Nur255 – Acute Care Cardiac Case Study

Total Points: 25 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. 5 points I would teach him that after the procedure he will need to remain in bed with his extremity flat for the first 12 to 24 hours with the HOB elevated at 30 degrees. That we will be placing an IV and giving his heparin and give teaching on antiplatelet med. They may use radial access but can possibly use the femoral access to get the job done. I would tell him that the doctor will be inserting a catheter that has a balloon like device to the blockage(s) and if the needed the doctor may place a stent. Advised the patient that he will have a pressure dressing in place that is to remain there and is not to be touched. The health care team will be monitoring him before during and after the procedure to ensure his wellbeing and safety by checking for pluses, bleeding, procedure complications, ECG monitoring and all vital signs. 2. Look at his past history. What other factors are present that could contribute to his risk for cardiac ischemia? 1 point. The past history of previous MI, HTN, being a male over the age of 45 y.o. and being a smoker, having increased stress trying to cope with the passing of his wife, having increased lipids / CAD, having a poor diet / lifestyle for his diseases and having chronic anemia as well as renal issues. 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. What is your evaluation of the catheterization results? 1 point He could now be having acute pulmonary edema, or he may be having fluid volume overload. Another possible issue could be that he is going into total heart failure since he is having crackles and edema that where not noted before. 4. Explain the significance of having an EF of 37%. 1 point The patient is only pumping out 37% of his blood in the heart. The normal level for EF is 55% (+) so the patient has a very low EF. This means that the patient’s heart failure damage is causing his ventricle to not pump as well as it should be normally. 5. What problems do the changes in assessment findings suggest to you? What led you to your conclusion? 1 point The assessment findings suggest that the patient is showing signs of heart failure because his heart is not contracting effectively and having both left sided heart failure because she is having lung crackles and decrease EF and congestion. He is also showing signs of right sided heart failure due to having edema and that he is having issues with management of his CAD since he has multiple blockages and decreased blood flow.