DATE & TIME FOCUS / DATA / ACTION / RESPONSE

October 4th,2021 F- Decrease cardiac output

7am
D-
Objective: Received patient on a supine position. Upon auscultation Murmur sounds were
noted and Shortness of breath, Bluish discoloration of the skin was noted. The patient was
weak and Fatigue. Swelling in the lower extremities was evidenced.
A-
Dx;
Assessed heart rate and blood pressure every 2 hours.
Noted skin color, temperature, and moisture
Checked for peripheral pulses, including capillary refill
Tx;
Positioned child in semi-Fowler’s position. Performed bedside caring.
Administered oxygen therapy as prescribed
Administered medication as prescribed
Dx;
Advised the subordinate other the need for patient’s frequent rest.
Encouraged fluid intake

2pm R- The significant other mentioned “she is still so weak”. Her latest heart rate is
70bpm, blood pressure 90/50mmhg.
DATE & TIME FOCUS / DATA / ACTION / RESPONSE
October 4th,2021 F- Risk for injury
7am
D-
Objective: Received patient on a semi fowler position. The patient was weak and Fatigue.
Swelling in the lower extremities was evidenced.
A-
Dx;
Assessed for risk of drug toxicity, a cardiac complication of heart failure.
Ensure that patient is on NPO to 46hrs prior to the surgery procedures.
Tx;
Performed bedside caring.
Administered medication as prescribed
Dx;
Advised the subordinate other the need for patient’s frequent rest.
Encouraged fluid intake, Advised on actions to take if the child becomes cyanotic
(knee-chest or squatting position, elevating head and chest), when to call the
physician.

2pm R. Patient latest heart rate is 70bpm, blood pressure 90/50mmhg.