Transcript dysrhythmias

CARDIAC DYSRHYTHMIAS
PYRAMID POINTS
• Six-second strip method to determine heart rate
• Recognizing rhythms and the appropriate
treatment measures
• Normal sinus rhythm
• Premature ventricular contractions
• Atrial fibrillation
• Ventricular tachycardia
• Ventricular fibrillation
• Cardioversion and defibrillation procedures
• Client teaching for pacemakers
SIX-SECOND STRIP METHOD TO
DETERMINE HEART RATE
• Can be used to determine heart rate for both
regular and irregular rhythms
• To determine atrial rate, count the number of P-P
intervals in 6 seconds and multiply by 10 to
obtain a full-minute rate
• To determine ventricular rate, count the number
of R-R intervals in 6 seconds and multiply by 10
to obtain a full-minute rate
• For accuracy, timing should begin on the P wave
or the QRS complex and end exactly at 30 large
blocks later
SIX-SECOND STRIP METHOD TO
DETERMINE HEART RATE
From Paul, S. & Hebra, J. (1998). The nurse’s guide to cardiac rhythm interpretation.
Philadelphia: W.B. Saunders
NORMAL SINUS RHYTHM
• DESCRIPTION
– Rhythm originates from the SA node
– Atrial and ventricular rhythms are regular
– Atrial and ventricular rates are 60 to 100 beats
per minute
NORMAL SINUS RHYTHM
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed
2, Philadelphia: W.B. Saunders
SINUS BRADYCARDIA
• DESCRIPTION
– Atrial and ventricular rates are below 60 beats
per minute
– Treatment may be necessary if the client is
symptomatic
– Note that a low heart rate may be normal for
some individuals
SINUS BRADYCARDIA
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice,
ed 2, Philadelphia: W.B. Saunders
SINUS BRADYCARDIA
• IMPLEMENTATION
– Attempt to determine cause and if a
medication is suspected as causing the
bradycardia, hold the medication and notify
the physician
– Administer oxygen as prescribed
– Administer atropine sulfate as prescribed to
increase the heart rate to 60 beats per minute
SINUS BRADYCARDIA
• IMPLEMENTATION
– Be prepared to apply a noninvasive pacemaker
initially as prescribed, if the atropine sulfate
does not increase the heart rate sufficiently
– Avoid additional doses of atropine sulfate
because they will induce tachycardia
– Monitor for hypotension and administer IV
fluids as prescribed
– Depending on the cause of the bradycardia,
the client may need a permanent pacemaker
SINUS TACHYCARDIA
• DESCRIPTION
– Atrial and ventricular rates are 100 to 180 beats
per minute
• IMPLEMENTATION
– Identify the cause of the tachycardia
– Decrease the heart rate to normal by treating
the cause
SINUS TACHYCARDIA
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice,
ed 2, Philadelphia: W.B. Saunders
ATRIAL FIBRILLATION
• DESCRIPTION
– Multiple rapid impulses from many foci
depolarize in the atria in a totally disorganized
manner at a rate of 350 to 600 times per minute
– The atria quiver, which can lead to the
formation of thrombi
– P wave is absent
ATRIAL FIBRILLATION
From Paul, S. & Hebra, J. (1998). The nurse’s guide to cardiac rhythm interpretation. Philadelphia: W.B. Saunders.
ATRIAL FIBRILLATION
• IMPLEMENTATION
– Administer oxygen
– Administer anticoagulants as prescribed
because of the risk of emboli
– Administer cardiac medications as prescribed
to control the ventricular rhythm and assist in
the maintenance of cardiac output
– Prepare the client for cardioversion as
prescribed
– Instruct the client in the use of medications as
prescribed to control the dysrhythmia
PREMATURE VENTRICULAR CONTRACTIONS
(PVCs)
• DESCRIPTION
– Early ventricular complexes result from
increased irritability of the ventricles
– PVCs frequently occur in repetitive rhythms
such as bigeminy, trigeminy, and quadrigeminy
– The QRS complexes may be unifocal or
multifocal
PREMATURE VENTRICULAR CONTRACTIONS
(PVCs)
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed
2, Philadelphia: W.B. Saunders
PREMATURE VENTRICULAR CONTRACTIONS
(PVCs)
• IMPLEMENTATION
– Notify the physician if PVCs are noted
– Identify the cause and treat based on the
cause
– Evaluate electrolytes, particularly the
potassium level, since hypokalemia can cause
PVCs
– Administer oxygen as prescribed
PREMATURE VENTRICULAR CONTRACTIONS
(PVCs)
• IMPLEMENTATION
– Administer lidocaine as prescribed
– Notify the physician if the client complains of
chest pain, if PVCs increase in frequency, are
multifocal, occur on the T wave (R on T), or
occur in runs of ventricular tachycardia
VENTRICULAR TACHYCARDIA (VT)
• DESCRIPTION
– Occurs when there is a repetitive firing of an
irritable ventricular ectopic focus at a rate of
140 to 250 beats per minute or more
– May present as a paroxysm of three selflimiting beats or more, or may be a sustained
rhythm
– Can cause cardiac arrest
VENTRICULAR TACHYCARDIA (VT)
From Paul, S. & Hebra, J. (1998). The nurse’s guide to cardiac rhythm interpretation. Philadelphia:
W.B. Saunders.
VENTRICULAR TACHYCARDIA (VT)
• STABLE CLIENT WITH SUSTAINED VT
– Administer oxygen as prescribed
– Administer antidysrhythmics as prescribed
VENTRICULAR TACHYCARDIA (VT)
• UNSTABLE CLIENT WITH VT
– Administer oxygen and antidysrhythmic
therapy as prescribed
– Prepare for synchronized cardioversion if
unstable
– Attempt cough cardiopulmonary resuscitation
(CPR) by asking the client to cough hard every
1 to 3 seconds
• PULSELESS CLIENT
– Defibrillation and cardiopulmonary
resuscitation (CPR)
VENTRICULAR FIBRILLATION (VF)
• DESCRIPTION
– Impulses from many irritable foci fire in a
totally disorganized manner
– Chaotic rapid rhythm in which the ventricles
quiver
– Rapidly fatal if not successfully terminated
within 3 to 5 minutes
– Client lacks a pulse, blood pressure,
respirations, and heart sounds
VENTRICULAR FIBRILLATION (VF)
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed
2, Philadelphia: W.B. Saunders
VENTRICULAR FIBRILLATION (VF)
• IMPLEMENTATION
– Defibrillate immediately, up to three times
consecutively at 200, 300, and 360 joules
– Initiate CPR
– Administer oxygen as prescribed
– Administer epinephrine (Adrenalin) and
antidysrhythmic therapy with lidocaine as
prescribed
– Prepare to administer additional prescribed
antidysrhythmics
VAGAL MANEUVERS
• DESCRIPTION
– Induce vagal stimulation of the cardiac
conduction system
– Used to terminate supraventricular
tachydysrhythmias
CAROTID SINUS MASSAGE
• The physician instructs the client to turn the head
away from the side to be massaged
• The physician massages over the carotid artery for 6
to 8 seconds until there is a change in cardiac
rhythm
• Observe the cardiac monitor for a change in rhythm
• Record an ECG rhythm strip before, during, and after
the procedure
• Have a defibrillator and resuscitative equipment
available
• Monitor VS, cardiac rhythm, and level of
consciousness (LOC) following the procedure
VALSALVA MANEUVERS
• The physician instructs the client to bear down or
induces a gag reflex in the client, both of which
stimulate a vagal reflex
• Monitor the heart rate, rhythm, and BP
• Observe the cardiac monitor for a change in
rhythm; record an ECG rhythm strip before,
during, and after the procedure
• Provide an emesis basin if the gag reflex is
stimulated, and initiate precautions to prevent
aspiration
• Have a defibrillator and resuscitative equipment
available
CARDIOVERSION
• DESCRIPTION
– Synchronized countershock to convert an
undesirable rhythm to a stable rhythm
– An elective procedure performed by the
physician
– A lower amount of energy is used than with
defibrillation
– Defibrillator is synchronized to the client’s R
wave to avoid discharging the shock during the
vulnerable period (T wave)
– If the defibrillator were not synchronized, it
would discharge on the T wave and cause VF
CARDIOVERSION
• PREPROCEDURE
– Obtain consent
– Administer sedation as prescribed
– Hold digoxin (Lanoxin) 48 hours preprocedure
as prescribed to prevent postcardioversion
ventricular irritability
CARDIOVERSION
• DURING THE PROCEDURE
– Ensure that the skin is clean and dry in the
area where the electrode paddles will be
placed
– Stop the oxygen during the procedure to avoid
the hazard of fire
– Be sure that no one is touching the bed or the
client when delivering the countershock
CARDIOVERSION
• POSTPROCEDURE
– Maintain airway patency
– Administer oxygen as prescribed
– Assess VS
– Assess LOC
– Monitor cardiac rhythm
– Monitor for indications of successful
response, such as conversion to sinus rhythm,
strong peripheral pulses, and an adequate BP
DEFIBRILLATION
• DESCRIPTION
– An asynchronous countershock used to
terminate pulseless VT or VF
– Three rapid, consecutive shocks are delivered
with the first at an energy of 200 joules
– If unsuccessful, the shock is repeated at 200 to
300 joules
– The third and subsequent shock will be at 360
joules
DEFIBRILLATION
• DURING THE PROCEDURE
– Stop the oxygen to avoid the hazard of fire
– Be sure that no one is touching the bed or the
client when delivering the countershock
DEFIBRILLATION
• USE OF PADDLE ELECTRODES
– Apply conductive pads
– One paddle is placed at the third intercostal
space to the right of the sternum; the other is
placed at the fifth intercostal space on the left
midaxillary line
– Apply firm pressure with the paddles
– Be sure that no one is touching the bed or the
client when delivering the countershock
ANATOMICAL POSITION OF THE HEART
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations
for clinical practice, ed 2, Philadelphia: W.B. Saunders
PADDLE PLACEMENT
From Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment
and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.
AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
• Used by laypersons and emergency medical
technicians for prehospital cardiac arrest
• Place the client on a firm dry surface
• Stop CPR
• Ensure that no one is touching the client to avoid
motion artifact during rhythm analysis
• Place the electrode paddles in the correct
position on the client’s chest
• Press the analyzer button to identify the rhythm,
which may take 30 seconds; the machine will
advise whether a shock is necessary
AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
• Shocks are recommended for pulseless VF only
• If shock is recommended, the shock is initially
delivered at an energy of 200 joules
• If unsuccessful, the shock is repeated at 200 to
300 joules
• The third and subsequent shock will be at 360
joules
• If unsuccessful, CPR is continued for 1 minute,
and then another series of 3 shocks are delivered
each at 360 joules of energy
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
• DESCRIPTION
– Monitors cardiac rhythm and detects and
terminates episodes of VT and VF
– It senses VT or VF and delivers 25 to 30 joules up
to four times if necessary
– Used in clients with episodes of spontaneous
sustained VT or VF unrelated to a myocardial
infarction or in clients whose medication therapy
has been unsuccessful in controlling lifethreatening dysrhythmias
– Electrodes are placed in the right atrium and
ventricle and apical pericardium; the generator is
implanted in the abdomen
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
From Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment
and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
• CLIENT EDUCATION
– Basic functioning of the ICD
– How to perform cough CPR
– How to take the pulse; the pulse is taken daily
and a diary of pulse rates is maintained
– Wear loose-fitting clothing
– Avoid contact sports and strenuous activities
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
• CLIENT EDUCATION
– Report any fever, redness, swelling, or
drainage from the insertion site
– Report symptoms of fainting, nausea,
weakness, blackouts, and rapid pulse rates to
the physician
– During shock discharge, the client may feel
faint or short of breath
– To sit or lie down if they feel a shock and to
notify the physician
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
• CLIENT EDUCATION
– How to access emergency medical system
– Encourage the family to learn CPR
– Maintain a diary of any shocks that are
delivered including the date, preceding
activity, the number of shocks, and if the
shocks were successful
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
• CLIENT EDUCATION
– Avoid electromagnetic fields directly over the
ICD because they can inactivate the device
– Move away from the magnetic field
immediately if beeping tones are heard, and
notify the physician
– Keep a pacemaker ID in the wallet and obtain
and wear a Medic Alert bracelet
– Inform all health care providers that an ICD is
inserted
PACEMAKERS
• DESCRIPTION
– A temporary or permanent device that
provides electrical stimulation and maintains
the heart rate when the client’s intrinsic
pacemaker fails to provide a perfusing rhythm
PACEMAKERS
• SETTINGS
– Synchronous or demand pacemaker: Senses
the client’s rhythm and paces only if the
client’s intrinsic rate falls below the set
pacemaker rate
– Asynchronous or fixed rate: Paces at a preset
rate regardless of the client’s intrinsic rhythm
– Overdrive pacing: To suppress the underlying
rhythm in tachydysrhythmias so that the sinus
node will regain control of the heart
PACEMAKERS
• SPIKES
– When a pacing stimulus is delivered to the
heart, a spike (straight vertical line) is seen on
the monitor or ECG strip
– The spike should be followed by a P wave
indicating atrial depolarization, or a QRS
complex indicating ventricular depolarization;
this pattern is referred to as “capture,”
indicating that the pacemaker successfully
depolarized, or captured, the chamber
PACEMAKERS
• SPIKES
– If the electrode is in the ventricle, the spike is
in front of the QRS complex; if the electrode is
in the atrium, the spike is before the P wave
– If the electrode is in both the atrium and
ventricle, the spike is before both the P wave
and QRS complex
PACEMAKER SPIKES
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice,
ed 2, Philadelphia: W.B. Saunders
TEMPORARY PACEMAKERS
• NONINVASIVE TEMPORARY PACING (NTP)
– Used as an emergency measure or when a
client is being transported and the risk of
bradydysrhythmia exists
– A large electrode patch is placed on the chest
and back
TEMPORARY PACEMAKERS
• NONINVASIVE TEMPORARY PACING (NTP)
– Wash the skin with soap and water prior to
applying electrodes
– Do not shave the hair or apply alcohol or
tinctures to the skin
– Place the posterior electrode between the
spine and left scapula behind the heart,
avoiding placement over bone
– Place the anterior electrode between V2 and V5
position over the heart
TEMPORARY PACEMAKERS
• NONINVASIVE TEMPORARY PACING (NTP)
– Do not place the anterior electrode over female
breast tissue; rather, displace breast tissue
and place under the breast
– Do not take the pulse or BP on the left side
because the results will not be accurate due to
the muscle twitching and electrical current
– Assure that electrodes are in good contact
with the skin
– If loss of “capture” occurs, assess the skin
contact of the electrodes and increase the
current until “capture” is regained
TEMPORARY PACEMAKERS
• TRANSVENOUS INVASIVE TEMPORARY PACING
– Pacing lead wire is placed through antecubital,
femoral, jugular, or subclavian vein into the
right atrium for atrial pacing, or through the
right ventricle, and positioned in contact with
the endocardium
– Monitor cardiac rhythm continuously
– Monitor vital signs
– Monitor pacemaker insertion site
– Restrict client movement to prevent lead wire
displacement
TRANSVENOUS INVASIVE TEMPORARY PACING
From Thelan LA et al (1998) Critical care nursing (3rd ed). St. Louis: Mosby.
TEMPORARY PACEMAKERS
• EPICARDIAL INVASIVE TEMPORARY PACING
– Applied using a transthoracic approach
– The lead wires are loosely threaded on the
epicardial surface of the heart after cardiac
surgery
EPICARDIAL INVASIVE TEMPORARY PACING
From Black, J. Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia:
W.B. Saunders
TEMPORARY PACEMAKERS
• REDUCING THE RISK OF MICROSHOCK
– Use only inspected and approved equipment
– Insulate the exposed portion of wires with
plastic or rubber material (fingers of rubber
gloves) when wires are not attached to the
pulse generator, and cover with nonconductive
tape
– Ground all electrical equipment using a threepronged plug
– Wear gloves when handling exposed wires
– Keep dressings dry
PERMANENT PACEMAKERS
• Pulse generator is internal and surgically
implanted in a subcutaneous pocket under the
clavicle or abdominal wall
• The leads are passed transvenously via the
cephalic or subclavian vein to the endocardium
on the right side of the heart
• May be single-chambered, in which the lead wire
is placed in the chamber to be paced, or dualchambered, with lead wires placed in the atrium
and right ventricle
PERMANENT PACEMAKERS
• It is programmed when inserted and can be
reprogrammed if necessary by noninvasive
transmission from an external programmer to the
implanted generator
• Pacemakers are powered by either a lithium
battery that has an average life span of 10 years,
nuclear-powered with a life span of 20 years or
longer, or are designed to be recharged externally
PACEMAKERS: CLIENT EDUCATION
• About the pacemaker including the programmed
rate
• The signs of battery failure and when to notify the
physician
• Report any fever, redness, swelling, or drainage
from the insertion site
• Report signs of dizziness, weakness or fatigue,
swelling of the ankles or legs, chest pain, or
shortness of breath
PACEMAKERS: CLIENT EDUCATION
• Keep a pacemaker identification card in the wallet
and obtain and wear a Medic Alert bracelet
• How to take the pulse, to take the pulse daily, and
maintain a diary of pulse rates
• Wear loose-fitting clothing
• Avoid contact sports
• Inform all health care providers that a pacemaker
is inserted
• Inform airport security about the pacemaker
because the pacemaker may set off the security
detector
PACEMAKERS: CLIENT EDUCATION
• Most electrical appliances can be used without
any interference with the functioning of the
pacemaker; however, advise the client not to
operate electrical appliances directly over the
pacemaker site
• Avoid transmitter towers and antitheft devices in
stores
• If any unusual feelings occur when near any
electrical devices to move 5 to 10 feet away and
to check the pulse
• The importance of follow-up with the physician