patient's chart....help!

[deanikins211]

hello everybody!

well..today,i experienced chart reading..and it was really difficult..then,at the end of the day,our teacher gave us an activity..here it is..please help me..

i have a problem in filling up the patient's chart especially the nurses notes because we are required to make a DAR(data,action,reaction). Please help me make a DAR for the chief complain of fever and cough.

Although we don't have an actual patient but the teacher expects that we see this activity as an actual one..

thanks!

[locolorenzo22, BSN, RN]

Hi....I'm going to tell you that we here all an.com really don't give out homework help....although your data should be your fever/cough...and issues related to that.

then action=what to do and reaction= what came of it.....hope that helps.

[Eirene, ASN, RN]

Data: Pt. has fever of 101.2 temporal; cough harsh and wet, coughing up copious amounts of purulent sputum. (Put VS in here). Breath sounds: Wheezes bilaterally in bilateral upper lungs; crackles heard bilaterally in lower bases.

Action: Administered pyretic and encouraged 2500 ml/day of fluid to liquify secretions.

Reaction: Fever down to 98.6; Coughing up purulent amounts of sputum; breath sounds improved to faint crackles in right lower lobe.

I hope that helps!

[Daytonite, BSN, RN]

if i'm not mistaken i posted a sample of dar (focus) charting on this thread some time ago:

• https://allnurses.com/forums/f205/nursing-documentation-168921.html - nursing documentation (in the nursing student assistance forum)

dar stands for data - action - response.

part of completing this exercise requires you to look up information about both of these two symptoms and the nursing interventions for both. you will use your imagination to create the charting for this exercise. assessing a cough includes things from this list:

• describe the cough
  
• is it productive or nonproductive of sputum?
  
• when was the onset
  
• what aggravates the cough
  
• what makes the cough better
  
• is there any accompanying breathing problems with the cough
  
• what is the patient's color like
  
• note the rate and depth of respirations
  
• note the lung sounds

here is just one example of how to do one item of dar charting for a cough:

d

-

patient coughed up large amount of thick yellow sputum.

a

- assessed lung sounds. crackles auscultated in right lower lobe. has cough with inspiration. no dyspnea.

r

- hob up 45 degrees. encouraged to deep breath and cough. discussed the importance of keeping secretions moving up and out of the lungs.

you will do similar for fever.