Coronary Artery Bypass Grafting (Cabg) :: Case Study Report

Republic of the Philippines
TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
NURSING DEPARTMENT
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel. No.: (045) 493-1865 Fax: (045) 982-0110 website: www/tsu.edu.ph
In Partial Fulfillment of the Requirement for the Subject

NCM 118 RLE Nursing of Clients with Problems with Life
CORONARY ARTERY BYPASS

GRAFTING (CABG):
CASE STUDY REPORT
Submitted by:
LIMON, Panjee Zandra Mae Ng
MALAMUG, Marinelle S.
MANALANG, Aravie Jeniffer
MANGAOANG, Mikayla S.
MESINA, Trina
MORIONES, Trisha Anne
NICOLAS, Sherena
RAMOS, Edlyn Faye
RAMOS, Princess
BSN IV – 1 / GROUP 4
SUBMITTED TO:
Prof. Maria Teresa Mendoza R.N. MAN

Clinical Instructor
November 2021
CASE SCENARIO
Patient D is a 73 years old Filipina who was rushed to the emergency department
of Tarlac Provincial Hospital last November 17, 2021 with a chief complaint of chest
pain, shortness of breath and fatigue with minimal exertion that started two hours prior
to presentation which was not improved through medications, it was also noted that she
has a history of Coronary Artery Disease which was treated by Coronary Artery Bypass
Graft 6 years ago (June 6, 2015). The Student Nurse has taken the vital signs as
follows:
Vital Signs:
 BP: 140/70 mmHg
 PR: 107 bpm
 RR: 22 cpm
 Temp: 98.6 o F or 37 o C
 O2sat: 89%
As a normal assessment in the Emergency Room, the physician in charged has
ordered the following procedure which includes Coronary Angiogram that revealed
another blood clot (a total blockage of coronary artery). The patient was diagnosed
CAD. She was referred to the emergency department for a full cardiac work up that
includes Chest X-ray, while waiting to emergency medical system(EMS) to further
determine the patients condition.
Lab Tests:
 ECG: ST Elevation
 Echocardiogram: Ejection Fraction was 20%
 Chest X-ray:
o Haziness seen in the left base
o Heart is magnified
o Aorta is calcified
o Spurs seen at the margins of the thoracic spine
 Total Cholesterol: 240 mg/dL
 LDL: 172 mg/dL
 HDL: 40 mg/dL
 WBC: Elevated WBC count
 Cardiac Isoenzyme: 20%
o Troponin T: 0.6 ng/ml
o CK MB: 6.0 ng/ml
 Coronary Angiogram: revealed another blood clot (total blockage of coronary
artery)
Oxygen cannula was administered as well as the medication that was prescribed
by the Physician. Ceftriaxone and Tramadol are the drugs that were given to him. With
a confirmed CAD the patient was referred for a Coronary Artery Bypass Graft (CABG)
procedure, things were discussed with the patient and her significant others for a
decision and a written consent was secured by the nurse on duty. Plavix meds were
also initiated but stopped 12 hours before the surgery.
Patient D was discharged after 5 days and was advised for a follow-up
appointment along with the health education for recovery.
Medical History
Six (6) years ago, Patient D had a Coronary Artery Bypass Graft procedure. In
the past 2 years, she has been admitted to the hospital several times due to chest
pain which was controlled with medications.
Angiography was done six years ago, revealing partial occlusion of the main
stem of the left coronary artery and partial occlusion of the obtuse marginal branch
while last month Coronary angiography demonstrated complete occlusion of
the main stem of the left coronary artery, with previous grafts to the left
anterior descending and circumflex branches; partial occlusion of the left anterior
descending graft; complete occlusion of the circumflex graft; complete occlusion of
the obtuse marginal branch; and partial occlusion of the right coronary artery. The
total occlusion of the obtuse marginal branch and partial occlusion of the right
coronary artery had developed since the previous angiograms. Following the
most recent angiogram, Patient D experienced a significant hypertensive episode
that was successfully treated with dopamine hydrochloride infusion, Micardis,
and nitroglycerin ointment was taken during her stay in the hospital.
Assessment and Diagnosis

The patient was examined by the attending physician. Vital signs were taken by
the student nurse. BP: 140/70mmHg PR: 107bpm RR: 22 cpm,
Temp: 36.8C and O2 saturation of 89% with labored breathing. Administration of
oxygen was given. An ECG shows changes consistent with old anteroseptal and inferior
infarcts as well as lateral ischemia. The result of the ejection fraction (EF) of the patient
was only 20%. For the Laboratory studies, CBC and Cardiac Isoenzymes also reveals
abnormalities and Urinalysis was within normal range. Based on the findings of the
assessment, Patient D was diagnosed with Coronary Artery Disease, and status post-
coronary artery bypass graft surgery, with one graft, clotted.
Management (D1)
The physician recommended to the patient that she has to undergo another
Coronary Artery Bypass Graft (CABG) surgery. Patient D discussed the proposed
surgery with her family and agreed since it is necessary. She was then scheduled for
surgery the next day.
Pre- Op: Since consent was secured. Patient was intubated and was put under
anesthesia, intubation will be necessary for her to breathe on her own during
surgery, providing sufficient oxygen to the body without assistance and IFC was
inserted to monitor the urine output or retention.
Intra op: During the procedure, the surgeon places grafts from the saphenous
veins on the aorta up to the obtuse marginal and circumflex branches of the left
coronary artery as well as to the right coronary artery, Ceftriaxone IV was started,
CTT was done which is a hollow plastic tube that was inserted between the ribs into
the pleural space. The tube will be connected to a machine to help with the
drainage. The tube will stay in place until the fluid, blood, or air is drained from the
chest.
Post op: following surgery, the patient was then brought to SICU for monitoring.
with an endotracheal tube and on a continuous mechanical ventilator. She was
weaned from the ventilator slowly and extubated the morning of the first
postoperative day. However, Patient D was reluctant to turn, deep breath, or cough.
The nurse ensured adequate pain relief before carrying out these postoperative
routines, provided encouragements and support. Family members were allowed to
help the patient because she coughs better with their help. Patient D recovered
steadily, but due to her debilitation prior to her surgery, her progress was slow. She
was discharged from the SICU on the fifth postoperative day after Discussion of
Follow Up and Health Education was done.
Post op Meds:
Ceftriaxone 1 g/IV q 12 h X 6 DOSES -started intraop
Tramadol 50 mg IV q 6 h X 6 DOSES THEN q6h PRN - to start upon arrival @ SICU
Post-surgery: once pt is eating
Crestor 20 mg PO q HS
Telmisartan (Micardis) 40 mg PO OD
Ibuprofen 400 mg q 6h po PRN
I. INTRODUCTION
a) Brief description of the disease condition

Coronary artery disease (CAD) is the narrowing of the coronary arteries – the
blood vessels that supply oxygen and nutrients to the heart muscle. CAD is caused by a
build-up of fatty material within the walls of the arteries. This build-up narrows the inside
of the arteries, limiting the supply of oxygen-rich blood to the heart muscle. (John
Hopkins Medicine, 2021)
Coronary artery bypass graft surgery (CABG) is a procedure used to treat

coronary artery disease. It involves taking a blood vessel from another part of the body
(usually the chest, leg or arm) and attaching it to the coronary artery above and below
the narrowed area or blockage.
This new blood vessel is known as the graft. The number of grafts needed will depend
on how severe your coronary heart disease is and how many of the coronary blood
vessels are narrowed.
A coronary artery bypass graft is carried out under general anaesthetic, which
means the client will be unconscious during the operation. It usually takes between 3
and 6 hours. (National Health Service, 2021)
b) Current Trends and Statistics About the Disease Condition
Local Statistics:
The Philippine Heart Center (PHC) is the center of cardiovascular care in the
country, catering to patients from all walks of life. The annual statistics of patients
undergoing coronary artery bypass graft (CABG) surgery is 500 to 600 and there has
been a comparable mortality rate in the institution with the foreign data, 3.69% vs.
2.5%, respectively. However, mortality rate significantly increases when CABG is done
with concomitant valve surgery and/or in the presence of other identified risk factors.
Galicio, R., Vicente, F. (2015) Outcome of Patients Who Underwent Coronary Artery
Bypass Graft with Concomitant Valve Surgery in Philippine Heart Center
Nationwide Statistics:
According to the latest WHO data published in 2018 Coronary Heart Disease
Deaths in Philippines reached 120,800 or 19.83% of total deaths. The age adjusted
Death Rate is 197.08 per 100,000 of population ranks Philippines #32 in the
world. (WHO, 2018)
Worldwide Statistics:
Coronary artery bypass grafting (CABG) is still the most commonly performed
cardiac surgery procedure worldwide, representing annual volumes of approximately
200,000 isolated cases in the US and an average incidence rate of 62 per 100,000
inhabitants in western European countries (Thorac, J. (2018) Fifty years of coronary
artery bypass grafting
The global coronary artery bypass graft market size was valued at USD 77.3
million in 2016 and is expected to grow with a CAGR of 5.8% during the forecast period.
Rise in prevalence of cardiovascular diseases such as Coronary Artery Disease (CAD)
or Coronary Heart disease (CHD), Myocardial Infarction (MI), hypertension, and
peripheral vascular disease, and introduction of technologically advanced products are
the key drivers expected to nurture market growth worldwide.
A sedentary lifestyle, mental stress, eating fatty foods and consumption of junk

food are the key reasons for developing Cardiovascular Diseases (CVDs) in individuals
around the globe. According to the World Health Organization, CVDs contribute to the
maximum number of deaths globally. In 2012, nearly 17.5 million deaths were reported
due to CVDs, representing 31.0% of the global death statistics. Out of the 17.5 million
deaths reported, 7.4 million were owing to CHD, and 6.7 million were due to stroke. The
number of deaths is anticipated to reach over 23.6 million by 2030. (Grand View
Research, 2021)
c) Reasons for choosing such Case Presentation
Our group was assigned to have coronary artery bypass graft
surgery (CABG) case study in order for the us to have a deeper knowledge and
understanding about the procedure. And for us to know what are the appropriate
nursing interventions and management for a patient dealing with coronary artery
disease. With the help of this study the nursing student could identify and address the
concerns and needs of their patients in the future by giving them the high-quality patient
care.
d) Objectives of the Study
General Objectives:
This case study aims to broaden the knowledge of nursing students
about CABG also to collect important information from the patient diagnosed with
coronary artery disease. Also, in order to develop their skills in formulating appropriate
nursing diagnosis and nursing care plan. Additionally, to be able to render proper
interventions to help our patients while promoting quality care for our future patients.
Specific Objectives:
a) To be able to perform thorough nursing assessment
b) To formulate an appropriate nursing diagnosis with the patient who had coronary
artery disease
c) To develop an effective and quality nursing care plan
d) To implement and perform the appropriate nursing interventions for the patient
e) To evaluate the nursing interventions performed by the patient
II. NURSING PROCESS
A. Assessment
1. Personal Data
a. Demographic Data
Patient’s name: Patient D
Age: 73 years old
Sex: Female
Civil status: Single
Occupation: Restaurant owner
Address: San Miguel, Tarlac City
Nationality: Filipino
Religion: Roman Catholic
Time and date admitted: November 17, 2021, at 9am
Chief complaint: Chest pain, shortness of breath, fatigue
Admitting Diagnosis: Coronary Artery Disease
Final Diagnosis: For Coronary Artery Bypass Graft (CABG) secondary to
CAD
2. Environmental Status
Patient D is residing in San Miguel, Tarlac together with her relatives. They live in
a bungalow type of house which is made of wood and cement that is sturdy and well
ventilated which was inherited by her brother from their parents. Their house is
surrounded by trees and plants. Their source of drinking is mineral water. The means of
their transportation is by the use of car, jeepneys and tricycles. Also, their house is
located a few meters away from the public market where there is always available pork,
chicken, fruits, and vegetables, in which pork is what they usually consume because
Patient D is fond of eating fatty foods.
3. Lifestyle
Patient D prefers to eat unhealthy foods like fatty foods such as Crispy Pata, sisig,
letchon kawali, dinakdakan and salty foods such as fries and instant noodles. She is not
fond of drinking water and is living a sedentary life. She is a non-smoker but drinks
alcoholic beverages occasionally. Since her passion is cooking, she started a small
restaurant back when she was on her 40’s that primarily serves Filipinos’ “putok-batok
menu” which has successfully grown in span of years. The patient weighs 80kg and
stands 5’2” and her BMI is 33.2 which is considered obese.
4. Family History of health and illness

Since Patient D was having difficulty expressing her thoughts due to her condition, most
of the data gathered during the interview were given by the client's relatives. According
to them, from the patient's paternal side, her grandfather died due to stroke at the age of
57 and her grandmother died at the age of 80 due to old age. From her maternal side,
her grandfather died at the age of 53 due heart failure while her grandmother died at the
age of 60 due to car accident. Patient D's father died at 70 years of age due to CHD,
and her mother has a history of hypertension and died at 81 years of age following a
stroke. She has two Brothers, the eldest died at the age of 60 due CHD and Diabetes
complications, while the younger Brother (70 years old) has a peripheral vascular
disease requiring lower extremity vascular bypass surgery. Patient D is the middle child
and she happened to be diagnosed also with Coronary Artery Disease.
GENOGRAM
PATERNAL SIDE MATERNAL SIDE
DIED AT 57 DIED AT 80 DIED AT 53 DIED At 80

/Stroke /Old age /Heart failure /Car accident
DIED AT 70 DIED AT 81
/CHD /stroke
70 YEARS OLD
DIED AT 60 PATIENT
/PVD
/CHD AND DIABETES /UNSTABLE ANGINA
5. History of past Illness
Patient D has a history of hypertension, hyperlipidemia and MI. Six years ago,
where in Angiography was done, revealing partial occlusion of the main stem of the
left coronary artery and partial occlusion of the obtuse marginal branch, which leads
her to having a Coronary Artery Bypass Graft (CABG) procedure. In the past two
years, she has been admitted to the hospital several times due to chest pain which
was controlled with medications
Coronary angiography one month ago demonstrated complete occlusion of
the main stem of the left coronary artery, with previous grafts to the left
anterior descending and circumflex branches; partial occlusion of the left
anterior descending graft; complete occlusion of the circumflex graft; complete
occlusion of the obtuse marginal branch; and partial occlusion of the right coronary
artery. The total occlusion of the obtuse marginal branch and partial occlusion of
the right coronary artery had developed since the previous angiograms. Following the
most recent angiogram, Patient D experienced a significant hypertensive episode that
was successfully treated with IV Hydralazine,verapamil, and nitroglycerin
ointment during her stay in the hospital.
Her childhood immunization was completed from their Rural Health Unit.
History of minor illnesses includes diarrhea, common colds and fever were just
treated with over-the-counter medicines. No past accidents, injuries and any
known allergies to medications or foods noted.
6. History of Present Illness

At exactly 7am Patient D was in their sala while drinking coffee and reading
some magazines, when she started to experienced chest pain that lasted 10 minutes
according to her relatives alarming them to admit her to the emergency department of
Tarlac Provincial Hospital at 9 am (November 17,2021) with chief complaints of chest
pain, shortness of breath and easy fatigability.
Upon admission, a full physical exam was conducted. ECG showed

changes consistent with old anteroseptal and inferior infarcts as well as lateral
ischemia. Laboratory studies (cbc, urinalysis, and cardiac isoenzyme levels) were
done. Vital signs were taken, BP: 140/70 mmhg, HR: 107 bpm with regular rhythm, RR
22 cpm, Temp: 98.6°f and O2sat: 89% with labored breathing. Oxygen inhalation @
2lpm was started, and medications were given. (Micardis, Nitroglycerine patch, IVF of
D5 NS @ 20 gtts/ min was started to give her Morphine 2.5 mg IV stat.
Based on the results of the assessment, Patient D was diagnosed with Coronary

Artery Disease.
7. PHYSICAL ASSESSMENT
13 Areas of Assessment
I. SOCIAL STATUS
Findings:
Patient D is a 73 years old Filipina, who owns a restaurant near the city which serves
as their financial support for her needs as well as for the grandchildren of her brother.
She didn’t marry for she was busy attending her dream business all her life, but she
managed to have a healthy relationship with her loved ones for she was loved,
respected, and supported by her so-called family of her brother where she resides at
especially in her difficulties in life. Before the pandemic, they used to attend mass
every Sunday and eat together in her restaurant as a way of their bonding. They
enjoy celebrating occasions by the means of food party. Patient D never felt alone
even after undergoing Coronary Artery Bypass Procedure six years ago, besides it
made her bond to her family even stronger as she continue to face her illness.
Norms:
Social status includes family relationships that state the patient’s support system in
times of stress and in times of need. It meets a fundamental need for social ties,
making life stressful, and social support buffers the negative effects of stress, thus
indicating indirectly contributing to good health outcomes (Kozier & Erb’s, 2018).
Analysis:
Based on the above statement, Patient D’s social status was normal and was not
affected due to her past and present illness, she maintained her good relationship and
communication with her relatives. Though this pandemic refrained them from
attending mass and eating outside, their bonding did not change and no other
concerns were noted.
II. MENTAL STATUS

Findings:
General appearance and behavior:
Upon admission, Patient D looked weak and pale in appearance with slouching
posture and guarding behavior and facial grimace due to her current condition and
chest pain that was not controlled with her current medications.
After the surgery, Patient D’s condition had improved and became well-groomed even
though she still looked pale and weak in appearance due to the surgery.
Level of consciousness:
Upon admission, Patient D was conscious and alert but could barely answer
questions being asked due to her chest pain. However, she was still oriented to place,
time, person, present situation and can slightly recall both of her long and short-term
memories.
After the surgery, Patient D was fully awake, alert, and still could barely response and
answer to questions being asked due to the acute pain that she was experiencing at
the site of her post-operative surgical incision. Chest tube thoracostomy was
connected to water seal chamber at right. Chest tube was intact and draining to
pinkish output within 50 ml.
Orientation:
Upon admission, Patient D has a normal level of comprehension as she was able to
fully understand and answer questions being asked to her even if she could barely
respond. She can state the date, time, and her full name.
After the surgery, Patient D could barely respond to every question being asked to her
due to the acute pain that she was experiencing at the site of her post-operative
surgical incision. Yet she’s still aware of the date, time, and can state her full name
and the names of her relatives to the student nurse.
Speech:
Upon admission, Patient D can barely express her feelings and speaks in a low tone
of voice followed by labored breaths, as she speaks facial grimace was also evident
during the assessment.
After the surgery, Patient D speaks in a low tone voice carefully and minimally uses
words to answer questions being asked to her due to the acute pain that she was
experiencing at the site of her post-surgical incision, but she was audibly understood
during the assessment
Intellectual function:
Upon admission, Patient D responds to every questions appropriately, she could
answer promptly, but she has difficulty in elaborating her thoughts due to her pain.
When the student nurse asked if she can still remember her past history, she just
nods her head as an answer.
After the surgery, Patient D was barely able to respond and answer to questions
being asked. She still managed to elaborate her thoughts and inquire questions even
though she was experiencing acute pain at the site of her post-operative surgical
incision.
Norms:
General appearance and behavior:
The patient should be able to stand still, have smooth and coordinated movement
(Jensen, 2019).
Level of consciousness:
The patient must be alert and awake with eyes open and looking at the examiner and
able to respond appropriately (Kelley & weber, 2018).
Orientation:
A person is normally aware of self, others, place, time, and address (Weber, 2018).
Speech:
Speech should be at a clear and moderate pace. It should be exerted effortlessly
(Jensen, 2019).
Intellectual function:
A person should respond normally and appropriately to topics discussed. Express full
and free-flowing thought during the interview and listen and responds with full thought
(Jensen, 2019).
Analysis:
Based on the above statements, Patient D was experiencing acute pain at the site of
her post-surgical incision and could barely answer questions. Patient D’s general
appearance was not normal because pale, weak in appearance, guarding behavior
and facial grimace were observed due to her condition. Patient D was awake and was
able to answer questions in low voice.
III. EMOTIONAL STATUS

Findings:
Upon admission, Patient D could understand and express her feelings well even
though she could barely talk due to her chest pain. Her relatives felt saddened and
nervous because it was already her second time to undergo coronary artery bypass
graft, but they already learned to accept it. Patient D stated that her condition is the
most stressful situation in her life because it affects her financially and emotionally,
she even stated that at her age, all that she can do is to be brave and ready for
whatever outcome.
After the surgery, Patient D became more religious and her faith never fades away.
Her relatives never left her side which motivated her to live longer. She remained
optimistic for her fast recovery and for her to have a bonding moment with her so-
called grandchildren.
Norms:
Normally, the patient should have the ability to manage stress and express emotion
appropriately. It also involves the ability to recognize, accept and express feelings and
to accept one’s limitations (Berman et.al., 2018)
Analysis:
Based on the above statements, Patient D’s emotional status was normal and stable
because her support system did not leave her in her most difficult times. She
managed to voice out her feelings and thoughts sincerely on how grateful she was for
having such a second family who was there for her through thick and thin.
IV. SENSORY PERCEPTION

Findings:
a) Vision:
Upon the assessment, the patient had no problem with her visual acuity. Both of her
eyes could move in coordination and pupil reaction to light test were tested and result
was both eyes at 3mm diameter. Patient D’s eyebrows were evenly distributed, and
periorbital skin was intact without swelling or inflammation. Eyebrows were
symmetrically aligned. Upon inspection, the skin of eyelids was intact, and no
discharges and discolorations were present. Iris were black in color and had a round,
smooth border.
b) Taste:
Patient D’s lips were slightly pale and dry. Both of her lower and upper teeth were
slightly yellowish in color and her tongue was pink and moist with a thin slightly white,
shiny coating on the surface and no lesions were noted. Tongue resistant test was
performed and noted that it was normally functioning. Oropharynx and tonsils were
inspected and gag reflex was tested and noted that it was also functioning well.
c) Hearing:
Upon inspection, Patient D’s auricles were of the same color as facial skin, were
symmetrically aligned with each other, and were aligned with the outer canthus of
each eye. Cerumen was present but was not impacted or excessive in amount. Upon
palpation, auricles were firm, and not tender as evidenced by the auricle being pulled
upward, downward, and backward without resistance, and the pinna being folded
forward without resistance and recoiling after folding. The patient was responsive.
d) Smell:
Upon inspection, Patient D’s external nose was symmetrical. The nose was uniform in
color and nostrils were patent. Patient D was able to smell normally and discriminate
an odor. There were no signs of lesion, swelling and flaring on the nasal septum, and
air moves freely as Patient D breathes. Sinuses were palpated and no evidence of
swelling or lumps was noted, and no pain was felt by the patient.
e) Tactile Sensitivity:
Light touch sensation was performed on patient D’s extremities which she could
distinguish the place touched. Patient D had no signs of jaundice and skin color were
uniform throughout her body. Skin temperature was uniform in all extremities when
touched. Bones appear to have no deformities. Palm sensation was also performed
and she could identify well the letter being drawn on her palm using the blunt end of a
pen.
Norms:
Vision:
Vision occurs when light is processed by the eye and interpreted by the brain. Light
passes through the transparent eye surface (the cornea). The pupil, the black opening
in the front of the eye, is an opening to the eye interior. It can get larger or smaller to
regulate the amount of light entering the eye. The colored portion, called the iris, is a
muscle controlling the pupil size. The inside of the eye is filled with a gel-like fluid.
There is a flexible, transparent lens that focuses light, so it hits on the back of the eye
(the retina). The retina converts light energy into a nerve impulse that is carried to the
brain and then interpreted
Taste:
Taste is intact in the posterior one-third of the tongue. (Health Assessment and
Physical Examination, Mary Ellen Zator Estes)
Hearing:
For the auditory acuity, the client should be able to repeat the whispered words from
two feet. (Health Assessment and Physical Examination, Mary Ellen Zator Estes)
Smell:
Your sense of smell helps you enjoy life. You may delight in the aromas of your
favorite foods or the fragrance of flowers. Your sense of smell is also a warning
system, alerting you to danger signals such as a gas leak, spoiled food, or a fire. Any
loss in your sense of smell can harm your quality of life. It can also be a sign of more
serious health problems.
Tactile Sensitivity:
The skin contains receptors for pain, touch, pressure, and temperature. Sensory
signals are transmitted along rapid sensory pathways, and less distinct signals such
as the pressure of localized touch are sent via slower sensory pathways. (Health
Assessment and Physical Examination, Mary Ellen Zator Estes)
Analysis:
a) Vision:
Based on the above statement, Patient D’s visual acuity was normal wherein there
were no abnormalities noted.
b) Taste:
Patient D’s sense of taste was normal.
c) Hearing:
Patient D’s sense of hearing can perceive to stimuli accordingly and her auditory
acuity was in a normal range
d) Smell:
Patient D’s sense of smell can perceive to stimuli accordingly which was considered
normal.
e) Tactile Sensitivity:
Patient D’s sensory transmission was functioning well as manifested by the date
presented.
V. MOTOR STABILITY
Findings:
During the assessment, Patient D’s head is still functioning well. She could move her
chin to her chest, her chin can point upward. Move her head towards her shoulders
and turned her head from left to right with less effort. However, due to acute pain that
she was experiencing at her post-surgical incision, there was a guarding behavior
observed. Upper extremities were assessed and Patient D can raise her arms parallel
to the bed and can resist when the student nurse tried to push them down. Lower
extremities were also assessed and Patient D cannot raise her legs properly due to its
weight that can affect patient’s post-op surgical incision. Pronator drift was also
performed, Patient D can close her eyes so she cannot compensate and extend her
arms, palms up, in front of her and her arms does not sway from its original position.
Patient D’s motor strength bilaterally was also assessed. Wherein she can flex and
extend her arm against the student nurse and squeeze student nurse’s fingers.
Norms:
The normal range is that the patient has a good posture, easy walks, transfers from
bed to chair, and walks fast not just slowly. In standing position, the torso and head
are upright. The head is midline and perpendicular to the horizontal line of the
shoulder and the pelvis. The shoulders and hips are levels, symmetry of the scapula
and iliac crests. The arms are free from the shoulders. The feet are aligned, and the
toes point forward. Walking initiated in one smooth rhythmic fashion (Jensen, 2019).
Analysis:
Based on the above statement, Patient D’s motor stability was not normal. Wherein
she showed guarding behavior due to acute pain at her post-surgical incision. She
appeared weak and poor walking gait was noted because she needs complete bed
rest after she undergone CABG and needs assistance. Her motor function was +4 –
full ROM, less than normal strength.
VI. BODY TEMPERATURE

Findings:
The table below shows the temperature of patient during the shift:
DATE ASSESSED TEMPERATURE ANALYSIS
November 17, 2021 37 °C Within the normal range
November 18, 2021 37.2 °C Within the normal range
November 22, 2021 37. 3 °C Within the normal range
Norms:
Normal axillary temperature is within 36.4 to 37.4 centigrade (Berman et.al., 2018)
Analysis:
Based on the findings given above, a body temperature was normal during Patient
D’s entire hospitalization.
VII. RESPIRATORY STATUS

Findings:
It was noted that patient arrived with a complaint of shortness of breath where labored
breathing, and pursed lip breathing was evident. On auscultation soft crackles were
heard over the left lower base of both lungs Initial assessment suggests that patient is
tachypneic on the first day with an oxygen saturation of 89% but was given an
immediate action through Oxygenation which later resulted to a normal state of
respiratory status.
The table below shows the respiratory status of Patient D during the assessment:
Respiratory Analysis
Date
November 17, 2021 22 cpm Above the normal range
November 20, 2021 20 cpm Within the normal range
O2 Sat Analysis
Date
November 17, 2021 89 % Below the normal range
November 18, 2021 95 % Within the normal range
November 22, 2021 96% Within the normal range
November 23, 2021 97% Within the normal range
Norms:
A normal respiratory rate for adult ranges from 12-20 cycles per minute. Average is
18 cycles per minute. Breathing patterns must be regular and even in rhythm. The
normal breath sound is bronchial which is high in pitch, loud in intensity and blowing
or hollow in quantity, Broncho vesicular is moderate in pitch, moderate intensity, and
combination of bronchial and vesicular, and vesicular is low in pitch, soft intensity and
gentle rustling or breezy in quality (Berman et al., 2018). Normal Oxygen saturation
on the other hand ranges from 95%-100%. Breathing patterns must be regular and
even in rhythm. The normal breath sound is bronchial which is high pitch, loud in
intensity and blowing or hollow in quantity. Bibasilar crackle is bubbling or crackling
sounds at the base of the lungs that are caused by fluid in the airways or alveoli
(Hinkle & Cheever, 2018).
Analysis:
Based on the assessment, patient’s respiratory status was altered, there was a
decrease in oxygen saturation and the utilization of accessory muscle for breathing
was noted. After the Oxygen Supplementation and CABG surgery, Patient D’s
respiratory status became normal.
VIII. CIRCULATORY STATUS

Findings:
Upon admission, patient’s pulse rate and blood pressure were above the normal
range. However, patient’s pulse rate on the second day until after the surgery became
normal. While patient’s blood pressure was still above the normal range for four days
and became stable on her fifth to seventh day in the hospital.
The table below shows the circulatory status of Patient D during the assessment:
Date Pulse rate Analysis

November 17, 2021 107 bpm Above the normal range
November 18, 2021 95 bpm Within the normal range
Date Blood pressure Analysis
November 17, 2021 140/70 mmHg Above the normal range
November 21, 2021 120/80 mmHg Within the normal range
Norms:
A typical blood pressure for a healthy adult is 120/80 mmHg (pulse pressure of 40).
The normal adult pulse rate is 80 (60–100) beats per minute. Blanch test was
performed, and the normal capillary refill is less than 2 seconds and is normal after it
returns within normal state in 1-2 seconds. The pulse must have a regular beat and
not bounding nor weak. Blood pressure is not measured on the patient’s limb if is
injured or diseased, has an intravenous infusion or blood transfusion (Berman et al.,
2018).
Analysis:
Based on the above statement, patient’s pulse rate and blood pressure were elevated
upon admission which contributed to the present condition of the patient. Because
elevated pulse rate was manifested by her chest pain which causes the release of
adrenalin that elevates her pulse rate and blood pressure. High blood pressure can
lead to CAD that adds force to the arterial walls which can damage blood vessels and
lead to more plaque buildup. Heart murmurs were noted before the surgery and
became normal heart sounds after CABG.
IX. NUTRITIONAL STATUS

Findings:
According to the patient's brother, Patient D loves to eat unhealthy foods like fatty
foods such as Crispy Pata, sisig, letchon kawali, dinakdakan and salty foods such as
fries and instant noodles. She is not fond in drinking water and was not performing
any exercise. She is a non- smoker, but drinks alcohol occasionally. The patient is
weighing 80kg and standing 5’2” and her BMI is 33.2 which is considered as obese.
NUTRITIONAL PARAMETER
COMPUTATION NORMS ANALYSIS
PARAMETER
BMI Weight(lbs)/height(in)/ 18.5= Underweight Patient X
BMI is 33.25
Height: 5’1 ft. 18.5-24.9 = Normal
height(in)x703 =33.2
indicating
Weight: 80kg 25.0-29.9=Overweight
that patient’s
30.0-34.9= Obesity class 1 BMI is
obesity
35.0-39.9= Obesity class 2
class 1
Above 40= Obesity class 3
Norms:
Eating well and balanced meals, engaging in physical activities regularly, not smoking
nor using alcohol or drinking in moderation, and maintaining a healthy body weight
affect a person’s health. Over the years, the effects of these lifestyle choices
accumulate and will manifest in a person’s life span. Normal BMI is 18.5–24.9
(Berman et al., 2018).
Analysis:
Based on the data taken from the patient, Patient D eats three time a day with an
afternoon snack and loves eating unhealthy foods which is not good in her condition
and the value of her height and weight which is BMI is 33.2 indicates that it is not in
normal state.
X. ELIMINATION STATUS
Findings:
The patient had a routine bladder elimination prior to admission to the hospital. she
said that urinating does not cause him any discomfort. she said that he urinated 3-4
times a day. Her urine is a bright yellow color. In terms of bowel habits, the patient
had routine bowel elimination once daily with normal consistency.
And now, the patient has a Foley Catheter attached to Urine drainage bags collect
urine that is draining 30 ml per hour of yellow colored urine and defecates once every
2 days and feces are brown in color.
Norms:
Normally defecation is painless, resulting in the passage of soft, formed stool.
Straining while having a bowel movement indicates that the patient may need
changes in diet or fluid intake or that there is an underlying disorder in GI function.
(Hall et al., 2020)
Analysis:
The elimination status of the patient is normal. She said that he had no pain or
difficulty voiding. Voids about 30 ml per hour and it is yellow in color and Defecates
Once a day with the stool color of brown with a normal consistency.
XI. REPRODUCTIVE STATUS

Findings:
Patient D is unmarried woman who doesn’t have any children and never had any
reproductive health related diseases. She started her menstruation at 12 years old
and her menopausal happened at the age of 55 years old.
Norms:
Sexual health is a state of well-being concerning sexuality across the lifespan that
involves physical, emotional, mental, and spiritual dimensions. It also includes the
ability to understand the benefits, risks, and responsibilities of sexual behavior. The
history of any reproductive-related diseases or sexually transmitted diseases should
be assessed. (Berman et al., 2018; Jensen, 2018).
Analysis:
Patient D never had a sexual intercourse, her reproductive status health is at the
state of well-being for she doesn’t have any history of reproductive-related diseases.
XII. SLEEP AND REST PATTERN

Findings:
Before hospitalization, the patient stated that she usually sleeps around 8-9 pm and
wakes up around 5-6 am to work. Since her condition started, she has been
experiencing difficulty sleeping due to shortness of breath.
Norms:
Adults generally sleep 6-8 hours per night. About 20% of sleep is rapid eye
movement. The complete sleep cycle is about 1.5 hours in adults. Maintaining a
regular sleep-wake rhythm is more important than the number of hours slept (Berman
et al., 2018).
Analysis:
Based on the given data, Patient X’s sleep-rest pattern was not normal, sometimes
she has difficulty sleeping because she experiences difficulty in breathing
XIII. STATE OF THE SKIN AND APPENDAGES

Findings:
The hair was short and white in color when assessed. Her hair was thin and uniformly
distributed, there is no infection or any infestations found. On palpation, there were no
lesions, lumps, or masses. The nail base was firm to touch, and the fingernails and
toenails had a smooth texture. There were no lesions on the epidermis covering the
nails. The patient’s skin is brown in color and is uniform across her body, wrinkled
skin was present due to aging. When all four extremities were touched, the skin
temperature was the same and when she was tested for a capillary refill examination,
she had a capillary refill of 3 seconds. Post-surgical incision was 6-8 inches’ incision
made down the center of the sternum for traditional CABG surgery. Presence of CTT
that was placed between the mid to anterior axillary line in the fifth intercostal space
tracking above the rib. Post-surgical incision was pinkish in color and there was
presence of marks/scars of wounds with normal fine-line scars in the chest due to last
post-surgical incision.
Norms:
Skin surfaces should not be tender, and the skin is dry with a minimum of
perspiration. Skin temperature should be warm and equal bilaterally, hands and feet
may be slightly cooler than the rest of the body. The skin should normally feel smooth.
The skin turgor returns within 2-3 seconds and edema are not present. The skin
should be free from lesions and inflammations. (Jensen, 2019). Normal hair is
resilient and evenly distributed (Berman et al., 2018).
Analysis:
Based on the above information, the patient capillary refill result lasted 3 seconds
because of inadequate fluid intake, Presence of surgical scars were also noted and
the rest of assessment were normal.
8. LABORATORY AND DIAGNOSTIC PROCEDURES
DATE NORMAL ANALYSIS/
DIAGNOSTIC NURSING
ORDERED/ INDICATION/PURPOSES VALUES RESULT INTERPRETATIO
PROCEDURE RESPONSIBILITIES
ADMINISTERED N
An ECG Before the procedure
(electrocardiogram
A ECG checks how ) records the The test result St elevation - Provide client’s privacy
your heart's chambers electrical activity of reveals ST elevated indicated infarction - Advise the patient to wear
ECG and valves are your heart at rest. loose-fitting clothing.
Nov. 17 2021 pumping blood through It provides - Explain to the patient the
your heart. information about need to lie still, relax, and
And uses electrodes to your heart rate and breathe normally during the
check your heart rhythm rhythm, and shows procedure.
and ultrasound if there is - Note current cardiac drug
technology to see how enlargement of the therapy on the test request
blood moves through your heart due to high ECG shows changes form as well as any other
heart. blood pressure consistent with old pertinent clinical
(hypertension) or anteroseptal and information, such as chest
evidence of a inferior infarcts as well pain or pacemaker.
previous heart as lateral ischemia - Explain that the test is
attack (myocardial painless and takes 5 to 10
infarction). minutes.
After the procedure
- Disconnect the equipment,

remove the electrodes,
and
remove the gel with
a moist cloth towel.
- Assist and provide for
client’s privacy
- If the patient is having
recurrent chest pain or if
serial ECGs are ordered,
leave the electrode
patches in place
DATE NORMAL ANALYSIS/

DIAGNOSTIC NURSING
ORDERED/ INDICATION/PURPOSES VALUES RESULT INTERPRETATIO
PROCEDURE RESPONSIBILITIES
ADMINISTERED N
This test is used to Between 50 and Ejection fraction was ABNORMAL Before:
checks how heart 70% 20%
ECHOCARDIOGR chambers and valves are - Confirm patient identity
AM pumping blood through using at least 2
The results
your heart. identifiers
revealed that the
- Explain the test
ejection fraction is
procedure
reduced. This
November 17, During:
means that
2021 - Assist and observe the
oxygen-rich blood
client during the test
is not pumped out
of the left ventricle
After:
efficiently.
- Monitor patient’s
response to other
treatment.
DATE NORMAL
DIAGNOSTIC ANALYSIS/ NURSING
ORDERED/ INDICATION/PURPOSES VALUES RESULT
PROCEDURE INTERPRETATION RESPONSIBILITIES
ADMINISTERED
A chest X-Ray is an Normal chest  Haziness  Atherosclerotic - Monitor patient
imaging test that uses X- X-ray shows seen in the Aorta especially the result of
Chest X-Ray rays to look at the normal size left base  Thoracic Spondylosis the X-ray and hand it
structures and organs in and shape of  Heart is to the physician.
the chest. It can help to the chest magnified
November 17, see how well the lungs wall and the
2021  Aorta is
and heart are working. main calcified
structures in  Spurs seen at
the chest. the margins of
the thoracic
spine
DATE NORMAL
ADMINISTERED
Cholesterol Nor Res Before
testing is often mal ult: -Monitor the patient.
used as part of a value 240 High cholesterol is a
cardiac risk s mg/ significant risk factor After
TOTAL Nov. 17 2021 assessment. Too less dL for coronary heart -Instruct patient to
CHOLESTERO much cholesterol than disease and a cause become
L in the blood can 200 of heart attacks.
damage arteries mg/d physically active.
and blood vessels L. -Encourage to do not
and elevate risk smoke.
for stroke, heart - Instruct patient
attack, and heart control the blood
disease. pressure and monitor
at home or in a
barangay center
- Instruct to reduce
Too many cholesterol the body weight.
LDL particles in your blood, Nor Res - Encourage to eat a
cholesterol may mal ult: low- fat diet.
accumulate on your value 172 Elevated LDL - Follow up with your
Nov. 17 2021 artery walls. Eventually, s mg/ causes the building clinician.
deposits called plaques less dL of fatty deposits
may form. The deposits than within the ateries
may narrow — or block 200 which reduces or
— your arteries. These mg/d blocks the flow of
plaques can also burst, L. blood and oxygen in
causing a blood clot to the heart that can
form. lead to chest pain
and heart attack.
High-density lipoprotein Normal Res Low HDL is associated
cholesterol (HDL-C) are Values: ult: with increased risk for
inversely associated with 45 to 70 40 MI and severe
HDL Nov. 17 2021 the risk of coronary artery mg/dL for mg/ premature
disease and its thrombotic men, 50 to dL atherosclerotic disease
complications. 90 mg/dL for in the proximal left main
women coronary artery
DATE NORMAL
ADMINISTERED
CBC Nov. 17, 2021 A complete blood RBC normal result Before:
count is often used
Complete Blood as a broad values 5.1 cells/mL  Check the Doctor's
Count screening test to 4.7 to 6.1 order.
determine an million  Check identity using
individual’s general
health status. It can cells/mL at least two
be used to screen identifiers
for a wide range of WBC  Explain the test
conditions, such as
anemia, infection, Normal Result procedure.
inflammation, bleeding Values 12, 100/mcL Elevated WBC count is a  Obtain a list of the
disorder or leukemia. 4,500- risk factor for patient’s
In addition, other 11,000/mcL atherosclerotic vascular medications,
components of the disease that occurs when nutritional
complete blood count, plaque buildup inside the supplements
such as hematocrit and Platelet arteries. Wherein the
the erythrocyte Normal Result arteries get hard and After:
sedimentation rate, also values 300,000/mcL narrow, which can restrict
are associated with 150,000 to blood flow and lead to  Refrain from doing
coronary heart disease, 450, 000/mcL blood clots. any vigorous
and the combination of exercise, which could
the complete blood count stimulate blood flow
with the white blood cell Hemoglobin result and may cause
count can improve our 138 to 172 g/L 169g/L bleeding from the
ability to predict coronary H site.
heart disease risk.  Instruct the patient to
resume normal
Hematocrit Result activities of possible
Normal 49% and proper diet.
Values - Send the specimen to
41-50% the medical lab to test
CBC levels
DATE NORMAL
ADMINISTERED
It is used to assess the Normal Values Result ABNORMAL Before:
state of differentiation of 3%- 5% 20% Cardiac Isoenzyme is
muscle and neural tissue elevated because of -Check the Doctor's
and following release into clotted particularly in vein order.
plasma as diagnostic that can cause death. -Check identity using at
markers for acute least two identifiers
myocardial infarction, -Explain the test
CARDIAC skeletal muscle disease, procedure.
Nov. 17, 2021
ISOENZYME and neurologic injury. It -Obtain a list of the
can also indicate whether patient’s medications,
the patient will likely have nutritional supplements.
a heart attack.
After:
-Monitor vital signs
- -Ensure safety of the
patient.
Troponin Test A Troponin test measures 0.51 ng/ml 1.72 ng/mL Troponin is not normal, - Instruct patient to take
Nov. 17, 2021 the levels of Troponin T Increased in the troponin medicine as prescribed
and Troponin I proteins in level often means that by the physician.
the blood. These proteins there has been some
are released when the damage in the heart.
heart muscle has been
damaged.
CK MB The CPK-MB test is a Normal 6.0 ng/ml ABNORMAL Before:
Nov. 17, 2021 cardiac marker used to < 5.0 ng/ml
assist diagnoses of an Result is higher than the -Check the Doctor's
acute myocardial normal range. It indicates order.
infarction. It measures the that the patient could have -Check identity using at
blood level of CK-MB or has recently had a heart least two identifiers
(creatine kinase attack. It also indicates a -Explain the test
myocardial band), the second heart attack or procedure.
bound combination of two ongoing heart damage. -Obtain a list of the
variants (isoenzymes patient’s medications,
CKM and CKB) of the nutritional supplements.
enzyme phosphocreatine
kinase. After:
-Monitor vital signs
-Ensure safety of the
patient.
DATE NORMAL
ADMINISTERED
The purpose of this Normal Coronary Coronary angiogram was Before:
procedure is to see if your coronary Angiography done to the patient and it
coronary arteries are angiography revealed another revealed that he has CAD. - Confirm patient identity
Coronary narrowed or blocked and was defined as blood clot (total using at least 2
Angiogram Nov. 17 2021 to look for abnormalities angiographic blockage of identifiers
of your heart muscle or findings with coronary artery) It - Explain the test
heart valves. stenosis <20% was done past 6 procedure
in all vessels years. Year 2015 During:
and 2 years ago - Assist and observe the
which is 2019 and client during the test
this year 2021. After:
Monitor patient’s
response to other
treatment.
9. ANATOMY AND PHYSIOLOGY
CIRCULATORY SYSTEM
The circulatory system is an organ system that permits blood to circulate and transport
nutrients (such as amino acids and electrolytes), oxygen, carbon dioxide, hormones,
and blood cells to and from the cells in the body to provide nourishment and help in
fighting diseases, stabilize temperature, and maintain homeostasis in the body.
Main Features of the Human Circulatory

System:
-The blood, a liquid substance used to
transport nutrients, wastes, oxygen and
carbon dioxide, and hormones.
The blood consists chiefly of liquid called
plasma, and three kinds of solid particles
known as formed elements. Plasma is made
up mostly of water, but it also contains
proteins, minerals, and other substances.
The three types of formed elements are
called:
 Red blood cells carry oxygen and carbon dioxide throughout the body.
 White blood cells help protect the body from disease.
 Platelets release substances that enable blood to clot. Platelets thus aid in
preventing the loss of blood from injured vessels.
-Two pumps (in a single heart): one to pump deoxygenated blood to the lungs and the
other to pump oxygenated blood to all the other organs and tissues of the body, and the
only organ responsible in doing this is the Heart.
Heart – It is a hollow, muscular organ that pumps blood all throughout the body.
-A system of blood vessels to distribute blood throughout the body

Specialized organs for exchange of materials between the blood and the external
environment; for example, organs like the lungs and intestine that add materials to the
blood and organs like the lungs and kidneys that remove materials from the blood and
deposit them back in the external environment
Blood Vessels – They form a complicated system of connecting tubes throughout the
body which serves as transportation of oxygenated and deoxygenated blood
3 Major Types of Blood Vessels
 Arteries carry oxygenated blood away from the heart.
 Veins carry the blood back to the heart.
 Capillaries connect the arteries to veins. The arteries deliver the oxygen-rich
blood to the capillaries, where the actual exchange of oxygen and carbon dioxide
occurs. The capillaries then deliver waste-rich blood to the veins for transport
back to the lungs and heart.
The heart
The heart consists of FOUR CHAMBERS:
 Right and left atria- the thin- walled receiving chambers for blood returning to the
heart by way of the great veins. Each atrium has a small earlike extension called
auricle that slightly increases in vol
 Right and Left Ventricles: the pumps that eject blood into the arteries and keep it
flowing around the body. The right ventricle constitutes most of the anterior aspect of
the heart, while the left ventricle forms the apex and inferior posterior aspect.
A wall of tissue called the septum separates the left and right atria and the left and right
ventricle. Valves separate the atria from the ventricles.
The heart’s walls consist of three layers of tissue:
 Myocardium: This is the muscular tissue of the heart.

 Endocardium: This tissue lines the inside of the heart and protects the valves
and chambers.
 Pericardium: This is a thin protective coating that surrounds the other parts.
 Epicardium: This protective layer consists mostly of connective tissue and forms
the innermost layer of the pericardium.
Left and right sides
The left and right sides of the heart work in unison. The atria and ventricles contract and
relax in turn, producing a rhythmic heartbeat.
Right side
The right side of the heart receives deoxygenated blood and sends it to the lungs.
 The right atrium receives deoxygenated blood from the body through veins called
the superior and inferior vena cava. These are the largest veins in the body.
 The right atrium contracts, and blood passes to the right ventricle.
 Once the right ventricle is full, it contracts and pumps the blood to the lungs via
the pulmonary artery. In the lungs, the blood picks up oxygen and offloads carbon
dioxide.
Left side
The left side of the heart receives blood from the lungs and pumps it to the rest of the
body.
 Newly oxygenated blood returns to the left atrium via the pulmonary veins.
 The left atrium contracts, pushing the blood into the left ventricle.
 Once the left ventricle is full, it contracts and pushes the blood back out to the
body via the aorta.
The heart has four valve to ensure that blood only flows in one direction:
 Atrioventricular (AV) valves: regulate the openings between the atria and
the ventricles.
 Semilunar valve: regulate the flow of blood from the ventricles into the
great arteries.
 Pulmonary valve: controls the opening from the right ventricle into the
pulmonary trunk.
 Aortic valve: controls the opening from the left ventricle into the aorta.
PHYSIOLOGY
 Generating blood pressure, Contractions of the heart generate blood pressure,

which is required for blood flow through the blood vessels.
 Routing blood. The heart separates the pulmonary and systemic circulations, which
ensures the flow of oxygenated blood to the tissue
 Regulating blood supply.
10. PATHOPHYSIOLOGY
Book-based:
MODIFIABLE: NON-MODIFIABLE:
*Unhealthy Lifestyle: Smoking *Age: 65y/o and older. *Gender:

Alcoholism most common in male.
Eating fatty foods *Genetically Acquired Diseases:
Overweight Cardiovascular Disease
*DM Type 1 and 2
*Hypertension
*Atherosclerosis
Elasticity of Arterial
blood vessels plaque build
up
Causing blood Narrowing of
vessel stiffness blood vessels
Plaque disruption and

continuous aggression
of platelets
Thrombus
formation
Size of thrombus in
coronary artery wall
Some major coronary artery partial

or complete blockage; disrupting
blood flow in myocardium
CAD/CHD
Damaged and weakening
of heart muscles Cardiac Ischemia Tissue Perfusion Tachypnea
Compromised Some cell may die and

Heart muscle
pumping of the heart leads to Necrosis
stiffen and hardens
Tachycardia CAD progression and

complication development
Coronary Artery Bypass Graft
LEGENDS:
-RISK FACTORS
-DISEASE PROCESS
-LABORATORY/DIAGNOSTIC RESULT
-SIGNS AND SYMPTOMS
Patient-based:
MODIFIABLE: NON-MODIFIABLE:
-Sedentary lifestyle *Age

-Obesity *Gender
-Alcohol consumption *Genes
*History of CAD
Formation of atherosclerotic plaque in the

coronary arteries Elevated Cholesterol Levels
Hardening/Thickening of the arterial wall
Cardiac stenosis
Increased WBC Rupture of arterial plaque
Thrombosis formation
Thrombus travel to other

Coronary thrombosis coronary artery
Decreased blood flow Blockage of other arterial wall
Heart muscles become large Cardiac Ischemia Chest Pain

and stiff
Tissue Perfusion Tachypnea

Compromised pumping of the
heart
Coronary Artery Bypass Graft
LEGENDS:
-RISK FACTORS
-DISEASE PROCESS
-LABORATORY/DIAGNOSTIC RESULT
-SIGNS AND SYMPTOMS
B. PLANNING
1) PRIORITIZATION OF PROBLEM
NURSING DIAGNOSIS RANK JUSTIFICATION

st
This is the 1 prioritized nursing diagnosis because:
Ineffective breathing 1st According to Maslow’s Hierarchy of Needs, physiological needs are the most essential things a person needs to survive.
pattern related to Which includes breathing that is vital to our survival and must be attained in order to help the patient to meet her other
decreased lung expansion needs.
as evidenced by chest
pain, shortness of breath As positively evidenced by shortness of breath, respiratory rate of 22 cpm, and O2sat of 89% it should be the first priority
and easy fatigability because when the breathing pattern in ineffective, the body is most likely not getting enough oxygen to the cells.
Ineffective breathing pattern is one of the issues that nurses need to focus on which considered the state in which the ate,
depth, timing, and rhythm, or the pattern of breathing is altered. Which could lead to hypoxemia.
This is the 2nd prioritized nursing diagnosis because:
According to Katherine Kolcaba’s Theory of Comfort, “Comfort is an antidote to the stressors inherent in health care
situations today, and when comfort is enhanced patients and families are strengthened for the tasks ahead. Also, nurses
Acute Pain related to
feel more satisfied with the care they are giving.” And according to Maslow’s Hierarchy of Needs, the most basic needs
presence of post-
are the physiologic needs of food, water, sleep, shelter, sexual expression, and freedom from pain-must be met first. For
operative surgical incision/
the Nursing Pain Scale, Nurses play such a crucial le in patient treatment and assessment. Being able to assess pain is
CTT as evidenced by
2nd vitally important to the effectiveness of nursing arond patient care. The best way of understanding a patient’s level of
verbal report of pain in the
pain, is by hearing it from the patient themselves or by facial grimace. The quality of the pain gives good information to
chest area, pain scale of
the nurse and that is helpful in making a proper diagnosis.
5/10 and guarding
behaviour
As positively evidenced by verbal report of pain in the chest area, pain scale of 5/10, guarding behaviour and facial
grimace, it should be the second priority because acute pain provides a protective purpose to make the patient informed
and knowledgeable about the presence of post-operative surgical incision. The unexpected onset of acute pain reminds
the patient to seek support, assistance, and relief.
Risk for Infection related 3rd This is the 3rd prioritized nursing diagnosis because:
to Post-op incision
According to Florence Nightingale’s Environmental Theory, she defined it as “the act of utilizing the patient’s environment
to assist him in her recovery” and a healthy environment is essential for healing. She stated that “nature alone cures.”
As positively evidenced by the verbalization of concerns of the patient’s significant other wherein the patient had
undergone coronary artery bypass graft (CABG). It should be the third priority because infections occur when the natural
defense mechanism of an individual are inadequate to protect them. Serious impairment can predispose to severe, even
life-threatening infections.
This is the 4th prioritized nursing diagnosis because:
According to Maslow’s Hierarchy of Needs under the Safety and Security, Injury prevention is (side rails, call lights, hand
hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts) fostering a climate of trust and
safety (therapeutic relationship) is one of the components of Basic Needs.
Risk for Injury related to 4th
presence of Chest Tube
As positively evidenced by the presence of Chest Tube Thoracostomy, it should be the third priority because it can lead
Thoracostomy
to tension pneumothorax if not monitored well. it is also one of the physiological components of Henderson’s Need
Theory. Wherein risk for injury is the state in which an individual is at risk for harm because of a perceptual or physiologic
deficit or a lack of awareness of hazards. The patient is prone to injury because of the presence of CTT. That is why
preventing patient from injury is very important.
2) Nursing Care Plan

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Ineffective Within 30 minutes of INDEPENDENT: INDEPENDENT: After 30 minutes of
breathing pattern rendering appropriate rendering
“Nurse related to nursing interventions: Administer oxygen via nasal For management of appropriate
nahihirapan pong decreased lung cannula at 2 lpm underlying pulmonary nursing
huminga yung expansion as - The patient will be condition and respiratory interventions:
evidenced by able to have relieved distress
lola namin at
chest pain, breathing pattern as - The patient was
mabilis din po shortness of evidenced by able to relieved
siyang mapagod” Monitor Pulse oximeter as indicated To verify maintenance or
breath and easy respiratory rate of 22 breathing pattern
As verbalized by improvement of oxygen
fatigability cpm to 20 cpm, as evidenced by
saturation
the patient’s O2sat of 89% to respiratory rate of
Provide a quiet environment A quiet environment reduces
significant other Scientific 95%, pulse rate of 22 cpm to 20 cpm,
the energy demands on the
Rationale: 107 bpm to 95 bpm to the patient O2sat of 89% to
patient
OBJECTIVE: and fatigue is 95%, pulse rate of
It is considered reduced as Position the patient with proper A sitting position permits 107 bpm to 95
alignment for maximum breathing maximum lung excursion
- Shortness of the state in which evidenced by bpm and fatigue
breath the rate, depth, walking from bed to pattern and chest expansion was reduced as
- Easy fatigability timing, and the comfort room evidenced by
- Chest pain rhythm, or the with minimal Elevate the head of the bed and/or To promote physiological walking from bed
pattern of assistance have the client sit up in a chair as and psychological ease of to the comfort
breathing is appropriate maximal inspiration room with minimal
Vital Signs:
altered. When the assistance
-BP: 140/70 breathing pattern Facilitate patient in doing deep To assist the patient in taking
mmHg is ineffective, the breathing technique and use of control of the situation Goal Met
- PR: 107 bpm body is most pursed-lip technique
- RR: 22 cpm likely not getting
- Temp: 98.6 F enough oxygen to
o Provide adequate Prevents fatigue and
or 37 o C the cells. rest conserve energy for healing.
- O2sat: 89% Respiratory periods and reposition as indicated May relieve pain and
failure may be enhance
correlated with circulation
variations in Encourage frequent rest Extra activity can worsen shortness
respiratory rate, periods and teach patient to of breath. Ensure the patient rests
abdominal, and pace activity between strenuous activities
thoracic pattern.
This conserves energy and avoids
Assist patient in ADLs as
necessary overexertion and fatigue
DEPENDENT: DEPENDENT:
Administer respiratory medications To prevent and control symptoms,
as indicated reduce frequency and severity of
exacerbations, and improve
exercise tolerance
COLLABORATION: COLLABORATION:
Refer the patient for evaluation of Exercise promotes conditioning of

exercise potential and development respiratory muscle and patient’s
of individualized exercise program sense of well-being

DIAGNOSIS
SUBJECTIVE: Acute pain SHORT TERM INDEPENDENT: To obtain baseline data SHORT TERM
related to GOAL: Monitor the patients’ vital signs GOAL:
"Inoperahan po presence of Monitor skin color/temperature and Which are usually altered in
yung lola namin postoperative Within 30 minutes to peripheral pulse frequently acute pain and to monitor After 30 minutes to
kanina, medyo surgical incision 1 hour of rendering tissue perfusion 1 hour of rendering
as evidenced by appropriate nursing Provide a quiet environment A quiet environment reduces appropriate
masakit daw
verbal report of interventions: to the patient the energy demands on the nursing
yung naoperahan pain in the chest interventions:
patient
sakanya at area, pain scale - The patient will Perform a comprehensive The patient experiencing
natatakot ako na of 5/10, guarding verbalize decrease assessment of pain. Determine the pain is the most reliable - The patient was
baka bumuka behavior and and relief of pain at location, characteristics, onset, source of information about able to verbalize
ang sugat niya” facial grimace the chest area from duration, frequency, quality, and their pain. Thus, decreased and
As verbalized by pain scale of 5/10 to severity of pain via assessment. assessment of pain by relieved of pain at
Scientific 3/10 which is conducting an interview the chest area
the patient’s
Rationale: tolerable helps the nurse in planning from pain scale of
significant other 5/10 to 3/10 which
optimal pain management
Post-operative - The patient will be strategies. is tolerable
OBJECTIVE: pain is able to display Reduce or eliminate factors that Personal factors can
considered a reduced tension, a precipitate or increase pain influence pain and pain - The patient was
- Facial Grimace form of acute relaxed manner, and experience such as fear, fatigue, tolerance. able to display
- Weak and pale pain due to ease of movement lack of knowledge. reduced tension,
in appearance surgical trauma Educate the patient about the use of The use of noninvasive pain relief relaxed manner,
- Guarding with an non-pharmacologic techniques such measures can increase the release and eased of
behavior inflammatory LONG TERM GOAL: movement
as relaxation, music therapy, of endorphin and enhance the
- Pain Scale: 5/10 reaction and distraction. therapeutic effect of pain relief
initiation of an Within 2-3 days of medication.
Vital Signs: afferent neuronal rendering appropriate
barrage. nursing interventions: Provide adequate Prevents fatigue and LONG TERM
- BP: 130/90 Peripheral GOAL:
rest conserve energy for healing
mmHg afferent neuronal - The patient will be
periods Reposition as indicated May relieve pain and enhance
- PR: 76 bpm barrage from free from any pain in Within 2-3 days of
- RR: 20 cpm circulation
tissue injury the incision site rendering
- Temp: 98.6 o F Demonstrate/facilitate patient Helpful in decreasing
produces central appropriate
or 37 o C to do relaxation techniques perception and response to
nervous system - The patient will nursing
- O2sat: 95% such as: deep and slow pain. Provides a sense of
hyper excitability verbalize that he has interventions:
breathing, distraction having some control over
which may improved her
behaviors, visualization, and the situation,
contribute to feeling/sense of - The patient was
guided imagery increase in positive attitude
increased control over her able to be free
postoperative present and future DEPENDENT: DEPENDENT: from any pain in
pain. situation Administer Opioids such as It is a powerful pain medication that the incision site
Tramadol as ordered diminish the perception of pain and
may be given after surgery - The patient
COLLABORATION: COLLABORATION: verbalized that she
Obtain a 12 lead ECG after the Serial ECG and stat ECG record had improved hrt
surgery and each time chest pain changes that can give evidence of feeling/sense of
recurs for evidence further infarction and other control over her
of further infarction as ordered complications present and future
Refer the patient to a pain To enable patient to receive more situation
specialist as required information and specialized care in
pain management if needed Goal met
DIAGNOSIS
OBJECTIVE Risk for Infection Short Term: INDEPENDENT: INDEPENDENT: Short Term:
DATA: related to post-op Within 8 hours of Practice and emphasize constant This is the first-line defense against Within 8 hours of
incision rendering of and proper hand hygiene by all healthcare associated infections. rendering of
- Post-operative appropriate nursing caregivers between therapies and appropriate
incision 6-8 Scientific interventions, the clients. Wash hands after glove nursing
inches’ incision Rationale client will be able at removal. Instruct the interventions, the
made down the lesser risk of client was at lesser
client/SO/visitors to wash hands as
center of the Infections occur infection. risk of infection.
indicated.
sternum when the
-Wound natural defense Long term: Cleanse incisions and insertion To reduce the potential of Long term:
dehiscence mechanisms of Within 3 days of sites per facility protocol with infections and to prevent growth of Within 3 days of
-Incision is pinkish an individual are rendering appropriate appropriate antimicrobial or bacteria. rendering
in color inadequate to nursing interventions, solution. appropriate
protect them. the patient will be Demonstrate coughing and, deep For mobilization and prevention nursing
Vital Signs: Microorganisms able to remain free of breathing techniques. of aspiration/respiratory interventions, the
such as bacteria, infection, as infections. patient was able to
- BP: 130/90 viruses, fungus, evidenced by normal Reposition every 2 hours and It prevents stasis of secretions and remain free of
mmHg and other vital signs and assist patient in position changes. pathogens in the lungs and infection, as
- PR: 76 bpm parasites invade absence of signs and bronchial tree evidenced by
- RR: 20 cpm susceptible hosts symptoms of infection Encourage sleep and rest. Adequate sleep is an essential normal vital signs
- Temp: 98.6 o F through inevitable and identify modulator of immune responses. A and absence of
or 37 o C injuries and interventions to lack of sleep can weaken immunity signs and
- O2sat: 95% exposures prevent or reduce risk and increased susceptibility to symptoms of
of infection. infection. infection and
Limit visitors Restricting visitation reduces the identify
transmission of pathogens. interventions to
Teach the importance of avoiding Other people can spread infections prevent or reduce
contact with individuals who have or colds to a susceptible patient risk of infection.
infections or colds. Teach the (e.g., immunocompromised)
importance of physical distancing. through direct contact, Goal met
contaminated objects, or air
currents.
DEPENDENT: DEPENDENT:
Administer/monitor medication To determine effectiveness of
regimen and note the client’s therapy or presence of side effects.
response.
COLLABORATIVE: COLLABORATIVE:
Refer patient into the Post- It is highly effective in helping
Anesthesia Care Unit (PACU). patient regain their strength while
guiding them back to regular life. It
also plays a key role in pain
management and care coordination
in a hygienic environment that
otherwise wouldn’t have been
possible at home.
DIAGNOSIS
OBJECTIVE: Risk for Injury Short-term Goals: INDEPENDENT: INDEPENDENT: Short-term Goals:
related to
- CTT connected presence of Within 4-6 hours of - Monitor patient’s vital signs such - To rapidly identify any After 2-6 hours of
to water seal Chest Tube rendering appropriate as HR, O2sat, BP and RR physiological change in condition rendering
chamber on the Thoracostomy Nursing appropriate Nursing
right side Interventions: Monitor rate, rhythm, and depth of - Changes may indicate onset of Interventions:
Scientific respiration. Note breathing pulmonary complications. Ability to
- Chest tube is Rationale: - The patient will be irregularities, for example, mobilize or clear secretions is an - The patient was
intact and free of injury related apneustic, ataxic, or cluster important airway maintenance free of injury related
draining to Placing chest to perioperative breathing. to perioperative
pinkish output tubes far into the disorientation - It is important to distinguish normal disorientation
last drainage thorax can result - Encourage deep breathing once respiratory sounds from abnormal
level (50 ml) in perforation of - The patient’s client is conscious. Auscultate ones in order to prevent any - The patient’s
heart, injuries to relatives will verbalize breath sounds, noting areas of complications relatives verbalized
large vessels, understanding of the hypoventilation and presence of understanding of the
Vital Signs: perforation of the chest tube’s purpose adventitious sounds. chest tube’s purpose
esophagus, and - Chest tubes are painful as the
- BP: 140/70 nerve injuries. Long-term Goal: - Inform patient that chest tube is parietal pleura is very sensitive. Long-term Goals:
mmHg painful Patient require regular pain relief for
- PR: 76 bpm Within 1-3 days of comfort, and to allot them to After 1-3 days of
- RR: 20 cpm rendering appropriate complete physiotherapy or mobilis rendering
- Temp: 98.6 o F Nursing appropriate Nursing
or 37 o C Interventions: - Doing so may cause fluid from the Interventions:
- O2sat: 97% - Never lift drain above chest level system to siphon back into the
- The patient will be patient’s chest - The patient was
free of untoward free of untoward
skin/tissue injury or - Continuous air bubbling in the skin/tissue injury or
changes lasting - Monitor for continuous air chamber can indicate a leak that changes lasting
beyond 24-48 hours leak/bubbling in the water seal should be evaluated beyond 24-48 hours
following procedure chamber following procedure
- Kinked or bent tubing could
- The patient will - Ensure tubing is not kinked/no interfere with the drainage of the - The patient
report resolution of obstruction pleural fluid reported resolution
localized numbness, of localized
tingling, or changes - To prevent pulling of drain numbness, tingling,
in sensation related - Anchor the tubing to the patient’s or changes in
to positioning within skin - Facilitates lung expansion and sensation related to
24-48 hours as ventilation, and reduces risk of positioning within 24-
appropriate - Observe hematoma formation, airway obstruction 48 hours as
resolution and presence of appropriate
bleeding and drainage amount,
color, odor - Prevents or reduces atelectasis Goal Met
and appearance
- Elevate head of bed as permitted - Myocardial depressant effect of

and position on sides, as indicated. various agent increases risk of
hypotension and/or bradycardia
- Reposition slowly at transfer from
table and in bed especially - To remove dressing when placed
halothane-anesthetized patient flat against the skin
- Lift corner from the skin and slowly

stretch in the dressing in a motion - To remove semi permeable
that is parallel to the skin dressing placed in a sandwich
position
- Hold the corners of the dressing on
either side of the drain and pull them
away from each other; this should - To clamp the tube right away as
create a pocket around the drain ordered and apply adhesive
dressing if it was removed
- Provide hemostatic and adhesive
dressing at the bedside DEPENDENT
- There is a risk of the patient

DEPENDENT: developing a tension pneumothorax
if a drain is clamped while an air
- Chest drains should not be leak is present
clamped unless ordered by medical
staff COLLABORATIVE:
- Close attention to proper

positioning can prevent muscle
COLLABORATIVE: strain, nerve damage, circulatory
compromise, and undue pressure
- Recommended position changes on skin and/or bony prominences.
to anesthesiologist and/or surgeon Although the anesthesiologist is
as appropriate responsible for positioning, the
nurse may be able to see and have
more time to note patient needs,
and provide assistance.
- Lack of exposure or lack of recall

can lead to information
misinterpretation. Chest tube is a
plastic tube that is used to drain fluid
- Explain purpose of chest drain to or air from the chest. Chest tube will
relatives and when it is likely to be be removed between one day or 1-2
removed weeks depending on how well the
patient is responding to treatment
- Physiotherapy is very important

after cardiac surgery as it will
enhance the patient’s recovery and
promote her independence
- Refer patient to Physiotherapist as
indicated
C. IMPLEMENTATION
1. Drugs
NAME OF DRUG ROUTE AND MECHANISM OF INDICATION CONTRA ADVERSE EFFECTS NURSING
DOSAGE ACTION INDICATION RESPONSIBILITY
75 mg PO q Secondary Contraindicated  Provide small frequent
GENERIC NAME: daily Clopidogrel works by prevention of MI, with allergy to CV: Chest pain, meals before
CLOPIDOGREL blocking platelets from stroke, and vascular clopidogrel and edema, hypertension, administering the
sticking together and death in patients with active thrombolytic purpura. medication to prevent GI
BRAND NAME: preventing them from with recent MI, pathological upset.
forming harmful clots. Body as a Whole:  Do not administer to
Plavix stroke, unstable bleeding such as
It is an antiplatelet Flu-like syndrome, persons with active
drug. It helps keep angina or peptic ulcer or fatigue, pain, pathologic bleeding.
CLASSIFICATION: blood flowing established intracranial arthralgia, back pain.  Carefully monitor for
ANTIPLATELET peripheral arterial hemorrhage
DRUG smoothly in the body. disease. signs and symptoms of
GI: Abdominal pain, GI bleeding, especially
dyspepsia, diarrhea, when co administered
nausea, with NSAIDs, aspirin,
hypercholesterolemia. heparin, or warfarin.
 Evaluate patients with
Hematologic: unexplained fever or
Thrombotic infection for
thrombocytopenic myelotoxicity.
purpura, epistaxis.  Monitor and advise
patient to notify health
CNS: Headache, care professional
dizziness, depression. promptly if fever, chills,
sore throat, and unusual
Respiratory: URI, bleeding or bruises
dyspnea, rhinitis, occur.
bronchitis, cough.
Skin: Rash, pruritus.

GENERIC NAME: 1gm IV q12h Long acting, broad Sepsis, meningitis, Contraindicated in CNS: fever,  Obtain specimen culture
ROCEPHIN spectrum abdominal biliary patients with headache, dizziness and sensitivity tests
cephalosporin tract, GIT, bone hypersensitivity to before giving first dose
BRAND NAME: antibiotic. The
joints, soft tissue,
drug or other CV: phlebitis  Note for the drug,
Ceftriaxone bactericidal activity of cephalosporins. dosage, time, route, client
ceftriaxone results renal, respiratory GI: diarrhea,  Should be taken with or
from inhibition of cell tract, ENT, genital, pseudomembranous without food
CLASSIFICATION:
wall synthesis. skin, and wound colitis  Push meds slowly
Cephalosporins Ceftriaxone exerts in infections, UTI  Monitor the IV site for the
vitro activity against a gonorrhea, periop- GU: genital, pruritis, presence of redness,
wide range of gram prophylaxis of candidiasis swelling, and tenderness
negative and gram  During the administration
infections
positive Hema: of medication observe
microorganisms. thrombocytosis, and ask the patient if she
eosinophilia, felt pain while pushing the
leukopenia medication
 Monitor PT and INR in
Skin: rash patients with impaired
vitamin k synthesis or low
vitamin k stores. Vitamin K
may be needed
 Monitor Blood levels in
patients taking this drug.
 Note the side effects of
the drugs
GENERIC NAME: 20 mg PO q A fungal metabolite As an adjunct to diet Contraindicated CNS: Headache, Before:
ROSUVASTATIN HS that inhibits the in the treatment of with allergy to any
dizziness, insomnia,  Assess vital signs
enzyme (HMG-CoA) elevated total components of the
hypertonia,
BRAND NAME: that catalyzes the first cholesterol and LDL product, active paresthesia,  Assess allergy to any
Crestor step in the cholesterol cholesterol and liver disease ordepression, anxiety, component of the
synthesis pathway, triglyceride levels in persistent elevated
vertigo, neuralgia. product, liver disease or
CLASSIFICATION: resulting in a patients with primary serum persistently elevated
decrease in serum hypercholesterolemia transaminases, CV: Hypertension, serum transaminases,
Antihyperlipidemic
cholesterol, serum (familial and pregnancy, angina pectoris, pregnancy, lactation,
HMG-CoA
LDLs (associated with nonfamilial), and in lactation. vasodilatation, alcoholism, renal
reductase inhibitor
increased risk of patients with mixed palpation, peripheral impairment, advanced
(statin)
coronary artery dyslipidemia. Use cautiously edema. age, and
disease) and either with impaired hypothyroidism.
an increase or no Adjunct to client to hepatic GI: Nausea,
change in serum slow atherosclerosis function, dyspepsia, diarrhea, During:
HDLs (associated progression in alcoholism, renal constipation,  Establish baseline serum
with decreased risk of impairment, gastroenteritis, lipid levels and liver
patients with
coronary artery advanced age, vomiting, flatulence, function test results
disease) elevated cholesterol. hypothyroidism. periodontal abscess, before beginning
gastritis, liver failure. therapy.
Respiratory:  Administer drug at

Pharyngitis, rhinitis, bedtime (highest rates of
sinusitis, cough, cholesterol synthesis
dyspnea, pneumonia. occur between midnight
and 5 am)
 Monitor patient closely

for signs of muscle
injury, especially at
higher doses, in Asian
patients, and when used
in combination with
gemfibrozil or
cyclosporine.
After:
 Instruct patient to take
drug during bedtime
 Stop the drug and

contact your health care
provider immediately I
you experience
unexplained muscle
pain, tenderness, or
weakness with fever and
malaise.
GENERIC NAME: 40 mg PO OD Blocks angiotensin II To reduce risk of MI, Contraindicated in Hypotension,  Check patient blood
TELMISARTAN from binding to stroke, or death from patients with high palpations, asthma, pressure regularly
receptor sites in many cardiovascular levels of potassium dyspnea, epistaxis,  Monitor liver function
BRAND NAME: tissues, including in the blood. Low pain, dizziness, UTI, test results, as
causes in patients at
Micardis vascular smooth blood pressure flu-like symptoms, appropriate, and
muscle, and adrenal high risk who are and dehydrated diarrhea, fatigue, assess for evidence of
glands. This action unable to take ace myalgia, n&v. drug toxicity in patients
CLASSIFICATION:
inhibits the inhibitors Abdominal pain, with severe hepatic
Angiotensin II vasoconstrictive and cough, pharyngitis, disease because
receptor aldosterone secreting chest pain they’re at increased
antagonist effects of angiotensin risk for toxicity from
Antihypertensive II, which reduces increased drug
blood pressure. accumulation
 Instruct patient to
change position slowly
to minimize effects of
orthostatic hypotension
 Urge patient to
immediately notify
prescriber about
diarrhea, dizziness,
severe nausea, or
vomiting
 Advise patient to drink
adequate amounts of
fluid during hot weather
and when exercising.
GENERIC NAME: 50 mg IV q6h Centrally acting Management of Hypersensitivity to CNS: drowsiness,  Assess for level, intensity,
TRAMADOL opiate receptor moderate to tramadol or other dizziness, vertigo, type and location of pain
agonist that inhibits moderately severe opioid as fatigue, headache, relief and administer prn
BRAND NAME: the uptake of analgesics; restless, euphoria, dose as needed but not
pain.
Tramal norepinephrine and patients on MAO confusion to exceed the
serotonin, suggesting inhibitors; patients CV: palpitations, recommended total daily
both opioid and acutely intoxicated vasodilation dose.
CLASSIFICATION:
nonopioid mechanism with alcohol, GI: nausea,
Analgesic; of pain relief. May hypnotics, constipation,  Monitor vital signs and
narcotic (opiate) produce opioid-like centrally acting vomiting, diarrhea, assess for orthostatic
agonist effects but causes analgesics, opioids abdominal pain hypotension or signs of
less respiratory or Skin: rash CNS depression
depression than psychotropic Special senses:
morphine. drugs; substance visual disturbances  Discontinue drug and
abuse; patients on Urogenital: urinary notify physician if S&S of
Tramadol may be a obstetric retention/ frequency hypersensitivity occur.
useful analgesic preoperative Tramadol has a minor
where interference medication; abrupt delaying effect on  Assess bowel and
with gut motor discontinuation; colonic transit, but no bladder function; report
function is alcohol toxication effect on upper urinary frequency or
undesirable. gastrointestinal transit retention.
or gut smooth muscle  Exercise caution with
tone. potentially hazardous
activities until response to
drug in unknown
NAME OF DRUG ROUTE AND MECHANISM OF INDICATION CONTRAINDICATI ADVERSE EFFECTS NURSING
DOSAGE ACTION ON RESPONSIBILITY
It is indicated for the Contraindicated to
GENERIC NAME: Works by relaxation acute relief of attack patient CV: fast,slow,  Use cautiously in patient
NITROGLYCERIN 5 to 10 of smooth muscle, or acute prophylaxis hypersensitive to pounding or uneven with hypotension or
mcg/minute producing a of angina pectoris nitrates and those heart rate. volume depletion.
BRAND NAME: via IV infusion vasodilator effect on due to CAD. with early MI,  Closely monitor vital
Nitronal the peripheral veins Severe anemia , Body as a Whole: signs during infusion.
and arteries with Increase ICP and weak or dizzy.  Asses for any adverse
DRUG more prominent orthostatic effect and advise patient
CLASSIFICATION: effects on the veins. hypotension GI: Abdominal pain, to report it immediately.
VASODILATOR Primarily reduces dyspepsia, diarrhea,
cardiac nausea,
oxygen demand by hypercholesterolemia.
decreasing pre load.
CNS: Headache,
dizziness, depression.
Skin: Rash, pruritus.

2. Medical Management
DATE ORDERED /
PERFORMED NURSING CLIENT’S REACTION TO
MEDICAL MANAGEMENT CHANGED / GENERAL DESCRIPTION INDICATIONS / PURPOSE
RESPONSIBILITY TREATMENT
DISCONTINUED
Oxygen administration via DATE ORDERED: Oxygen therapy is used to deliver - Assess nasal - Patient was able to
nasal cannula @2-3L/m a treatment that delivers supplemental oxygen or patency tolerate oxygen
Nov. 17, 2021 oxygen gas for you to increased airflow to a - Set oxygen to support and have
breathe. You can receive patient or person in need
oxygen therapy from tubes prescribe rate improved breathing
of respiratory help. - Ensure that oxygen
resting in your nose, a face pattern
mask, or a tube placed in is flowing freely from - Patient did not show
your trachea, or windpipe. the tubing
This treatment increases any complication
- Encourage the
the amount of oxygen your
patient to breathe
lungs receive and deliver to
your blood. through the nose
rather than the
mouth and expire
from the mouth
DATE ORDERED /
MEDICAL PERFORMED GENERAL INDICATIONS / NURSING CLIENT’S REACTION
MANAGEMENT CHANGED / DESCRIPTION PURPOSE RESPONSIBILITY TO TREATMENT
DISCONTINUED
Peripherally inserted DATE ORDERED: A peripherally inserted  A PICC line is used to  Always assess for  Patient was able to
central catheter (PICC) central catheter (PICC), deliver medications good blood flow and tolerate PICC line
November 18, 2021 also called a PICC line, and other treatments easy flushing every  Patient did not show
is a long, thin tube that's directly to the large shift to ensure PICC any complication
inserted through a vein central veins near
in your arm and passed line patency.  There is no presence
your heart.
through to the larger  Assess site at least of redness, swelling,
 it can be used for other
veins near your heart. every 8 hours or tenderness in the
things, too, such as
Very rarely,  Note redness, site.
blood draws, blood
the PICC line may be swelling, drainage,  Dressing is in a good
transfusions and
placed in your leg.
receiving contrast tenderness & condition
material before an condition of dressing
imaging test.
MEDICAL DATE ORDERED / INDICATIONS / NURSING CLIENT’S REACTION TO

PERFORMED GENERAL DESCRIPTION
MANAGEMENT CHANGED / PURPOSE RESPONSIBILITY TREATMENT
DISCONTINUED
IFC DATE ORDERED: Insertion of an  To empty the  Don gloves  IFC insertion is done
Indwelling Foley indwelling foley catheter (IFC) bladder completely  Assist to place and aseptically
Catheter November 19, 2021 is an invasive procedure that prior to surgery
 To accurately secure the catheter  Patient was able to
should only be carried using an
16Fr (for female) aseptic technique, either by a measure and drainage bag below tolerate IFC catheter
nurse, or doctor if monitor the urine the level of the  Patient did not show
output bladder and off the any complication
complications or difficulties with
 To relieve
insertion are anticipated. floor  Foley Catheter is intact
discomfort due to
bladder distention  Empty drainage draining to urine bag
bags regularly with yellow color urine
 To manage  Keep the catheter with no sediments
incontinence
and all tubing from  The Foley Catheter is
kinking/ obstruction intact and draining
 To obtain a urine
specimen  Evaluate catheter normally, with urine that
function and is yellow in color and
 To provide for amount, color, odor, aromatic odor.
intermittent or and quality of urine
continuous bladder
drainage and
irrigation
DATE ORDERED /
MEDICAL PERFORMED GENERAL INDICATIONS / NURSING CLIENT’S REACTION
MANAGEMENT CHANGED / DESCRIPTION PURPOSE RESPONSIBILITY TO TREATMENT
DISCONTINUED
Endotracheal tube DATE ORDERED: An endotracheal tube To Keep the airway  Ensure the  Patient was able to
(ET) is a flexible plastic open in order to give endotracheal tube tolerate ET
November 19, 2021 tube that is placed oxygen, medicine, or remains properly  Patient did not show
through the mouth anesthesia. Support
positioned and any complication
into the trachea breathing in certain
(windpipe) to help a illnesses, such as secured in place  Dressing is in a good
patient breathe. The pneumonia,  Maintain skin condition and the
endotracheal tube is emphysema, heart integrity. Change tube is intact and
then connected to a failure, collapsed lung tape and dressing patent.
ventilator, which or severe trauma. as needed or per
delivers oxygen to
protocol
the lungs.
 Auscultate the lungs
 Monitor for signs
and symptoms of
infection, including
temperature and
white blood cell
count
 Provide good oral
hygiene
3) Surgical Management
NAME OF THE DATE BRIEF DESCRIPTION INDICATION/PURPOSE CLIENT’S RESPONSE NURSING RESPONSIBILITIES
PROCEDURE TO OPERATION
Before
-Verify presence of laboratory and

diagnostic test results in the chart
Coronary bypass surgery to treat a blockage or Patient tolerated the
is a procedure that narrowing of one or more procedure well - Type and crossmatch four or more units of
restores blood flow to of the coronary arteries to blood as ordered.
Coronary November your heart muscle by restore the blood supply
Artery Bypass 19, 2021 diverting the flow of blood to your heart muscle. After
Graft Surgery around a section of a -Monitor vital signs, oxygen saturation, and
blocked artery in your hemodynamic parameters every 15 minutes
heart. Coronary bypass
surgery redirects blood -Auscultate heart and breath sounds on
around a section of a admission and at least every 4 hours
blocked or partially
blocked artery in your -Assess skin color and temperature,
heart. peripheral pulses, and level of
consciousness with vital signs.
-Continuously monitor and document

cardiac rhythm.
-Measure intake and output hourly. Report

urine output less than 30 mL/h for 2
consecutive hours.
-Administer intravenous fluids, fluid boluses,

and blood transfusions as ordered.
-Administer medications as ordered.

NAME OF THE DATE BRIEF DESCRIPTION INDICATION/PURPOSE CLIENT’S RESPONSE NURSING
PROCEDURE TO OPERATION RESPONSIBILITIES
CHEST TUBE DATE ORDERED: A chest tube is a plastic A chest tube can help The chest tube was able During
THORACOSTOMY November 19, 2021 tube that is used to drain drain air, blood, or fluid to drain the excess fluid
fluid or air from the from the space and blood after surgery  Open sterile
chest. Air or fluid (for insertion tray and
DATE PERFORMED: surrounding your lungs, and there is no
example blood or pus) add cleansing
November 19, 2021 that collects in the space called the pleural space. complication showed to
Chest tube insertion is the patient. agent, chest tube
between the lungs and
DATE DISCONTINUED: chest wall (the pleural also referred to as chest and suture to tray.
November 21, 2021 space) can cause the tube thoracostomy. It's  Provide local
lung to collapse. typically an emergency anaesthetic vial
procedure. It may also Drainage output: 70-100 for physician to
be done after surgery on ml per hour with a dark access.
organs or tissues in your red color on the first day  Reassure and
chest cavity. first op, pinkish color on support patient
second day post op and during procedure.
pale yellow in color on NOTE: Observe
third day of post op patient’s color,
pulse and
respirations
throughout
Incision doesn’t show procedure.
any reaction or infection  Attach drainage
system to chest
tube when
directed by
Dressing is secured, physician.
clean and intact  Tape all tubing
connections at
chest tube to
chest drain unit
securely with
water-proof tape.
 Ensure that
tubing is never
kinked or looped.
 Ensure
connection
between chest
tube and drainage
tubing are
securely taped
with waterproof
tape in a spiral
fashion,
extending 5 cm
on either side of
connection.
 Never tape in-line
connector (see
picture in section
E, step 5). Doing
so would increase
risk of tube
disconnection.
 Always keep
chest drainage
system upright
and below the
level of patient’s
chest.
 Do not clamp
chest tube during
transport (i.e., to
X-ray
department),
unless ordered by
physician.
 Never clamp
chest tube for
more than one
minute unless
specifically
ordered by
physician.
 Ensure a
container of
sterile water is at
bedside. In case
of disconnection,
rapidly prepare
and attach new
drainage system
while submerging
distal end of chest
tube in sterile
water.
 If there are
visible clots in
tubing, obtain a
physician’s order
to gently “milk”
chest tube.
Starting at
proximal end,
gently squeeze
and release chest
tube between
your fingers along
length of tubing.
 Never “strip”
chest tube, which
means squeezing
length of tube
without releasing
it.
 Milk chest tube
only as directed
by physician.
After
 A bottle of sterile
water must be
located at the
bedside to use in
case of accidental
disconnection of
chest tube from
drainage unit.
Two (2) chest
tube clamps must
be always with
the client while
chest tubes are in
place.
4) Diet
TYPE OF DIET DATE ORDERED INDICATION/PURPOSE NURSING RESPONSIBILITIES
1. Fiber-rich diet – Fibre November 23, 2021 A high-fiber diet has many benefits,  Provide health teaching to the client and family members
contributes to a healthy digestive including normalizing bowel to understand the importance of diet and dietary
system and offers a prolonged movements, helping maintain bowel compliance.
feeling of fullness, which helps integrity and health, lowering blood  Maintain adequate diet plans for the client.
prevent overeating. To ensure an cholesterol levels, and helping  Monitor conditions like vomiting, input-output, electrolytes
adequate fibre intake, aim to control blood sugar levels. A high- to add different components in diet.
include vegetables, fruit, pulses fiber diet may also help you
and wholegrain foods in all meals. maintain a healthy weight.
Whole grains foods include oats,
brown pasta and rice, quinoa and
whole-wheat bread and wraps,
rather than refined grain foods
such as white pasta and rice, and
white bread.
2. A low-carb diet- is a diet that November 23, 2021 The low-carb diet was most  Provide health teaching to the client and family members
restricts carbohydrates, such as beneficial for lowering triglycerides, to understand the importance of diet and dietary
those found in sugary foods, pasta the main fat-carrying particle in the compliance.
and bread. It is high in protein, fat bloodstream, and also delivered the  Maintain adequate diet plans for the client.
and healthy vegetables. biggest boost in protective HDL
cholesterol.  Monitor conditions like vomiting, input-output, electrolytes to add
different components in diet.
5) Activity and Exercise

TYPE OF EXERCISE DESCRIPTION INDICATION/PURPOSE CLIENT RESPONSE
Passive exercise it is prevent stiffness and regain  Can help improved blood circulation in “Para maexercise po ako
PASSIVE RANGE OF MOTION range of motion in muscle. And Is the movement the body by decreasing stiffness of the iniistretch ko po yung
applied to a joint solely by another person’s or a arteries and helping them dilate. kamay at paa ko” as
passive motion machine. When passive range of  Passive range of motion helps to verbalized by the patient
motion is applied, the joint of an individual maintain joint and connective tissue
receiving exercise is completely relaxed while the mobility, help maintain the patient’s
outside force moves the body part, such as a leg awareness of movement.
or arm, throughout the available range. Injury,
surgery or immobilization of a joint may affect the
normal joint range of motion
AEROBIC EXERCISE Aerobic exercise is essential for keeping the heart,  It helps to improve circulation, which “Lumakas ang katawan ko
lungs and blood vessel healthy. And Regular results in lowered in blood pressure at mga muscles ko nung
aerobic exercise can help prevent heart and heart rate, In addition it also gumaling na ako
WALKING disease and reduce the risk of death from this increases overall aerobic fitness and sinabayan ko ito ng
RUNNING condition helps your cardiac output (how well exercise” as verbalized by
SWIMMING your heart pump. It may help to the the patient
JUMPING ROPE people who carry a lot of body fat, and
also It may help to reduce fat and
create leaner muscle mass
6) NURSING MANAGEMENT (SOAPIE CHARTING)
SOAPIE #1 (Ineffective Breathing Pattern)

S > “Nurse nahihirapan pong huminga yung lola namin at mabilis din po siyang
mapagod” As verbalized by the patient’s significant other
O>
 Shortness of breath
 Easy fatigability
 Chest pain
Vital Signs:
 -BP: 140/70 mmHg

 PR: 107 bpm
 RR: 22 cpm
 Temp: 98.6 o F or 37 o C
 O2sat: 89%
A > Ineffective breathing pattern related to decreased lung expansion as evidenced

by chest pain, shortness of breath and easy fatigability
P > Within 30 minutes of rendering appropriate nursing interventions:
 The patient will be able to have relieved breathing pattern as evidenced by

respiratory rate of 22 cpm to 20 cpm, O2sat of 89% to 95%, pulse rate of 107 bpm to
95 bpm and fatigue is reduced as evidenced by walking from bed to the comfort
room with minimal assistance
I>
 Administered oxygen via nasal cannula at 2 lpm
 Monitored Pulse oximeter as indicated
 Provided a quiet environment to the patient
 Positioned the patient with proper alignment for maximum breathing pattern
 Facilitated patient in doing deep breathing technique and use of pursed-lip
technique
 Provided adequate rest periods and reposition as indicated
 Encouraged frequent rest periods and teach patient to pace activity
 Assisted patient in ADLs as necessary
 Administered respiratory medications as indicated
 Referred the patient for evaluation of exercise potential and development of
individualized exercise program
E > After 30 minutes of rendering appropriate nursing interventions:
 The patient was able to relieved breathing pattern as evidenced by respiratory rate of
22 cpm to 20 cpm, O2sat of 89% to 95%, pulse rate of 107 bpm to 95 bpm and
fatigue was reduced as evidenced by walking from bed to the comfort room with
minimal assistance
SOAPIE #2 (Acute Pain)
S > "Inoperahan po yung lola namin kanina, medyo masakit daw yung naoperahan
sakanya at natatakot ako na baka bumuka ang sugat niya” As verbalized by the
patient’s significant other
O>
 Guarding behavior
 Facial Grimace
 Weak and pale in appearance
 Pain Scale: 5/10
Vital Signs:
 BP: 130/90 mmHg
 PR: 76 bpm
 RR: 20 cpm
 Temp: 98.6 o F or 37 o C
 O2sat: 95%
A > Acute pain related to presence of postoperative surgical incision as evidenced by

verbal report of pain in the chest area, pain scale of 5/10, guarding behavior and
facial grimace
P>
Short Term Goal:
Within 30 minutes to 1 hour of rendering appropriate nursing interventions:
 The patient will verbalize decrease and relief of pain at the chest area from
pain scale of 5/10 to 3/10 which is tolerable
 The patient will be able to display reduced tension, a relaxed manner, and
ease of movement
Long Term Goal:

Within 2-3 days of rendering appropriate nursing interventions:
 The patient will be free from any pain in the incision site
 The patient will verbalize that he has improved her feeling/sense of control over
her present and future situation
I>
 Monitored the patients’ vital signs
 Monitored skin color/temperature and peripheral pulse frequently
 Provided a quiet environment to the patient
 Performed a comprehensive assessment of pain. Determine the location,
characteristics, onset, duration, frequency, quality, and severity of pain via
assessment.
 Reduced or eliminate factors that precipitate or increase pain experience such
as fear, fatigue, lack of knowledge.
 Educated the patient about the use of non-pharmacologic techniques such as
relaxation, music therapy, distraction.
 Provided adequate rest periods
 Repositioned the patient as indicated
 Demonstrated/facilitated patient to do relaxation techniques such as: deep and
slow breathing, distraction behaviors, visualization, and guided imagery
 Administered Opioids such as Tramadol as ordered
 Obtained a 12 lead ECG after the surgery and each time chest pain recurs for
evidence of further infarction as ordered
 Referred the patient to a pain specialist as required
E>
Short Term Goal:
Within 30 minutes to 1 hour of rendering appropriate nursing interventions:
 The patient will verbalize decrease and relieved of pain at the chest area from
pain scale of 5/10 to 3/10 which is tolerable
 The patient was able to display reduced tension, relaxed manner, and ease of
movement
Long Term Goal:

Within 2-3 days of rendering appropriate nursing interventions:
 The patient was able to be free from any pain in the incision site
 The patient verbalized that she had improved her feeling/sense of control over
her present and future situation
SOAPIE #3 (Risk for Infection)
S> “Inoperahan po siya kanina, natatakot ako na baka mainpeksyon siya “as verbalized by
the patient’s significant other
O>
 Post-operative incision 6-8 inches incision made down the center of the sternum
 wound dehiscence
 Incision is pinkish in color
Vital signs:
 BP: 140/70 mmHg
 PR: 76 bpm
 RR: 20 cpm
 Temp: 98.6 o F or 37 o C
 O2sat: 95%
A > Risk for Infection related to post-op incision

P>
Short Term: Within 8 hours of rendering of appropriate nursing interventions,
the client will be able at lesser risk of infection.
Long term: Within 3 days of rendering appropriate nursing interventions, the

patient will be able to remain free of infection, as evidenced by normal vital signs
and absence of signs and symptoms of infection and identify interventions to
prevent or reduce risk of infection.
I>
 Practiced constant and proper hand hygiene by all caregivers between therapies
and clients. Washed hands after glove removal. Instructed the client/SO/visitors
to wash hands as indicated.
 Cleansed incisions and insertion sites per facility protocol with appropriate
antimicrobial or solution.
 Demonstrated coughing and, deep breathing techniques.
 Repositioned every 2 hours and assisted patient in position changes.
 Encouraged sleep and rest.
 Limited visitors.
 Taught the importance of avoiding contact with individuals who have infections
or colds and the importance of physical distancing.
 Administered and monitored medication regimen and noted the client’s response
 Referred patient into the Post-Anesthesia Care Unit (PACU).
E>
Short Term: Within 8 hours of rendering of appropriate nursing interventions,
the client was at lesser risk of infection.
Long term: Within 3 days of rendering appropriate nursing interventions, the

patient was able to remain free of infection, as evidenced by normal vital signs
and absence of signs and symptoms of infection and identify interventions to
prevent or reduce risk of infection.
- goal met.
SOAPIE # 4 (Risk for Injury)
S>
O>
 CTT connected to water seal chamber on the right side
 Chest tube is intact and draining to pinkish output last drainage level (50 ml)
Vital Signs:
 BP: 140/70 mmHg

 PR: 76 bpm
 RR: 20 cpm
 Temp: 98.6 o F or 37 o C
 O2sat: 97%
A > Risk for Injury related to presence of Chest Tube Thoracostomy

P>
Short-term Goals:
Within 4-6 hours of rendering appropriate Nursing Interventions:
 The patient will be free of injury related to perioperative disorientation

 The patient’s relatives will verbalize understanding of the chest tube’s purpose
Long-term Goal:
Within 1-3 days of rendering appropriate Nursing Interventions:
 The patient will be free of untoward skin/tissue injury or changes lasting

beyond 24-48 hours following procedure
 The patient will report resolution of localized numbness, tingling, or changes in
sensation related to positioning within 24-48 hours as appropriate
I>
 Monitored patient’s vital signs such as HR, O2sat, BP and RR

 Monitored rate, rhythm, and depth of respiration. Note breathing irregularities,
for example, apneustic, ataxic, or cluster breathing.
 Encouraged deep breathing once client is conscious. Auscultate breath
sounds, noting areas of hypoventilation and presence of adventitious sounds.
 Informed patient that chest tube is painful
 Never lift drain above chest level
 Monitored for continuous air leak/bubbling in the water seal chamber
 Ensured tubing is not kinked/no obstruction
 Anchored the tubing to the patient’s skin
 Observed hematoma formation, resolution and presence of bleeding and
drainage amount, color, odor and appearance
 Elevated head of bed as permitted and position on sides, as indicated.
 Repositioned slowly at transfer from table and in bed especially halothane-
anesthetized patient
 Lifted corner from the skin and slowly stretch in the dressing in a motion that is
parallel to the skin
 Held the corners of the dressing on either side of the drain and pull them away
from each other; this should create a pocket around the drain
 Provided hemostatic and adhesive dressing at the bedside
 Chest drains should not be clamped unless ordered by medical staff
 Recommended position changes to anesthesiologist and/or surgeon as
appropriate
 Explained purpose of chest drain to relatives and when it is likely to be
removed
 Referred patient to Physiotherapist as indicated
E>
Short-term Goals:
After 2-6 hours of rendering appropriate Nursing Interventions:
 The patient was free of injury related to perioperative disorientation

 The patient’s relatives verbalized understanding of the chest tube’s purpose
Long-term Goals:
After 1-3 days of rendering appropriate Nursing Interventions:
 The patient was free of untoward skin/tissue injury or changes lasting beyond
24-48 hours following procedure
 The patient reported resolution of localized numbness, tingling, or changes in
sensation related to positioning within 24-48 hours as appropriate
D. EVALUATION
Heart bypass surgery – discharge
Heart bypass surgery creates a new route, called a bypass, for blood and oxygen to
go around a blockage to reach your heart. The surgery is used to treat coronary
heart disease. This article discusses what you need to do to care for yourself when
you leave the hospital.
What to Expect at Home
After surgery, it takes 4 to 6 weeks to completely heal and start feeling better.
Educate patient that it is normal to:
 Have pain in her chest area around your incision
 Have a poor appetite for 2 to 4 weeks
 Have mood swings and feel depressed
 Have swelling in the leg that the vein graft was taken from
 Feel itchy, numb, or tingly around the incisions on your chest and leg for 6
months or more
 Have trouble sleeping at night
 Be constipated from pain medicines
 Have trouble with short-term memory or feel confused ("fuzzy-headed")
 Be tired or not have much energy
 Have some shortness of breath. This may be worse if she also has lung
problems. Some people may use oxygen when they go home.
 Have weakness in her arms for the first month
Self-care
 Patient should have someone stay with her in her home for at least the first
1 to 2 weeks after surgery.
 Learn how to check her pulse, and check it every day
 Do the breathing exercises patient had learned in the hospital for 4 to 6
weeks
 Shower every day, washing the incision gently with soap and water. DO NOT
swim, soak in a hot tub, or take baths until your incision is completely healed.
Follow a heart-healthy diet.
 If patient feel depressed, talk with her family and friends. Ask her health care
provider about getting help from a counselor.
 Continue to take all her medicines for her heart, diabetes, high blood
pressure, or any other conditions you have
o Do not stop taking any medicine without first talking with her provider.
o Patient’s provider may recommend antiplatelet (blood-thinning) drugs
such as aspirin, clopidogrel (Plavix), prasugrel (Effient), or ticagrelor
(Brilinta) to help keep her artery graft open.
o If she is taking a blood thinner, such as warfarin (Coumadin), you may
need to have extra blood tests to make sure your dose is correct.
Activity
Stay active during her recovery, but start slowly.

 Do not stand or sit in the same spot for too long. Move around a little bit.
 Walking is a good exercise for the lungs and heart after surgery. Do not be
concerned about how fast you are walking. Take it slow.
 Climbing stairs is OK, but be careful. Balance may be a problem. Rest halfway
up the stairs if you need to.
 Light household chores, such as setting the table, folding clothes, walking, and
climbing stairs, should be OK.
 Slowly increase the amount and intensity of her activities over the first 3 months.
 Do not exercise outside when it is too cold or too hot.
 Stop if she feels short of breath, dizzy, or any pain in her chest. Do not do any
activity or exercise that causes pulling or pain across your chest, such as using a
rowing machine or weight lifting.
 Keep her incision areas protected from the sun to avoid sunburn.
Do not drive for at least 4 to 6 weeks after your surgery. The twisting involved in
turning the steering wheel may pull on her incision. Ask her provider when she may
return to work, and expect to be away from work for about 6 to 8 weeks.
She may be referred to a formal cardiac rehabilitation program. She will get
information and counseling regarding activity, diet, and supervised exercise.
Wound Care
For the first 6 weeks after her surgery, she must be careful about using her arms
and upper body when moving.
 Do not reach backward.
 Do not let anyone pull on her arms for any reason -- for instance, if they are
helping her move around or get out of bed.
 Do not lift anything heavier than 5 to 7 pounds (2 to 3 kilograms).
 Do not do even light housework for at least 2 to 3 weeks.
 Check with your provider before using her arms and shoulder more.
Brushing her teeth is OK, but do not do other activities that keep your arms above
your shoulders for any period of time. Keep her arms close to her sides when she is
using them to get out of bed or a chair. She may bend forward to tie her shoes.
Always stop if she feels pulling on her breastbone.
Her provider will tell her how to take care of her chest wound. She will likely be
asked to clean her surgical cut every day with soap and water, and gently dry it. Do
not use any creams, lotions, powders, or oils unless your provider tells you it is OK.
If she had a cut or incision on her leg:

 Keep her legs raised when sitting.
 Wear elastic TED hose for 2 to 3 weeks until the swelling goes away
When to Call Doctor
Call her provider if:
 Her have chest pain or shortness of breath that does not go away when she
rest.
 Her pulse feels irregular -- it is very slow (fewer than 60 beats a minute) or
very fast (over 100 to 120 beats a minute).
 She has dizziness, fainting, or you are very tired.
 She has a severe headache that does not go away.
 She has a cough that does not go away
 She is coughing up blood or yellow or green mucus.
 She has problems taking any of your heart medicines.
 Her weight goes up by more than 2 pounds (1 kilogram) in a day for 2 days in
a row.
 Her wound changes. It is red or swollen, it has opened, or there is more
drainage coming from it.
 She has chills or a fever over 101°F (38.3°C).
E. CONCLUSION
Coronary artery disease is caused by plaque buildup in the wall of the arteries
that supply blood to the heart (called coronary arteries). People age 65 and older are
much more likely than younger people to suffer a heart attack, to have a stroke, or to
develop coronary heart disease (commonly called heart disease) and heart failure.
Sedentary lifestyle, mental stress, eating fatty foods and consumption of junk food are
the key reasons for developing cardiovascular diseases and so coronary artery bypass
grafting (CABG) is performed for patients with coronary artery disease (CAD) to improve
quality of life and reduce cardiac-related mortality. With the help of this case study the
nursing students identified the disease of their patient through proper nursing
assessment, diagnosis, planning, interventions and evaluation. And now, they
understand and became knowledgeable enough on what is the disease all about with
appropriate nursing management that they may apply too in their future nursing
practice.
F. RECCOMENDATION
To the Client’s Family:
One of the most important factors of recovery for a certain illness is the participation of
the patient himself. However, our client has suffered a disease CABG wherein, her
emotional status was affected. The family’s involvement in the treatment of the patient is
very essential and highly needed. The family should know all the basic facts and
information about the patient’s illness because more than anybody else, they are
expected not just to care but also to accept her condition with utmost understanding.
Being aware of the illness itself and its treatment will elicit awareness and would
definitely pave the way to the prevention and alleviation of any ailment that any of the
family members may possibly have.
To the Student Nurses:
In line with this case study, the group members would like to encourage all student
nurses to get more involved in the promotion of health in our country. We are to provide
health services to the greater population in a way that it is more generalized. We must
impart to those who are in need, our knowledge regarding health and on how they could
maintain a healthy lifestyle.
We must apply to them the skills that we have learned by rendering them a
quality-based service. We must also teach the patients as well as the significant others
on the alternative means of promoting health and on how to prevent the possible
occurrence of a disease.
To the Medical World:
We would like to encourage the medical practitioners or the members of the

health care team that they should have to be more committed or compassionate in their
chosen profession. They must have to cater the health needs of the people of different
kinds without putting levels of discrimination on them. Their job is not that easy but they
must have to be very careful because they are already dealing here with the life of a
person.
They must have to extend their hands not only in the physical means but also in a
holistic way of giving or providing care to individuals, families, and the population groups
especially in significant others who may have lost loved ones. They are tasked to render
their services in order to achieve the good health condition of the citizens of the country
because the health of the nation lies in the health of the populace.
G. REVIEW OF RELATED LITERATURE
Foreign
Coronary artery bypass grafting (CABG) has become much safer over the last 50 years
due to advancement in clinical practice and technology development. However, it is still
a complex and high-risk operation that carries significant morbidities and mortality. The
most serious adverse events are death, stroke, bleeding requiring further surgery, peri-
operative myocardial infarction, cardiac arrhythmias, and deep sternal wound infection.
Each complication has an approximate risk of 1%-2%, and they must be fully discussed
with the patient during the consent process. Many other complications can occur as the
procedure affects the entire circulatory system and the visceral organs. Advancements
have been made in cardiopulmonary bypass, graft selection, operating room practices,
and multi-disciplinary team-working to reduce the risk of such complications occurring.
(Amer Harky and Syed Mohammad Hussain, 2019)
Local
Prolonged mechanical ventilation (PMV) after coronary artery bypass grafting (CABG)
increases postoperative morbidity, mortality, and the cost of hospitalization. Post-
cardiac surgery patients who are reintubated following extubation are likewise prone to
more complications and have a higher mortality rate. In recent years, early extubation
(EE)—or extubation within 8 hours of arrival at the postoperative care unit—has gained
popularity because the practice has been shown to improve cardiac performance,
reduce respiratory complications, allow early mobilization and feeding, increase patient
autonomy and comfort, and reduce the workload of medical and nursing staff. EE,
however, may not apply to all patients such as those who are at high risk for post-
operative complications. Identifying patients who are at high risk for PMV can help
physicians optimize health care to improve the outcomes of patients undergoing CABG.
However, the key factors associated with early PMV, and EE are poorly understood. To
start with, PMV has been defined differently from study to study, with some setting the
cut-off at 12 hours or less after surgery, and then others at 24 hours 48 hours, or even
72 hours post-operatively. Studies with PMV cut-offs lower than 24 hours usually report
only a few predictors for PMV while in studies that report PMV as more than 72 hours,
only patients with serious, non-transient issues remained ventilated. (Joseph Jasper
Acosta and Jessie Orcasitas, 2016)
I. REVIEW OF RELATED STUDY

Coronary revascularization for multivessel disease remains a common and costly
source of hospitalizations in the United States. Surgical techniques influence outcomes
for coronary bypass and also affect the need for percutaneous coronary intervention in
the future. As more radial access has been used for coronary angiography,
consideration for use of the radial artery as a surgical conduit remains unclear.
Saphenous vein grafts are commonly used for coronary bypass, however long-term
patency remains suboptimal, and is also associated with a higher risk of adverse events
with percutaneous coronary intervention. Thus, understanding the interplay between
coronary bypass techniques and percutaneous coronary intervention has become
increasingly important (McNichols, B., Spratt, J.R., George, J. et al., 2021).
BIBLIOGRAPHY
Book References:
Alligood Nursing Theorists and their Works Porth’s Essentials of Pathophysiology

Concepts of Altered Health States Second Edition
Brunner & Suddarth’s Textbook of Medical and Surgical Nursing Fourteenth Edition
Davis’s Drug Guide for Nurses Fifteenth Edition
Doenges, M., Moorhouse, M., & Murr, A. (2017) Nurse’s Pocket Guide Diagnoses,
Prioritized Interventions, and Rationales Fourteenth Edition
Internet References:
Armer H. et al, (2019) Complications of Coronary Artery Bypass Grafting

Retrieved from https://www.google.com/url?
sa=t&source=web&rct=j&url=http://www.ijmedrev.com/article_87430.html&ved=2ahUKE
wi35Ma27rT0AhXIPXAKHa2xAokQFnoECAQQAQ&usg=AOvVaw2W_D2YnpVNEd2Ui
mfG2WMN
Coronary heart disease in Philippines. World Life Expectancy. (n.d.). Retrieved

November 26, 2021, from https://www.worldlifeexpectancy.com/philippines coronary-
heart-disease.
Joseph A. et al,(2016)Prolonged mechanical ventilation (PMV) after coronary artery

bypass grafting (CABG) Retrieved from https://www.google.com/url?
sa=t&source=web&rct=j&url=http://www.spmcpapers.com/V2N1Galley/Acosta/Acosta.p
df&ved=2ahUKEwi9hbrl77T0AhVLQd4KHWIlCq4QFnoECAQQAQ&usg=AOvVaw3zaVk
0oksR5DW3gvLJlzcS
McNichols, B., Spratt, J.R., George, J. et al. Coronary Artery Bypass: Review of
Surgical Techniques and Impact on Long-Term Revascularization Outcomes. Cardiol
Ther 10, 89–109 (2021). https://doi.org/10.1007/s40119-021-00211-z
Www-hopkinsmedicine-org.cdn.ampproject.org. 2021. Coronary Artery Bypass Graft
Surgery. [online] Available at: <https://www-hopkinsmedicine-
org.cdn.ampproject.org/v/s/www.hopkinsmedicine.org/health/treatment-tests-and-
therapies/coronary-artery-bypass-graft-surgery?
amp=true&amp_gsa=1&amp_js_v=a6&usqp=mq331AQKKAFQArABIIACAw%3D
%3D#amp_tf=From%20%251%24s&aoh=16378469918779&referrer=https%3A%2F
%2Fwww.google.com&ampshare=https%3A%2F%2Fwww.hopkinsmedicine.org
%2Fhealth%2Ftreatment-tests-and-therapies%2Fcoronary-artery-bypass-graft-
surgery> [Accessed 25 November 2021].
nhs.uk. 2021. Coronary artery bypass graft (CABG). [online] Available at:
<https://www.nhs.uk/conditions/coronary-artery-bypass-graft-cabg/> [Accessed 25
November 2021].

Joseph A. et al,(2016)Prolonged mechanical ventilation (PMV) after coronary artery
bypass grafting (CABG) Retrieved from https://www.google.com/url?
sa=t&source=web&rct=j&url=http://www.spmcpapers.com/V2N1Galley/Acosta/Acosta.p
df&ved=2ahUKEwi9hbrl77T0AhVLQd4KHWIlCq4QFnoECAQQAQ&usg=AOvVaw3zaVk
0oksR5DW3gvLJlzcS

Coronary Artery Bypass Grafting (Cabg) :: Case Study Report

Uploaded by

Copyright:

Available Formats

Coronary Artery Bypass Grafting (Cabg) :: Case Study Report

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Coronary Artery Bypass Grafting (Cabg) :: Case Study Report

Uploaded by

Copyright:

Available Formats

Republic of the Philippines

TARLAC STATE UNIVERSITY

In Partial Fulfillment of the Requirement for the Subject

CORONARY ARTERY BYPASS

Prof. Maria Teresa Mendoza R.N. MAN

Assessment and Diagnosis

a) Brief description of the disease condition

Coronary artery bypass graft surgery (CABG) is a procedure used to treat

A sedentary lifestyle, mental stress, eating fatty foods and consumption of junk

4. Family History of health and illness

PATERNAL SIDE MATERNAL SIDE

DIED AT 57 DIED AT 80 DIED AT 53 DIED At 80

6. History of Present Illness

Upon admission, a full physical exam was conducted. ECG showed

Based on the results of the assessment, Patient D was diagnosed with Coronary

II. MENTAL STATUS

III. EMOTIONAL STATUS

IV. SENSORY PERCEPTION

VI. BODY TEMPERATURE

VII. RESPIRATORY STATUS

VIII. CIRCULATORY STATUS

Date Pulse rate Analysis

IX. NUTRITIONAL STATUS

XI. REPRODUCTIVE STATUS

XII. SLEEP AND REST PATTERN

XIII. STATE OF THE SKIN AND APPENDAGES

- Disconnect the equipment,

DATE NORMAL ANALYSIS/

Main Features of the Human Circulatory

-A system of blood vessels to distribute blood throughout the body

The heart consists of FOUR CHAMBERS:

The heart’s walls consist of three layers of tissue:

 Myocardium: This is the muscular tissue of the heart.

Left and right sides

 Generating blood pressure, Contractions of the heart generate blood pressure,

*Unhealthy Lifestyle: Smoking *Age: 65y/o and older. *Gender:

Plaque disruption and

Some major coronary artery partial

Compromised Some cell may die and

Tachycardia CAD progression and

Coronary Artery Bypass Graft

-Sedentary lifestyle *Age

Formation of atherosclerotic plaque in the

Hardening/Thickening of the arterial wall

Increased WBC Rupture of arterial plaque

Thrombus travel to other

Decreased blood flow Blockage of other arterial wall

Heart muscles become large Cardiac Ischemia Chest Pain

Tissue Perfusion Tachypnea

Coronary Artery Bypass Graft

NURSING DIAGNOSIS RANK JUSTIFICATION

This is the 2nd prioritized nursing diagnosis because:

This is the 4th prioritized nursing diagnosis because:

2) Nursing Care Plan

Refer the patient for evaluation of Exercise promotes conditioning of

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

- Elevate head of bed as permitted - Myocardial depressant effect of

- Lift corner from the skin and slowly

- There is a risk of the patient

Unhealthy Lifestyle: Smoking Age: 65y/o and older. *Gender: