Cardiac electrical activity can be monitored by using ECG a resting ambulatory Holter monitoring continuous cardiac monitoring or by telemetry Cardiac dysrhythmias are heartbeat disturbances beat formation ID: 775183
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Slide1
Dysrrhythmia
Monitoring & Intervening
Slide2Cardiac electrical activity can be monitored by using ECG; a resting, ambulatory (Holter monitoring), continuous cardiac monitoring, or by telemetryCardiac dysrhythmias are heartbeat disturbances (beat formation, beat conduction, myocardial response to beat).Dysrhythmias are classified by the:Site of origin: SA node, atria, atrioventricular (AV) node, or ventricle.Effect on heart’s rate and rhythm: Bradycardia, tachycardia, heart block, premature beat, flutter, fibrillation, or asystole.
Key Points
Slide3Atrial Fibrillation
Slide4Slide5Dysrhythmias may be benign or life-threatening; decreased cardiac output and ineffective tissue perfusion.Cardiac dysrhythmias are 1ry cause of death in clients suffering acute MI, and other sudden death disorders.Therefore, rapid Dx & Rx of serious dysrhythmias is essential to preserve life.Dysrhythmia Rx is based on the client’s symptoms and the cardiac rhythm.
Key Points
Slide6Cardioversion is the delivery of synchronized direct counter-shock to the heart for the elective treatment of atrial dysrhythmias or ventricular tachycardia with pulse.Defibrillation is the delivery of an unsynchronized, direct countershock to the heart during ventricular fibrillation or pulseless ventricular tachycardia. Defibrillation stops all electrical activity of the heart, allowing the sinoatrial (SA) node to take over and reestablish a perfusing rhythm
Key Points
Slide7Dysrhythmia
Medication
Electrical Management
Bradycardia
(any rhythm < 60 beats/min)
Treat if client is symptomatic
Atropine,
isoproterenol
Pacemaker
Atrial Fibrillation, Supraventricular Tachycardia
(SVT), or Ventricular Tachycardia with pulse
Amiodarone
,
adenosine, verapamil
Synchronized
cardioversion
Ventricular Tachycardia without pulse or
Ventricular Fibrillation
Amiodarone
,
lidocaine
,
epinephrine
Defibrillation
Slide8Cardiovascular diseaseMIHypoxiaAcid-base imbalancesElectrolyte disturbancesChronic renal, hepatic, or lung diseasePericarditisDrug use or abuseHypovolemiaShock
Risk Factors for Dysrhythmias
Slide9Perform 12-lead ECG by:Monitor for S & Sx of decreased perfusion (chest pain, decreased LOC, SOB) and hypoxia.PreventionReduce risk factors for CAD.Correct electrolyte imbalances.Treat substance abuse.Manage stress, fever, and anxiety.Assess/monitor for signs of decreased cardiac output (hypotension, irregular heart beats, fatigue, dyspnea, chest pain, syncope).Monitor for pulmonary or systemic emboli following cardioversion.Administer oxygen.
Nursing Interventions
Slide10Administer prescribed antidysrhythmic agent or other prescribed medications.Perform CPR for cardiac asystole or other pulseless rhythms.Defibrillate immediately for ventricular fibrillationPrepare the client for cardioversion if prescribed.
Nursing
Interventions
Slide11Cardioversion is the treatment of choice for symptomatic clients.Clients with atrial fibrillation of unknown duration must receive adequate anticoagulation prior to cardioversion therapy.Administer oxygen and sedation as prescribed.Cardioversion requires activation of the synchronizer button in addition to charging the machine. Failure to synchronize can lead to development of a lethal dysrhythmia, such as ventricular fibrillation.After defibrillation or cardioversion, check vital signs, assess airway patency, and obtain an ECG.Provide reassurance and emotional support to the client and family.
Nursing Interventions
Slide12Documentation:Client’s condition prior to interventionPre- and postprocedure rhythmNumber of defibrillation or cardioversion attempts, energy settings, time, and responseVital signsEmergency medications administered including times and dosagesThe client’s condition and state of consciousness following the procedureTeach the client and family regarding the need for compliance with prescribed medication regimen.Teach the client and family how to assess pulse.
Nursing Interventions
Slide13EmbolismPE – dyspnea, chest pain, air hunger, decreasing SaO2CVA – decreased LOC, slurred speech, muscle weakness/paralysisMI – chest pain, ST segment depression or elevationProvide therapeutic anticoagulation for clients with dysrhythmias.Decreased Cardiac Output and Heart FailureMonitor for signs of decreased cardiac output (hypotension, syncope,tachycardia) and of heart failure (dyspnea, productive cough, edema, venous distention).Provide medications to increase output (inotropic agents) and to decrease cardiac workload.
Complications and Nursing Implications
Slide14Slide15Heart Failure and Cardiomyopathy
Slide16HF: inability of the heart to maintain adequate circulation to meet tissue needs for oxygen and nutrients. Heart failure occurs when the heart muscle is unable to pump effectively, resulting in: inadequate cardiac output, myocardial hypertrophy, and pulmonary/systemic congestion. Causes: an acute or chronic cardiopulmonary problem (systemic HTN, PE, pulmonary HTN, dysrhythmias, valvular heart disease, pericarditis, and cardiomyopathy).
Key Points
Slide17Severity of heart failure is graded on classification scale indicating how little, or how much, activity it takes to make the client symptomatic (chest pain, SOB).Class I: Client exhibits no symptoms with activity.Class II: Client has symptoms with ordinary exertion.Class III: Client displays symptoms with minimal exertion.Class IV: Client has symptoms at rest.Cardiomyopathy is a change in the structure of cardiac muscle fibers that causes impaired cardiac function . HF.Blood circulation is impaired to the lungs or body when the cardiac pump is compromised. There are three main types:Dilated – decreased contractility and increased ventricular filling pressures.Hypertrophic – increased thickness of ventricular and/or septal muscles.Restrictive – ventricles become rigid and lose their compliance.
Key Points
Slide18. Low output heart failure can initially occur on either Lt/Rt side of the heart.Left-sided heart (ventricular) failure results in inadequate left ventricle (cardiac) output and consequently in inadequate tissue perfusion. Right-sided heart (ventricular) failure results in inadequate right ventricle output and systemic venous congestion (for example, peripheral edema)
Key Points
Slide19Risk Factors/Causes: Left-Sided Heart (Ventricular) Failure HTNCAD, angina, myocardial infarction (MI)Valvular disease (mitral and aortic)Risk Factors/Causes: Right-Sided Heart (Ventricular) FailureLeft-sided heart (ventricular) failureRight ventricular myocardial infarctionPulmonary problems (COPD, ARDS)Risk Factors/Causes: CardiomyopathyCADInfection or inflammation of the heart muscleVarious cancer treatmentsProlonged alcohol abuseHeredity
Key Factors
Slide20Hemodynamic Monitoring: Increased CVP, increased right arterial pressure, increased pulmonary artery pressure (PAP), and decreased cardiac output (CO)Ultrasound (echocardiogram): 2D or 3D to measure both systolic and diastolic function of the heart.Chest x-ray can reveal cardiomegaly and pleural effusions.Electrocardiogram (ECG), cardiac enzymes, electrolytes, and ABGs.Assess factors contributing to heart failure and/or the impact of heart failure.
Diagnostic Procedures and Nursing Interventions
Slide21A ventricular assist device (VAD) is a mechanical pump that assists a heart that is too weak to pump blood through the body. A VAD is used in clients who have severe end-stage congestive heart failure and are not candidates for heart transplants. Heart transplantation is the treatment of choice for clients with severe dilated cardiomyopathy.Heart transplantation is a possible option for clients with end-stage heart failure.Immunosuppressant therapy is required post transplantation to prevent rejection.
Therapeutic Procedures and Nursing Interventions
Slide22S & Sx of Left-sided failureDyspnea, orthopnea, nocturnal dyspneaFatigueDisplaced apical pulse (hypertrophy)S3 heart sound (gallop)Pulmonary congestion (dyspnea, cough, bibasilar crackles)Frothy sputum (may be blood-tinged)Altered mental statusSymptoms of organ failure, such as oliguriaHemodynamic findings:CVP/right atrial pressure (normal = 1 to 8 mm Hg): Normal or elevatedPulmonary Artery Pressure (normal = 15 to 26 mm Hg/5 to 15 mm Hg): ElevatedCO (normal = 4 to 7 L/min): Decreased
Assessments
Slide23Right-sided failureJugular vein distentionAscending dependent edema (legs, ankles, sacrum)Abdominal distention, ascitesFatigue, weaknessNausea and anorexiaPolyuria at rest (for example, nocturnal)Liver enlargement (hepatomegaly) and tendernessWeight gainHemodynamic findingsCVP/right atrial pressure (normal = 1 to 8 mm Hg): Elevated
Assessments
Slide24CardiomyopathyFatigue, weaknessHeart failure (left with dilated type, right with restrictive type)Dysrhythmias (for example, heart block)S3 gallopCardiomegaly
Assessments
Slide25Oxygen saturationV SHeart rhythmLung sounds for crackles, wheezesLevel of dyspnea upon exertionSerum electrolytes (especially potassium if receiving diuretics)Daily WtChanges in LOCI & OFor signs of drug toxicityCoping ability of client and family
Assess/Monitor
Slide26Impaired gas exchangeDecreased cardiac outputActivity intoleranceExcess fluid volumeIneffective tissue perfusion (cerebral)Risk for ineffective tissue perfusion (renal)
NANDA Nursing Diagnoses
Slide27Place the client in high-Fowler’s, if a client is experiencing respiratory distressO2 as prescribed.Encourage bed rest until the client is stable.Encourage energy conservation by assisting with care and ADLMaintain dietary restrictions (restricted fluid intake, restricted sodium intake).
Nursing Interventions
Slide28Administer medications as prescribed.Diuretics: To decrease preloadLoop diuretics, such as furosemide (Lasix), bumetanide (Bumex)Thiazide diuretics, such as hydrochlorothiazide (HydroDIURIL)Potassium-sparing diuretics, such as spironolactone (Aldactone)Teach the client taking loop or thiazide diuretics to ingest foods and drinks that are high in potassium to counter hypokalemia effect.Potassium supplementation may be required. Administer IV furosemide (Lasix) no faster than 20 mg/min.
Nursing Interventions
Slide29Afterload-Reducing AgentsACE inhibitors, such as enalapril , captopril; monitor for initial dose hypotension.Beta-blockers, such as carvedilol , metoprolol Angiotensin receptor II blockers, such as losartanInotropic agents, such as digoxin, dopamine, dobutamine, milrinone: To increase contractility and thereby improve cardiac outputVasodilators, such as nitrates: To decrease preload and afterload
Nursing Interventions
Slide30Anticoagulants, such as warfarin (Coumadin), heparin: Toprevent thrombus formation (risk associated with congestion/stasis and associated atrial fibrillation)Teach clients who are self-administering digoxin (Lanoxin) to:Count pulse for one full minute before taking the medication. If the pulse rate is irregular or less than 60 or greater than 100), instruct the client to hold the dose and to contact the primary care provider.Take digoxin dose at same time each day.Do not take digoxin at the same time as antacids (Separate by 2 hr)???.Report signs of toxicity, including fatigue, muscle weakness, confusion, and loss of appetite.Regularly have digoxin and potassium levels checked.Provide emotional support to the client and family.
Nursing Interventions
Slide31Take medications as prescribed.Take diuretics in early morning and early afternoon.Maintain fluid and sodium restriction – a dietary consult may be useful.Increase dietary intake of potassium (?) if taking potassium-losing diuretics such as loop diuretics and thiazide diuretics.Weigh self daily at the same time and notify the primary care provider for weight gain of 1kg in 24 hr or 2.5 in 1 week.Schedule regular follow-ups with the primary care provider.Get vaccinations (pneumococcal vaccine and yearly influenza vaccine).
Client Education
Slide32Acute pulmonary edema is a life-threatening medical emergency, ( anxiety, tachycardia, ARDS, dyspnea at rest, change in LOC, and an ascending fluid level within lungs (crackles, cough productive of frothy, blood-tinged sputum). Urgent Rx:Positioning the client in high-Fowler’s position.Administration of oxygen, positive airway pressure, and/or intubation and mechanical ventilation.IV morphine (to decrease anxiety, respiratory distress, and decrease venous return).IV administration of rapid-acting loop diuretics, such as furosemide (Lasix).Effective intervention should result in diuresis (carefully monitor output), reduction in respiratory distress, improved lung sounds, and adequate oxygenation.
Complications and Nursing Implications
Slide33Cardiogenic shock is a serious complication of pump failure. It is a class IV heart failure. Symptoms include tachycardia, hypotension (BP less than 90 mm Hg or less than 30 mm Hg from baseline BP), inadequate urinary output (less than 30 mL/hr), altered LOC, respiratory distress (crackles, tachypnea), cool clammy skin, decreased peripheral pulses, and chest pain. Interventionoxygen; possible intubation and ventilation; IVadministration of morphine, diuretics, and/or nitroglycerin to decrease preload;and IV administration of vasopressors and/or positive inotropes to increase cardiac output and to maintain organ perfusion. Other possible emergency interventions include use of an intra-aortic balloon pump and/or emergency coronary artery bypass surgery CABAG.
Complications and Nursing Implications
Slide34Pericardial effusion and pericardial tamponade is an accumulation of fluid within the pericardial sac. Immediate intervention, such as a pericardiocentesis, sternotomy, and creation of a pericardial window, may be necessary in addition to measures to improve cardiac output. Administer anti-inflammatory medications as prescribed.Systemic and pulmonary emboli are possible complications due to decreased cardiac output and systemic congestion. New onsets of atrial fibrillation need to be reported.Organ failure, such as renal failure, is possible due to tissue ischemia
Complications and Nursing Implications