Romero. Pamela A.

April 20, 2022

BSN 4 – 2

MITRAL VALVE REPLACEMENT CHARTING

Subjective:

- Nahihirapan akong huminga” as verbalized by the patient.

Objective:

- Restless
- Weak in appearance
- Dyspnea
- O2 sat: 90%
- Vital signs taken as follows:
o Temp: 36.7°C
o RR: 25 cpm
o PR: 136 bpm
o BP: 122/63 mmHg

Assessment:

- Impaired Gas Exchange

Planning:

- Within 30 minutes of nursing interventions, the patient will maintain an optimal gas
exchange as evidenced by unlabored respirations at 12-20 per minute, SpO2 results
within normal range and heart rate of 100 bpm or less.

Interventions:
 - Positioned the patient in a High Fowler’s position with the head of the bed elevated
up to 90°.
- Suctioned secretions
- Provided oxygen therapy as ordered.
- Administered medications as prescribed.
- Encouraged frequent rest periods and teach the patient to pace activity

Planning:

- After 30 minutes of rendering proper nursing interventions, the patient was able to
maintain an optimal gas exchange as evidenced by unlabored respirations at 16 cpm,
SpO2 results within normal range and heart rate of 86 bpm.
CORONARY ARTERY BYPASS GRAFT CHARTING

Subjective:

- N/A

Objective:

- Irregular heart rate

- Cold clammy skin
- Restless
- O2 sat: 93%
- Vital signs taken as follows:
o RR: 23 cpm
o PR: 109 bpm
o BP: 140/90 mmHg

Assessment:

- Decreased Cardiac Output

Planning:

- Within 2 hours of nursing interventions, the patient will demonstrate adequate cardiac
output as evidenced by blood pressure and pulse rate and rhythm within normal
parameters.

Interventions:

- Positioned the patient in supine

- Monitored vital signs every 30 minutes
- Monitored bowel function
- Suctioned secretions
- Provided oxygen therapy as ordered.
 - Administered medications as prescribed.
- Performed periodic hemodynamic measurement as indicated

Planning:

- After 2 hours of rendering proper nursing interventions, the patient was able to
demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate
and rhythm within normal parameters.
-