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FDAR

The document contains notes from a nurse on their care of a patient experiencing acute pain after a hysterectomy surgery. On July 18 at 8:00 am, the nurse assessed the patient and found signs of pain like an 8/10 on the pain scale. The nurse monitored vitals, encouraged relaxation techniques, adequate fluid intake and rest, administered pain medication as ordered, and reassessed the patient at 12 pm when the patient reported their pain had decreased to a 5/10 scale.

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Joan Quebalayan
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526 views1 page

FDAR

The document contains notes from a nurse on their care of a patient experiencing acute pain after a hysterectomy surgery. On July 18 at 8:00 am, the nurse assessed the patient and found signs of pain like an 8/10 on the pain scale. The nurse monitored vitals, encouraged relaxation techniques, adequate fluid intake and rest, administered pain medication as ordered, and reassessed the patient at 12 pm when the patient reported their pain had decreased to a 5/10 scale.

Uploaded by

Joan Quebalayan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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DATE/TIME FOCUS DATA ACTION RESPONSE

July 18, 2022 D: Recieved patient lying on


8:00 am bed awake but appears weak
and in pain. She has an
Acute pain secondary to onging IVF of D5LRS,
surgical procedure dripping well with the ff. Vital
(hysterectomy) signs of:
BP: 100/70 mmHg
PR: 105 cpm
RR: 40 bpm
Temp: 37 C
(+) Irritability
>facial grimaing
>Pain scale of 8/10
> on the first day post-op
A: > assessed pain regularly
noting characteristics,
location, and intensity
> identified specific activity
limitations
> repositioned the patient as
indicated
>monitored and recorded
I&O accurately
> encoureged to do
relaxation technique like
deep breathing exercise
> encouraged to increased
fluid intake
> encouraged patient to eat
iron rich foods such as green
leafy vegetables, red meat,
fish , eggs etc.
>encouraged safety at all
times
> provied divertional
activities like watching t.v or
reading books
> provided adequete rest
periods.
> administered analgesic
medication as ordered.

July 18, 2022 R: Resting in bed “medyo


12 pm Acute pain secondary to nabawasan po ang sakit ng
surgical procedure sugat ko” with the pain scale
(hysterectomy) of 5/10

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