Question

Please answer these question on this case study

Case study

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 (about the same time that he had his MI) and that 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 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.

2. Look at his past history. What other factors are present that could contribute to his risk for cardiac ischemia?

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 was 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. What is your evaluation of the catheterization results?

4. Explain the significance of having an ejection fraction of 37%.

5. What problem do the changes in assessment findings suggest to you? What led you to your conclusion?

6. List five actions you should take as a result of your evaluation of the assessment, and state your rationales.

After assessing K.Z., the physician admits him (with a diagnosis of CAD and HF) for CABG surgery. Significant laboratory results drawn at this time are Hct 25.3%, Hgb 8.8 g/dL, BUN 33 mg/dL, and creatinine 3.1 mg/dL. K.Z. is given furosemide (Lasix) and 2 units of packed RBCs (PRBCs).

7. Review K.Z.'s health history. Can you identify a probable explanation for his chronic renal insufficiency and anemia?

8. Why did he receive 2 units of PRBCs instead of whole blood? What was the purpose of the furosemide?

Five 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 (SICU), 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 hemoglobin (Hgb) is 10.3 mg/dL. You review his first hemodynamic readings and arterial blood gases.

ABG:

pH = 7.37

PaCO2 = 46 mmHg

PaO2 = 61 mmHg

SaO2 = 85%

9. Why are arterial blood gases necessary in K.Z's case? Explain why it would be inappropriate to use pulse oximetry to assess his oxygen saturation status.

10. What is your interpretation of his arterial blood gases on 70% oxygen?

11. what is your evaluation of K.Z's hemodynamic status, base on the results displayed?

12. Do you think the hemodynamic values reported previously reflect poor left ventricular function or fluid overload, and why?

13. K.Z is receiving continues IV infusions of norepinephrine (Levophed) and dobutamine. Why is K.Z receiving these medication.

14. What are your responsibilities when administering norepinephrine and dobutamine to K.Z?

After 3 days in the SICU, K.Z.'s condition is stable, and he is returned to your telemetry floor. Now, 5 days later, he is ready to go home, and you are preparing him for discharge.

15. List at least four general areas related to his CABG surgery in which he should receive instruction before he goes home.

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Answer 1

1.The five priority topics to be addressed are

• Nutrition:
  • Will be kept NBM for atleast 8 to 12 or atleast 6 to 8hours before surgery
• Medication
  • No blood thinners,OTC ,herbs or any vitamin supplements before surgery
  • Pre medication as per order
• Skin preparation
  • The arms (lower arm) ,lower limbs(at groin) will be shaved off to do the catheterization
• Allergy
  • It is very important to gain knowledge regarding the allergic status of any iodine or related products because in catheterization due is administered
• Consent
  • Inform and get the consent to avoid legal consequences
• Progress
  • Risk and prognosis as to explained

2.The factors which could contribute to cardiac ischemia are

• Long standing cardiovascular diseases or issues
• Active smoking
• Age

3.The catheterization evaluates the patient has 90% block on LAD and 70 to 80% block on RCA.

4.The normal EF should range between 55 to 77%.A level below it indicates the amount of blood pumped out from the ventricle is decreased or inadequate. Here a EF of just 37% indicates that only 37% of blood is pumped out of ventricle which is very dangerous and is an indicator of cardiomyopathy or heart failure.