Sir Dex Case

MISSION
MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

VISION and extension service programs at all educational levels as
its monumental contribution to national and global growth
Governor Panotes Avenue, and development.
“MABINI COLLEGES shall cultivate a CULTURE
Specifically, it transforms students into:
of EXCELLENCE in education.” Daet, Camarines Norte
1. God – fearing;
Tel. no. (054) 721-1281 local 109 2. Nation – loving;
3. Law abiding;
Email: mabinicollege@hotmail.com
4. Earth caring;
5. Productive; and
6. Locally and Globally competitive persons
ACTIVITY
NCM 118 RLE CLINICAL

Sunday 2:00 PM – 8:00 PM
Submitted by:
REGALA, BIANCA YSABELLE M.
BSN IV – B
Group 1
MISSION

7. God – fearing;
9. Law abiding;
10. Earth caring;
11. Productive; and
CORONARY ARTERY BYPASS GRAFT

What is coronary bypass graft surgery?
Coronary artery bypass graft surgery (CABG) is a procedure used to treat coronary
artery disease. 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.
One way to treat the blocked or narrowed arteries is to bypass the blocked portion
of the coronary artery with a piece of a healthy blood vessel from elsewhere in your body.
Blood vessels, or grafts, used for the bypass procedure may be pieces of a vein from your
leg or an artery in your chest. An artery from your wrist may also be used. Your doctor
attaches one end of the graft above the blockage and the other end below the blockage.
Blood bypasses the blockage by going through the new graft to reach the heart muscle.
This is called coronary artery bypass surgery.
Traditionally, to bypass the blocked coronary artery, your doctor makes a large
incision in the chest and temporarily stops the heart. To open the chest, your doctor cuts
the breastbone (sternum) in half lengthwise and spreads it apart. Once the heart is
exposed, your doctor inserts tubes into the heart so that the blood can be pumped through
the body by a heart-lung bypass machine. The bypass machine is necessary to pump
blood while the heart is stopped.
MISSION

7. God – fearing;
9. Law abiding;
10. Earth caring;
11. Productive; and
While the traditional "open heart" procedure is still commonly done and often
preferred in many situations, less invasive techniques have been developed to bypass
blocked coronary arteries. "Off-pump" procedures, in which the heart does not have to be
stopped, were developed in the 1990's. Other minimally invasive procedures, such as
keyhole surgery (done through very small incisions) and robotic procedures (done with
the aid of a moving mechanical device), may be used.
Why might I need coronary artery bypass surgery?
Your doctor uses coronary artery bypass graft surgery (CABG) to treat a blockage
or narrowing of one or more of the coronary arteries to restore the blood supply to your
heart muscle.
Symptoms of coronary artery disease may include:
 Chest pain
 Fatigue (severe tiredness)
 Palpitations
 Abnormal heart rhythms
 Shortness of breath
 Swelling in the hands and feet
 Indigestion
MISSION

7. God – fearing;
9. Law abiding;
10. Earth caring;
11. Productive; and
Unfortunately, you may not have any symptoms in early coronary artery disease,
yet the disease will continue to progress until there’s enough artery blockage to cause
symptoms and problems. If the blood supply to your heart muscle continues to decrease
as a result of increasing blockage of a coronary artery, you may have a heart attack. If
the blood flow can’t be restored to the particular area of the heart muscle affected, the
tissue dies.
There may be other reasons for your doctor to recommend CABG surgery.
What are the risks of coronary artery bypass surgery?
Possible risks of coronary artery bypass graft surgery (CABG) include:
 Bleeding during or after the surgery
 Blood clots that can cause heart attack, stroke, or lung problems
 Infection at the incision site
 Pneumonia
 Breathing problems
 Pancreatitis
 Kidney failure
 Abnormal heart rhythms
 Failure of the graft
 Death
There may be other risks depending on your specific medical condition. Be sure to
discuss any concerns with your doctor before the procedure.
How do I get ready for coronary artery bypass surgery?
 Your doctor will explain the procedure and you can ask questions.
 You will be asked to sign a consent form that gives your permission to do the test.
Read the form carefully and ask questions if anything is unclear.
 Along with a review of your health history, your doctor will do a complete physical
exam to make sure you are in otherwise good health before having the procedure.
You may need blood tests or other diagnostic tests.
 You will be asked to not eat or drink for 8 hours before the procedure, generally
after midnight.
MISSION

7. God – fearing;
9. Law abiding;
10. Earth caring;
11. Productive; and
 You may be asked to shower with a soap or special cleanser the night before and
the morning of surgery.
 Tell your doctor if you are pregnant or think you could be.
 Tell your doctor if you are sensitive to or are allergic to any medicines, iodine, latex,
tape, or anesthetic medicines (local and general).
 Tell your doctor about all medicines (prescription and over-the-counter), vitamins,
herbs, and supplements that you are taking.
 Tell your doctor if you have a history of bleeding disorders or if you are taking any
blood-thinning medicines, aspirin, or other medicines that affect blood clotting. You
may be told to stop some of these medicines before the procedure.
 Your doctor may do blood tests before the procedure to find out how long it takes
your blood to clot.
 Tell your doctor if you have a pacemaker or any other implanted cardiac device.
 If you smoke, quit smoking as soon as possible. This will improve your chances
for a successful recovery from surgery and benefit your overall health.
 Based on your medical condition, your doctor may ask you to do other things to
get ready.
What happens during coronary artery bypass?
Coronary artery bypass graft surgery (CABG) requires a stay in a hospital.

Procedure may vary depending on your condition and your doctor's practices.
Generally, CABG follows this process:
1. You will be asked to remove any jewelry or other objects that may interfere with
the procedure.
2. You will change into a hospital gown and empty your bladder.
3. You will lie on your back on an operating table.
4. The anesthesiologist will continuously monitor your heart rate, blood pressure,
breathing, and blood oxygen level during the surgery. Once you are sedated (put
into a deep sleep), a breathing tube will be put into your throat and you will be
connected to a ventilator, which will breathe for you during the surgery.
MISSION

7. God – fearing;
9. Law abiding;
10. Earth caring;
11. Productive; and
5. A healthcare professional will insert an intravenous (IV) line in your arm or hand.
Other catheters will be put in your neck and wrist to monitor your heart and blood
pressure, as well as to take blood samples.
6. A catheter will be put into your bladder to drain urine.
7. The skin over the surgical site will be cleaned with an antiseptic solution.
8. Once all the tubes and monitors are in place, your doctor will make incisions (cuts)
in one or both of your legs or one of your wrists to access the blood vessel(s) to
be used for the grafts. He or she will remove the vessel(s) and close those
incision(s).
9. The doctor will make an incision (cut) below the Adam's apple to just above the
navel.
10. The doctor will cut the sternum (breastbone) in half lengthwise. He or she will
separate the halves of the breastbone and spread them apart to expose your heart.
Coronary artery bypass graft surgery--on-pump procedure
1. To sew the grafts onto the very small coronary arteries, your doctor will need to
stop your heart temporarily. Tubes will be put into the heart so that your blood can
be pumped through your body by a heart-lung bypass machine.
2. Once the blood has been diverted into the bypass machine for pumping, your
doctor will stop the heart by injecting it with a cold solution.
3. When the heart has been stopped, the doctor will do the bypass graft procedure
by sewing one end of a section of vein over a tiny opening made in the aorta, and
the other end over a tiny opening made in the coronary artery just below the
blockage. If your doctor uses the internal mammary artery inside your chest as a
bypass graft, the lower end of the artery will be cut from inside the chest and sewn
over an opening made in the coronary artery below the blockage.
4. You may need more than one bypass graft done, depending on how many
blockages you have and where they are located. After all the grafts have been
completed, the doctor will closely check them as blood runs through them to make
sure they are working.
5. Once the bypass grafts have been checked, the doctor will let the blood circulating
through the bypass machine back into your heart and he or she will remove the
tubes to the machine. Your heart may restart on its own, or a mild electric shock
may be used to restart it.
MISSION

7. God – fearing;
9. Law abiding;
10. Earth caring;
11. Productive; and
6. Your doctor may put temporary wires for pacing into your heart. These wires can
be attached to a pacemaker and your heart can be paced, if needed, during the
initial recovery period.
Coronary artery bypass surgery--off-pump procedure
1. Once your doctor has opened the chest, he or she will stabilize the area around
the artery to be bypassed with a special instrument.
2. The rest of the heart will continue to function and pump blood through the body.
3. The heart-lung bypass machine and the person who runs it may be kept on stand-
by just in case the procedure need to be completed on bypass.
4. The doctor will do the bypass graft procedure by sewing one end of a section of
vein over a tiny opening made in the aorta, and the other end over a tiny opening
made in the coronary artery just below the blockage.
5. You may have more than one bypass graft done, depending on how many
blockages you have and where they are located.
6. Before the chest is closed, the doctor will closely examine the grafts to make sure
they are working.
Procedure completion, both methods
1. Your doctor will sew the sternum together with small wires (like those sometimes
used to repair a broken bone).
2. He or she will insert tubes into your chest to drain blood and other fluids from
around the heart.
3. Your doctor will sew the skin over the sternum back together.
4. Your doctor will put a tube through your mouth or nose into your stomach to drain
stomach fluids.
5. He or she will then apply a sterile bandage or dressing.
What happens after coronary artery bypass surgery?
In the hospital
After the surgery, you will be taken to the intensive care unit (ICU) to be closely
monitored. Machines will constantly display your electrocardiogram (ECG) tracing, blood
pressure, other pressure readings, breathing rate, and your oxygen level. Coronary artery
bypass surgery (CABG) requires an in-hospital stay of at least several days.
MISSION

7. God – fearing;
9. Law abiding;
10. Earth caring;
11. Productive; and
You will most likely have a tube in your throat to help with breathing through a
ventilator (breathing machine) until you are stable enough to breathe on your own. As you
continue to wake up from the anesthesia and start to breathe on your own, your doctor
can adjust the breathing machine to allow you to take over more of the breathing. When
you are awake enough to breathe completely on your own and you are able to cough,
your doctor will remove the breathing tube.
After the breathing tube is out, a nurse will help you cough and take deep breaths
every couple of hours. This will be uncomfortable due to soreness, but it is very important
that you do this to keep mucus from collecting in your lungs and possibly causing
pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while
coughing to help ease the discomfort.
The surgical incision may be tender or sore for several days after a CABG
procedure. Take a pain reliever for soreness as recommended by your doctor. Aspirin or
certain other pain medicines may increase the chance of bleeding. Be sure to take only
recommended medicines.
Your doctor may delivery medicines through the IV to help your blood pressure
and your heart, and to control any problems with bleeding. As your condition stabilizes,
he or she will gradually decrease and then stop these medicines.
Once your doctor removes the breathing and stomach tubes and you are stable,
you may start to drink liquids. You can gradually include more solid foods as you can
handle them.
When your doctor determines that you are ready, you will be moved from the ICU
to a post-surgical nursing unit. Your recovery will continue there. You can gradually
increase your activity as you get out of bed and walk around for longer periods. You can
eat solid foods as soon as you can tolerate them.
A member of your care team will arrange for you to go home and schedule a follow-
up visit with your doctor.
DRUG STUDY
Warfarin
 The main side  Assessment

Generic Name: Warfarin is a [vitamin K] Indicated for: Absolute
effect of warfarin  Assess for signs of
antagonist which acts to contraindications
Warfarin
is bleeding. If bleeding and
inhibit the production of 1) Prophylaxis and treatment Some of the absolute
of venous thromboembolism you're taking hemorrhage (bleeding
vitamin K by vitamin K and related pulmonary contraindications to
Brand Name: embolism. warfarin, you may gums; nosebleed;
epoxide reductase. The
warfarin include:
have trouble unusual bruising; tarry,
Coumadin, Jantoven reduced form of vitamin
 Large esophageal stopping the black stools; hematuria;
K, vitamin KH2 is a 2) Prophylaxis and treatment
Drug Class: of thromboembolism varices bleeding from a fall in hematocrit or BP;
cofactor used in the γ- associated with atrial
Anticoagulants cut on the hand or guaiac-positive stools,
carboxylation of fibrillation.  Patients who have
Dosage Form: coagulation factors VII, undergone major a nosebleed. urine, or nasogastric
3) Prophylaxis and treatment surgery within the More-serious aspirate).
Tablet: IX, X, and thrombin.
of thromboembolism
last 72 hours bleeding may be  Assess for evidence of
 1mg Carboxylation induces a associated with cardiac valve
 2 mg replacement. inside the body additional or increased
conformational change  A platelet count
 2.5mg (internal). thrombosis. Symptoms
allowing the factors to less than 50 x
 3mg 4) Use as adjunct therapy to  Seek immediate depend on area of
 4mg bind Ca2+ and to reduce mortality, recurrent 109/cu.mm, which
 5mg help if you take involvement.
phospholipid surfaces. myocardial infarction, and constitutes
 6mg thromboembolic events post warfarin and you  Lab Test Considerations:
 7.5 mg Uncarboxylated factors myocardial infarction. significant
 10mg VII, IX, X, and thrombin thrombocytopenia
are biologically inactive have any of the  Monitor PT, INR and
Off-label uses include:  Hypersensitivity to
and therefore serve to following: other clotting factors
the drug, such as
interrupt the 1) Secondary prevention of  Severe bleeding, frequently during
skin ischemic
coagulation cascade. stroke and transient ischemic including heavier therapy; monitor more
necrosis or
The endogenous attacks in patients with than usual frequently in patients
priapism
anticoagulation proteins rheumatic mitral valve menstrual with renal impairment.
 A clinically
C and S also require γ- disease but without atrial bleeding Therapeutic PT ranges
significant
carboxylation to fibrillation.  Red or brown 1.3–1.5 times greater
bleeding
function. This is urine than control; however,
condition;
particularly true in the  Black or bloody the INR, a standardized
however, the
case of thrombin which stool system that provides a
patient's risks of
must be activated in  Severe headache common basis for
warfarin can be
order to form a or stomach pain communicating and
reassessed after
thrombus. vitamin KH2  Joint pain, interpreting PT results, is
three months
is converted to vitamin K discomfort or usually referenced.
epoxide as part of the γ-  Pregnancy and swelling, especially Normal INR (not on
carboxylation reaction within 48 hours of after an injury anticoagulants) is 0.8–
catalyzed by γ-glutamyl delivery because  Vomiting of blood 1.2. An INR of 2.5–3.5 is
carboxylase. Vitamin K of warfarin's or material that recommended for
epoxide is then known looks like coffee patients at very high risk
converted to vitamin K1 teratogenicity, as grounds of embolization (for
by vitamin K epoxide well as its capacity  Coughing up blood example, patients with
reductase then back to to induce  Bruising that mitral valve replacement
vitamin KH2 by vitamin K spontaneous develops without and ventricular
reductase. Warfarin abortion and a remembered hypertrophy). Lower
binds to vitamin K fetal/perinatal injury levels are acceptable
epoxide reductase bleeding  Dizziness or when risk is lower.
complex subunit 1 and weakness Heparin may affect the
 Coagulation
irreversibly inhibits the  Vision changes PT/INR; draw blood for
defects at baseline
enzyme thereby  Head injury, even PT/INR in patients
such that the
stopping the recycling of without bleeding receiving both heparin
international
vitamin K by preventing  Rarely, warfarin and warfarin at least 5 hr
normalized ratio
the conversion of can cause the after the IV bolus dose, 4
(INR) is over 1.5
vitamin K epoxide to death of skin hr after cessation of IV
 Decompensated
vitamin K1. This process tissue (necrosis). infusion, or 24 hr after
liver disease
creates a This complication subcut heparin
hypercoagulable state Relative contraindications occurs within a injection. Asian
for a short time as Relative contraindications few days of patients and those who
proteins C and S degrade require a careful starting warfarin carry the CYP2C9*2
first with half lives of 8 balancing of the risks of treatment. Seek allele and/or the
and 24 hours, with the warfarin against the risks immediate CYP2C9*3 allele, or
exception of factor VII of thromboembolism medical care if you those with VKORC1 AA
which has a half life of 6 before making a decision notice sores, genotype may require
hours. Factors IX, X, and to administer the drug. changes in skin more frequent
finally thrombin degrade These relative color or monitoring and lower
later with half lives of 24, contraindications include: temperature, or doses.
36, and 50 hours severe pain on  Geri: Patients over 60 yr
 Previous history of
resulting in a dominant your skin. exhibit greater than
intracranial
anticoagulation effect.  Talk to your health expected PT/INR
hemorrhage
In order to reverse this care provider response. Monitor for
 Recent history of a
anticoagulation vitamin about these less side effects at lower
major extracranial
K must be supplied, serious side therapeutic ranges
bleed without
either exogenously or by effects.  Pedi: Achieving and
known cause
removal of the vitamin K  Bleeding from the maintaining therapeutic
epoxide reductase  History of peptic gums after PT/INR ranges may be
inhibition, and time ulceration within toothbrushing more difficult in
allowed for new the past three  Bleeding between pediatric patients.
coagulation factors to be months. In these menstrual periods Assess PT/INR levels
synthesized. It takes cases, it is  Diarrhea, vomiting more frequently
approximately 2 days for recommended or inability to eat  Monitor hepatic
new coagulation factors that the patient for more than 24 function and CBC before
to be synthesized in the waits to begin hours and periodically
liver. Vitamin K2, warfarin therapy  Fever throughout therapy.
functionally identical to until treatment of  Monitor stool and urine
vitamin K1, is peptic ulcer is for occult blood before
synthesized by gut completed.
bacteria leading to and periodically during
 Recent history of
interactions with therapy.
repeated falling
antibiotics as elimination  Toxicity and Overdose:
episodes with a
of these bacteria can  Withholding 1 or more
patient at a higher
reduce vitamin K2 doses of warfarin is
risk for bleeds
usually sufficient if INR is
 Likelihood of poor
excessively elevated or if
patient
minor bleeding occurs. If
compliance due to
overdose occurs or
dementia or
anticoagulation needs to
cognitive
be immediately
impairment,
reversed, the antidote is
particularly in
vitamin K
cases when there
(phytonadione,
is no available
Aquamephyton).
caretaker.
Administration of whole
 Alcoholism, blood or plasma also
especially binge may be required in
drinking severe bleeding because
 Poorly controlled of the delayed onset of
or untreated vitamin K.
hypertension  Implementation
 High Alert: Do not
confuse Coumadin
(warfarin) with Avandia
(rosiglitazone) or
Cardura (doxazosin). Do
not confuse Jantoven
(warfarin) with Janumet
(sitagliptin/metformin)
or Januvia (sitagliptin).
 Because of the large
number of medications
capable of significantly
altering warfarin's
effects, careful
monitoring is
recommended when
new agents are started
or other agents are
discontinued. Interactive
potential should be
evaluated for all new
medications (Rx, OTC,
and herbal products).
 PO Administer
medication at same time
each day. Medication
requires 3–5 days to
reach effective levels;
usually begun while
patient is still on heparin.
 Do not interchange
brands; potencies may
not be equivalent.
 Patient/Family Teaching
 Instruct patient to take
medication as directed.
Take missed doses as
soon as remembered
that day; do not double
doses. Inform health
care professional of
missed doses at time of
checkup or lab tests.
Inform patients that
anticoagulant effect may
persist for 2–5 days
following
discontinuation. Advise
patient to
read Medication
Guide before starting
therapy and with each Rx
refill in case of changes.
 Review foods high in
vitamin K (see food
sources for specific
nutrients). Patient
should have consistent
limited intake of these
foods, as vitamin K is the
antidote for warfarin,
and alternating intake of
these foods will cause PT
levels to fluctuate.
Advise patient to avoid
cranberry juice or
products during therapy.
 Caution patient to avoid
IM injections and
activities leading to
injury. Instruct patient to
use a soft toothbrush,
not to floss, and to shave
with an electric razor
during warfarin therapy.
Advise patient that
venipunctures and
injection sites require
application of pressure
to prevent bleeding or
hematoma formation.
 Advise patient to report
any symptoms of
unusual bleeding or
bruising (bleeding gums;
nosebleed; black, tarry
stools; hematuria;
excessive menstrual
flow) and pain, color, or
temperature change to
any area of your body to
health care professional
immediately. Patients
with a deficiency in
protein C and/or S
mediated anticoagulant
response may be at
greater risk for tissue
necrosis.
 Instruct patient not to
drink alcohol or take
other Rx, OTC, or herbal
products, especially
those containing aspirin
or NSAIDs, or to start or
stop any new
medications during
warfarin therapy
without advice of health
care professional.
 Rep: May cause fetal
harm. Advise females of
reproductive potential
to use effective
contraception during
and for 1 month after
last dose. Advise patient
to notify health care
professional if
pregnancy is planned or
suspected or if breast
feeding.
 Instruct patient to carry
identification describing
medication regimen at
all times and to inform
all health care personnel
caring for patient on
anticoagulant therapy
before lab tests,
treatment, or surgery.
 Emphasize the
importance of frequent
lab tests to monitor
coagulation factors.
 Evaluation/Desired
Outcomes
 Prolonged PT (1.3–2.0
times the control; may
vary with indication) or
INR of 2–4.5 without
signs of hemorrhage.

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MISSION

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

NCM 118 RLE CLINICAL

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

CORONARY ARTERY BYPASS GRAFT

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

Why might I need coronary artery bypass surgery?

Symptoms of coronary artery disease may include:

 Fatigue (severe tiredness)

 Abnormal heart rhythms

 Swelling in the hands and feet

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

What are the risks of coronary artery bypass surgery?

Possible risks of coronary artery bypass graft surgery (CABG) include:

 Bleeding during or after the surgery

 Infection at the incision site

 Abnormal heart rhythms

 Failure of the graft

How do I get ready for coronary artery bypass surgery?

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

What happens during coronary artery bypass?

Coronary artery bypass graft surgery (CABG) requires a stay in a hospital.

Generally, CABG follows this process:

3. You will lie on your back on an operating table.

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

6. A catheter will be put into your bladder to drain urine.

Coronary artery bypass graft surgery--on-pump procedure

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

Coronary artery bypass surgery--off-pump procedure

Procedure completion, both methods

5. He or she will then apply a sterile bandage or dressing.

What happens after coronary artery bypass surgery?

MABINI COLLEGES INCORPORATED MABINI COLLEGES provides quality instruction, research

 The main side  Assessment

 Poorly controlled of the delayed onset of

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