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).