PowerPoint Presentation2013.
• Primary problem:
INTRODUCTION
• 3 children ages 33, 36, 42
• JD and his wife live in Florida for 6 months of the
year, and in Boston the other 6 months.
• Dog named Skipper who is 5 years old
• Standard of living: Middle class
• Work: Insurance executive for 48 years, and
recently started his own insurance company.
• Religious background: Roman Catholic
heart failure and pulmonary edema.
• Complaints were shortness of breath
• JD is considered obese, with a BMI of 37.
• It was recommended he undergo Coronary
Artery Bypass Graft (CABG) surgery.
NORMAL ANATOMY AND PHYSIOLOGY
flow in the coronary arteries
• This can result in angina, myocardial infarction
and sudden death.
• Hypertension, diabetes, obesity, atherosclerosis,
Signs & Symptoms of
Congestive Heart Failure
rest or when lying flat in bed.
• Fluid and water retention. Less blood to your kidneys
causes fluid and water retention, resulting in swollen
ankles, legs, abdomen (called edema), and weight gain.
Symptoms may cause an increased need to urinate during
the night. Bloating in your stomach may cause a loss of
appetite or nausea.
major organs and muscles makes you feel tired and weak.
Less blood to the brain can cause dizziness or confusion.
• Rapid or irregular heartbeats. The heart beats faster to
pump enough blood to the body. This can cause a rapid or
irregular heartbeat
LABORATORY FINDINGS Laboratory Lab Value Normal Value
Hemoglobin 13.4 12-16
Hematocrit 39.8 35-47
Sodium 134 136-145
Potassium 4.1 3.2-5.1
CO2 27 22-30
Glucose 198 74-100
BUN 25 6-20
Creatinine 1.4 0.4-1.4
Calcium 9.5 8.0-10.2
Albumin 4.3 3.5-5.2
GFR 49.1 >60
HgbA1C 6.4 3.0-6.0
Cholesterol 127 <200
HDL 42 >41
LDL 69 < = 100
Triglyceride 80 35-160
Laboratory Values at
which was causing him to experience
shortness of breath.
condition.
bypass graft (CABG) due to the
degeneration of his cardiac tissue.
Complications of CABG Surgery
• Mortality and complications increase
(CABG) when a person is older than 70
years, has poor heart muscle function,
diabetes, chronic lung disease, or
chronic kidney failure.
function, diabetes, and his kidneys
were not functioning properly, this
increases his risk of mortality and
complications for the CABG surgery.
* The surgical procedure that JD underwent was a coronary
artery bypass graft (CABG), on December 31, 2013.
*The CABG helps to generate new routes around narrowed and
blocked arteries, making it possible for sufficient blood to flow
to the heart muscle to deliver oxygen and nutrients.
*The right or left lower extremities have veins harvested using
endoscopic technique, and were then attached to the aorta and
the coronary arteries beyond the narrowing or blockage.
*JD had a CABG times 3, meaning an artery was placed to the left
internal mammary artery (LIMA) to the left atrial dimension
(LAD), saphenous vein to the posterior descending artery (PDA),
and saphenous vein to diagonal.
*The postoperative diagnoses were coronary artery disease,
obesity, carotid artery disease, and bradyarrhythmia, which was
a possible atrial fibrillation.
*He continued to have atrial fibrillation, but it was being
controlled by ventricular response, with Lovenox medication.
*Atrial fibrillation is an irregular heart rate, often rapid, causing
poor blood flow to the body (Heart Rhythm Society).
MEDICATIONS
Warfarin 7.5 mg Anticoagulant Vitamin K Hemorrhage, fever, rash, hair
loss
with excessive use
normal bowel function
with excessive use
normal bowel function
vision changes
Lasix 20 mg, BID Diuretic, antihypertensive Ethacrynic acid Low BP, dizziness, blurred vision,
headache, rash, weakness
Chlorhexidine,
topical
hand or feet
reductase inhibitor
Headache, stuffy nose, difficult
or painful urination, hoarseness
Aspirin 81 mg Anti-inflammatory pain relief Caffeine, alcohol Minor GI symptoms
Amlodipine 5 mg Calcium channel blocker Vitamins, minerals Swelling of the ankles or feet,
dizziness
thirst/urination
• JD was seen two days after his CABG surgery
• Patient was sitting up in the chair at the time of the visit.
• Visibly the patient was weak.
• Psychologically he was ready to make changes in his
lifestyle and spiritual life.
• Wife was in the room at time of visit. While patient was
answering questions about diet and lifestyle, his wife was
making jokes about how horrible he ate.
• JD was still determined to make changes, despite his wife's
pessimistic attitude.
NUTRITION HISTORY
• JD’s usual eating pattern was to eat breakfast, lunch, dinner and
a night time snack.
• Breakfast at 9 am, lunch at 3:30 pm, and dinner and 7pm.
• Typically he would drink 8 ounces of Jack Daniels alcohol each
day.
• The patient said that he would drink his alcohol with 6 cheese
crackers and peanut butter each day.
• Evening snack consisted of a handful of gingersnap cookies or 1
½ cups of Bluebonnet ice cream each night.
• Dining out took place two to three times a week.
• JD’s wife is the one who purchases and cooks the food at home.
• There are no foods that JD was avoiding.
• Most of the food JD would eat was ready-prepared (frozen
dinners).
• Protein: 86-107 g/day
soup
cheese crackers
cookies
Daniels
Eaten
Status
Calories
Over
Total Fat 20 - 35% Calories 34%
Calories
OK
Calories
Over
ANALYSIS OF PREVIOUS DIET
Vitamin B6 1.7 mg 1.6 mg Under
Vitamin B12 2.4 µg 4.2 µg OK
Vitamin C 90 mg 62 mg Under
Vitamin D 15 µg 7 µg Under
Vitamin E 15 mg AT 5 mg AT Under
Vitamin K 120 µg 62 µg Under
Folate 400 µg DFE 301 µg DFE Under
Thiamin 1.2 mg 1.7 mg OK
Riboflavin 1.3 mg 2.5 mg OK
Niacin 16 mg 19 mg OK
Choline 550 mg 326 mg Under
CURRENT PRESCRIBED DIET
• JD’s diet, while in the hospital, was a diabetic, controlled
carbohydrate 1800 calorie diet.
• The Glucerna was ordered for him after the dietitian spoke
with him, and realized that he was not eating enough of his
food to meet his calorie and protein needs.
*JD was educated on a cardiac, heart healthy diet, Coumadin and vitamin K interaction, as well as a diabetic diet.
*During the education he seemed to be extremely interested in knowing how he could change his diet to live and healthier life.
*He stated that the surgery was a wake-up call for him, and that he was now ready to take control of his health and chose healthier diet options.
*He understood the diabetic diet and how to count his carbohydrates for each meal so that the intake would be consistent.
*There were no apparent barriers that would prevent him from understanding.
*JD was discharged on January 8, 2014, eleven days after
he was admitted to the hospital.
*Discharged on Coumadin, aspirin, statins, and Norvasc
after being discharged.
encouraged to participate in the cardiac rehabilitation
program.
*3 times a week the patients exercise for an hour each
visit, while being monitored by nurses.
LABORATORY FINDINGS
Hemoglobin *10.4 12-16
Hematocrit *30.4 35-47
Sodium 138 136-145
Potassium 4.2 3.2-5.1
CO2 25 22-30
Glucose *138 74-100
BUN *39 6-20
Creatinine *1.5 0.4-1.4
Calcium 9.7 8.0-10.2
GFR *45.4 >60
Hemoglobin *10.4 12-16
PROGNOSIS
• JD’s recovery prognosis is very high. Most patients tolerate
the CABG surgery and are able to recover from it fairly
quickly.
• If he plans on attending the cardiac rehabilitation program his
outcome will be even better, especially if he is following the
diabetic and cardiac diet at home.
• Since his kidney function is below normal, this could cause
him some difficulties in the future, if they do not return to
normal function.
• If his kidney functions continue to be below normal, he may
encounter some of these symptoms.
SUMMARY & CONCLUSION
• JD was such a nice man, that when I met him I immediately
knew I wanted to do my case study on him.
• About a month before my cardiac rotation I was able to
watch the doctor perform a CABG surgery on a patient. It
was the first surgery I had ever seen, and it was completely
amazing.
• Coronary artery bypass graft surgery is a very invasive
procedure that can be avoided if a person is following a
healthy lifestyle.
• If heart disease is not dealt with in a quick manner it can lead
to a tough future.
• Studying this patient made me realize how diabetes affects
the heart and kidneys, and I was able to see it first hand in
this mans life.
WebMD. WebMD Medical Reference. August 23, 2012. Web.
January 16, 2014.
2. Daniel Lee Kulick, MD. William C. Shiel Jr., MD. “Coronary Artery
Bypass Graft.” MedicineNet.
4. “Coronary Artery Bypass Graft Surgery (CABG).” John Hopkins
Medicine Health Library.
6. Atrial fibrillation (Afib). Heart Rhythm Society.
http://www.hrsonline.org/Patient-Resources/Heart-Diseases-