Question

On September 16, 2020 Patient Juan Dela Cruz, 73 years old came to the ER with complaints of anterior chest discomfort that radiated to her neck, jaw, and back and was accompanied by shortness of breath. He was referred to Cardiology department and was attended to by the physician STAT. Assessment findings included a heart rate of 84 beats per minute, blood pressure 172/68 mm Hg, height 5'5", and weight 171 pounds. Waist-hip ratio was 0.75, and skin fold calipers measured 42% body fat. Lipid profile included total cholesterol of 239 mg/dL, HDL 40 mg/dL, LDL 159 mg/dL, ratio 5.9 mg/dL, and triglycerides 248 mg/dL. Fasting glucose was 79 mg/dL. Past medical history included hiatal hernia, cholecystectomy, hypothyroidism, arthritis, insomnia, and a long-standing history of ankle edema. The patient also reported symptoms suspicious of sleep apnea. The diagnostic workup included a 12-lead EKG and nuclear medicine stress test (thallium scan), and was scheduled for cardiac catheterization. He was not considered a candidate for the exercise EKG due to her advanced age and other comorbidities, specifically arthritis, which would limit his ability to exercise at adequate intensity levels. The 12-lead EKG revealed nonspecific T-wave changes in the inferior leads, and the nuclear medicine test was positive, suggestive of single-vessel disease of the left circumflex artery. A day later, Cardiac catheterization was then performed and showed triple vessel disease with significant left main disease. Her occlusions were 50% to 60% of the left main, 90% of the circumflex, and 60% of the right coronary artery. EF was estimated at 60%, indicating preserved left ventricular function. Based on these diagnostic findings, the patient was referred for cardiac surgery and after 2 days, patient Juan Del Cruz underwent CABG surgery with internal mammary grafting. On the first postoperative day, the patient remained in the intensive care unit on the IABP and ventilator, Lab values showed a creatine phosphokinase of 3113 IU/L and creatine kinase isoenzyme MB of 169.4 IU/L. A bedside echocardiogram confirmed an inferior-posterior and right ventricular infarct. The patient was transferred to the cardiac surgical ward on the second postoperative day, where he developed atrial fibrillation where patient is also complaining of mild shortness of breath but denied chest pain, he also complained about dizziness and palpitation (PR of 130 bpm) Physical Examination revealed revealed a PR of 130 bpm, BPof 120/80 mmhg, normal oxygenation and no signs of heart failure. Oxygen was still at 5 LPM per nasal cannula and her ambulation was significantly limited.

case study

assessment

nursing intervention

rationale

diagnostics

Answer 1

Case study : CABG wiih atrial fibrillation 2nd post op day

Coronary Artery bypass grafting (CABG) circumvents an occluded coronary artery with an autogenous graft,there by restoring blood flow to the myocardium.Atrial fibrillation is one of the common complications of cardiac surgery

Atrial fibrillation Pathophysiology: An electrical activity disturbance in the heart that causes an irregular and often rapid heart beat.The atria quiver sending confusing electrical signals to the ventricles,leaving them unsure of when to contract thus beating irregularly.During atrial fibrillation,the heart is a less effective pump because of the quivering as well as not emptying completely.This causes the blood to pool and a clot can form.The clot can venture out of the heart into the lungs,pulmonary embolism (PE),Brain (stroke) or extremities (DVT)

Desired outcome

• Decreasing risks of clot formation,a heart rate within normal limits and rhythm control.The ultimate outcome is converting back to normal sinus rhythm.

2)Nursing assessment

Subjective data

• Heart palpitation
• Dizziness
• Mild shortness of breath

Objective data

• Irregular heartbeat
• Tachycardia
• Vitals: BP 120/80,pulse130bpm.

3) Nursing interventions

1)Obtain a 12 lead ECG.

Rationale:

• Used to diagnose atrial fibrillation
• The waves are more chaotic and random
• The beat is irregular
• Observe the atria quivering between the QRS( ventricles pumping)
• Nodiscernible P waves.The ventricular rate is often 110-160 bpm and the QRS complex is usually less than 120 ms.

2) Potential rhythm control: Electrocardioversion,Ablation,Pacemaker

Rationale: Electrocardioversion,is used to “reset” the hearts electricity. The patient will be shocked on the outside of the chest wall.This treatment is used for patients who have infrequent episodes of atrial fibrillation because if the patient has it frequently,they have a high probability of the a fib returning after being cardioverted. If there is blood clot in the atria,cardioverting may send the clot out of the heart to the brain,lungs or extremities.The chance of blood clot increases the longer the patient in a fib,consider anti coagulation prior to cardio version.

Ablation used for patients that have not been able to control their afib for a long time with medication,or cardioversion.A catheter is inserted into the patients heart and destroys cardiac muscle cells so they scar,causing the activity to stop In those cells,thus eliminating the passing of chaotic electrical activity

Pacemaker: A temporary pacemaker can be performed for immediate relief if persists permanently placed under the skin and is a device that sends electrical signals to the heart to help it beat with the right rhythm and pace.

3)Heart rate control: Beta blockers:- Propranolol,Metoprolol,Atenolol Calcium channel blockers,Dilitiazem,Verapamil,Cardiac glycosides:- Digoxin

Rationale:

A Heart can only sustain rapid beating for so long before it tries out. Using beta blockers,calcium channel blockers and cardiac glycosides well help control of the heart beat.

Beta Blockers: They block beta 1 receptors from being stimulated.Stimulation of Beta 1 can cause positive inotropic( force of contraction)and chronotropic( pace of the heart) effects.If you block beta 1 you will have decreased force of contraction and decreased heart rate

Calcium Channel blockers: They block calcium channels.When calcium enters the cell in causes the cell to contract,thus when the channels are blocked,it decreases the production of electrical activity innately deceasing the heart rate.

Cardiac Glycosides: This medication stimulates the vagus nerve,which when stimulated slows the heart rate down.The vagus nerve is a CNS nerve that also works with the PNS- specifically the autonomic parasympathetic system AKA rest and digest.So if this is stimulated the body will rest/slow down,thus decreased heart rate

4)Anticoagulation Therapy: Coumadin, Aspirin,Lovenox,Plavix,Eliquis

Rationale: Thinning the blood helps to disintegrate and break up the clot as well as increasing flow of blood.There are many options for blood thinners each with their own pros and cons

5) Fall education

Rationale: Being on blood thinner,the patient needs to be informed of their risk of bleeding out especially if they fall and hit their head .

6) Stroke education: Use the FAST mnemonic F: Facial drooping A:Arm weakens S:Slurred speech T: Time to call emergency help

Rationale: The risk of a clot forming and moving to the brain is fairly high,so it is important to teach the patient and family members the SS  of stroke

7)Cardiac enzyme Monitoring: Troponin I Creatine KinaseMB

Rationale: Initial measurement of the cardiac enzymes is important because it helps with any trending information,the sooner you get this information the better.Also getting trending results over specific periods of time is helpful.