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.

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.

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).

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%

10. 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.

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

Answer 1

Case history

Name of the patient: K.Z.

Age: 58 years

Personal history:

• His wife died a year ago (about the same time that he had his MI)
• He does not have any children.

Past medical health history:

• The client 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).
• 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.

Lifestyle :

• He is a current cigarette smoker with a 50-pack-year smoking history.

Present medical history:

• This morning, he is being admitted to your telemetry unit for a same-day cardiac catheterization.

Vital signs (VS) :

• Blood pressure: 158/94
• Pulse: 88
• Respiration: 20
• Body temperature: 97.2° F (36.2° C)

Catheterization report:

The 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)
• Old apical infarct
• Ejection fraction (EF) : 37%.

Physical assessment:

• It reveals grade III/VI systolic ejection murmur at the cardiac apex
• Crackles bilaterally in the lung bases
• Trace pitting edema of his feet and ankles.

Diagnosis: (CAD and HF) for CABG surgery.

Significant laboratory results:

• Hct 25.3%
• Hgb 8.8 g/dL
• BUN 33 mg/dL
• Creatinine 3.1 mg/dL. K.Z.

Treatment given

• furosemide (Lasix)
• 2 units of packed RBCs (PRBCs).

Surgical diagnosis:

• three-vessel coronary artery bypass graft (CABG × 3 V)

5 days postoperative day:

• The patient is in SICU, he has a Swan-Ganz catheter in place for hemodynamic monitoring
• He is intubate
• He is put on a ventilator at

1. FiO2 0.70
2. positive end-expiratory pressure (PEEP) at 5 cm H2O

• His latest hemoglobin (Hgb) : 10.3 mg/dL.
• ABG:
  • pH = 7.37
  • PaCO2 = 46 mmHg
  • PaO2 = 61 mmHg
  • SaO2 = 85%

10. Nursing responsibilities while administering norpinephrine to K.Z.

• Monitor blood pressure and apical pulse continuously during the therapy.
• K.Z. should be continuously monitored using cardiac monitor.
• During the norepinephrine infusion, defibrillator and crash cart should be kept ready in the bedside.
• Titrate the infusion rate of norepinephrine to maintain a systolic B.P. of 80-100mm hg
• Assess the client regularly for chest pain , headache and other sign s of toxicity.
• Do not mix any other drug with norepinephrine with the infusion.
• Extravasation of norepinephrine can cause tissue necrosis, therefore monitor the IV site every hour. Have phentolamine at the patient bedside.

Nursing responsibilities while administering Dobutamine to K.Z.

• Observe the IV site for extravasation.
• Monitor the patient for adverse effects like headache, hypertension, tachycardia, chest pain, shortness of breath, nausea, etc.
• Monitor blood pressure, pulse regularly during the infusion.
• Monitor ECG of the patient during the therapy
• Monitor the client for therapeutic effectiveness. Generally drug takes 10-20mins to produce peak effects.
• Monitor the fluid balance as urine output and sodium excretion generally increase because of improved cardiac output.

11. Four general areas of instructions related to his CABG surgery that should be given before he goes home are:

Self care :

• The client should have some kind of help at home with him for at least 1-2 weeks after surgery.
• Teach the client of how to check carotid and pulse by himself.
• Continue breathing exercises at home for at least 4 to 6 weeks
• Take shower every day and wash the incision area gently with soap and water.
• Do not swim, or soak in the hot tub until the incision is healed completely.
• Have a salt-restricted diet which is heart-friendly.
• Continue taking the medicines as prescribed by physician
• Do not stop taking any medicines by yourself

Activity

• Do not stand or sit for a long time, move around a little
• A brisk walk every day for 30 minutes, it's a good exercise for heart and lungs.
• Climbing stairs is fine , but should be careful. Take a pause and rest while climbing stairs.
• Patient can participate in light household chores like folding clothes, cutting vegetables etc.
• Slowly increase the intensity of exercise and activities for over 3 months.
• During any activity, if the client feels dizzy, chest pain, shortness of breath then the activity should be discontinued and client should have rest.
• Do not drive for at least 4-6 weeks post-surgery.
• Do not lift weights more than 2-3 kg.

Wound care

• Do not reach backward.
• Do not pull or push anything, as it put pressure on you incision.
• Do not lift anything more than 2-3 kg ( 5-7 lbs).
• Do not do activities that keep your arms above the shoulder level.
• Keep the incision area dry and clean.
• Do not apply any ointment on the incision site unless prescribed by the physician.

When to report to the hospital

• Chest pain or shortness of breath that does not resolve with rest.
• When the heart rate is very low ( below 60beat/min ) or very fast ( more than 120 beats/min).
• Severe headache that does not resolve
• Weight increases by more than 2 lbs ( 1kg) in a day
• The incision area becomes swollen, red, it has opened or is having excessive bleeding or drainage