Transcript Chapt27
Chapter 27 Management of Patients With Dysrhythmias and Conduction Problems Copyright © 2008 Lippincott Williams & Wilkins. Dysrhythmias (See Chart 27-1) • Dysrhythmias: disorders of the formation or conduction (or both) of the electrical impulses in the heart • These disorders can cause disturbances of: – Rate – Rhythm – Both rate and rhythm • Potentially can alter blood flow & cause hemodynamic changes • Diagnosed by analysis of ECG waveform Copyright © 2008 Lippincott Williams & Wilkins. Relationship of ECG Complex, Lead System, and Electrical Impulse Copyright © 2008 Lippincott Williams & Wilkins. ECG Electrode Placement Copyright © 2008 Lippincott Williams & Wilkins. ECG Graph and Commonly Measured Components Copyright © 2008 Lippincott Williams & Wilkins. Heart Rate Determination Copyright © 2008 Lippincott Williams & Wilkins. Normal Sinus Rhythm Copyright © 2008 Lippincott Williams & Wilkins. Sinus Bradycardia Copyright © 2008 Lippincott Williams & Wilkins. Sinus Tachycardia Copyright © 2008 Lippincott Williams & Wilkins. Sinus Arrhythmia Copyright © 2008 Lippincott Williams & Wilkins. Premature Atrial Complexes Copyright © 2008 Lippincott Williams & Wilkins. Atrial Flutter Copyright © 2008 Lippincott Williams & Wilkins. Atrial Fibrillation Copyright © 2008 Lippincott Williams & Wilkins. Multifocal PVCs-Quadrigeminy Copyright © 2008 Lippincott Williams & Wilkins. Ventricular Tachycardia Copyright © 2008 Lippincott Williams & Wilkins. Ventricular Fibrillation Copyright © 2008 Lippincott Williams & Wilkins. Asystole Copyright © 2008 Lippincott Williams & Wilkins. First-Degree AV Block Copyright © 2008 Lippincott Williams & Wilkins. Second-Degree AV Block, Type 1 Copyright © 2008 Lippincott Williams & Wilkins. Second-Degree AV Block, Type 2 Copyright © 2008 Lippincott Williams & Wilkins. Third-Degree AV Block Copyright © 2008 Lippincott Williams & Wilkins. Nursing Process: The Care of the Patient with a Dysrhythmia: Assessment • Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness. • Physical assessment includes: – Rate and rhythm of apical and peripheral pulses – Assess heart sounds – Blood pressure and pulse pressure – Signs of fluid retention • Health history: include presence of coexisting conditions and indications of previous occurrence • Medications Copyright © 2008 Lippincott Williams & Wilkins. Nursing Process: The Care of the Patient with a Dysrhythmia: Diagnosis • Decreased cardiac output • Anxiety • Deficient knowledge Copyright © 2008 Lippincott Williams & Wilkins. Collaborative Problems/Potential Complications • Cardiac arrest • Heart failure • Thromboembolic event, especially with atrial fibrillation Copyright © 2008 Lippincott Williams & Wilkins. Nursing Process: The Care of the Patient with a Dysrhythmia: Planning • Goals may include eradicating or decreasing the occurrence of the dysrhythmia to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia and its treatment. Copyright © 2008 Lippincott Williams & Wilkins. Decreased Cardiac Output • Monitoring – ECG monitoring – Assessment of signs and symptoms • Administration of medications and assessment of medication effects • Adjunct therapy: cardioversion, defibrillation, pacemakers Copyright © 2008 Lippincott Williams & Wilkins. Other Interventions • Anxiety – Use a calm, reassuring manner. – Measures to maximize patient control to make episodes less threatening – Communication and teaching • Teaching self-care – Include family in teaching Copyright © 2008 Lippincott Williams & Wilkins. Pacemakers • An electronic device that provides electrical stimuli to the heart muscle • Types: – Permanent – Temporary • NASPE-BPEG code for pacemaker function Copyright © 2008 Lippincott Williams & Wilkins. Implanted Transvenous Pacemaker Copyright © 2008 Lippincott Williams & Wilkins. Transcutaneous Pacemaker Copyright © 2008 Lippincott Williams & Wilkins. ECG On-Demand Pacing Copyright © 2008 Lippincott Williams & Wilkins. Complications of Pacemaker Use • Infection • Bleeding or hematoma formation • Dislocation of the lead • Skeletal muscle or phrenic nerve stimulation • Cardiac tamponade • Pacemaker malfunction See Table 27-2 Copyright © 2008 Lippincott Williams & Wilkins. Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Assessment • Device function; ECG • Cardiac output and hemodynamic stability • Incision site • Coping • Patient and family knowledge Copyright © 2008 Lippincott Williams & Wilkins. Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Diagnosis • Risk for infection • Risk for ineffective coping • Knowledge deficiency Copyright © 2008 Lippincott Williams & Wilkins. Nursing Process: The Care of the Patient with an Implanted Cardiac DevicePlanning • Goals include absence of infection, adherence to self-care program, effective coping, and maintenance of device function. Copyright © 2008 Lippincott Williams & Wilkins. Interventions • Risk for ineffective coping – Support of patient and family coping – Setting of realistic goals – Allow patient to talk, share feeling and experiences – Support groups or referral – Stress reduction techniques • Knowledge deficiency – Patient and family teaching See Chart 27-3 Copyright © 2008 Lippincott Williams & Wilkins. Cardioversion and Defibrillation • Treat tachydysrhythmias by delivering an electrical current that depolarizes a critical mass of myocardial ceils. When cells repolarize, the sinus node is usually able to recapture its role as heart pacemaker. • In cardioversion, the current delivery is synchronized with the patient’s ECG. • In defibrillation, the current delivery is unsynchronized. Copyright © 2008 Lippincott Williams & Wilkins. Safety Measures • Ensure good contact between skin and pads or paddles. Use a conductive medium and 20-25 pounds of pressure. • Place paddles so that they do not touch bedding or clothing and are not near medication patches or oxygen flow. • If cardioverting, turn the synchronizer on. • If defibrillating, turn the synchronizer off. • Do not charge the device until ready to shock. • Call “clear” three times; follow checks required for clear and ensure that no one is in contact with the patient, bed, or equipment. Copyright © 2008 Lippincott Williams & Wilkins. Paddle Placement for Defibrillation Copyright © 2008 Lippincott Williams & Wilkins. Implantable Cardioverter Defibrillator (ICD) • A device that detects and terminates life-threatening episodes of tachycardia or fibrillation • NASPE-BPEG code • Antitachycardia pacing Copyright © 2008 Lippincott Williams & Wilkins. ICD Copyright © 2008 Lippincott Williams & Wilkins. Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias • Electrophysiologic studies • Cardiac conduction surgery – Maze procedure – Catheter ablation therapy Copyright © 2008 Lippincott Williams & Wilkins.