FDAR CHARTING
DATE &
TIME
FOCUS
FOCUS
September
4, 2023 @
8:am
Electrolyte imbalance (low
K & Na)
PROGRESS NOTES
DATA:
-RR: 28cpm
- O2sat: 90%
-dyspnea
- experiencing orthopnea
- Pitting edema
- s.K - 3.3 mmol/L (hypokalemia)
- s. Na- 130 mEq/L (hyponatremia)
ACTION:
 Evaluated the patient's neurological status,
including mental alertness, orientation, and
reflexes
 Started PNSS 1L @KVO rate done by NOD
 Monitored strict I/O q shift
 Monitored VS q 2 hrs
 Implemented a Low Salt Low-fat Diet
 Placed the patient in a semi-Fowler's position
 Monitored the patient's cardiac rhythm
through continuous ECG
 Administered potassium meds (e.g., kalium
durule) done by NOD
 Collaborated with the dietitian to develop and
implement a diet plan
RESPONSE:
 The patient is alert and oriented.
 K & Na level within the normal range
 Vital signs are within the normal range
 No signs of fluid retention and worsening of
edema
 Increased comfort and improved breathing
pattern
MARJORIE L. DELA CRUZ
SIGNATURE NAME