Cardiac Conditions Case Study-Student Version PDF

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notes for cardiac lecture. different conditions that occurr with the cardiovascular system in the body, how you can treat them....

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Cardiac Conditions Case Study NUR 202 JL is a 32-year-old male, who arrives at the Outpatient surgery center for pre-Operative screening. Current History: JL was admitted to the hospital last month with chest pain. His cardiac enzymes were positive for an MI, his EKG had ST elevation in leads I, V5 and V6 indicating a lateral wall MI. A cardiac catheterization revealed blockage to his circumflex artery in 2 places. JL has a diastolic heart murmur heard at the 2nd ICS L sternal border. A transesophageal echocardiogram was done revealing an enlarged heart and aortic regurgitation. An ascending aortic aneurysm was also noted. The cardiac monitor reveals Atrial fibrillation with a heart rate between 60 & 120. Medical History: JL was born with a congenital heart condition. JL’s distal aorta did not develop fully resulting in a small aorta. To compensate his innominate artery enlarged to provide adequate blood flow. In addition, JL was also born with a bicuspid aortic valve which caused him to develop aortic stenosis at an early age. He had a valve replacement at age 13. He has hypertension that is mostly controlled. He has no other known medical history. Home Medications: 1. Lisinopril 10mg one time a day (ace inhibitor) 2. Atorvastatin 40 mg one time a day (cholesterol control) 3. Carvedilol CR mg two times a day 4. Isosorbide mononitrate 20 mg two times a day 5. ASA 81mg po q day (antiplatelet) 6. Apixaban 2.5 mg one time a day (anticoagulant for afib)

NOTICING 1. What is significant about JL’s current problem and past medical history that you, as the nurse, notice? Chest pain, lateral wall MI present (decreases cardiac output), Blockage to circumflex artery in 2 places, diastolic heart murmur at 2nd ICS Left sternal border (indicates aortic valve regurgitationaffects cardiac output), enlarged heart and aortic regurgitation, ascending aortic aneurysm (risk for rupture or dissection), Afib (The HR is ok because its not consistently high), has enlarged heart (heart does not pump well) leading to thick ventricle which cause smaller space for volume which leads to decreased stroke volume Born with congenital heart condition, aortic stenosis Hypertension (need to control BP to prevent rupture

2. What surgery(s) do you anticipate JL will need to have done? CABG Aortic valve replacement Ascending aortic aneurysm Repair 3. What nursing care should the community health nurse prioritize in managing JL’s care prior to surgery? BP Monitoring Vaping and alcohol cessation Run diagnostic tests, go over medications, prepare client for what is to be expected 4. What diagnostic tests do you anticipate JL will need? Why? Echocardiography to visualize structure and movement of heart TEE or TTE Labs: H/H, CBC, platelet, electrolytes, Glucose, BUN, Creatinine, GFR, blood screening, chest xray, assessment of heart and lungs, swas for MRSA 5. What pre-operative teaching should you include? Incentive spirometer, sequential pumps, foley, NG, ICU Medications are going to change Incision care (signs and symptoms of infection, CHG bath) Educate on expectations, to decrease anxiety Pain control (pain can increase stress on the heart) Activity restrictions 6. Are there any additional preoperative exams that JL will need before being cleared for surgery? Dental exams because they will not be able to get any done 6 months after surgery

7. What legal and ethical issues should you explore at the pre-operative visit? signing advance directives, healthcare proxy, and having the surgeon go over the benefits and risk of the procedure, witness the informed consent

Pre-operative screening results: Test

Result

Test

Result

Sodium

142mEq/L

Platelets

97 x10(9)/L

Potassium

3.0mEq/L

PT

13.4 seconds

Calcium

9.7mg/dL

INR

1.8

Glucose

186mg/dL

CXR

No lung consolidation.

Cardiac silhouette is enlarged BUN

18mg/dL

ECG

Atrial Fibrillation

Creatinine

0.8mg/dL

Blood Pressure

114/62

GFR

98mL/min

Pulse

54

WBC

8.6 x 10(9)/L

RR

18

RBC

3.8 x10(12)/L

Temp.

97.2 F

HGB

12.8 g/dL

HCT

38%

Pre-operative assessment findings: Lungs are clear Client Reports DOE (dyspnea on exertion) Apical pulse is strong with a murmur Skin: Pink, warm & dry Pedal pulses 1 + Bilat: Radial 2 + Reports chest pain 2-3/10 with activity. States he does not push himself because he is a “baby when it comes to pain.”

Interpreting 8. What assessment findings are you concerned about? Why? DOE, pedal pulse +1 (cardiac output is decreased), chest pain w activity, murmur present Potassium, High Blood sugar (can affect wound healing, possible unknown diabetes), low platelets (bleeding risk), INR high (bleeding risk) Hgb is low (concerned with blood loss from surgery)

9. What further actions should you take? Contact PCP, surgeon, and get glucose under control. JL is transferred to the ICU after an 8-hour surgery. He had a CABG x 2 to the circumflex, a mechanical aortic valve replacement and a repair of the ascending aortic aneurysm. 10. What actions do you prioritize in the immediate post-operative period? Why? Respiratory assessment & airway (pt on ventilator), pulse ox, ABGs circulation, temperature (hyperthermia-metabolic acidosis, too dilated), rewarm slowly, infection, incision site, pain control, bowel function, I&O, cardiac monitoring, CBC, INR, Electrolytes, monitor chest tube drainage (max 150ml/hr at first)

What potential complication(s) for each system (listed in the chart) will you monitor? What nursing interventions will you implement to prevent? System Cardiac

Potential Complication(s ) Dysrhythmias (brad dysrhythmias, Afib heart block Timpani (JVD)

Nursing Intervention(s) Monitor respiratory and potassium, utilize pacemaker as ordered

Respiratory

Respiratory distress, hypoxic Pneumonia (ventilator associate0

Monitor respiratory system incentive spirometer

Hematological

Hemorrhage,

Monitor labs, drainage

Neurological

Change in baseline neuro checks

Frequent neuro checks

Renal

Renal dysfunction

Monitor I&O, renal labs

Fluid and electrolytes

Dysrhythmias

Monitor lab, cardiac assessment

Skin

Infection, breakdown

Monitor sign and symptoms, turn patient, CHG bath

Pain

Elevated

Manage pain

Metabolic

Vascular

Decreased perfusion, Clots

Monitor pulses, early ambulation, SCDs

Other

11. Are there any complications that you are concerned about that are specific to each surgery? Aneurysm repair: bleeding and rupture Valve replacement: risk for bleeding (they are on anticoags) CABG: protecting the graph from blowing or collapsing (control BP)

12. The nurse is assessing JL 3 days post-operative. Which finding should the nurse be most concerned about? ▪ ▪ ▪ ▪ ▪

Low CVP reading ST depression in all leads BP of 122/70 in the right arm, 115/62 in the left arm Difficulty auscultating heart sounds-tamponade (very concerning) Increased cardiac output

JL is doing well, and it is time for him to be discharged. 13. What discharge instructions should the nurse include in the plan of care? CABG Valve Replacement Aneurysm Prophylactic antibiotics No heavy lifting for 6-12 Walking/exercise lifelong weeks Minimize fatigue Driving for a few weeks Anticoagulants with Stairs limit follow up blood work No dental procedure for 6 months

All New meds and med changes Incision care :s/s of infection

The home health nurse is visiting JL 2 weeks post-operative. JL states he is sleeping in a recliner because he has had chest pain of 6/10 for the past day, it feels better when he is sitting up.

14. What additional information do you want from JL? What make it better/worse? Does it radiate anywhere else?

15. What do you anticipate is cause of the chest pain? What is the treatment? Could be pericarditis (they feel better leaning forward)-NSAIDs, steroids, antibiotics Pericardial friction rub (sounds like sand paper on wood)

16. What is the greatest complication that can occur? How do you assess for this? Cardiac tampanode (too much fluid developing in the space (JVD, decreased HR, muffled heart sounds, hypotension)—pericardio centesis is treatment (put needle in pericardial sac and aspirate fluid....