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ECG (ELECTROCARDIOGRAM) Graphical recording of the electrical activities of the heart 1st diagnostic test done when cardiovascular disorder is suspected. used to measure any damage to the heart used to measure how fast your heart is beating and whether it is beating normally used to measure the effects of drugs or devices used to control the heart (such as a pacemaker) used to measure the size and position of your heart chambers You have chest pain or palpitations You are scheduled for surgery You have had heart problems in the past You have a strong history of heart disease in the family There are no risks. No electricity is sent through the body, so there is no risk of shock. Pre-Test: a. Remove all the metallic objects. B. Skin preparations are done like shaving, etc. Intra-Test: a. Lie still and relax. Post-Test: a. Can continue your daily activities.

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ECHOCARDIOGRAM a type of ultrasound test that uses high-pitched sound waves that are sent through a device called a transducer. The device picks up echoes of the sound waves as they bounce off the different parts of your heart. These echoes are turned into moving pictures of your heart that can be seen on a video screen. Look for the cause of abnormal heart sounds (murmurs or clicks), an enlarged heart, unexplained chest pains, shortness of breath, or irregular heartbeats. Check the thickness and movement of the heart wall. Look at the heart valves and check how well they work. See how well an artificial heart valve is working. Measure the size and shape of the heart's chambers. Check the ability of your heart chambers to pump blood (cardiac performance). During an echocardiogram, your doctor can calculate how much blood your heart is pumping during each heartbeat (ejection fraction). You might have a low ejection fraction if you have heart failure. Detect a disease that affects the heart muscle and the way it pumps, such as cardiomyopathy. Look for blood clots and tumors inside the heart. Look for congenital heart defects or to check the

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effectiveness of previous surgery to repair a congenital heart defect. Check how well your heart works after a heart attack. Identify the specific cause of heart failure. Look for a collection of fluid around the heart (pericardial effusion Look for a thickening of the lining (pericardium) around the heart. An echocardiogram is safe, because the test uses only sound waves to evaluate your heart. These highfrequency sound waves have not been shown to have any harmful effects. If contrast material is used, there is a slight risk of having an allergic reaction. Most reactions can be controlled using medicine. Pre-Test: a. Need to remove jewelry and clothes above your waist. May be given a gown. Intra-Test: a. Client has to remain still, in supine position slightly turned to the left side, with head of bed elevated 15-20. b. Small metal discs (electrodes) will be taped to your arms and legs to record your heart rate during the test. c. A small amount of gel will be rubbed on the left side of your chest to help pick up the sound waves. d. A small instrument (transducer) that looks like a microphone is pressed firmly against your chest and moved slowly back and forth. Post-Test: a. The test usually takes from 30 to 60 minutes Echocardiogram

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The heart chambers and walls of the heart are of normal size and thickness, and they move normally. Heart valves are working normally, with no leaks or narrowing. There is no sign of infection. The amount of blood pumped from the left ventricle with each heartbeat (ejection fraction) is more than 55%. There is no excess fluid in the sac surrounding the heart, and the lining around the heart is not thickened. There are no tumors and blood clots in the heart chambers.

Abnormal: Heart chambers are too big. The walls of the heart are thicker or thinner than normal. A thin heart wall may mean poor blood flow to the heart muscle or an old heart attack. A thin, bulging area of the heart wall may indicate a bulge in the ventricle (ventricular aneurysm). The heart muscle walls do not move normally

because of a decreased blood supply from narrowed coronary arteries. One or more heart valves do not open or close properly (are leaking) or do not look normal. Signs of infection are present. The amount of blood pumped from the left ventricle with each heartbeat (ejection fraction) is less than 55%. There is fluid around the heart (pericardial effusion). The lining around the heart is too thick. A tumor or blood clot may be found in the heart.

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CHEST X-RAY Painless diagnostic test that evaluates structure of bones and soft tissues Involves exposing a part of the body to a small dose of ionizing radiation to produce images of the inside of the body show the structures in and around the chest. The test is used to look for and track conditions of the heart, lungs, bones, and chest cavity create two-dimentional pictures Help find the cause of common symptoms such as a cough, shortness of breath, or chest pain. Find some heart problems, such as an enlarged heart, heart failure, and problems causing fluid in the lungs (pulmonary edema), and to monitor treatment for these conditions. Look for problems from a chest injury, such as rib fractures or lung damage. Find foreign objects, such as coins or other small pieces of metal, in the tube to the stomach (esophagus), the airway, or the lungs. A chest X-ray may not be able to see food, nuts, or wood fibers. See if a tube, catheter, or other medical device has been placed in the proper position in an airway, the heart, blood vessels of the chest, or the stomach. The amount of radiation is very small gives out a radiation dose similar to the amount of radiation you're naturally exposed to over 10 days Pre-Test: a. Practice the client on how to hold his breath and to do deep breathing b. May be asked to undress from the waist up and wear a gown c. Instruct to avoid wearing jewelry and other metal objects d. Let the x-ray technician (a person specially trained to do x-ray tests) know if you have any body piercings on your chest; if pregnant (contraindicated)

Intra-Test: a. Usually takes about 15 minutes b. You'll stand, sit, or lie c. May cover you with a heavy lead apron to protect certain parts of your body from the radiation d. May feel some discomfort from the coolness of the exam room and the x-ray plate Post-Test: can go back to your normal routine right after Chest X-ray Normal: The lungs look normal in size and shape, and the lung tissue looks normal. No growths or other masses can be seen within the lungs. The pleural spaces (the spaces surrounding the lungs) also look normal. The heart looks normal in size, shape, and the heart tissue looks normal. The blood vessels leading to and from the heart also are normal in size, shape, and appearance. The bones including the spine and ribs look normal. The diaphragm looks normal in shape and location. No abnormal collection of fluid or air is seen, and no foreign objects are seen. All tubes, catheters, or other medical devices are in their correct positions in the chest. Abnormal: An infection, such as pneumonia or tuberculosis, is present. Problems such as a tumor, injury, or a condition such as edema from heart failure may be seen. In some cases, more X-rays or other tests may be needed to see the problem clearly. A problem such as an enlarged heart-which could be caused by heart damage, heart valve disease, or fluid around the heart-is seen. Or a problem of the blood vessels, such as an enlarged aorta, an aneurysm, or hardening of the arteries (atherosclerosis), is seen. Fluid is seen in the lungs (pulmonary edema) or around the lungs (pleural effusion), or air is seen in the spaces around a lung (pneumothorax). Broken bones (fractures) are seen in the rib cage, collarbone, shoulder, or spine. Enlarged lymph nodes are seen. A foreign object is seen in the esophagus, breathing tubes, or lungs. A tube, catheter, or other medical device looks like it has moved out of the correct position.

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CARDIAC CATHETERIZATION medical procedure used to diagnose and treat some heart conditions Assess: oxygen levels, pulmonary blood flow, cardiac output, heart structures. Coronary artery visualization The most common reason is to evaluate chest pain. show whether plaque is narrowing or blocking your coronary arteries Can treat CHD during cardiac catheterization using a procedure called angioplasty (catheter with a balloon at its tip is threaded to the blocked coronary artery. Once in place, the balloon is inflated, pushing the plaque against the artery wall. This creates a wider path for blood to flow to the heart) Sometimes a stent is placed in the artery during angioplasty. A stent is a small mesh tube that supports the inner artery wall Bleeding, infection, and pain at the catheter insertion site. Damage to blood vessels. Rarely, the catheter may scrape or poke a hole in a blood vessel as it's threaded to the heart. An allergic reaction to the dye that's used during coronary angiography. Other, less common complications include: Arrhythmias (irregular heartbeats). These irregular heartbeats often go away on their own. However, your doctor may recommend treatment if they persist. Kidney damage caused by the dye used during coronary angiography. Blood clots that can trigger a stroke, heart attack, or other serious problems. Low blood pressure. A build-up of blood or fluid in the sac that surrounds the heart. This fluid can prevent the heart from beating properly. Pre-Test: a. Provide psychological support. (to allay anxiety) b. Assess for allergy to iodine/seafoods. The contrast medium used is iodinated. c. Obtain baseline vital signs. d. Withhold meals before the procedure. (to prevent nausea and vomiting) e. Have client void. (to promote comfort) f. Administer sedative as ordered. g. Mark distal pulses. h. Do cardiac monitoring. (to assess dysrhythmias) i. Done under local anesthesia. j. May experience warm or flushing sensation as the

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contrast medium is injected. Fluttering sensation is felt, as the catheter enters the chambers of the heart. Post-Test: Bed rest; if the catheter insertion site is an upper extremity until vital signs are stable; while if it is in a lower extremity, bed rest for 6-8 hours. (to prevent bleeding) Monitor vital signs, especially peripheral pulse. Diminished or absent pulse indicates circulatory impairment. This may be due to vasospasm or obstruction caused by thromboembolism. Monitor ECG, note for dysrhythmias. Apply pressure dressing and a small sand bag or ice over the puncture site. (to prevent bleeding) Immobilize affected extremity in extension. (to promote circulation) Do not elevate HOB more than 30 if femoral site was used. (acute hip flexion causes circulatory impairment) Monitor extremities for color, temperature, pulse, and sensation. o Impaired circulation in the affected extremity is manifested by pallor or cyanosis, cold skin, diminished pulse, and numbness or tingling sensation.

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ANGIOCARDIOGRAM is examination of the blood vessels or chambers of the heart. It is performed by tracing, via x-ray or nuclear medicine, the course of a contrast dye or radionuclide that has been injected into the bloodstream. These pictures are called angiograms. The left ventricle, heart valves, coronary arteries, aorta, and pulmonary arteries are the structures most often examined with this technique. Can provide both structural (anatomic) and functional (hemodynamic) information about the heart and its vessels. It may reveal anatomical abnormalities such as aneurysms, narrowed or obstructed vessels, or heart chamber enlargement Can also demonstrate abnormal blood flows or the failure of a valve to close that result in a reflux of blood Used to evaluate individuals for surgery on the heart and its associated blood vessels. Various techniques measure the volume of blood pumped the effectiveness of heart contractions, the patency of heart valves, and the condition of the coronary and pulmonary (lung) arteries. During angiocardiography, procedures such as angioplasty, coronary stenting, and valvuloplasty may be performed. Allergic reactions may include hives (urticaria) and

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inflammation of eye and eyelid tissues (conjunctivitis). Lung spasms (bronchospasm), swelling of the throat (laryngeal edema), and difficulty breathing (dyspnea) Major complications such as cardiac arrest, bleeding, infection, a blood clot in a vessel, muscle contractions and capillary dilation (anaphylactic reactions), shock, convulsions, blue skin (cyanosis), and kidney (renal) toxicity are rare. Should a blood clot become loosened, it could damage other parts of the body and result in very serious disability or, in rare cases, death. In very rare cases, perforation of a coronary artery occurs, necessitating emergency cardiac surgery. Abnormal ventricular rhythms (arrhythmias) are common if the catheter tip contacts the wall of the ventricle. Pre-Test: a. Provide psychological support. (to allay anxiety) b. Assess for allergy to iodine/seafoods. The contrast medium used is iodinated. c. Obtain baseline vital signs. d. Withhold meals before the procedure. (to prevent nausea and vomiting) e. Have client void. (to promote comfort) f. Administer sedative as ordered. g. Mark distal pulses. h. Do cardiac monitoring. (to assess dysrhythmias) i. Done under local anesthesia. j. May experience warm or flushing sensation as the contrast medium is injected. k. Fluttering sensation is felt, as the catheter enters the chambers of the heart. Post-Test: a. Bed rest; if the catheter insertion site is an upper extremity until vital signs are stable; while if it is in a lower extremity, bed rest for 6-8 hours. (to prevent bleeding) b. Monitor vital signs, especially peripheral pulse. Diminished or absent pulse indicates circulatory impairment. This may be due to vasospasm or obstruction caused by thromboembolism. c. Monitor ECG, note for dysrhythmias. d. Apply pressure dressing and a small sand bag or ice over the puncture site. (to prevent bleeding) e. Immobilize affected extremity in extension. (to promote circulation) f. Do not elevate HOB more than 30 if femoral site was used. (acute hip flexion causes circulatory impairment) g. Monitor extremities for color, temperature, pulse, and sensation. o Impaired circulation in the affected extremity is manifested by pallor or cyanosis, cold skin, diminished pulse, and numbness or tingling sensation.

o Although the actual procedure only takes about 1 hour, preparation and recovery are an all-day process, and some individuals may need to remain in the hospital overnight. o In terms of the procedure itself, nonstrenuous work may resume within a few days to a week following the procedure. Strenuous physical activity or exercise should be temporarily avoided.

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VENOGRAM An X-ray test that takes pictures of blood flow through the veins in a certain area of the body looks at the condition of your veins and the valves in your veins Check the blood flow in veins Find the right placement in blood vessels for medical devices such as filters Thrombolysis; bloot clots There is a small risk of developing an allergic reaction to the dye. There is a small risk of infection or damage to the veins being studied. In rare cases, a venogram can cause a deep vein thrombosis. There is a risk of kidney problems if you take Metformin (Glucophage) to control your diabetes. There is always a slight chance of damage to cells or tissue from radiation, including the low levels of radiation used for this test. But the chance of damage from the Xrays is usually very low compared with the benefits of the test. In rare cases, a venogram can cause an infection or a blood clot in the area studied. Call your doctor immediately if you have: A fever. Increasing pain, redness, or swelling in the arm or leg studied. Pre-Test: a. Do not eat for 4 hours before a venogram. You may drink only clear fluids for 4 hours before the test. Before a venogram, tell your doctor if you: o Are or might be pregnant. o Are allergic to any medicines, contrast material, or iodine dye. o Have bleeding problems or take blood-thinning medicines, such as aspirin, heparin, or warfarin (Coumadin). o Have asthma. o Have had a severe allergic reaction (anaphylaxis). o Have had kidney problems. o Have diabetes, especially if you

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take metformin (Glucophage) Will be asked to sign a consent form for this test. Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results may mean. To help you understand the importance of this test, fill out the medical test information form. b. Take off all jewelry and metal objects before the test. You will need to take off all or most of your clothes. You will be given a gown to use during the test. You may be asked to urinate just before the test begins. c. You will lie on an X-ray table. A tilting X-ray table is usually used when studying the legs. Safety straps will help you lie still if the table is tilted. Intra-Test: a. You will feel a quick sting or pinch when the numbing medicine is given. When the dye is put into the vein, you may feel a warm flush or have a metallic taste in your mouth. b. You may feel like your arm or leg is going to sleep during the test. This goes away after the test. Post-Test: a. A sterile salt solution (saline) may be put into the vein to help flush out the dye. Heparin, a blood thinner, may be put into the vein to prevent a blood clot. A small bandage will be placed on the IV site. Drink extra fluids after the test to help flush the dye out of your body. b. This test usually takes 30 to 45 minutes.

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LYMPHOGRAHY/ LYMPHOANGIOGRAPHY Radiographic examination of the lymph vessels & nodes following the injection of radiopaque contrast media to identify sites of blockage in lymphatic drainage This test is not used as often as it once was, because of the adoption of CT scan and the PET scan technologies. Generic term which includes: Lymphangiography - study of only the lymph vessels, usually carried out immediately after injection Lymphadenography - study of only the lymph nodes, generally requiring films 24 hours after injection Unexplained peripheral swelling Suspected carcinoma Post-op evaluation of nodal dissection Evaluation of treated nodes for effects of chemotherapy Cancer of reproductive organs (male & female) Prostatic carcinoma

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Patency of deep lymphatic trunks Contraindicated to: Known sensitivity to contrast media Cardiac disease Severe hepatorenal disease Vascular involvement due to diabetes Advanced pulmonary disease Leg exposures to radiation Interruptions of lymphatics by surgery or pathology is a relative contraindication Patients with tremors are poor candidates 1. A needle or catheter is inserted into a lymphatic channel in either the foot or arm, and a contrast medium is injected into the body at a very slow rate (approximately 60 to 90 minutes for all the contrast medium to be injected). 2. A fluoroscope is used to follow the dye as it spreads through the lymphatic system through the legs, into the groin, and along the back of the abdominal cavity. 3. Once the contrast medium is injected, the catheter is removed, and the incisions are stitched and bandaged. Xrays are taken of the legs, pelvis, abdomen, and chest areas. The next day, another set of X-rays may be taken. 4. If a site of cancer (breast or melanoma) is being studied to evaluate spreading, a mixture of blue dye and a radioactive tracer is injected next to the mass. Special cameras detect the spread of tracer along lymph channels to outlying nodes. 5. A surgeon will then use the visible blue dye or radioactivity within nodes to guide biopsy within adjacent tissues (such as the arm pit for breast cancer) to determine possible routes of cancer spread. Radiographic contrast media is injected directly into the lymphatics of an extremity Lymphatics look just like veins & require use of Indicator dye Absorbed by the lymphatics, in 15-20 minutes, without staining the rest of field: Direct Blue 1 (Chicago Blue 6B) Direct Blue 53 ( Evans Blue) Brilliant Blue FCF (Erioglaucine) Alphazurine 2G (Patent Blue) Oily contrast - Ethiodol or Lipiodol Remains in lymphatic system for as long as 2 years Unused portions must be discarded Water-soluble may be used More patient discomfort Contrast starts diffusing through the lymphatic vessels 5-10 min. after the start of the injection 5-10 ml. is administered over 1-3 hours, at a rate of 0.1-0.2 ml./min by injector Pre-Test: a. Inform patient beforehand that the procedure

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will take two days Day 1 - 4-5 hours - bring a book Day 2 - about 1 hour b. Caution them of the temporary skin & urine discoloration caused by the indicator dye c. Day of procedure Cleanse & shave injection site Have patient empty bladder Intra-Test: a. Place patient on table b. Scout films as required c. Inject indicator solution d. Perform cut-down to expose lymphatics e. Cannulate the lymphatic & inject contrast Post-Test: FILMING: Lymphangiography - Films are taken immediately after injection of contrast media Lower extremity AP mid-tibia AP mid-femur AP low pelvis Abdominal region AP abdomen 30 LPO & RPO Thoracic region AP Lt. Lateral Upper extremity AP & lateral wrist & arm AP & lateral humerus AP & 45 posterior oblique axilla

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BONE MARROW ASPIRATION removes a small amount of bone marrow fluid and cells through a needle put into a bone. The bone marrow fluid and cells are checked for problems with any of the blood cells made in the bone marrow. Cells can be checked for chromosome problems. Cultures can also be done to look for infection Look for the cause of problems with red blood cells, white blood cells, or platelets in people who have conditions such as thrombocytopenia, anemia, or an abnormal white blood cell count. Find blood disorders, such as leukemia, certain anemias, or problems that affect the bone marrow, such as multiple myeloma or polycythemia vera. Check to see if a known cancer, such as Hodgkin's lymphoma or non-Hodgkin's lymphoma, has spread to the bone marrow. This is part of what is called staging. It is done to find out if the cancer has spread and how much it has spread. This helps plan cancer treatment.

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Staging can be done for other cancers, such as prostate, breast, or lung cancer that may have spread to the bone marrow. Find infections or tumors that may start in or spread to the bone marrow. If you have an infection, a culture and sensitivity test of the bone marrow sample may be used to find out which antibiotics will work best to treat the infection. Find the best treatment for a bone marrow problem. Once treatment has been started, a bone marrow aspiration and biopsy may be done to see if the leukemia cells are gone, which means the treatment is working. Collect a sample of bone marrow for medical procedures, such as stem cell transplantation or chromosomal analysis. Bleeding from the biopsy site. People with bleeding problems have a higher chance for this. If you have bleeding problems, pressure will be put on the biopsy site for at least 10 minutes after the biopsy. In rare cases, you may be given a blood product (clotting factor or platelets) in a vein in your arm before the biopsy to prevent bleeding after the biopsy. Infection of skin or the bone (osteomyelitis) at the biopsy site. Injury to your heart, a lung, or a major blood vessel if the sample is taken from the breastbone (sternum). This complication is very rare. Samples are not often taken from the breastbone, so most people do not have to worry about this risk. Pre-Test: a. You will be asked to sign a consent form. b. Tell your doctor if you: o Are taking any medicines. o Are allergic to any medicine, including anesthetics. o Have any bleeding problems or take bloodthinners, such as aspirin, heparin, or warfarin (Coumadin). o Are or might be pregnant. c. Arrange for someone to drive you home after the biopsy because you may be given a medicine (sedative) to help you relax. Intra-Test: a. You need to lie very still while the sample is taken. The needle is then taken out. b. This procedure may be painful, but only for a few seconds. You may feel a sharp sting and burn when the anesthetic numbs your skin over the aspiration or biopsy site. c. You may hear a crunching sound and feel pressure and some pain when the needle enters the bone (normal). d. During an aspiration, you may feel a quick,

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shooting pain down your leg as the sample is taken. e. The biopsy site may feel stiff or sore for several days after the biopsy. You may have a bruise on the site. Post-Test: a. After the samples have been taken, pressure is put on the site to stop any bleeding. A bandage is put on the area. b. Each biopsy takes about 20 minutes. c. If the bleeding has stopped, you may do your normal activities. d. If you have been given a sedative, you may need several hours to rest. e. If you have an aspiration and biopsy from several places on your body, you may be given pain medicines to take at home or you may need to stay in the hospital overnight. f. You will lie down for 30 to 60 minutes after the biopsy so the site can be checked for bleeding. g. If you had a sedative, you will need someone to drive you home after the biopsy. h. You may feel sore at the biopsy site for several days. Ice packs to the site, walking, and pain medicine, such as acetaminophen (Tylenol), can be used to help you feel better. Call your doctor immediately if you have: o More tenderness, pain, redness, or swelling at the biopsy site. o A fever. o Bleeding or drainage, such as pus, from the biopsy site. If you are bleeding, put pressure on the site and call your doctor. Bone Marrow Biopsy and Aspiration

The marrow has normal amounts of fat, connective tissue, and iron. Normal numbers of both mature and immature (growing) bone marrow cells are present.
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No signs of infection are seen. No cancer cells, such as leukemia, lymphoma, or multiple myeloma, are seen. No cancer cells have spread from other cancer sites, such as breast cancer. The cells in the bone marrow do not look normal. There are too many or too few bone marrow cells. The bone tissue does not look normal.

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Too much iron or too little iron (iron deficiency anemia) is seen in the bone marrow. Signs of infection are seen in the bone marrow. Cancer cells, such as leukemia, lymphoma, or multiple myeloma, are seen.

The bone marrow has been replaced by scar tissue.

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CABG (CORONARY ARTERY BYPASS GRAFTING) Other Names for Coronary Artery Bypass Grafting Bypass surgery Coronary artery bypass surgery Heart bypass surgery a type of surgery that improves blood flow to the heart The surgery improves or completely relieves angina symptoms in most patients. Although symptoms can recur, many people remain symptom-free for as long as 10 to 15 years. CABG also may lower your risk of having a heart attack and help you live longer. Improving your quality of life and reducing angina and other CHD symptoms Allowing you to resume a more active lifestyle Improving the pumping action of your heart if it has been damaged by a heart attack Lowering the risk of a heart attack (in some patients, such as those who have diabetes) Improving your chance of survival The presence and severity of CHD symptoms The severity and location of blockages in your coronary arteries Your response to other treatments Your quality of life Any other medical problems you have Wound infection and bleeding Reactions to anesthesia Fever Pain Stroke, heart attack, or even death Some patients have a fever associated with chest pain, irritability, and decreased appetite. This is due to inflammation involving the lung and heart sac. This complication sometimes occurs after surgeries that involve cutting through the pericardium (the outer covering of the heart). The problem usually is mild, but some patients may develop fluid build-up around the heart that requires treatment. Memory loss and other issues, such as problems concentrating or thinking clearly, might occur in some people. These problems are more likely to affect older patients and women. These issues often improve within 612 months of surgery. In general, the risk of complications is higher if CABG is done in an emergency situation (for example, during a heart attack). The risk also is higher if you have other diseases or conditions, such as diabetes, kidney disease, lung disease, or peripheral arterial disease (P.A.D.). A. Coronary artery bypass grafting (CABG) requires a team of experts. A cardiothoracic surgeon will do the surgery with

support from an anesthesiologist, perfusionist (heart-lung bypass machine specialist), other surgeons, and nurses. The traditional type of surgery usually lasts 36 hours, depending on the number of arteries being bypassed. Many steps take place during traditional CABG. 1. You'll be under general anesthesia for the surgery. The term "anesthesia" refers to a loss of feeling and awareness. General anesthesia temporarily puts you to sleep. 2. During the surgery, the anesthesiologist will check your heartbeat, blood pressure, oxygen levels, and breathing. A breathing tube will be placed in your lungs through your throat. The tube will connect to a ventilator (a machine that supports breathing). 3. The surgeon will make an incision (cut) down the center of your chest. He or she will cut your chest bone and open your rib cage to reach your heart. 4. You'll receive medicines to stop your heart. This allows the surgeon to operate on your heart while it's not beating. You'll also receive medicines to protect your heart function during the time that it's not beating. 5. A heart-lung bypass machine will keep oxygen-rich blood moving throughout your body during the surgery. 6. The surgeon will take an artery or vein from your body for example, from your chest or legto use as the bypass graft. For surgeries with several bypasses, both artery and vein grafts are commonly used. Artery grafts. These grafts are much less likely than vein grafts to become blocked over time. The left internal mammary artery most often is used for an artery graft. This artery is located inside the chest, close to the heart. Arteries from the arm or other places in the body also are used. Vein grafts. Although veins are commonly used as grafts, they're more likely than artery grafts to become blocked over time. The saphenous veina long vein running along the inner side of the leg typically is used. 7. When the surgeon finishes the grafting, he or she will restore blood flow to your heart. Usually, the heart starts beating again on its own. Sometimes mild electric shocks are used to restart the heart. 8. You'll be disconnected from the heart-lung bypass machine. Then, tubes will be inserted into your chest to drain fluid. 9. The surgeon will use wire to close your chest bone (much like how a broken bone is repaired). The wire will stay in your body permanently. After your chest bone heals, it will be as strong as it was before the surgery. 10. Stitches or staples will be used to close the skin incision. The breathing tube will be removed when you're able to

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breathe without it. Pre-Test: a. You may have tests to prepare you for coronary artery bypass grafting (CABG). For example, you may have blood tests, an EKG (electrocardiogram),echocardiography, a chest x-ray, cardiac catheterization, and coronary angiography. b. The doctor will advise you about what you can eat or drink, which medicines to take, and which activities to stop (such as smoking). You'll likely be admitted to the hospital on the same day as the surgery. c. If tests for coronary heart disease show that you have severe blockages in your coronary (heart) arteries, your doctor may admit you to the hospital right away. You may have CABG that day or the day after. Post-Test: a. After surgery, you'll typically spend 1 or 2 days in an intensive care unit (ICU). Your health care team will check your heart rate, blood pressure, and oxygen levels regularly during this time. b. An intravenous (IV) line will likely be inserted into a vein in your arm. Through the IV line, you may get medicines to control blood flow and blood pressure. You also will likely have a tube in your bladder to drain urine and a tube in your chest to drain fluid. c. You may receive oxygen therapy (oxygen given through nasal prongs or a mask) and a temporary pacemaker while in the ICU. A pacemaker is a small device that's placed in the chest or abdomen to help control abnormal heart rhythms. d. Your doctor also might recommend that you wear compression stockings on your legs. These stockings are tight at the ankle and become looser as they go up the legs. This creates gentle pressure that keeps blood from pooling and clotting. e. While in the ICU, you'll also have bandages on your chest incision (cut) and on the areas where arteries or veins were removed for grafting. f. After you leave the ICU, you'll be moved to a less intensive care area of the hospital for 35 days before going home. Your doctor will give you instructions for recovering at home, such as: How to care for your healing incisions How to recognize signs of infection or other complications When to call the doctor right away When to make followup appointments You'll also learn how to deal with common side effects from surgery. Side effects often go away within 46 weeks after surgery, but may include: Discomfort or itching from healing incisions

Swelling of the area where arteries or veins were removed for grafting Muscle pain or tightness in the shoulders and upper back Fatigue (tiredness), mood swings, or depression Problems sleeping or loss of appetite Constipation Chest pain at the site of the chest bone incision (more frequent with traditional CABG) Full recovery from traditional CABG may take 612 weeks or more. Nontraditional CABG doesn't require as much recovery time. a. Your doctor will tell you when you can become active again. It varies from person to person, but there are some typical timeframes. b. Often, people can resume sexual activity and return to work after about 6 weeks. Some people may need to find less physically demanding types of work or work a reduced schedule at first. c. Talk with your doctor about when you can resume activity, including sexual activity, working, and driving. Ongoing Care: a. Care after surgery may include periodic checkups with doctors. During these visits, you may have tests to see how your heart is working. Tests may include an EKG(electrocardiogram), stress testing, echocardiography, and a cardiac CT scan. b. CABG is not a cure for coronary heart disease (CHD). After the surgery, your doctor may recommend a treatment plan that includes lifestyle changes. Following the plan can help you stay healthy and lower the risk of CHD getting worse. c. Lifestyle changes might include changing your diet, quitting smoking, being physically active, losing weight or maintaining a healthy weight, and reducing stress. d. Your doctor also may refer you to cardiac rehabilitation (rehab). Cardiac rehab is a medically supervised program that helps improve the health and well-being of people who have heart problems. o Cardiac rehab includes exercise training, education on heart healthy living, and counseling to reduce stress and help you return to an active life. Your doctor can tell you where to find a cardiac rehab program near your home. e. Taking medicines as prescribed also is important after CABG. Your doctor may prescribe medicines to manage pain during recovery, lower your cholesterol and blood pressure, reduce the risk of blood clots forming, manage diabetes, or treat depression.

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Procedure:

PTCA (PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY) a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle is performed to open blocked coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open-heart surgery. A special catheter (long hollow tube) is inserted into the coronary artery to be treated. This catheter has a tiny balloon at its tip. The balloon is inflated once the catheter has been placed into the narrowed area of the coronary artery. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow. to restore coronary artery blood flow when the narrowed artery is in a location that can be reached in this manner. Not all coronary artery disease can be treated with PTCA. Your doctor will decide the best treatment of your CAD based on your individual circumstances. Bleeding at the catheter insertion site (usually the groin, but the arm may be used in certain circumstances) Blood clot or damage to the blood vessel at the insertion site Blood clot within the vessel treated by PTCA or stent Infection at the catheter insertion site Cardiac dysrhythmias or arrhythmias (abnormal heart rhythms) Myocardial infarction Chest pain or discomfort Rupture of the coronary artery, requiring open-heart surgery Pre-Test: a. Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure. b. 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 something is not clear. c. Notify your doctor if you have ever had a reaction to any contrast dye, or if you are allergic to iodine. d. Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general). e. You will need to fast for a certain period of time prior to the procedure. Your doctor will notify you how long to fast, whether for a few hours or overnight. f. If you are pregnant or suspect that you may be pregnant, you should notify your doctor. g. Notify your doctor if you have any body piercings on your chest and/or abdomen. h. Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.

i. Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant or antiplatelet (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop some of these medications prior to the procedure. j. Your doctor may request a blood test prior to the procedure to determine how long it takes your blood to clot. Other blood tests may be done as well. k. Notify your doctor if you have a pacemaker. l. You may receive a sedative prior to the procedure to help you relax. m. Based on your medical condition, your doctor may request other specific preparation. Intra-Test: a. You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your dentures or hearing aid if you use either of these. b. You will be asked to remove clothing and will be given a gown to wear. c. You will be asked to empty your bladder prior to the procedure. d. If there is excessive hair at the area of the catheter insertion (groin area), the hair may be clipped off. e. An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed. f. You will be placed in a supine (on your back) position on the procedure table. g. You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure. h. There will be several monitor screens in the room, showing your vital signs, the images of the catheter being moved through the body into the heart, and the structures of the heart as the dye is injected. i. You will receive a sedative medication in your IV before the procedure to help you relax. However, you will likely remain awake during the procedure. j. Your pulses below the insertion site will be checked and marked so that the circulation to the limb below the site can be checked after the procedure. k. A local anesthetic will be injected into the skin at the insertion site. You may feel some stinging at the site for a few seconds after the local anesthetic is injected.

l. Once the local anesthetic has taken effect, a sheath, or introducer, will be inserted into the blood vessel. This is a plastic tube through which the catheter will be inserted into the blood vessel and advanced into the heart. If the arm is used, a small incision (cut) may be made to expose the blood vessel for insertion of the sheath. m. The angioplasty catheter will be inserted through the sheath into the blood vessel. The physician will advance the catheter through the aorta into the heart. Fluoroscopy will be used to assist in advancing the catheter to the heart. n. The catheter will be advanced into the coronary arteries. Once the catheter is in place, contrast dye will be injected through the catheter into your coronary arteries in order to see the narrowed area(s). You may feel some effects when the contrast dye is injected into the IV line. These effects include a flushing sensation, a salty or metallic taste in the mouth, and/or a brief headache. These effects usually last for a few moments. o. You should notify the doctor if you feel any breathing difficulties, sweating, numbness, itching, nausea and/or vomiting, chills, or heart palpitations. p. After the contrast dye is injected, a series of rapid, sequential X-ray images of the heart and coronary arteries will be made. You may be instructed to take in a deep breath and hold it for a few seconds during this time. q. When the doctor locates the narrowed artery, the catheter will be advanced to that location and the balloon will be inflated to open the artery. It is possible to experience some chest pain or discomfort at this point as a result of blood flow being temporarily blocked by the inflated balloon. Any chest discomfort or pain should go away when the balloon is deflated. However, if you notice any continued discomfort or pain, such as chest pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing difficulty, tell your doctor immediately. r. The doctor may inflate and deflate the balloon several times. The decision may be made at this point to insert a stent in order to maintain the artery's opening. In some cases, the stent may be inserted into the artery before the balloon is inflated. The inflation of the balloon will open the artery and fully expand the stent. s. The doctor will take measurements after the artery has been opened. Once it has been determined that the artery is opened sufficiently, the angioplasty catheter will be removed. t. The insertion site may be closed with a closure device that uses collagen to seal the opening in the

artery, by the use of sutures, or by applying manual pressure over the area to keep the blood vessel from bleeding. Your doctor will determine which method is appropriate for your condition. u. If a closure device is used, a sterile dressing will be applied to the site. If manual pressure is used, the doctor (or an assistant) will hold pressure on the insertion site so that a clot will form. Once the bleeding has stopped, a very tight bandage will be placed on the site. A small sandbag or other type of weight may be placed on top of the bandage for additional pressure on the site, especially if the site is in the groin. v. Your doctor may decide not to remove the sheath, or introducer from the insertion site for approximately four to six hours, in order to allow the effects of blood-thinning medication given during the procedure to wear off. You will need to lie flat during this time. If you become uncomfortable in this position, your nurse may give you medication to make you more comfortable. w. You will be assisted to slide from the table onto a stretcher so that you can be taken to the recovery area. NOTE: If the insertion was in the groin, you will not be allowed to bend your leg for several hours. To help you remember to keep your leg straight, the knee of the affected leg may be covered with a sheet and the ends tucked under the mattress on both sides of the bed to form a type of loose restraint. If the insertion site was in the arm, your arm will be kept elevated on pillows and kept straight by placing your arm in an arm guard (a plastic arm board designed to immobilize the elbow joint). In addition, a plastic band (works like a belt around the waist) may be secured around the arm near the insertion site. The band will be loosened at given intervals and then removed at the appropriate time determined by your doctor. Post-Test: a. After the procedure, you may be taken to the recovery room for observation or returned to your hospital room. You will remain flat in bed for several hours after the procedure. A nurse will monitor your vital signs, the insertion site, and circulation/sensation in the affected leg or arm. b. You should immediately inform your nurse if you feel any chest pain or tightness, or any other pain, as well as any feelings of warmth, bleeding, or pain at the insertion site in your leg or arm. c. Bed rest may vary from two to six hours depending on

your specific condition. If your doctor placed a closure device, your bed rest may be of shorter duration. o In some cases, the sheath or introducer may be left in the insertion site. If so, the period of bed rest will be prolonged until the sheath is removed. After the sheath is removed, you may be given a light meal. d. You may feel the urge to urinate frequently because of the effects of the contrast dye and increased fluids. You will need to use a bedpan or urinal while on bed rest so that youre affected leg or arm will not be bent. e. After the specified period of bed rest has been completed, you may get out of bed. The nurse will assist you the first time you get up, and will check your blood pressure while you are lying in bed, sitting, and standing. You should move slowly when getting up from the bed to avoid any dizziness from the long period of bed rest. f. You may be given pain medication for pain or discomfort related to the insertion site or having to lie flat and still for a prolonged period. g. You will be encouraged to drink water and other fluids to help flush the contrast dye from your body. h. You may resume your usual diet after the procedure, unless your doctor decides otherwise. i. You will most likely spend the night in the hospital after your procedure. Depending on your condition and the results of your procedure, your stay may be longer. You will receive detailed instructions for your discharge and recovery period. At home: a. You should monitor the insertion site for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the insertion site. A small bruise is normal. If you notice a constant or large amount of blood at the site that cannot be contained with a small dressing, notify your doctor. b. If your doctor used a closure device for your insertion site, you will be given specific information regarding the type of closure device that was used and how to take care of the insertion site. There will be a small knot, or lump, under the skin, where the insertion site was. This is normal. The knot should gradually disappear over a few weeks. c. It will be important to keep the insertion site clean and dry. Your doctor will give you specific bathing instructions. d. You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you can return to work and resume normal activities. Notify your doctor to report any of the following: Fever and/or chills Increased pain, redness, swelling, or bleeding or other drainage from the insertion site

Coolness, numbness and/or tingling, or other changes in the affected extremity Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness, and/or fainting

Laboratory Test: Description:

CBC (COMPLETE BLOOD COUNT) Series of blood tests that provides information about the components of blood including red blood cells, white blood cells, and platelets. CBC test results can help diagnose diseases and determine their severity. These tests may be measured any time of the day without fasting. Normal Values:

Red Blood Cells Count (RBC) Number of circulating erythrocytes in 1 ul of whole blood Hemoglobin (Hgb) Oxygen combining Hematocrit (Hct) Volume of packed red blood cells per 100ml of blood Platelet (Plt) Thrombocytes

Men: 4.5 6.2 million/ul

Female: 4.0 5.5 million/ul

Male: 13.5 - 17.5 g/dL

Female: 12.0 - 16.0 g/Dl

Male: 40 - 55%

Female: 36 - 48%

150, 000 400, 000/ cubic meter Elevated RBCs inadequate tissue oxygenation Hypoxia stimulates renal secretion of erythropoietin. This stimulates the bone marrow to increase RBC production (polycythemia). Elevated WBCs indicates infectious heart diseases and myocardial infarction.

Interpretation:

TEST NORMAL VALUES INCREASE DECREASE White Blood Cell 4 500 11 000/ul Bacterial infection, Viral infection Count (number of severe sepsis leukocytes in cubic millimetre) White Blood Cell Differential (enumeration of individual leukocyte distribution) Neutrophil 3 000 7 500 ul Bacterial infection, Acute viral infection, 54 57% inflammation, stress, alcoholic ingestion drug reaction Eosinophils 50 400 ul Allergic disorder, Endocrine disorder 1 4% parasitic infection Basophils 25 100 ul Myeloproliferative Anaphylactic reaction, 0 1% disease hyperthyroidism Lymphocytes 1 500 4 500 ul Chronic bacterial Leukemia 25 40% infection, viral infection

Laboratory Test: Description: Normal Values: Interpretation:

ERYTHROCYTE SEDIMENTATION RATE (ESR) measurement of the rate at which RBCs settle out of anticoagulated blood in an hour. Male 15-20mm/hr Female 20-30mm/hr Elevated: infectious heart disorders or myocardial infarction

Laboratory Test: Description:

Normal Values: Increased: Decreased:

BLOOD COAGULATION TESTS a. Prothrombin Time (PT, Pro time) Measures the time required for clotting to occur after thromboplastin and calcium are added to decalcified plasma. Tests extrinsic clotting stages II and III Valuable in evaluating the effectiveness of Coumadin (Warfarin) 11 -15 seconds Interpretation: Anticoagulant therapy, DIC, malabsorption Digitalis therapy, diuretic reaction, vitamin K therapy

Laboratory Test: Description:

Normal Values: Increased: Decreased:

BLOOD COAGULATION TESTS b. Partial Thromboplastin Time (PTT) Measures the time required for clotting to occur after a partial thromboplastin reagent is added to blood plasma Best single screening test for disorders of coagulation mechanism; stage I deficiencies To evaluate the effectiveness of Heparin Activated: 30 46 sec. Non-activated: 40 100 sec. Interpretation: Deficiency factors: VII, IX, X, XI, XII; anticoagulant therapy Extensive cancer

Laboratory Test: Description:

Normal Values:

Increased: Decreased:

BLOOD LIPIDS TESTS a. Serum Cholesterol Directly linked to risk of heart and blood vessel disease Preparation: This test may be measured any time of the day without fasting. However, if the test is drawn as part of a total lipid profile, it requires a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury or pregnancy to check cholesterol levels. o Cholesterol is a type of fat, found in your blood. It is produced by your body and also comes from the foods you eat (animal products). Cholesterol is needed by your body to maintain the health of your cells. Too much cholesterol leads to coronary artery disease. Your blood cholesterol level is related to the foods you eat or to genetic conditions (passed down from other generations of family members). 75-169 mg/dL for those age 20 and younger 100-199 mg/dL for those over age 21 Interpretation: Liver disease with biliary obstruction, nephrotic stage of glomerulonephritis, runs in the family Malnutrition, extensive liver disease, hyperthyroidism

Laboratory Test:

Description:

Normal Values: Increased: Decreased:

BLOOD LIPIDS TESTS b. Serum Triglycerides Elevated in obese or diabetic patients. Level increases from eating simple sugars or drinking alcohol. Associated with heart and blood vessel disease. Preparation: Blood should be collected after a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least 2 months after a heart attack, surgery, infection, injury or pregnancy to check triglyceride levels. o Triglycerides are a type of fat found in the blood. The blood level of this type of fat is most affected by the foods you eat (such as sugar, fat or alcohol) but can also be high due to being overweight, having thyroid or liver disease and genetic conditions. High levels of triglycerides are related to a higher risk of heart and blood vessel disease. 140 200 mg/dL Interpretation: Overweight , having thyroid or liver disease and genetic conditions; related to a higher risk of heart and blood vessel disease Malnutrition, extensive liver disease, hyperthyroidism

Laboratory Test:

Description:

Normal Values: Increased: Range with Myocardial Infarction:

SERUM ENZYMES STUDIES a. Aspartate Aminotransferase (AST) Formerly, SGOT (Serum Glutamic Oxaloacetic Transaminase) A liver enzyme that is released into the bloodstream following injury or death of cells. Increased AST is seen with liver disease, myocardial infarction (MI) and some medications. May increase when using cholesterol-lowering medications. 7-40 mu/ml Interpretation: Tissue necrosis; MI; pulmonary infarction Initial elevation: 4-6 hours Peaks: 24-36 hours Returns to normal: 4-7 days

Laboratory Test:

Description:

SERUM ENZYMES STUDIES b. Creatine Phosphokinase (CK-MB) Most cardiac specific enzyme Accurate indicator of myocardial damage A muscle enzyme found in the heart and muscles. Increased CK-MB is seen with heart muscle damage. Increased CK-MM is noted with skeletal muscle injury. Strenuous exercise, weight lifting, surgical procedures, high doses of aspirin and other medications can elevate CK. May increase when using cholesterol-lowering medications. Male: 50-325 mu/ml Female: 50-250 mu/ml CK may also be reported as percentages: CKBB: 0%; CKMB: 0 - 4% ; CKMM: 96 - 100%

Normal Values:

Range with Myocardial Infarction:

Onset: Peaks: Returns to normal:

3-6 hours 12-18 hours 3-4 days

Laboratory Test: Description: Normal Values:

Increased: Range with Myocardial Infarction:

SERUM ENZYMES STUDIES c. Lactic Dehydrogenase (LDH) LDH is an enzyme released in the blood with cell injury. It is often used as a late marker to detect a heart attack. 100-225 mU/ml Interpretation: liver and kidney disease, pernicious and megaloblastic anemias, malignancy, progressive muscular dystrophy, and pulmonary emboli Onset: 10-12 hours Peaks: 48-72 hours Returns to normal: 10-14 days

Laboratory Test:

Description:

Normal Values: Increased:

SERUM ENZYMES STUDIES d. Troponin Test Most specific laboratory test to detect MI Has 3 components: I, C, & T a. Troponin I modulates the contractile state - persists for 4-7 days. b. Troponin C binds calcium c. Troponin T binds I & C 0.0 - 0.10 g/mL Interpretation: as sensitive as CK-MB for the detection of myocardial injury

Laboratory Test: Description:

Normal Values: Increased:

BLOOD UREA NITROGEN (BUN) Indicator of renal function Decreased cardiac output leads to low renal perfusion and reduction in glomerular filtration rate (GFR). The BUN level becomes elevated 10-20 mg/dL (5-25 mg/dL is also acceptable level) Interpretation: Decreased cardiac output leads to low renal perfusion and reduction in glomerular filtration rate (GFR).

Laboratory Test: Description:

Normal Values: Increased:

BLOOD URIC ACID (BUA) Reflects adequacy of renal perfusion thereby glomerular filtration of metabolites Cardiovascular diseases result to decreased renal tissue perfusion. This will cause impairment of the ability of the kidneys to clear the plasma of end products of metabolism like uric acid. 2.5-8 mg/dL Interpretation: Cardiovascular related diseases

Laboratory Test: Description:

Interpretation:

URINALYSIS To assess the effects of cardiovascular diseases on renal function and the existence of concurrent renal or systemic diseases (glomerulonephritis, HPN, or DM) Albuminuria detected in clients with malignant HPN & CHF Myoglobunuria supports diagnosis of Myocardial Infarction

Laboratory Test: Description: Sodium (Na+) Potassium (K+) Calcium (Ca+)

SERUM ELECTROLYTES Affect cardiac contractility, specifically Na+, K+, and Ca+. Normal Values: 135 145 mEq/L 3.5 5.5 mEq/L 4.5 5.7 mEq/L

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