Patient Y, a woman 76 years of age, was seen in the Women's Cardiac Center for a

personalized health and risk factor assessment. 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.
Based on this assessment, cardiovascular risk factors were identified, and the patient was
instructed on risk factor modification. Four months later, she phoned the Women's Cardiac Center
with complaints of anterior chest discomfort that radiated to her neck, jaw, and back and was
accompanied by shortness of breath. She was referred to Cardiology and seen three days later.
The diagnostic workup included a 12-lead EKG and nuclear medicine stress test (thallium
scan), followed by cardiac catheterization. She was not considered a candidate for the exercise
EKG due to her advanced age and other comorbidities, specifically arthritis, which would limit her
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. 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.
Two weeks later, Patient Y underwent CABG surgery with internal mammary grafting.
During surgery, she required inotropic support with dobutamine and epinephrine and
atrioventricular sequential pacing. An intra-aortic balloon pump (IABP) was also placed via the
right femoral artery due to right heart failure. 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 stepdown unit on the third
postoperative day, where she developed atrial fibrillation and was digitalized. Oxygen was
administered at 5 L per nasal cannula and her ambulation was significantly limited. In addition, a
bruit was noted in her right groin. An echo-Doppler revealed a two-chamber pseudoaneurysm,
which was unsuccessfully compressed. On the sixth postoperative day, the patient went in and
out of atrial fibrillation/flutter and converted to sinus rhythm on postoperative day 7. As a result,
she was weaned from oxygen and progressed with independent ambulation. However, she
remained hospitalized until postoperative day 12 for observation of her heart rhythm and right
groin pseudoaneurysm.
Two days after discharge, the patient received a follow-up telephone call from the Cardiac
Liaison Nurse to assess her condition. Patient Y stated she was "feeling pretty good," yet indicated
some difficulty with incisional pain, anorexia, fluid loss, insomnia, and confusion about her
medications. After recuperating at home, the patient enrolled in a phase II cardiac rehabilitation
program. Currently, the patient reports no angina or chest discomfort. She is progressing in her
exercise program and tolerating activity. Problems experienced since discharge include a urinary
tract infection, depression, and increasing heart failure. Her furosemide dosage has been
increased, and she has obtained good relief of her symptoms.

1. What coronary risk factors are present?

During the health and risk factor assessment, the patient manifested a number of
factors that could contribute to coronary diseases. First is her age, wherein women past
the age of 55 are at risk due to the plaque build up (National Heart, Lung, and Blood
Institute), the walls thickening and the arteries stiffening. Next is the presence of high
blood pressure as evidenced by her blood pressure of 172/68 mm Hg which is considered
as stage 2 hypertension, and a pulse pressure of 104 mm Hg. Blood pressure is a key
determinant to coronary heart disease because it means that the heart is working harder
and the arteries are less flexible. Another possible factor is the patient’s weight wherein
she is overweight as evidenced by a BMI of 28.5 and a 42% body fat. Extra weight may
increase cholesterol levels, blood pressure, and blood glucose levels which are major risk
factors for coronary diseases. Lastly is the patient’s cholesterol levels, which is a major
factor for coronary heart diseases. As shown in her lipid profile, she has a high cholesterol
level of 239 mg/dL. Having high cholesterol levels allows the possibility for fatty deposits
to develop in the blood vessels which could make it difficult for blood to flow through the
arteries. The results also show a low high density lipoprotein of 40 mg/dL which means
that there could be a possibility of excess cholesterol in the body, and a high low-density
lipoprotein of 159 mg/dL which indicates that more cholesterol are brought to the arteries,
the ratio shows 5:9 mg/dL which is also considered high. All three results predisposes the
patient for atherosclerosis due to the possible plaque buildup in the arteries. Moreover,
the lipid profile shows a high triglyceride level of 248 mg/dL. High triglyceride levels may
cause the arteries to harden, which also causes atherosclerosis.

The patient's medical history may reveal other coronary risk factors as well. First,
cholecystectomy have been studied to have a correlation with an increased risk of
metabolic syndrome (MetS). MetS's many components, include high blood pressure, and
others such as visceral obesity, dyslipidemia, impaired fasting glucose, and insulin
resistance. Furthermore, results from a specific study shows that people with complex
gallstone disorders, which frequently necessitate cholecystectomy, are more likely to
develop MetS than patients with simple gallstone disease. Shen et al. evaluated data from
5672 people in a cross-sectional research and discovered that the prevalence of MetS
was 53.2% among patients with gallstone disease and 63.5% among cholecystectomized
subjects. This analysis shows that cholecystectomy may be a risk factor for MetS, and
particularly coronary conditions such as high blood pressure. Second, hypothyroidism is
known to impair cardiac contractility, which is frequently diastolic and can result in lower
cardiac output. Frequent pathophysiological alterations include increased systemic
vascular resistance, reduced arterial compliance, and atherosclerosis (plaque in the
arteries). Third, arthritis, as we all know, affects the joints. However, having arthritis –
particularly inflammatory conditions such as rheumatoid arthritis (RA), gout, lupus, and
psoriatic arthritis – increases one's risk of coronary diseases such as heart attack, stroke,
atrial fibrillation (irregular heartbeat), high blood pressure, heart failure, and
atherosclerosis. According to the Arthritis Foundation, people with RA are 50 to 70% more
likely than the general population to have cardiovascular disease. On the other hand,
people with OA have a 24% greater risk of developing cardiovascular disease than the
general population. They also found that atherosclerosis affects about half of all persons
with heart disease. Lastly, Jean-Louis et al. have found that people with obstructive sleep
apnea had higher amounts of endothelin and lower levels of nitric oxide than healthy
sleepers. This increased endothelin is also thought to compromise blood pressure control.
As a result, people with obstructive sleep apnea frequently have increased blood vessel
constriction.
2. What surgical procedures were done to the client? Describe these surgical
procedure and discuss the pre procedure and post procedure nursing responsibilities.
Based on the diagnostic findings, it suggests that patient Y has triple vessel
disease with significant left main disease. Revealing 50-60% occlusion of the left main
coronary artery, 90% of the left circumflex artery, and 60% of the right coronary artery.
With this, patient Y underwent Coronary artery bypass graft (CABG) surgery with internal
mammary grafting. To further elaborate, CABG surgery or also known as bypass graft is
a surgical procedure that restores normal blood flow by creating a detour or bypass around
the occluded or blocked artery/arteries wherein it is done by using a healthy blood vessel
that is located in the chest, arm or leg of the patient and is grafted to an occluded coronary
artery, as such it creates a new pathway to carry oxygenated blood into the heart and
inorder for the blood to flow beyond the occlusion. Moreover, CABG surgery is indicated
for alleviating angina that cannot be controlled with medications, treatment for left main
coronary artery stenosis or multivessel Coronary Artery Disease (CAD), prevention and
treatment for Myocardial Infarction (MI), dysrhythmias, and heart failure. Furthermore, the
recommendation for CABG surgery is determined by a number of factors which includes:
the number of diseased coronary vessels, the degree of left ventricular dysfunction, the
presence of other health problems, and patient’s symptoms such as sleep apnea, chest
discomfort, and shortness of breath. In order for a patient to be considered for CABG, the
coronary arteries to be bypassed must have at least 70% occlusion, or at least 50%
occlusion if it is in the left main coronary artery. In addition, it is recommended that the
internal mammary artery should be used for CABG surgery, as stated by recent studies
Internal mammary artery (IMA) grafts have been associated with long-term patency of
blood flow with improved survival rate as it does not develop atherosclerotic changes as
quickly.

Nursing Responsibilities before patient undergoes procedure:

• Obtain informed consent.
• Assess the patient's physical and psychological needs.
• Pain management
• Review the patient’s preoperative diagnostic and laboratory test.
• Review the patient’s medication history and ensure that medications that can
interfere with normal wound healing were discontinued for preparation for the
procedure.
• Answer questions and concerns regarding the patient's surgical procedure .
• Perform skin preparation to the surgical incision site.
• Prepare surgical equipment and ensure a sterile OR environment.

Nursing Responsibilities after patient undergoes procedure:

• Maintain airway patency and monitor pulmonary status.
• Monitor vital signs, intake, & output.
• Assess the patient’s hemodynamic and cardiac status as atrial fibrillation is a
common complication of cardiac surgery.
• Perform peripheral and neurovascular assessments every hour for the first 8
hours. After the patient is stable, assess every 2 hours for the next 8 hours, then
every 4 hours for the succeeding 8 hours.
• Monitor neurologic status. Notify the physician and/or anesthesiologist if the
patient hasn’t woken up after 8 hours.
 • Provide health teaching on medications, mobilization limits, and diet that will
ensure faster recovery.
• Pain management
• Monitoring and dressing surgical wound routinely

3. If you are the Nurse in the Holding area, What are the necessary information and
assessment that you should perform?
As a Nurse in the Holding area, the nurse should strive to complete Admission history and
physical assessment as soon as the patient arrives at the unit or status is changed to an
inpatient data collected should be entered on the Nursing admission assessment sheet
and may vary depending on the facility additional data collected should be added. The
necessary information for Admission History are
Documentation: Name, medical record number, age, date, time, probable medical
diagnosis, chief complaint, the source of information (two patient identifiers)
Past medical history: Prior hospitalizations and major illnesses and surgeries
Assess pain: Location, severity, and use of a pain scale
Vital signs: Temperature recorded in Celsius, heart rate, respiratory rate, blood pressure,
pain level on admission, oxygen saturation
For the Physical examination, the necessary information are:
Cardiovascular: Heart sounds; pulse irregular, regular, weak, thready, bounding, absent;
extremity coolness; capillary refill delayed or brisk; presence of swelling, edema, or
cyanosis
Integument: Turgor, integrity, color, and temperature, Braden Risk Assessment,
diaphoresis, cold, warm, flushed, mottled, jaundiced, cyanotic, pale, ruddy, any signs of
skin breakdown, chronic wounds

4. Enumerate and describe the roles of the Circulating Nurse and the role and
responsibilities of the Scrub Nurse.

The circulating nurse (also known as the circulator) must be a registered nurse.
He or she manages the operating room and protects the patient’s safety and health by
monitoring the activities of the surgical team, checking the operating room conditions, and
continually assessing the patient for signs of injury and implementing appropriate
interventions. The main responsibilities include verifying consent, coordinating the team,
and ensuring cleanliness, proper temperature, humidity, and lighting; the safe functioning
of equipment; and the availability of supplies and materials. The circulating nurse monitors
aseptic practices to avoid breaks in technique while coordinating the movement of related
personnel (medical, radiography, and laboratory) as well as implementing fire safety
precautions (Phippen & Wells, 2000). The circulating nurse monitors the patient and
documents specific activities throughout the operation to ensure the patient’s safety and
well-being. Nursing activities directly relate to preventing complications and achieving
optimal patient outcomes.
 Activities of the scrub nurse include performing a surgical hand scrub; setting up
the sterile tables; preparing sutures, ligatures, and special equipment (such as a
laparoscope); and assisting the surgeon and the surgical assistants during the procedure
by anticipating the instruments that will be required, such as sponges, drains, and other
equipment (Phippen & Wells, 2000). As the surgical incision is closed, the scrub person
and the circulator count all needles, sponges, and instruments to be sure they are
accounted for and not retained as a foreign body in the patient. Tissue specimens obtained
during surgery must also be labeled by the scrub person and sent to the laboratory by the
circulator.

5. What is a safety checklist? When and how many times should this safety
measure be performed?

A Safety Checklist or a Surgical Safety Checklist is a safety measure tool that is utilized
inside the operating room before, during and after a surgical procedure. This checklist was
developed after extensive consultation aiming to decrease errors and adverse events during
surgery (World Health Organization, 2009). This tool serves as a communication tool for the
operating room personnel, which includes the surgeon, anesthesiologists, and nurses to discuss,
review and confirm the pertinent information and details about the surgery, such as; the patient’s
identity, surgical site, surgical procedure and other significant considerations. The surgical safety
checklist preserves and protects the patient through preventing avertable surgical complications
and reducing detrimental outcomes during the surgical procedure. In addition, the strict
compliance of the surgical safety checklist helps the OR personnel avoid communication failure
that leads to different surgical errors.

In the United States alone, over 40 counts of wrong-site surgeries occur every week, and
foreign objects were left inside a patient’s body (Spectrum Health, 2014). These mistakes are all
preventable with the use of the Surgical Safety Checklist which ensures patient safety and also
safeguards the rights of the staff. There are three key areas or instances in checking the checklist:
the briefing, the timeout, and the debriefing.

• Prior to every surgery, the briefing period is done when the patient is taken into the room
just before they are put to sleep. This is also known as Sign-In for some institutions.
Everybody who will be involved in the case is present and the staff is introduced. Other
procedures are also done such as the checking of the wristband, birthdate, procedure,
and so on.
• The second time that the checklist is reviewed is during the timeout which is probably the
most important period for checking where everything is already draped and in position.
This one last check is done before an incision is made or any step is taken by the surgical
team.
• Lastly is during the debriefing or the sign-out which is after the surgery is all over and just
before the patient leaves the operating room; the staff looks back and makes sure that the
necessary information was captured. The surgeon will review what he did including the
specimens that may have been removed from the client and if the labels were correct. The
sponge, needles, and other instruments are also counted and confirmed to be correct.
6. What are the roles and responsibilities of the Circulating and Scrub Nurse?

REFERENCES:

Spectrum Health. (2014, August 27). Surgical Safety Checklist [Video]. Youtube.
https://www.youtube.com/watch?v=1ufwtP36id8

https://my.clevelandclinic.org/health/symptoms/21629-pulse-pressure
healthline.com/health/coronary-artery-disease/risk-factors#risk-factors
https://www.texasheart.org/heart-health/heart-information-center/topics/heart-disease-risk-
factors/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2546461/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5512679/
https://medlineplus.gov/ency/patientinstructions/000775.htm
https://www.arthritis.org/health-wellness/about-arthritis/related-conditions/other-
diseases/arthritis-and-heart-disease
https://www.nature.com/articles/labinvest201795

https://journals.lww.com/nursing/Citation/2004/07000/Caring_for_a_patient_after_CABG_surger
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https://www.nursingcenter.com/journalarticle?Article_ID=638956&Journal_ID=54006&Issue_ID=
638936

https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_00005082-
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