CABG Patient Progress Note Template
A comprehensive CABG progress note template should include vital sign trends, fluid balance assessment, cardiovascular status with specific attention to graft patency signs, respiratory function, pain control, and medication management with emphasis on antiplatelet and statin therapy. 1
Patient Identification and Basic Information
- Patient name, medical record number, date of birth
- Date of CABG procedure and type (on-pump vs. off-pump)
- Grafts placed (specify vessels: LIMA to LAD, SVG to other vessels)
- Post-operative day number
- Attending surgeon
Subjective Assessment
- Chest pain/discomfort (character, severity, relation to activity/rest)
- Dyspnea or respiratory symptoms
- Incisional pain (sternotomy site and graft harvest sites)
- Activity tolerance
- Sleep quality
- Appetite and bowel function
- Patient concerns
Objective Assessment
Vital Signs
- Temperature, heart rate, blood pressure, respiratory rate, oxygen saturation
- Vital sign trends over past 24 hours (particularly noting any tachycardia or hypotension)
Cardiovascular
- Heart sounds (murmurs, rubs, gallops)
- Rhythm (regular vs. irregular, presence of atrial fibrillation)
- Peripheral pulses (radial, femoral, dorsalis pedis)
- Jugular venous pressure
- Presence/absence of peripheral edema
- Chest tube drainage (if still in place) - amount and character
Respiratory
- Breath sounds
- Respiratory effort
- Oxygen requirements
- Chest X-ray findings (if available)
Wound Assessment
- Sternal wound appearance (erythema, drainage, dehiscence)
- Leg/arm harvest site appearance
- Signs of infection
Fluid Balance
- 24-hour intake and output
- Weight trend
- Diuretic response (if applicable)
Laboratory Values
- Complete blood count (hemoglobin/hematocrit trends)
- Basic metabolic panel (renal function, electrolytes)
- Cardiac enzymes (if indicated)
- Coagulation studies (if on anticoagulation)
- Blood glucose levels
Assessment and Plan
Cardiovascular Status
- Overall hemodynamic stability
- Management of post-CABG medications:
- Antiplatelet therapy (aspirin 81-325mg daily should be initiated within 6 hours postoperatively) 1
- Beta-blockers (to reduce risk of postoperative atrial fibrillation) 1
- Statin therapy (target LDL <70 mg/dL for high-risk patients) 1
- ACE inhibitors/ARBs (especially for patients with EF ≤40%, hypertension, diabetes, or CKD) 2
- Anticoagulation if indicated (e.g., for atrial fibrillation) 1
Respiratory Status
- Oxygenation plan
- Pulmonary toilet measures
- Incentive spirometry use
Pain Management
- Current regimen
- Effectiveness
- Plan for titration
Fluid Management
- Assessment of volume status
- Diuretic needs
- Electrolyte replacement
Glycemic Control
- Blood glucose targets (maintain ≤180 mg/dL in immediate postoperative period) 1
- Insulin or oral hypoglycemic regimen
Wound Care
- Current management
- Signs of complications
- Need for surgical consultation if concerns
Nutrition and Mobility
- Diet advancement
- Activity progression
- Physical therapy involvement
Discharge Planning
- Anticipated discharge date
- Home care needs
- Follow-up appointments
- Cardiac rehabilitation referral (reduces cardiovascular mortality by 26%) 1
Critical Elements to Monitor for Complications
Early Graft Failure
- New-onset chest pain
- ECG changes
- Hemodynamic instability
- Elevated cardiac enzymes
Infection
- Fever
- Leukocytosis
- Wound changes
- Need for antibiotics
Atrial Fibrillation
- New irregular rhythm
- Rate control strategy
- Anticoagulation considerations
Pleural Effusion/Pneumothorax
- Respiratory distress
- Decreased breath sounds
- Chest X-ray findings
Patient Education Documentation
- Medication instructions provided
- Activity restrictions reviewed
- Wound care instructions
- Signs/symptoms requiring immediate attention
- Chest pain protocol explained (take nitroglycerin for chest pain >1-3 minutes, call emergency services if pain doesn't subside) 1
Overall Plan
- Summary of current status
- Key interventions for next 24 hours
- Anticipated clinical course
This template follows the American College of Cardiology/American Heart Association guidelines for post-CABG care, emphasizing the importance of medication management, complication surveillance, and comprehensive documentation to ensure optimal patient outcomes and communication among the healthcare team.