Tolentino (FDAR) - Nursing FDAR example PDF

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Summary

Nursing FDAR example...

Description

NAME OF PATIENT: CD Date/Time 10/27/2020 8 am

Focus Immediate Preoperative Care/post transfer

Room/Ward: MMW/Bed #5 Data In from male surgical ward; conscious and oriented

Action Pre-op checklist reviewed for completeness,

Doctor: Dr. A Date/time 8:15 am

;with IVF D5 transferred, LR K with 400 to OR

8:30 am

cc left attach -ed at right cephalic vein infusion good; with consent signed for lobectomy of The right middle and right lower lobe

stretcher, vital signs taken, side rails raised, brought to OR #1, transferred and secured at OR table, attached to monitor and prepared for induction.

Intraoperative General Care Endotracheal

placed in supine posi-

Anesthesia Induced by Doctor Villaruz; Patient Draped;

tion; final skin prep and draping done aseptically; initial count of sponges,

11:45 pm

Response Pre-op Checklist complete; PR= 90 bpm RR= 25 breaths per minute T= 37.5 B/P= 120/80 mmHg O2 Sat= 96%

PR= 85 bpm RR= 15 cycles/min T=37.3 oC B/P= 110/70 O2 Sat= 95% All counts complete

12:00 NN

Surgery Started by Dr. Alabang Assisted by Dr. Alabado And Dr. Sy; Procedure Ended @ 12:00 NN

needles and instruments done; continuous monitoring done; bleeders clamped and ligated as encountered; specimen secured and properly labeled; closure done layer by layer after complete and final count of sponges, needles and instruments; painted with betadine with top dressing applied.

Immediate Post-op Care/ Pre transfer

S/P lobectomy of the right

Transferred To PACU via Stretcher

Assessment

middle lobe and right lower lobe; drowsy with IV of D5LR 1L with 120cc

With side Rails Raised, Monitors Attached, Endorsed to

12:05 pm

Latest V/S PR= 80 bpm RR=14 cycles/min T= 37.3 oC B/P= 110/70 O2 Sat= 96%

more, infusing well with foley catheter to urobag draining to amber yellow colored urine, with dressing dry and intact.

Nurse XB @ 12:10 PM....