: Discharge Plan (12:00nn) D1: discharged order given by Dr.Name/Time M advised SO to give the ff. meds at the right time, dose, frequency and route E encouraged to maintain cleanliness of the house and surroundings T advised to go to follow-up consultations on the prescribed date H encouraged to do chest tapping to facilitate mobilization of secretion O - observed for signs of super infections such as fever, black fury tongue and foul odor discharges D encouraged to eat fresh vegetables and fish S advised to continue praying to God and hear mass on Sunday 2:00pm out of the room per wheelchair with improved condition Discharge plan for patient who undergo Surgery H Health Teachings A Anticipatory Guidance S - Spirituality M - Medications I Incision in Care N - Nutrition E - Environment