Written Case Presentation

Written Case Presentation

Abstract

Heart diseases have been prevalent nowadays, especially with the aging population of 55-88 years. These include cardiac arrest, heart failure, mitral regurgitation, myocardial infarction, and coronary heart disease, among others. Some of these heart diseases are fatal to the health of the victims and may lead to instant deaths, thus increasing morbidity and mortality rates among the aging population. A diagnosis of these infections is very vital, and most of them lead to cardiac surgery for them to be cured. Medical practitioners should take critical steps in diagnosing the diseases and using the necessary interventions that result in the wellbeing of the victims. Cardiac surgery also referred to as cardiovascular surgery, should be performed on the heart or the great vessels of the center of the affected persons by cardiac surgeons. This is a very delicate procedure that should be done keenly because, according to the National Institute for Health and Clinical Excellence (NICE), the survival chances of the surgery might be 96-97 percent depending on the type of the operation.

Introduction

In the field of critical care nursing, very close attention should be paid to the status of patients in post cardiothoracic surgery to prevent and limit the onset of difficulties and ensure the better patient outcome. The nature and the type of the procedure used and past medical history of the patient plays a vital role in the postoperative recovery course of the patient because it can be used to determine the onset of further complications. The main focus of this case study is examining a patient who is undergoing cardiovascular surgery concerning pertinent past medical history, current nursing diagnosis, evaluation of the outcomes, and Pharmacotherapy treatment with rationale.

Case Presentation

This 82-year-old male worker was admitted to one of the emergency rooms in a large hospital for treatment with a complaint of increasingly worsening exertional breath shortness for the past three weeks. The patient claimed that his shortness of breath had been temporarily relieved by resting, and adds that he has had bilateral fringe swelling that had developed over the past week. The patient also says that he had to reduce his daily activities dramatically over the past two weeks due to the increasing shortness of breath and that his urinary sequence had progressively reduced (Hardin & Kaplow, 2019). He denies orthopnea, cough, chest pain, fever, palpitations, or chills. He is currently on the Progressive Care Unit status of post aortic valve replacement, excision, and elimination of his left atrial thrombus and left-sided procedure; the patient is now in postoperative day 6.

From the review of the patient’s past medical history, it is evidential that he had suffered from hypertension, hyperlipidemia, sleep apnea, coronary artery disease, which included a post stent placement to his Left Anterior Descending artery in 2008, moderate aortic stenosis and lastly, benign prostatic hypertrophy. Going through his past surgical history in addition to the aforementioned stent placement, the patient also had back and shoulder surgeries in approximately 25 years ago. In a review of his social status, the patient refuses to have consumed alcohol or any illicit drug use. He had previously smoked half a pack of cigarettes each day for the last 34 years and quit smoking cigarettes three years ago, but currently, the patient chews tobacco two times a day (Hardin & Kaplow, 2019). His family history is also contributory, and he denies any allergies associated with medication and food. A review of his current symptoms gives positive findings that are associated with shortness of breath, generalized fatigue, and a decrease in weight, which is a result of the bilateral lower extremity swelling.

Clinical presentation and Lab and diagnostic test results

Vital signs of the patient: oral temperature of 36.5 degrees Celsius, heart rate 61 bpm and which is seen to be in sinus rhythm, noninvasive blood pressure through his right arm of 135/74, oxygen saturation on room air of 98% and respiration rate of 18 bpm (Hardin & Kaplow, 2019). The patient is currently awake, oriented, and alert. Equal bilateral weakness is evident in lower and upper extremities, and he is neurologically intact. Bowel sounds are noted in all his quadrants, contrary for guarding, and pain; other than the surgical incision, the patient’s remaining skin is pink and intact. The patient is also found to be voiding the recommended amount of bright yellow urine without any difficulty (Voltelen, Konradsen, & Østergaard, 2016). The postoperative transesophageal echocardiogram shows a progressive increase in the injection fraction from 24% to 33%, indicating there is a presence of systolic heart failure. His prescribed current medications include fish oil, vitamin C, simvastatin, enoxaparin, nicotine patch, docusate, aspirin, amiodarone, potassium, and warfarin.

Comparison between expected and actual findings

Care Plan

The care plan for the patient includes the following;

1. Nursing Diagnoses

The first diagnosis concerns the activity of the patient in intolerance related to entirely his generalized weakness and disproportion in oxygen supply and demand, which results from the shortness of breath with fatigue and exertion (Voltelen, Konradsen, & Østergaard, 2016). The second diagnosis concerns the patient’s unsuitable voiding sequence that is related to his systolic heart failure, which is a result of the decreased urinary output, heightened creatinine levels, and increased brain natriuretic peptide level.

1. Nursing Interventions and their goals

The care plan of the patient includes intervention that helps in maximizing his energy, controlling pain levels, promoting rest, and increasing his complexity so as he can practice activities of daily life before he is discharged. These include close monitoring of the vital signs during the operation because increased heart rate could decrease the myocardial perfusion and result in the recurrence of arrhythmias (Hardin & Kaplow, 2019). Secondly, the patient should be administered antihypertensive and diuretic medications because such medications increase the myocardial perfusion of the patient and in the long run, decrease the amounts of preload. Lastly, the patient should be assessed on his weight daily and educating the patient on the signs and symptoms of heart failure, which might result in his condition of systolic heart failure and volume overload conditions (Hardin & Kaplow, 2019).

• Evaluation

The evaluation of these interventions will take place, especially during the daily multidisciplinary activities imposed on the patient at his bedside. The clinical nurse specialist, the bedside nurse, case manager, clinical pharmacist, and any other social worker should participate in the goal creation, evaluation, and assessment of the patient’s condition (Voltelen, Konradsen, & Østergaard, 2016). Monitoring the patient’s signs and symptoms allows them to evaluate his cardiac workload after his daily activities. Daily radiographs should be conducted to the patient’s chest, which will help in assessing his fluid status and the progress of coercion and the need for any other medical intervention.

Summary

In summary, the patient in this case study underwent a maze procedure, aortic valve replacement, and removal of his left atrial appendage despite his complex past medical and surgical histories. The aforementioned rounding sessions by the multidisciplinary surgical team yielded thoroughly through the careful interventions and care plan that enabled healing of the patient and positive outcome. The continued planning, assessment, and evaluation of these interventions and goals allowed the care plan to be tailored to the patient’s social and individual needs, which in turn promotes patient-centered care. Finally, the thorough execution of the care plan made it possible for the patient to be discharged from the hospital to home with physical and health therapy on postoperative day 10.

References

Avery, K. R., O’Brien, M., Pierce, C. D., & Gazarian, P. K. (2015). Use of a nursing checklist to facilitate the implementation of therapeutic hypothermia after cardiac arrest. Critical care nurse, 35(1), 29-37.

Hardin, S. R., & Kaplow, R. (2019). Cardiac surgery essentials for critical care nursing. Jones & Bartlett Learning.

Voltelen, B., Konradsen, H., & Østergaard, B. (2016). Family nursing therapeutic conversations in heart failure outpatient clinics in Denmark: Nurses’ experiences. Journal of family nursing, 22(2), 172-198.