NURS 313 Post-Sim Case Study

NURS 313 Post-Sim Case Study Name Abby Carrick Class/Group Adult Health 1 Date November 8th, 2020 Scenario Your patient, 58-year-old K.Z., has a significant cardiac history. He has long-standing coronary artery disease (CAD) with occasional episodes of heart failure (HF). One year ago, he had an apicalmyocardial infarction (MI). In addition, he has chronic anemia, hypertension, chronic renal insufficiency, and a recently diagnosed 4-cm suprarenal abdominal aortic aneurysm. Because of his severe CAD, he had to retire from his job as a railroad engineer about 6 months ago. This morning, he is being admitted to your telemetry unit for a same- day cardiac catheterization. As you take his health history, you note that his wife died a year ago (at about the same time he had his MI) and he does not have any children. He is a current cigarette smoker with a 50- pack-year smoking history. His vital signs are 158/94, 88, 20, and 97.2°F (36.2 ° C). As you talk with him, you realize he has only a minimal understanding of the catheterization procedure. 1. Before he leaves for the cath lab, you briefly teach him the important things he needs to know before having the procedure. List 5 priority topics you will address. 1. The patient should be informed how the procedure is performed. The location it is going to be done. 2. The patient should be told that after the procedure, the limb will need to be kept straight for 4-6 hours after surgery. 3. The patient should be told that the catheter will administer blood easier to the heart 4. The patient should be told the complications that could arise from the procedure. 5. The patient should be told if they are going to shower, then the dressing from the surgery should be covered. 2. Look at his past history. What other factors are present that could contribute to his risk for cardiac ischemia? 1. Hypertension 2. Stress from his wife passing and having to retire due to health issues 3.Smoking- 50 pack-year history 4. Aneurysm CASE STUDY PROGRESS Several hours later, K.Z. returns from his catheterization. The catheterization report shows 90% occlusion of the proximal left anterior descending (LAD) coronary artery, 90% occlusion of the distal LAD, 70% to 80% occlusion of the distal right coronary artery (RCA), an old apical infarct, and an ejection fraction (EF) of 37%. About an hour after the procedure is finished, you perform a brief physical assessment and note a grade III/VI systolic ejection murmur at the cardiac apex, crackles bilaterally in the lung bases, and trace pitting edema of his feet and ankles. Except for the soft systolic murmur, these findings were not present before the catheterization. 3. Using the following diagram, identify the superior vena cava, the aorta, and the left and right ventricles. Identify the main coronary arteries and circle the areas of the LAD and RCA that have significant occlusion, as identified in the previous report. Lightly shade the area of the heart where K.Z. had the earlier infarct. RCA LAD 4. What is your evaluation of the catheterization results? He is not getting the blood, or the oxygen is not effectively pumped to his heart. Most of his anterior heart has been effected by the earlier infarct. 5. Explain the significance of having an EF of 37%. This is an indication of how well your heart is pumping out blood and can help to diagnose and track heart failure. The 37% is an ejection fraction meaning that 37% of. The total amount of blood in the left ventricle is pushed out with each heartbeat. 6. What problem do the changes in assessment findings suggest to you? What led you to your conclusion? According to the symptoms of the size/sound of the murmur, bilateral crackles in the lung bases, and pitting edema he could be developing systolic heart failure. The crackles and edema are both signs of fluid buildup in the body. Fluid buildup is one of the first signs of heart failure. If the kidneys aren’t functioning properly then they can’t get rid of the excess fluid because of the weak heart. 7. List 5 actions you should take as a result of your evaluation of the assessment and state your rationale for each. 1. The patient needs supplemental oxygen put on him. 2. Raise the head of the bed so patient can breathe easier. 3. Start fluid restriction 4. Restrict sodium. 5. See the medications the pt. is on and see if a diuretic should be administered to help with the excess fluid. 8. You decide to notify the physician of K.Z.’s condition. Using SBAR (Situation, Background, Assessment, Recommendation), what information would you provide to the physician when you call? Doctor, this is Abby the RN for the patient K.Z. I wanted to tell you the change of condition and see what we should do next. I have his chart here, he is having a multitude of cardiac problems, He has a history of CAD, hypertension, smoking, previous MI, and renal insufficiency. He had a cath this morning and the results show a severe occlusion on both sides of the heart. When assessing him about five minutes ago, he has an increase in heart murmur, crackles bilaterally in lung bases and pitting edema in the lower extremities. I think we should order some labs for him like his ABGs to see what the issue he may be having. A diuretic could also be ordered to help with the excess fluid in his legs and ankles. CASE STUDY PROGRESS After assessing K.Z., the physician admits him with a diagnosis of CAD and HF and plans coronary artery bypass graft (CABG) surgery. Results of significant lab tests performed at this time are Hct 25.3%, Hgb 8.8 g/dL (88 g/L), BUN 33 mg/dL (11.8 mmol/L), and creatinine 3.1 mg/dL (274 mcmol/L). K.Z. is given furosemide (Lasix) and 2 units of packed red blood cells (PRBCs). 9. Review K.Z.’s health history. Can you identify a probable explanation for his chronic renal insufficiency and anemia? The chronic renal insufficiency could be from renal artery stenosis. This can be caused from hypertension. His anemia could also be related to the renal issues he is having. 10. Why is he receiving 2 units of PRBCs? What is the purpose of the furosemide? He is getting the two units of PRBCs because his Hct and HGB are both below the normal limits. This will help bring them up and he Is getting the furosemide to help the fluid and edema in the lower extremities. CASE STUDY PROGRESS Two days later, after his condition is stabilized, K.Z. is taken to surgery for a three-vessel coronary artery bypass graft (CABG × 3 V). When he arrives in the surgical intensive care unit, he has a Swan-Ganz catheter in place for hemodynamic monitoring and is intubated. He is put on a ventilator at FiO2 0.70 and positive end-expiratory pressure (PEEP) at 5 cm H2O. His latest Hgb is 10.3 mg/dL (103 g/L). You review his first hemodynamic readings and arterial blood gases. Chart View Hemodynamic Readings Pulmonary artery pressure (PAP) 38/23 Central venous pressure (CVP) 14 mm Hg Pulmonary artery wedge pressure (PAWP) 18 mm Hg Cardiac index (CI) 1.88 L/min/mm2 Arterial Blood Gases pH 7.37 Paco2 46 mm Hg Pao2 61 mm Hg Sao2 85% 11. Why are ABG values necessary in K.Z.’s case? Explain why it would be inappropriate to use pulse oximetry to assess his O2 saturation status. A pulse ox is not appropratie in this situation because patients with a mild or moderate heart falure can still have normal O2 stats at rest, ABGs are more accurate because. They tell of the components relating to ventilation and prefusion which is what we need in this case. They give a more accurate level of oxygen in the blood. We can see the reason for the edema and the pulmonary edema. 12. What is your interpretation of his ABG values on 70% oxygen)? PAP, CVP, and PAWP are all elevated while his CI is decreased. His PH is within normal limits and his PaCO2 is slightly elevated and PaO2 and SaO2 are both decreased. 13. What is your evaluation of K.Z.’s hemodynamic status, based on the results displayed? The PH is the only normal value. The hemoglobin is not right, because he is getting 70% oxygen and his O2 is still 85%. His hemodynamic status is not stable. 14. Do you think the hemodynamic values reported previously reflect poor left ventricular function or fluid overload? Defend your answer. I believe the LV is not functioning properly, most of the values in the hemodynamic reading and arterial blood gas labs are decreased. His body is not getting the oxygen needed. His heart is not pumping the blood with the oxygen effectively to the rest of the body and so the abs are decreased. 15. K.Z. is receiving continuous IV infusions of norepinephrine (Levophed) and dobutamine. Why is K.Z. receiving these medications? He is receiving these two medications to increase CO. The NE is a vasoconstrictor and increases BP. As a result, this increases the oxygenation of the myocardium and decreases the heart’s workload. Dobutamine increases CO and contractility without raising the HR too much, his heart is already working too hard to compensate for the LV dysfunction. It had this affect by stimulating myocardial adrenergic receptors 16. What assessment findings would indicate that these drugs are having a therapeutic effect? If the blood pressure is increased to normal limits then you can say the NE is effective and working. A therapeutic effect for Dobutamine is an increase CO. Peripheral pulses should be strong and the edema should decrease within the lower extremities. His O2 should be increased. He should be able to tolerate more and be able to get up and move around more. 17. What are the major side effects of norepinephrine and dobutamine, and what do you monitor while these drugs are infusing? Major side effects of NE are anxiety, bradycardia, and palpitations. Major side effects of Dobutamine can include HTN, hypotension, palpitations, dysrhythmias, nausea and vomiting and dyspnea. While the rugs are infusing, vital signs should be monitored, you would need to do an assessment to make sure the patient isn’t experiencing any of these side effects. The blood pressure and the ECG should be watched and monitored as well. When infusing a drug via IV, check for infiltration to make sure the tissue will not be necrosed. 18. K.Z. states that he is feeling more “skipping beats,” even while lying quietly in the bed. What will you do next? a. Stop the dobutamine immediately. b. Assess his vital signs and cardiac rhythm. c. This is a normal side effect; no interventions are needed. d. Titrate the dobutamine to a higher dose to reduce the palpitations. A. Stop the dobutamine immediately. CASE STUDY PROGRESS After 3 days in the SICU, K.Z.’s condition was stable, and he was returned to your telemetry floor. Now, 5 days later, he is ready to go home, and you are preparing him for discharge. 19. List at least four general areas related to his CABG surgery in which he should receive instruction before he goes home. 1. Instruct the patient on each medication he is taking and the use of each. 2. What symptoms to report to your health care provider right away.- arms feel tender, warm, are painful or swollen. If your fever goes above 101 or if the wound is bleeding or red and swollen. 3. Instruct the patient on the importance of exercise. The patient should also go to cardiac rehab to improve relaxation techniques, stress management and to learn more about a heart- healthy nutrition. Instruct patient the importance of smoking cessation. 4. Use the teach back method for wound care, the wound can be washed with a mild soap and water and a new bandage should be applied to the site. CASE STUDY OUTCOME K.Z. decided to sell his home and move to a seniors’ apartment complex. He completed the cardiac rehabilitation program and became a volunteer to support others who have had heart surgery. He has not had a cigarette since his surgery.