NUR 401 Case Study 13 Coronary Artery Disease and Coronary Artery Bypass Surgery

Case Study 13 Coronary Artery Disease and Coronary Artery Bypass Surgery Difficulty: Advanced Setting: Hospital Index Words: coronary artery disease (CAD), heart failure (HF), coronary artery bypass graft (CABG), cardiac catheterization, hemodynamic monitoring, laboratory values, medications, assessment Giddens Concepts: Clinical Judgment, Coping, Gas Exchange, Patient Education, Perfusion HESI Concepts: Assessment, Clinical Decision Making—Clinical Judgment, Gas Exchange, Patient Education, Perfusion, Stress & Coping 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 anterior wall myocardial 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 that 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 (VS) are 158/94, 88, 20, and 97.2 ° F (36.2 ° C). As you talk with him, you realize that he has only a minimal understanding of the catheterization procedure. 1. Before he leaves for the catheterization laboratory, you briefly teach him the important things he needs to know before having the procedure. List five priority topics you will address. ◦ The importance of smoking cessation ◦ Extensive measures are taken to reduce the need for RBC transfusion, but there is a possibility of having to get a blood transfusion if bleeding occurs ◦ Fasting 6 to 8 hours prior to procedure ◦ Avoid strenuous activity until your provider gives the OK to resume normal activities ◦ Must lie flat after procedure is done ◦ You will be awake during procedure but they will give you something to take the edge of 2. Look at his past history. What other factors are present that could contribute to his risk for cardiac ischemia? • 50 pack- year smoking history • Anterior wall Myocardial Infarction • Long standing coronary artery disease • Hypertension • Chronic anemia 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. Identify the area of the heart where K.Z. had the earlier infarct. 1. Superior vena cava 2. aorta 3. left coronary artery 4. right coronary artery ◦ The RCA occlusion is the big circle located distal to the aorta. ◦ Both the LAD occlusion are located above the bigger circle located at the apex of the heart • 4. What is your evaluation of the catheterization results?