FDAR FORMAT

DATE AND TIME FOCUS DATA/ACTION/RESPONSE

10/18/24 Fatigue related to disease process Data:
09:30 AM (CML) and anemia. - The patient reports feeling
extreme fatigue and states, "I feel
tired all the time, even after
sleeping."
- Hemoglobin level: 10.9 g/dL
(slightly low), indicating mild
anemia.
- The patient appears weak, with
reduced activity tolerance and
shortness of breath on exertion.

Action:
- Educated the patient on energy
conservation techniques, including
taking frequent rest periods and
pacing activities throughout the
day.
- Administered prescribed iron
supplements and evaluated for the
need for a blood transfusion.
- Encouraged a balanced diet with
iron-rich foods to improve
hemoglobin levels.
- Coordinated with the medical
team to adjust medications if
necessary to address the patient's
anemia.

Response:
- The patient acknowledged the
importance of energy conservation
and expressed willingness to try
the suggested strategies.
- Follow-up on lab results and
response to interventions planned
for the next assessment.
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DATE AND TIME FOCUS DATA/ACTION/RESPONSE

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10/18/24 Pain related to splenomegaly Data:
01:00 PM (enlarged spleen). - The patient reports constant pain
in the left upper quadrant, rated as
6/10 on the pain scale. She
describes it as "a dull, aching pain
that gets worse when I move."
- Physical assessment reveals
tenderness upon palpation of the
left upper quadrant. Splenomegaly
is present.

Action:
- Administered prescribed pain
medication (e.g., acetaminophen)
and non-pharmacological
interventions such as repositioning
to alleviate discomfort.
- Educated the patient on avoiding
heavy lifting or sudden movements
that could exacerbate splenic pain.
- Provided supportive care,
including heat therapy applied to
the area, as tolerated by the
patient.

Response:
- After medication administration,
the patient reports a reduction in
pain from 6/10 to 3/10.
- The patient feels more
comfortable and is resting without
distress. Continued monitoring of
pain levels and response to
interventions is planned.
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DATE AND TIME FOCUS DATA/ACTION/RESPONSE
10/18/24 Anxiety related to the diagnosis of Data:
03:30 PM CML and concerns about - The patient expresses feelings of
prognosis. worry and fear about her diagnosis
and future. She states, "I am scared
about what this disease means for
me long term."
- The patient appears restless and
preoccupied during interactions,
with periods of tearfulness.
- Family members report that the
patient has become more
withdrawn since learning about her
diagnosis.

Action:
- Provided emotional support by
listening to the patient’s concerns
and encouraging her to express her
feelings.
- Offered educational materials on
CML, explaining the treatment plan
and expected outcomes in simple
terms to reduce fear of the
unknown.
- Referred the patient to a
counselor for emotional and
psychological support.
- Encouraged family involvement
and suggested participation in a
cancer support group for additional
support.

Response:
- The patient verbalized feeling
somewhat reassured after
discussing her treatment plan and
prognosis. She stated, "I feel better
knowing more about the treatment
options."
- The patient agreed to meet with
the counselor and expressed
interest in joining a support group.
Will continue to monitor her
emotional state and provide
further support as needed.
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