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?
• Due to the fact that all the arteries are at least over 70%
occluded means that the heart is not getting enough perfusion
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?
• Due to the fact that all the arteries are at least over 70%
occluded means that the heart is not getting enough perfusion
