CHAPTER III CLIENT PRESENTATION Patient B.S.C is an 86 year old male, born on month of January 13, 1927.

The patient is a married Filipino Catholic currently residing in a condominium in Taguig City, known as a judge in a Zamboanga City and has five children currently residing out of the country. Patient has known co-morbidities which is Hypertension and Diabetes Mellitus Type 2. The patient has a history of Congestive Heart Failure (May 2012) and Pneumonia. Patient had surgical procedure of exploratory of lungs (1998). He has a family history of hypertension (both parents). He is a known smoker and occasional alcoholic drinker but stopped 10 years ago. Maintenance medications were taken as follow: Betazol 100mg tablet once daily, Diovan tablet once daily, Augmentin 625mg three times a day, Fluimucil 600mg twice a day, Censomar once daily, Lasix 40mg table once daily, Glimepiride 2mg tablet taken before breakfast and Metformin 750mg per tablet 1 tablet in morning and 2 tablets in the evening He denies headache, vomiting, or dizziness at that time. No medications were taken. Patient was immediately taken at MMC-ER hence admission. Pertinent review of systems showed weak in gait, poor in vision and the patient is obese class 2. After the brief interview, the patient underwent head to toe assessment and presented the following data: the patient walks with support and the vital signs taken are as follows: blood pressure of 130/70 mmHg, pulse rate of 74 beats per minute, respiratory rate of 18 cycles per minute, temperature of 36.1 Celsius and denies any pain. Also, adventitious breath sounds were heard in mid lung fields, a grade 2/6 murmur was heard in the left parasternal area and pitting bilateral bipedal edema was noted with grade 2 numbness on digits on the right foot. The body

mass index of the patient was also taken. The patient had a weight of 94 kilograms and a height of 173 centimeters, thus classifying him under obese type 2. After the initial assessment, the patient was then transferred to the ninth floor of the hospital. The patient underwent 2D echo, venous Doppler imaging of lower extremities, coronary angiogram and chest x-ray. Results were as follows: Chest X-ray impression was Cardiomegaly, for the Venous color Doppler venous insufficieny, left femoral and greater saphenous veins and no venous thrombosis noted, and for the 2D echocardiogram

interventricular septal hyperthrophy with mild hypokinesia of inferoseptal, inferior and posterior wall, from base to apex. These diagnostic exams confirmed that the patient had severe 3-vessel disease wherein the left anterior descending artery had an 80-90% blockage, the left circumflex had a 95% blockage and the right coronary artery had a 95-100% blockage which led to the patients coronary artery bypass graft procedure. The procedure was supposed to be done the on the 14th of February 2013 but due to the request of the patient, the procedure was deferred to the 18th of February 2013. The patient underwent coronary artery bypass grafting 4 vessels (Left Internal Mammary Artery to Left Anterior Descending Artery, Saphenous Vein Graft to Obtuse Marginal, Saphenous Vein Graft to Obtuse Marginal 2, Saphenous Vein Graft to Posterior Descending Artery). On February 14, 2013 (0800H) the patient had undergone left heart catherization with coronary angiogram with no complication. Patient did not experience any discomfort or difficulty of breathing. Patient is conscious, coherent and responsive with a Left Ventricular Ejection Diastolic Pressure (LVEDP) of 36 with running fluids of PNSS 1L at 40ml/hour and Sodium Bicarbonate 450mg in D5Water 1L at 80ml/hour with latest vital signs of Blood pressure: 142/80 mmHg, Heart rate: 94 beats per minute, respiratory rate: 20 cycles per minute

with Oxygen Saturation of 100%. The patient was scheduled for Coronary Artery Bypass Graft (CABG) on February 18, 2013. On February 18, 2013 (1800H), patient had undergone Coronary Artery Bypass Graft (CABG). The patient had pitting edema on his entire body accompanied by easy fatigability and elevated sodium level. Interventions done were administration of Furosemide, placement of 2 pillows when he sleeps. No chest pain, palpitation and paroxysmal nocturnal dyspnea were noted. Post- operative orders were given: Diet- Clean liquid diet when fully awake and extubated. Advance to soft diet, low salt low fat; Activity- may dangle legs as tolerated when chest tubes are removed. Acute Cardiovascular Care rendered: Record Heart rate, Respiratory rate, systolic / diastolic blood pressure and MAP every 30 minutes until intravenous vasoactive drugs are discontinued; record rectal or core temperature every 1 hour for 8 hours the every 4 hours; if Swan Ganz Catheter record Pulmonary Artery Wedge Pressure (PAWP), Cardiac Output (CO), Systemic Vascular resistance (SVR) STAT then every 4 hours and as needed until stable or intravenous vasoactive drugs are discontinued; Continue 3-6ml per hour heparin flushing on pressure lines; Record intake and output every 1 hour; Chest tubes continue 20cm wall suction, milk tube as needed, record output every hour; Check for warmth, color, circulation and pulses of the legs every 2 hours. The patient was ordered for Chest X-ray (1600H); STAT Complete Blood Count (CBC) BUN, CREA, CPK, CPKMB on post- operative day 1 and 2; STAT Protime and PTT; Complete Blood Glucose (CBG) every 6 hours for 2 days; STAT 12 lead ECG every morning; and Start Arterial Blood Gas (ABG) as necessary to wean. The patient was admitted in Medical Step Down 4 (MSD4). Latest vital signs were (admission) Blood pressure: 142/80 mmHg, Heart rate: 94 beats per minute, respiratory rate: 20 cycles per minute with Oxygen Saturation of 100%. CBC result: Hemoglobin LOW 10.50g/dL (NV: 14.0

17.5), Hematocrit LOW 31.20% (NV: 41.5 50.4), RBC LOW 3.5 x 10^6/uL (NV: 4.5 5.9), WBC HIGH 16.54 x 10^3/uL (4.4 11.0), Platelet LOW 147,000 /uL (NV: 150,000 450,000), Calcium LOW 7.74 mg/dL (NV: 8.6 10.2), CPK HIGH 1490.0 U/L (NV: 39 308), Na LOW 135 meQ/L (NV: 136- 145) and CPKMB Isoenzyme HIGH 10.9 ng/mL (NV: 0-4). Arterial Blood Gas (ABG); PO2 149, pH 7.38, pCo2 33, HCO3 20.4 oxygen saturation of 99% with FiO2 40% AC mode. Latest Hemodynamics were as follows: CO 6.34, PAWP 18 , CVP 7. Intravenous fluid flowing - Calcium gluconate 5 grams in D5W 450ml x 60ml/hr. Medications of nitroglycerin of 1mg per hour and Furosemide of 10mg/ ml. At 2100H, the patient complaint for pain in the invasive site given Morphine Sulfate 2mg intravenous push. At 2130H, his latest Capillary Blood Glucose (CBG) was 232 mg/dL. The doctor

ordered to administer give 3 units if CBG is 180 -200 mg/dL and 4 units if its greater than 200 mg/dL. At 2321H, Furosemide drip was started 1900H, latest Urine Output: 2000H 150cc, 2100H 180cc, 2200H 130cc and 2300H 380cc. The doctor then ordered Furosemide drip to decrease to 8mg/ml. On February 19, 2013, (0015H) The patient is asleep, comfortable, prefers upright or sitting position. Negative dyspnea, chest pain, palpitation and desaturation episodes. Latest vital signs were as follows: Blood Pressure 139/55 mmHg, Pulse rate of 104 beats per minute, Respiratory rate of 21 cycles per minute and temperature of 37.3 C and oxygen saturation of 100%. Decreased nitroglycerin to 0.5mg/hr. Shifted to CPAP and given Ipratropium. May take shower 48 hours after chest tube are pulled out. Chest physiotherapy care of ICU nurse. Done deep breathing technique. Given Isosorbide dinitrate 5g, Nabivolol 5g/tablet and rosuvastatin.

At 0940H, latest hemodynamics were taken through the Arterial Line; Blood pressure of 137/54 mmHg, Heart rate of 104 beats per minute, Central Venous pressure (CVP) of 13, Cardiac output of 6.78, Pulmonary Artery Wedge Pressure (PAWP) of 19. At 1331H, the patient was extubated. The patient was first handled on the 20th of February 2013, from 0600H to 1400H. At that time, observations and procedures in the telemetry were observed. Head to toe assessment was done. The patient was received asleep on bed in moderate high back rest. The contraptions present were the following: central venous line at right subclavian, introducer heplock at the left antecubital vein, O2 therapy at 3 liters per minute, pulse oximeter at left index finger, chest tube at right pleura and TED stockings. The wound dressings were minimally soaked with blood and pitting edema of +2 was observed in the upper and lower extremities with slow capillary refill. Episodes of dyspnea and chest pain with a pain scale of 4 out of 10 were observed during the shift. Thus, Acute Pain related to post- procedure discomfort as evidenced by pain in the operative site and pain scale of 4/10 and Fluid Volume excess related to ineffective

pumping of the heart rate as evidenced by edema on both extremities were identified. Intravenous fluid of PNSS 500ml x 20ml/hr and Furosemide 200mg in D5W to make 100ml x8mg/hr (4ml/hr). Vital signs revealed, Temp.= 35.8C, PR= 104 bpm, RR=19 cpm, BP= 107/44. CBG before meals revealed 168 mg/dl. Patient was able to move upper extremity against gravity mildy. Medications given were tramadol and paracetamol (dolcet) 1 tablet every 8 hours as needed. Upon interview to the patient complained of difficulty of breathing. He was noted to have decrease muscle strength and limited range of motion. His latest hemodynamics are as follows: Pulmonary Artery Systolic (PAS) = 57mmHg (NV: 15-30mmHg); Pulmonary Artery Diastolic

(PAD) = 24mmHg (NV: 3-8mmHg); Cardiac Output (CO) = 3.6 L/min (4-8L/min); Cardiac Index (CI) = 7.73 L/min (NV: 2.5 -4.2 L/min); Pulmonary Artery Wedge Pressure (PAWP) = 1g (NV: 6-12mmHg); Central Venous Pressure (CVP) = 16mmHg (NV: 2-6mmHg); Systemic Vascular Resistance (SVR) = 1444 (800-1200 dynes-sec/mL); and SVRI = 3003 (NV: 19202390 dynes-sec/mL) Thus, decreased cardiac output related to dysrhythmias as evidenced by frequent premature arterial contraction and premature ventricular contraction was identified. On February 21, 2013, 2 nd day of student nurse-patient interaction from 0600H-1400H, patient B.C.S. was still on bed rest but able to move a little but still has difficulty. Vital signs revealed, Temp= 36.7C, PR= 109, RR=20, BP= 139/66 and has no pain. Intake of 200 ml, output of 940 ml, and no stool. CBG result of 183 mg/dl and was relayed to the attending physicians. Same medications were also given (Apidra 3 units), student nurse observed difficulty in swallowing medications even if it is given one by one. The patient has poor sleep last night. Patient had atrial fibrillation in Premature ventricular contraction (PVC) was asymptomatic. The patient had 140s- 150s Heart rate and blood pressure of 116/13 mmHg. The patient was given amiodarone 60mg in 500ml in D5Water for 2 hours. Medications: Nebivolol 5g 1 tablet. The patient attempted to stand with the assistance of the nurses but the patient was easy fatigable and had dyspnea and desaturated. The patient was having a difficulty of breathing due to unproductive cough, by that the nurse done oral suctioned the patient and noted thick whitish phlegm. Upon auscultation, patient had crackles on both lung fields. Patient was observed using accessory muscles during inspiration. He has a regular respiratory rate was 20 cycles per minute. Thus, Ineffective airway clearance related to tracheal-bronchial inflammation/ secretions in the bronchi as evidenced by wheezes and tachypnea was identified. Interventions rendered

to promote effective airway clearance were: Assist patient to changed position every 2 hours; elevated head of bed and align head in the middle; suctioned secretions as needed; administered medications as ordered. After the interventions were given, patient verbalized, I feel more comfortable now. On February 22, 2013. 3rd day of student nurse-patient interaction from 0600H-1400H, patient B.C.S. was still on bed rest but able to move a little but still has difficulty. The patient was transferred from bed to bedside chair, still has difficulty in walking, and during transferring it was accompanied by difficulty in breathing and desaturation of oxygen. Back clapping and incentive spirometer to enhance expand his lungs was given. The patient is still on soft diabetic; 1600kcal/day low salt low fat, and with aspiration precaution. Patient was then responding to treatments and has a self assurance to be cured. Vital signs revealed, Temp= 36.4C, PR= 103, RR=20, BP= 112/42 and has no pain. Intake of 560 ml, output of 840 ml, and no stool. CBG result of 221 mg/dl and was relayed to the attending physicians. Same medications were also given (Apidra 4 units), student nurse observed difficulty in swallowing medications even if it is given one by one. The patients wound dress was changed. On February 26, 2013, fourth day of handling the patient from 1400H to 2200H, there were contraptions removed such as the chest tubes and the foley catheter. During initial assessment, there were no significant findings seen except for the improvement of the pitting edema of the extremities from +2 to +1 and for the presence of crackles and the use of accessory muscles during breathing wherein the patient denies difficulty of breathing. The patients diet was also shifted to low salt, low fat soft diabetic diet with a maximum intake of 1.2 liters a day. Bed bath, changing of linens and cleaning and changing of wound dressings were done. Patients

wound dressings were minimally soaked with blood when checked, it was noted that the incision site were minimally open and still fresh it was relayed to the doctors then performed minor incision on the open area. The patients insicion site is slightly erythematous, but with no presence of pus. Thus, Risk for infection related to post operative incision was identified. Intervention rendered to prevent occurrence of infection were: observed for localized sign of infection at surgical incisions; kept the dressing dry; applied bactroban and hydrogen peroxide; change the dressing twice a day in 0800H and 1400H as ordered. Routine capillary blood glucose was done and was noted to be high thus 4 units of Apidra was given and relayed to the doctor. During the last day of nurse-patient interaction, asymptomatic sinus tachycardia was noted at 1405H with a heart rate of 123 beats per minute. The patient denies any pain or discomforts and was not in distress. The patient was experiencing a cycle of shifts from atrial fibrillation to sinus tachycardia and premature ventricular contractions. Head-to-toe assessment was done. Patient was received on bed in moderate high back rest, conscious, coherent and awake. The subclavian vein introducer was removed and shifted to heplock at left antecubital vein with three ports. The patient was still attached to a cardiac monitor with a pulse oximeter at the left finger. O2 therapy was no longer maintained but as needed during episodes of dyspnea at 2 liters per minute. The wound dressings were intact and dry with additional sutures on the right thigh. TED stocking are worn and were minimally soaked with blood. Pitting +1 edema was noted in the upper and lower extremities. The patient has lost 1 kilogram of body weight from 94 kilograms to 93 kilograms and was on a low salt, low fat diabetic diet and is still classified as Obese 2. The patient was voiding freely through a diaper but with no bowel movement yet. Musculoskeletal improvements were observed such as standing up and moving from bed to chair

was less strenuous than previous transfers. Lasix was discontinued by the cardiologist due to the increase in output and Kalium durules, 2 durules were given every 2 hours as ordered by the nephrologist. CBG was also changed to pre-breakfast and 2 hours post meals. One of the physicians ordered verbally to direct discharge the patient by Friday (March 1, 2013) also at the end of the shift, the patient was sent to the cardiac rehab for the first time thus ending the nursepatient interaction.