Scenario Amber Saylor
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.
Five priorities I will discuss with the patient are checking for sensitivity to contrast media,
withhold food and fluids for 6-12 hrs before procedure, advise him there will be use of a local
anesthesia at insertion site, a flushed feeling is felt at injection of dye, and possible flutter
sensation of heart as the catheter is passed. He may be asked to cough or take deep breaths. This
patient will need hydration therapy because of his chronic renal insufficiency, baseline serum
creatinine levels will be obtained as well because the contrast can worsen renal dysfunction.
Medical Surgical by Lewis p. 677, 717
2. Look at his past history. What other factors are present that could contribute to his risk
for cardiac ischemia?
Factors that are present that could contribute to his risk for cardia ischemia are tobacco use, this
damages the inside wall of the arteries. Hypertension because it accelerates atherosclerosis. He is
at risk for chest pain associated with MI from his wife passing and loosing his job.
https://www.mayoclinic.org/diseases-conditions/myocardial-ischemia/symptoms-causes/syc-
20375417#:~:text=Conditions%20that%20can%20cause%20myocardial,common%20cause
%20of%20myocardial%20ischemia.
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.
Superior Vena Cava
Right Coronary Artery Left Coronary Artery
Left Ventricle Aorta Right Ventricle
(Modified from Fuller JK. Surgical Technology: Principles and Practice. 5th ed. St. Louis, MO:
Saunders; 2010.)
4. What is your evaluation of the catheterization results?
The LAD branches off from the left coronary artery and supplies the blood to the front of the left
side of the heart, this is almost completely blocked. As well as the RCA which supplies blood to
the right ventricle, right, atrium, and the SA and AV nodes, are completely blocked. The blocking
of the LAD will stop the flow to the left side of the heart, the left side of the heart is what
supplies the body with oxygenated blood. The RCA which is almost completely blocked as well,
can cause irregular heart rhythm, the ventricle, atrium and nodes are not getting supplied with
enough blood. The crackles and edema signal blockage.
https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronary-heart-disease
5. Explain the significance of having an EF of 37%.
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.
Five priorities I will discuss with the patient are checking for sensitivity to contrast media,
withhold food and fluids for 6-12 hrs before procedure, advise him there will be use of a local
anesthesia at insertion site, a flushed feeling is felt at injection of dye, and possible flutter
sensation of heart as the catheter is passed. He may be asked to cough or take deep breaths. This
patient will need hydration therapy because of his chronic renal insufficiency, baseline serum
creatinine levels will be obtained as well because the contrast can worsen renal dysfunction.
Medical Surgical by Lewis p. 677, 717
2. Look at his past history. What other factors are present that could contribute to his risk
for cardiac ischemia?
Factors that are present that could contribute to his risk for cardia ischemia are tobacco use, this
damages the inside wall of the arteries. Hypertension because it accelerates atherosclerosis. He is
at risk for chest pain associated with MI from his wife passing and loosing his job.
https://www.mayoclinic.org/diseases-conditions/myocardial-ischemia/symptoms-causes/syc-
20375417#:~:text=Conditions%20that%20can%20cause%20myocardial,common%20cause
%20of%20myocardial%20ischemia.
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.
Superior Vena Cava
Right Coronary Artery Left Coronary Artery
Left Ventricle Aorta Right Ventricle
(Modified from Fuller JK. Surgical Technology: Principles and Practice. 5th ed. St. Louis, MO:
Saunders; 2010.)
4. What is your evaluation of the catheterization results?
The LAD branches off from the left coronary artery and supplies the blood to the front of the left
side of the heart, this is almost completely blocked. As well as the RCA which supplies blood to
the right ventricle, right, atrium, and the SA and AV nodes, are completely blocked. The blocking
of the LAD will stop the flow to the left side of the heart, the left side of the heart is what
supplies the body with oxygenated blood. The RCA which is almost completely blocked as well,
can cause irregular heart rhythm, the ventricle, atrium and nodes are not getting supplied with
enough blood. The crackles and edema signal blockage.
https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronary-heart-disease
5. Explain the significance of having an EF of 37%.
