lOMoARcPSD|24448587
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Case Study 13 Coronary Artery Disease
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and Coronary Artery Bypass Surgery
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Difficulty: Advanced
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Setting: Hospital
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Index Words: coronary artery disease (CAD), heart failure (HF), coronary artery bypass graft (CABG),
cardiac
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catheterization, hemodynamic monitoring, laboratory values, medications, assessment
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Giddens Concepts: Clinical Judgment, Coping, Gas Exchange, Patient Education, Perfusion
HESI Concepts: Assessment, Clinical Decision Making—Clinical Judgment, Gas Exchange, Patient Education,
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Perfusion,
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Stress & Coping
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Scenario
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Your patient, 58-year-old K.Z., has a significant cardiac history. He
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has long-standing coronary artery disease (CAD) with occasional
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episodes of heart failure (HF). One year ago, he had an anterior wall
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myocardial infarction (MI). In addition, he has chronic anemia,
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hypertension, chronic renal insufficiency, and a recently diagnosed
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4-cm suprarenal abdominal aortic aneurysm. Because of his severe
CAD, he had to retire from his job as a railroad engineer about 6
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months ago. This morning, he is being admitted to your telemetry
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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
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time that he had his MI) and he does not have any children. He is a
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current cigarette smoker with a 50–pack-year smoking history. His
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vital signs (VS) are 158/94, 88, 20, and 97.2 ° F (36.2 ° C). As you
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talk with him, you realize that he has only a minimal understanding
of the catheterization procedure.
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1. Before he leaves for the catheterization laboratory, you briefly
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teach him the important things he needs to know before
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having the procedure. List five priority topics you will address.
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• The importance of smoking cessation sh
• Extensive measures are taken to reduce the need for RBC transfusion, but there
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is a possibility of having to get a blood transfusion if bleeding occurs
• Fasting 6 to 8 hours prior to procedure
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• Avoid strenuous activity until your provider gives the OK to resume normal
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activities
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• Must lie flat after procedure is done
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• You will be awake during procedure but they will give you something to take
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the edge of
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2. Look at his past history. What other factors are present that
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could contribute to his risk for cardiac ischemia?
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• 50 pack- year smoking history
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• Anterior wall Myocardial Infarction
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• Long standing coronary artery disease
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• Hypertension
• Chronic anemia
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Several hours later, K.Z. returns from his catheterization. The
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catheterization report shows 90% occlusion of the proximal left
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anterior descending (LAD) coronary artery, 90% occlusion of the
distal LAD, 70% to 80% occlusion of the distal right coronary artery
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(RCA), an old apical infarct, and an ejection fraction (EF) of 37%.
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About an hour after the procedure is finished, you perform a brief
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physical assessment and note a grade III/VI systolic ejection
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murmur at the cardiac apex, crackles bilaterally in the lung bases,
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and trace pitting edema of his feet and ankles. Except for the soft
systolic murmur, these findings were not present before the
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catheterization.
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la
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3. Using the following diagram, identify the superior vena cava, the
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aorta, and the left and right ventricles. Identify the main coronary
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arteries and circle the areas of the LAD and RCA that have
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significant occlusion, as identified in the previous report. Identify
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the area of the heart where K.Z. had the earlier infarct.
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Sp
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1. Superior vena cava
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2. aorta
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3. left coronary artery
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4. right coronary artery
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• The RCA occlusion is the big circle
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located distal to the aorta.
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• Both the LAD occlusion are located
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above the bigger circle located at the
a
apex of the heart
•
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4. What is your evaluation of the catheterization results?
• Due to the fact that all the arteries are at least over 70%
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occluded means that the heart is not getting enough perfusion
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Downloaded by Martin muthii ()
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Case Study 13 Coronary Artery Disease
ne
and Coronary Artery Bypass Surgery
la
tz
Difficulty: Advanced
sh
Setting: Hospital
Sp
Index Words: coronary artery disease (CAD), heart failure (HF), coronary artery bypass graft (CABG),
cardiac
ne
catheterization, hemodynamic monitoring, laboratory values, medications, assessment
la
Giddens Concepts: Clinical Judgment, Coping, Gas Exchange, Patient Education, Perfusion
HESI Concepts: Assessment, Clinical Decision Making—Clinical Judgment, Gas Exchange, Patient Education,
sh
Perfusion,
Sp
Stress & Coping
ne
Scenario
la
Your patient, 58-year-old K.Z., has a significant cardiac history. He
tz
has long-standing coronary artery disease (CAD) with occasional
sh
episodes of heart failure (HF). One year ago, he had an anterior wall
Sp
myocardial infarction (MI). In addition, he has chronic anemia,
ne
hypertension, chronic renal insufficiency, and a recently diagnosed
la
4-cm suprarenal abdominal aortic aneurysm. Because of his severe
CAD, he had to retire from his job as a railroad engineer about 6
sh
Sp
months ago. This morning, he is being admitted to your telemetry
ne
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
la
time that he had his MI) and he does not have any children. He is a
tz
current cigarette smoker with a 50–pack-year smoking history. His
sh
Sp
vital signs (VS) are 158/94, 88, 20, and 97.2 ° F (36.2 ° C). As you
ne
talk with him, you realize that he has only a minimal understanding
of the catheterization procedure.
la
sh
1. Before he leaves for the catheterization laboratory, you briefly
Sp
ne
teach him the important things he needs to know before
la
having the procedure. List five priority topics you will address.
tz
• The importance of smoking cessation sh
• Extensive measures are taken to reduce the need for RBC transfusion, but there
Sp
ne
is a possibility of having to get a blood transfusion if bleeding occurs
• Fasting 6 to 8 hours prior to procedure
la
• Avoid strenuous activity until your provider gives the OK to resume normal
sh
activities
Sp
• Must lie flat after procedure is done
ne
• You will be awake during procedure but they will give you something to take
a
the edge of
tz
l
sh
Sp
ne
la
sh
Sp
la
Downloaded by Martin muthii ()
Sp
, lOMoARcPSD|24448587
ne
sh
2. Look at his past history. What other factors are present that
ne
could contribute to his risk for cardiac ischemia?
la
• 50 pack- year smoking history
tz
• Anterior wall Myocardial Infarction
sh
Sp
• Long standing coronary artery disease
ne
• Hypertension
• Chronic anemia
la
Several hours later, K.Z. returns from his catheterization. The
sh
Sp
catheterization report shows 90% occlusion of the proximal left
ne
anterior descending (LAD) coronary artery, 90% occlusion of the
distal LAD, 70% to 80% occlusion of the distal right coronary artery
la
(RCA), an old apical infarct, and an ejection fraction (EF) of 37%.
tz
sh
About an hour after the procedure is finished, you perform a brief
Sp
physical assessment and note a grade III/VI systolic ejection
ne
murmur at the cardiac apex, crackles bilaterally in the lung bases,
la
and trace pitting edema of his feet and ankles. Except for the soft
systolic murmur, these findings were not present before the
sh
catheterization.
Sp
ne
la
tz
3. Using the following diagram, identify the superior vena cava, the
sh
aorta, and the left and right ventricles. Identify the main coronary
Sp
arteries and circle the areas of the LAD and RCA that have
ne
significant occlusion, as identified in the previous report. Identify
la
the area of the heart where K.Z. had the earlier infarct.
sh
Sp
ne
1. Superior vena cava
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2. aorta
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3. left coronary artery
sh
Sp
ne
4. right coronary artery
la
• The RCA occlusion is the big circle
sh
located distal to the aorta.
Sp
• Both the LAD occlusion are located
ne
above the bigger circle located at the
a
apex of the heart
•
tz
l
sh
Sp
ne
4. What is your evaluation of the catheterization results?
• Due to the fact that all the arteries are at least over 70%
la
occluded means that the heart is not getting enough perfusion
sh
Sp
la
Downloaded by Martin muthii ()
Sp
