You are on page 1of 20

CASE STUDY CABG

BY: NUR SYAKILA MASNOM 07DPY0013 (COHORT1)

Personal details.
Name: Mr. M MRN: 22xxx Age: 61 years old Sex: male Race: Indian Job: retired from bank staff Date of admission: 17/6/09 Date of referral: 20/6/09 for pre-op CABG Date of operation: 22/6/09 Date of assessment: 24/6/09 (post-op day 2) Dr diagnosis : Coronary artery disease (CAD) Dr management : post-op CABG (3 graft)

Subjective Assessment
Present history Pt admitted to DSH on 17/6/09 for elective CABG On 22/6/09 pt transferred to CICU for close observation post-op CABG

Pt c/o: Pt complaint of pain at the operation site, back aching, mild dizziness, and sleepy.

Past medical history

Pt had done right AKA in 92 d/t MV A Pt had DM since 4 years ago

Medication

Actrophid 50mg IV dopamine 200mg IV levophed

Social history

Pt was a smoker since 40 years ago and take roughly 5 sticks for a day time but has been stopped since 5 month ago Pt lived with his wife accompanied with his children

Investigation

Angiography on 16/6/09 Result:1) Left mainstem 50% stenosis 2) Left anterio descending (LAD) 3) Left circumflex 60% stenosis 4) Right coronary artery (RCA) proximal 60% stenosis, middle 95%stenosis X-ray on 17/6/09 Result: normal (NAD) Echo on 18/6/09 Result: good LV function, EF 70%, chambers size normal and no pericardial effusion

Vital sign

Bp: 102/56 mmhg HR: 92 bpm RR: 23 bpm Temp: 36c Spo2: 100%

ABG on 24/6/09
pH: 741.7 ( 7.35-7.45) PCO2: 35.8 mmol/l (35-45) PO2: 167 mmol/l (95-100) HCO3: 23 mmol/l (22-26) BE: -1 ~ interpretation: metabolic normal

Lab result

Hemoglobin: 10.2 Platelet: White blood cell:

Objective assessment
General observation A medium size Indian man was slumped on bed Pt conscious and obey to command Pt look tired and sleepy Pt on nasal prong 3 l/min Pt on IV drip at the left hand Pt CVL on right neck Pt on CBD drainage

Local observation

Pt was covered by gauze at the incision site (chest and left leg) Swelling noted at the operation site of left leg and ankle Pt had right AKA

On palpation

Chest expansion: symmetrical Upper lobe: fair Lateral costal: fair Diaphragm: poor

Auscultation Crackle sound at the left and right lower lobes

Chest measurement
Resting 1 2
93
86

Inspiration 1
94.5
87

Expiration 1
94
86.5

3
93
86

2
94
87.5

3
94.5
87

2
93.5
86

3
93
86

Axillary
Xiphoid process 10th rib

93
86.5

86.5 86.5 86.5 87.5

87.5

87

87

87

87

Coughing - unproductive cough Sputum -slightly thick and greenish + blood with minimal amount Test result -spirometry: 1000ml (3x) Muscle power - grade 3/5 : able to do by against gravity

Problem listing

Pain at the operation site Back aching Reduce chest expansion and secretion retention Unable to produce an effective cough Muscle weakness at both upper and lower limb

PT Impression

Pain at anterior chest wall area d/t operation wound Back aching d/t prolonged lying and poor blood ciculation Reduce chest expansion d/t poor breathing effort and pain Secretion retention over left and right basal d/t effect of GA and poor breathing pattern

Analysis
Short term goal

Produce effective and productive cough by using pillow to support at operation site at the chest Increase chest expansion Increase muscle strength Improve to normal breathing pattern

Long term goal


To prevent other chest complication To regain normal ADL

Treatment plan

Component of ACBT x2 set DBE 3X Spirometer with coughing 3x Active exercise 3x Sit up at the edge of bed with support - 3x

Home instruction

Keep doing spirometer to increase chest expansion Do the active exercise that has been teach by therapist Support the chest wound with pillow when coughing Elevate the leg same level with heart when sitting or lying Dont lift up the heavy things