Author Question: After assessing K.Z., the physician admits him with a diagnosis of CAD and HF for coronary artery ... (Read 31 times)

aabwk4 · **on:** Jun 25, 2018

After assessing K.Z., the physician admits him with a diagnosis of CAD and HF for coronary artery bypass graft (CABG) surgery.

Significant laboratory results drawn at this time are Hct 25.3, Hgb 8.8 g/dL, BUN
33 mg/dL, and creatinine 3.1 mg/dL. K.Z. is given furosemide (Lasix) and 2 units of packed red blood cells
(PRBCs).

Review K.Z.'s health history. Can you identify a probable explanation for his chronic renal
insufficiency and anemia?

Why is he receiving 2 units of PRBCs? What is the purpose of the furosemide?

Question 2

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.

What is your evaluation of the catheterization results?

Explain the significance of having an EF of 37.

What problem do the changes in assessment findings suggest to you? What led you to your conclusion?

List five actions you should take as a result of your evaluation of the assessment, and state
your rationales.

mbcrismon · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

If the perfusion to the kidneys is poor over a prolonged period, renal insufficiency develops.
One major cause of chronic, poor perfusion to his kidneys may be renal artery vascular disease
promoted by his long-term smoking habit. In addition, poorly perfused kidneys are not able to
produce adequate amounts of erythropoietin, an important factor stimulating RBC production. This
contributes to a chronic anemic condition.

K.Z. was anemic, and RBCs are necessary to carry oxygen and remove carbon dioxide. The
furosemide is a diuretic and is given to help K.Z. eliminate excess fluid and decrease the risk of
exacerbating the HF with the PRBC transfusions.

Answer to Question 2

He has severe occlusion of two major coronary arteries (RCA, LAD), meaning that much of
his ventricular muscle is without adequate blood supply. The old apical infarct is now tough,
noncontractile scar tissue. The coronary occlusions and scar tissue contribute to the low EF. An EF of 37 indicates that his left ventricle has lost almost half of its ability to pump blood.

The ejection fraction is the percentage of blood that is ejected from the heart during systole. EF in a normal heart is 50 to 70. When it drops to below 40, it indicates left ventricular HF and a serious drop in cardiac output (CO) from the left ventricle having lost much of its pumping ability. This is especially important because this is the working ventricle that pumps blood throughout the body.

K.Z. is developing HF with valve involvement. He has crackles in bilateral bases, pitting edema in his lower extremities, and a systolic ejection murmur (indicating valve involvement).

Take K.Z.'s VS and continue taking them every 15 minutes. K.Z. is experiencing some sudden
changes in his cardiovascular status that require close monitoring.
Ask him about symptoms relevant to HF such as shortness of breath and anxiety. Subjective
reports of how the patient feels (symptoms) supplement the objective data (signs) obtained by
your assessment.
Note K.Z.'s mental status. Is he restless, confused, or lethargic? Mental status is a good indicator of
cerebral perfusion and hypoxemia. Watch carefully for changes.
Determine his need for supplemental oxygen. Initiate oxygen therapy if needed. The crackles
indicate the development of pulmonary edema and potential need for oxygen.
Call the physician immediately, and report the previous findings.