Case study 3 - CABG

Question 1

explain the pathway of blood in the heart from lungs to body

Answer 1

• deoxygenated blood into right atrium
• tricupsid valve
• right ventricle
• pulmonary artery
• lungs
• oxygenated blood into pulmonary vein
• left atrium
• mitral valve
• left ventricle
• aorta
• body

Question 2

name nerves in the heart

Answer 2

• sinoatrial node (cause atria to contract)
• atrioventricular node (cause ventricles to contract)
• bundle of HIS (electrical conduction in the heart)
• punkunje fibres (electrical impulse to the ventricles)

Question 3

what is a myocardial infarction

Answer 3

heart attack caused by blockage in arteries

Question 4

what causes a coronary artery disease

Answer 4

• plaque depositis build up in the arteries
• this is called athlerosclerosis
• therefore arteries cannot supply oxygen rich blood to the heart

Question 5

where is left descending artery

Answer 5

branches of left coronary artery and supplies blood to the front of the left side of the heart

Question 6

name the arteries of the heart

Answer 6

• left + right coronary arteries
• circumflux artery (supply back of heart)
• left anterior descending arteries (blockage of these are most common in heart failure)
• right posterior descending arteries

Question 7

what is coronary bypass grafting

Answer 7

• surgery to treat coronary artery disease
• ## Involves taking a blood vessel (graft) usually forearm or chest and attaching it to coronary artery above or below blockage

Question 8

what is the progression of mobility after CABG

Answer 8

• Generally, you should be able to sit in a chair after 1 day, walk after 3 days, and walk up and down stairs after 5 or 6 days.

Question 9

what arteries would the graft most likely been taken from?

Answer 9

• arm: radial artery
• chest: internal mammory artery
• leg: saphernorus vein

Question 10

What assessment would you do for decreased chest expansion?

Answer 10

• tactile fremitus feeling for equal chest epansion (likely to feel decreased in anterior + posterior lower lobes due to atelectasis)
• palpation of accessory muscles feeling for hypertorphy
• observe respiratory rate, likely to be decreased due to respiratory acidosis (hypoventilation)
• use dyspnoea scale (rate of perceived exertion)

Question 11

How would you treat decreased chest expansion?

Answer 11

• use incentive spirometer
• teach ACBT technques

Question 12

What evidence is there for treatment of decreased chest expansion using incentive spirometer

Answer 12

• Sum et al, 2019
• help him to increase his chest expansion use 3-5 seconds, 10x an hour for 8 hours a day.
• Edmond has left lower lobe atelectasis, this evidence supports the use of incentive spirometer and decreasing the risk of developing pulmonary complications.
• Using this will help diminish atelectasis and prevent micro-atelectasis as well as other complications, such as pneumonia

Question 13

What assessment would you do for secretion retention in left lower lobe?

Answer 13

• sputum sample
• auscultation (hear crackles left lobe and diminished sounds left lower lobe due to atelectasis)
• vocal fremitus
• cough strength

Question 14

How would you treat secretion retention?

Answer 14

• postural drainage (right side lying)
• ACBT technique
• supported cough

Question 15

What evidence is there to treat secretion retention?

Answer 15

• Zisi et al 2022
• explain aim, method, findings, conclusion
• ACBT is effective in increasing the expectorated sputum volume, in reducing viscoelasticity of the secretion.
• He can then expectorate secretions by using supported cough technique

Question 16

what is atelectasis?

Answer 16

• complete or partial collapse of lung
• there are 6 types
• most common is obstructive when there is obstruction from sputum decreasing area for gaseous exchange.
• but also could be due to surgery

Question 17

what are the causes of atelectasis?

Answer 17

• smoking
• anesthesia
• duration of surgery
• prolonged bed rest
• ventilators

Question 18

what is prolonged standing hypertension?

Answer 18

• increased hypertrophy of the left ventricular artery

Question 19

what are the symptoms of prolonged standing hypertension?

Answer 19

• severe headaches.
• chest pain.
• dizziness.
• difficulty breathing.
• nausea.
• vomiting.
• blurred vision or other vision changes.

Question 20

how would you assess decreased exercise tolerance

Answer 20

• use dyspnoea scale/rate of percieved exertion
• respiratory rate
• 5 times STS, should be able to complete 5 within 3.6 to 4.2 second. Likely to find this difficult, back up by evidence fromZhang et al 2018.

Question 21

how would you treat decreased exercise tolerance

Answer 21

• marches on spot, sit and rest
• progress to mobilise patient with WZF to sit on in chair
• Teach ACBT to ensure breathing pattern is maintained and risk of pulmonary complication decreased
• outcome measure using dyspnoea scale used.
• this will also help to improve his left lower lobe atelectasis

Question 22

what evidence is there to show how is mobilising patient with respiratory acidosis is okay for treatment

Answer 22

• Bailey et al 2007
• explain aim, method, findings, conclusion
• early activity is feasible and safe in respiratory failure patients.
• therefore, mobilising Amiel is important to help increase exercise tolerance and decrease risk of muscle weakness

Question 23

what does the left anterior descending artery do.

Answer 23

The left anterior descending artery branches off the left coronary artery and supplies blood to the front of the left side of the heart.

Question 24

what are the layers of the heart

Answer 24

• epiocardium
• myocardium
• endocardium

Question 25

what does it mean if Ed has ABG values of:
pH: 7.30, PaCo2: 6.5, Pao2: 8, HC03: 24

Answer 25

ph = low
PaCo2 = high
HCO3 = normal
= respiratory acidosis