FDAR

Date and Time

Focus
9/21/15
Post-operative
9:30PM care

9:45PM

10:45PM Body
temperature

11:25PM Pain

Data, Action, Response

D Received patient from PACU s/p
Laminotomy, Discectomy L5-S1, Left
under Dr. Bernal and Dr. Pineda; with
dressing over
D With minivac drain maintained on
negative pressure; noted bloody
drainage---------------JN
A Hooked to oxygen source at 2Lpm
via
nasal
cannula--------------------------------------------JN
A Encouraged deep breathing
exercises----JN
A Minivac drained and recorded with
an
output
of
7ml
-------------------------------------JN
A

Placed
call
light
within
reach---------------JN
A Assisted to a comfortable
position--------JN
A - Instructed to call if in need of
assistance
A Instructed to maintain side rails up
when
in
bed-----------------------------------------------JN
D Temperature of 37.9OC and skin is
flushed
and
warm
to
touch-------------------------------JN
A Encouraged deep breathing
---------------JN
A Encouraged adequate oral fluid
intake--JN
A

Encouraged
adequate
rest-----------------JN
D Ang sakit ng kaliwang kamay ko,

11:30PM

11:50PM

9/22/15

Post-operative
care

4:15PM Body
Temperature
5:45PM Pain

kung san nakatusok yung swero., as

verbalized by the patient. Pain scale
6/10;
swollen
upon
inspection.----------------------------------------JN
A Placed warm compress on area for
10
minutes.------------------------------------------JN
A Reassessed patient, with 5/10
pain.-------JN
A- Changed IV site to right hand with
IVF
infusing
well.--------------------------------------JN
R Dressing dry and intact; total
minivac output for entire shift of
15mL,
with
bloody
drainage-------------------------------------------JN
R Reassessed patient; with a body
temperature
of
37.4
O
C--------------------------JN
R Onting sakit na lang yung dito sa
left hand ko., as verbalized by the
patient. With no complaints of pain on
the new site. 2/10 on the previous
site. -------------------------------------JN