Collin Jasper C.

Pachingel

BSN 1 C

FDAR and NCP proper Activity

3. Patient C has had a cardiac arrest. He’s weak in appearance and needs moderate assistance in performing
activities of daily living. He’s able to move extremities against gravity. “Hindi ko magawa ng maayos trabaho
ko”. He’s most of the time confined in bed, does not communicate with others and often seen moving from
side to side.

Date and time Focus Nursing Notes (DAR)

Activity intolerance related to D> “Hindi ko magawa ng maayos trabaho ko”. Weak in
decreased cardiac output appearance. Needs moderate assistance. Able to move
extremities against gravity. Most of the time confined in
bed,
A> Assessed signs of poor ventricular function and/or
impending heart failure, such as chest discomfort,
intolerance to exertion, and growing breathing difficulty.
Frequently checked vital indicators to see how they
responded to activities and interventions. Assisted in
undertaking daily tasks. Planned activities and assessment
to maximize rest periods
R> Able to get appropriate rest and do daily tasks without
hardship or risk of cardiac output reduction.
Collin Jasper C. Pachingel: SN1-1C,ECL

4. Patient D is diagnosed with a terminal illness. “Kinakabahan ako” as verbalized by patient. The cardiac rate
reveals 125 bpm. He perspires minimally. He shuffles his feet at times and has poor eye contact during
conversation. He gets easily irritated most of the time and can’t focused on a certain activity.

Date and time Focus Nursing Notes (DAR)

Anxiety related to confronting the D> “Kinakabahan ako”. Cardiac rate reveals 125 bpm.
reality of terminal disease. Perspires minimally. Shuffles his feet at times. Poor eye
contact during conversation. Gets easily irritated. Can’t
focus on a certain activity.
A> Observed behavior that reflected the client's level of
anxiety (moderate to panic). Listened for expressions of
inability to find meaning in life or suicidal ideation. As
needed, included a calm, serene environment, and privacy.
Used therapeutic communication skills like listening, silence,
and recognition that created an open and trusting
connection. Started to encourage to express his emotions.
Recognized anxiety/fear. Did not dismiss or promised the
client that everything will be fine. Assisted in participating in
mental gains, such as prayer/meditation and forgiveness, if
desired.
R> Able to relax and talk effectively while maintaining eye
contact. Effectively voiced his emotions, is approachable,
and his ability to concentrate has recovered. The cardiac
output recovers to regular.
Collin Jasper C. Pachingel: SN1-1C,ECL
5. Patient E is diagnosed with luekemia. “hindi ko maintindihan ang sakit ko” as verbalized. He asks often, does
not respond to questions when asked. Stares at health care providers most of the time. Eager to read
literatures about current condition.

Date and time Focus Nursing Notes (DAR)

Insufficient knowledge of condition, risk D> “hindi ko maintindihan ang sakit ko”. Asks often. Eager
for health illiteracy to read literatures about current illness.
A>The level of literacy capabilities and possibilities were
assessed. The ability to learn new knowledge regarding the
illness is assessed. Allowing enough time for new
information to be digested and processed step by step.
Determined learning style. Positive remarks and pertinent
information about the illness were provided. Created a
learning strategy and a welcoming environment in which
information is absorbed
R> Capable of participating in the learning process with full
collaboration. Ability to describe the pathology of the
condition, the process, and the treatment. Questions were
answered, and knowledge of leukemia was improved.
Collin Jasper C. Pachingel: SN1-1C,ECL

6. Patient F has abrasions on his upper left thigh. He does not take medications religiously specifically
antibiotics. He consumes 20-30% of food served. He drinks liberal amounts of water. Wound dressing is done
only when the doctor in charge is available. Abrasion is characterized as reddish in color. Patient is developing
a low-grade fever for the past 2 days. Patient appears weak. Laboratory results show that there is minimal
decrease in White blood cell count.

Date and time Focus Nursing Notes (DAR)

Failure to exercise proper preventive D> Does not take medications religiously, consumes 20-30%
measures, risk for moderate infection food served. Wound dressing is done only when doctor is
present. Abrasion is characterized as reddish in color, bleeds
minimally and has whitish and greenish discharge.
Developing low grade fever for the past 2 days.
A>Evaluated several therapy settings and techniques.
Certain drugs were evaluated, as well as the presence and
absence of immunity. Interventions to prevent or minimize
the risk of infection have been identified. Environmental
exposure was monitored. For contaminated goods,
considered suitable cleaning, changing, and disposal
techniques. The need of taking antibiotics was emphasized.
R> Took proper precautions to avoid infection and wound
healing was completed on time.
Collin Jasper C. Pachingel: SN1-1C,ECL
 NCP

Patient E is diagnosed with luekemia. “hindi ko maintindihan ang sakit ko” as verbalized. He asks often, does
not respond to questions when asked. Stares at health care providers most of the time. Eager to read
literatures about current condition.

Data Goals and Nursing interventions Rationales Evaluation

objectives
Subjective: STO: Dx: Dx: STG: Fully met
 “hindi ko  After 24  Assessed  This is to  Note:
maintindihan hours, the literacy level determine if an Client demonstrated
ang sakit ko” px’s  Assessed individual can motivation and hope
as verbalized curiosity is ability and do so. after 24 to 48 hours
by the lessened readiness to of NI in terms of
 To see if they're
learn
patient absorbing and continuing to retain
Tx:
 Within 48 applying new and acquiring new
 Provided
Objective: hours px’s enough time information. information.
 Asks often shows for new  Note: as the patient
 Eager to read more information to Tx: will verbalize “medyo
literatures interest retain.  To retain naiintindihan ko na
about and is well  Determined understandings ang sakit ko”.
current versed on learning style. and learnings
condition what his  Giving of LTG: Partially for px is yet to
health positive  To have a bird's unveil more sources and
Focus/Nursing illness is. remarks eye view of how information relating his
Diagnosis: Edx: you'll approach illness.
Insufficient knowledge LTO:  Encouraged a your teaching
of condition, risk for learning
 Px will plan.  Identified learning
health illiteracy strategy and a
continue to welcoming  To motivate and impediments and
do self- environment. support detailed actions to
learning continued address them
efforts.  Showed an increase
Edx: in interest and took
 This helps to responsibility for their
reinforce the own learning by
learning process beginning to research
while also and ask questions.
allowing the  Followed all
customer to important
work at his own components and
speed. explained why they
were taken.
 Participated in
learning process.