NURS 4540 Module 7 Annotated

• Active learning guides help students focus their study time
• Active learning guides use knowledge-level information, application, and analysis
• Review the active learning guide before engaging with module content
• Active learning guides serve as guides to help students navigate course content, and are not the same as study or test blueprints
• Reviewing questions beforehand previews key concepts and takeaways
• Completing the active learning guide should be done while working through module content
• Some questions may require finishing all content prior to responding
• Analyze Atwood text strips starting on page 192 for cardiovascular dysfunction complications post-MI
• Rate and analyze strips, noting atrial, ventricular, or AV pacing
• Answer with the type of pacing, without percentages
• Answer first before checking answers
• Use a different color to show where answers were changed if correcting
• Read pages 124-132 in Atwood, S., Stanton, C., & Story-Davenport, J. (2019). Introduction to basic cardiac dysrhythmias (5th ed.). Jones & Bartlett Learning, LLC.
• Heart rate 70 Beats Per Minute Regular is an example of Ventricular Pacing
• Heart rate 70 Beats Per Minute Regular is an example of Atrial Pacing
• Heart rate 80 Beats Per Minute Regular is an example of Dual Chamber Pacing
• Heart rate 60 Beats Per Minute Irregular is an example of Wandering Pacemaker
• Heart rate 70 Beats Per Minute Regular is an example of Atrial Pacing
• Heart rate 0 Beats Per Minute is an example of Asystole with a functional pacemaker
• Heart rate 70 Beats Per Minute is an example of Ventricular Pacing
• Heart rate 70 Beats Per Minute is an example of Dual Chamber Paced
• Heart Rate 75 Beats Per Minute Regular is an example of Atrial Pacing with Failure to Capture
• Heart Rate 60 Beats Per Minute Regular is an example of Ventricular Pacing with Failure to Capture
• Heart rate 70 Beats Per Minute Regular is an example of Ventricular Pacing
• Heart rate 70 Beats Per Minute Regular is an example of Biventricular Paced

Case Study 1: Cardiomyopathy Comparison

• Mr. E has hypertrophic cardiomyopathy with an ejection fraction of 30%.

Hypertrophic Cardiomyopathy

• Thickened heart muscle, usually in the left ventricle
• Obstructs blood flow during ventricular contraction
• Primarily affects diastolic function (filling)
• Maintains relatively normal systolic function (contraction)
• Presents with exertional chest pain, a "left sternal border" quality, and dyspnea on exertion.

Dilated Cardiomyopathy

• Enlarged and weakened heart chambers, leading to decreased systolic function and reduced ejection fraction
• Impairs the heart's ability to pump blood effectively
• Causes peripheral edema (swelling in legs), significant fatigue, dyspnea at rest, and irregular heartbeat.

Restrictive Cardiomyopathy

• Stiffened ventricular walls, restricting ventricular filling
• Occurs without significant chamber enlargement, typically with near-normal systolic function.
• Results in prominent jugular venous distention, paradoxical pulse, and ascites (fluid buildup in abdomen)

Shared Symptoms of Cardiomyopathies

• Shortness of breath (dyspnea): Common due to impaired ventricular filling, often exacerbated with exertion
• Fatigue: Reduced cardiac output can lead to fatigue across all cardiomyopathies
• Chest pain: May occur in all types, especially with exertion
• Syncope or near-syncope: Can be present in all forms due to decreased cardiac output in certain situations

Treatments for Cardiomyopathies

• Lifestyle modifications: Exercise as tolerated, weight management, sodium restriction, and smoking cessation.
• Medications: Beta-blockers to control heart rate, diuretics for fluid management, and antiarrhythmic drugs for rhythm disturbances.
• Septum-myectomy surgery to relieve obstruction in severe cases, alcohol septal ablation, and beta-blockers are first-line therapy for hypertrophic cardiomyopathy
• Cardiac resynchronization therapy (CRT) in selected cases, implantable cardioverter defibrillator (ICD) for arrhythmia management, and heart transplant in advanced stages for dilated cardiomyopathy
• Treatment focused on managing underlying causes like amyloidosis, and diuretics to manage fluid overload for restrictive cardiomyopathy
• HCM usually presents with a preserved ejection fraction
• A 30% ejection fraction finding could indicate the presence of a different cardiomyopathy or require further evaluation to clarify the diagnosis.

Implantable Cardioverter Defibrillator (ICD)

• ICDs are implanted in patients at risk for life-threatening arrhythmias like Vtach and Vfib
• ICDs continuously monitor heart rhythm for abnormalities
• Administers therapy when needed

ICD Therapies

• Antitachycardia Pacing (ATP): Sends small electrical impulses to interrupt VTach
• Cardioversion: Low energy shock to restore normal rhythm
• Defibrillation: High energy shock for life-threatening rhythms (VFib or pulseless VT)

Nursing Responsibilities for Monitored Vtach

• Assess the patient's level of consciousness
• Determine id the patient has a pulse
• Assess signs/symptoms (dizziness, chest pain, syncope)

Nursing Actions for Stable Vtach with Pulse

• Stay with the patient and closely assess/monitor ECG
• Prepare for potential ICD discharge and warn the patient of impending shock
• Administer antiarrhythmic medications (Sodium Channel Blockers/Potassium Channel Blockers) as ordered

Nursing Actions for Unstable Vtach with no Pulse or Severe Symptoms

• Call a code Blue and start CPR if pulseless
• Prepare for external defibrillation if ICD fails
• Ensure IV access, oxygen, and emergency medications are prepped and ready

Potential Priority Nursing Diagnoses

• Decreased Cardiac Output r/t arrhythmias and structured heart disease
• Risk for Ineffective Tissue Perfusion r/t ventricular dysrhythmias
• Activity Intolerance r/t reduced cardiac function
• Anxiety/Fear r/t ICD shocks and risk of sudden cardiac arrest
• Risk for Infection r/t ICD implantation

Mr. E and Mitral Regurgitation

• Stethoscope should be placed at the apex of the heart to best hear the murmur
• The apex of the heart is at the 5th intercostal space, midclavicular line on the left side of the body
• The regurgitation murmur would be heard during systole
• During left ventricular contraction (systole), the mitral valve would fail to close properly which allows blood to flow backward (regurgitate) into the left atrium
• This creates a blowing, high-pitched murmur, heard best at the apex and can radiate to the axilla

Mitral Regurgitation

• Mitral regurgitation is a condition where the mitral valve doesn't close properly

Causes of Mitral Regurgitation

• Mitral valve prolapse (most common)
• Rheumatic heart disease (from untreated strep throat)
• Coronary artery disease (heart attack)
• Congenital heart defects, infective endocarditis (heart valve infection)
• Cardiomyopathy (weakened heart muscle)
• Radiation therapy to the chest
• Certain connective tissue disorders
• Damage to the valve leaflets or supporting structures due to trauma or surgery

Significance of Mitral Regurgitation

• The mitral valve in the heart doesn't close properly
• Blood leaks backwards, preventing the heart from efficiently pumping blood to the body
• Leads to complications like heart failure, pulmonary hypertension, and atrial fibrillation if left untreated
• Requires the heart to work harder to compensate for the blood leakage
• Even mild cases can worsen over time and require medical attention

Acute Mitral Regurgitation (MR)

• Symptoms develop suddenly and can be severe
• Symptoms include severe shortness of breath, abnormal heart rhythms, hypotension, tachycardia, pulmonary edema, palpitations
• Can be life-threatening and can result from a heart attack, valve infection, or spontaneously

Chronic MR

• Symptoms develop gradually and may be mild or asymptomatic early on
• Symptoms include exercise intolerance, dyspnea on exertion, edema in the lower extremities, hepatic congestion, and orthopnea (need to sit up to breathe)
• Develops slowly and gradually, often due to a failure of the heart's left ventricle.

Case Study 2: Acute Myocardial Infarction (MI)

• Mrs. S came to the ED with crushing chest pain and was diagnosed with a large ST Elevated anterior wall MI
• She was treated with oxygen, morphine sulfate, a nitroglycerin infusion, heparin infusion, and thrombolytic therapy

Complications Seen with Acute MI

• Mechanical complications like ventricular septal rupture, left ventricular free wall rupture, papillary muscle rupture leading to mitral regurgitation, cardiogenic shock, acute heart failure, arrhythmias (abnormal heart rhythms), pericarditis, and thromboembolic events
• Severity of complications often depends on the size and location of the infarct area

Most Common Complications Seen with an Anterior MI

• Left ventricular dysfunction, heart failure, cardiogenic shock, ventricular septal rupture, left ventricular mural thrombus, and pericarditis
• Potential for complications like free wall rupture and sudden cardiac death due to life-threatening arrhythmias in severe cases

Pharmacologic Treatment Options (Rationale & Hemodynamic Goals)

• Furosemide: Decreases pulmonary congestion by reducing preload and pulmonary venous pressure
• Nitroglycerin: Decreases preload with vasodilation and decrease pulmonary congestion
• Morphine: Decreases preload & decrease dyspnea & anxiety
• Inotropes: Increase cardiac output
• Oxygen Administration: Improve oxygen delivery

Hemodynamic Goals for Acute MI

• Increase urine output

• Assess/monitor BP & electrolytes

• Decrease myocardial oxygen demand

• Decrease LV wall stress

• Sustain oxygen saturation greater than 94%

• Despite treatment, Mrs. S continued to have chest pain and hypotension

• IABP and PA catheters were placed

Mrs. S, Hemodynamic Values

• BP 81/45
• CVP18
• PAOP 22
• SVR 1645
• LVSWI 32
• CI 1.6
• SVO2 50%

ABGs (on 6 lpm Nasal Cannula)

• pH 7.29
• PaCO2 33
• PaO2 100
• HCO3 18
• SaO2 98%

Analysis of Oxygenation and Acid-Base Balance

• Metabolic Acidosis with lactic acidosis due to low cardiac output and tissue hypoxia
• Cardiac Index is 1.6

Analysis of the Following

• Preload CVP & PAOP ↑ → Fluid is backing up into the lungs
• Afterload SVR↑→ Compensatory vasoconstriction as a result of low Cardiac Output
• Contractility/ Cardiac Output ↓ → Severe left ventricular failure after myocardial infarction

Intra Aortic Balloon Pump (IABP)

• Inflates during diastole to ↑ coronary artery perfusion
• Deflates right before systole to↓ afterload and workload for the Left Ventricular
• Benefits coronary artery perfusion and cardiac Output
• Reduces LV workload and Afterload
• Reduces pulmonary congestion

Nursing Responsibilities for IABP

• Continuous Arterial Blood Pressure Monitoring
• Assess/Monitor Cardiac Output/Cardiac Index, SVR for improvement
• Patient Position : Bed rest with head of bed less than or equal to 30 degrees; Avoid hip flexion on IABP side, and keep legs straight
• Balloon Function Monitoring: Assess/Monitor for proper inflation timing and balloon rupture
• Perfusion Check for Limb Ischemia: Assess distal pulses (particulary on IABP insertion side) and assess/Monitor capillary refill, skin color and temperature of limb
• Prevention of Bleeding and Infection: Assesses Monitor insertion site for hematoma, bleeding and signs and symptoms of infection

Potential Complications Nurse Should Monitor While Patient is on IABP Therapy

• Limb Ischemia → Assess/Monitor pulses, skin color and temperature
• Bleeding at the Insertion Site → Risk of retroperitoneal hemorrhage
• Stringent or strict aseptic technique must be used to prevent Infection
• Balloon rupture, indicated if there is blood in helium tubing → Emergency
• Monitor platelets count for Thrombycytopenia
• Balloon Malfunction (Timing is off) → Can worsen hemodynamics instead of helping

Contraindications to Intra-Aortic Balloon Pump (IABP) Therapy

• Significant aortic regurgitation (moderate to severe): As inflating the balloon during diastole can worsen the regurgitation, significantly increasing cardiac workload
• Aortic dissection or aneurysm: Placement of the balloon could potentially worsen the dissection or cause rupture of the aneurysm
• Severe peripheral vascular disease: Difficulty in accessing the femoral artery for balloon placement due to poor blood flow
• Uncontrolled bleeding diathesis: Increased risk of bleeding complications during insertion or during therapy
• Uncontrolled sepsis: Systemic inflammation can worsen the patient's condition
• Inability to adequately position the balloon: Anatomical limitations preventing proper balloon placement
• Patient refusal

Diagnostic Tests While Patient is on the Balloon Pump

• Arterial Blood Gas → Assess/Monitor oxygenation & Acidosis
• Hemodynamic Normal Ranges (PAOP,CVP, CO/CI) → Assess/Monitor effectiveness of IABP
• ECG Monitoring→ Assess for arrhythmias; Balloon may stress/irritate myocardium
• Doppler Ultrasound→ Assess/Monitor for limb ischemia
• Platelet Count → Assess/Monitor for thrombocytopenia, which results from Platelet destruction due to the IABP

Potential Priority Nursing Diagnoses

• Reduced Cardiac Output r/t impaired myocardial function
• Impaired Gas Exchange r/t pulmonary congestion
• Risk for Ineffective Tissue Perfusion r/t cardiologenic shock & IABP Therapy
• Risk for Infection r/t invasive catheter placement
• Risk for Peripheral Neurovascular Dysfunction r/t IABP induced ischemia

Outcomes Indicating Patient Improvement

↑ Cardiac Index > 2.2 L/min/m² → Improved cardiac output ↑ Blood Pressure > 90/60 mmHg → Improved perfusion ↓PAOP <= 18 mmHg → Reduced pulmonary congestion ↑ Urine Output > 30 mL/hr → Improved renal perfusion SVO2 > 60% → Improved oxygen delivery to tissue ↓Reduced Shortness of Breath, Crackles, RR, and improved ABGs

Case Study 3: Acute Inferior MI

• Mr. A was admitted with an acute Inferior MI
• Bradyarrhythmias → Sinus Bradycardia, AV Blocks particularly 2nd Degree type 1 and 3rd degree heart block
• Right Ventricular Infarction → Hypotension, JVD, clear lungs. Needs assessment to monitor preload and avoid nitrates
• Papillary Muscle Rupture → Acute Mitral regurgitation, pulmonary edema
• Pericarditis → Chest pain worsened by inspiration, relieved by sitting up
• Cardiogenic Shock

Nursing Actions

• Assess/Monitor for hemodynamic instability
• Assess BP, LOC, pulse quality, skin color, cap refill
• Apply transcutaneous pacemaker, notify if signs/symptoms of hypotension, syncope, altered mental status Oxygen therapy and IV Access, monitor ECG continuously.
• Prepare for transvenous pacing if TCP ineffective or prolonged
• Administer Atropine 0.5 mg IV push q3-5 mins, but is ineffective in high degree AV blocks
• Contemplate the use of dopamine/epinephrine infusion if BP remains low

Nursing Assessments and Management

• Assess pulse and blood pressure, don't rely on ECG
• Monitor for discomfort, TCP is painful so consider the administration of analgesia/sedation
• Evaluate ECG for pacing spikes followed by QRS complexes (Capture)
• Assess skin under the electrode pads for burns
• Ensure proper electrode placement
• Set appropriate pacing rate and output by adjusting mA until electrical & mechanical capture is achieved
• Offer sedation using Benzodiazepines or Opioids, only if patient is conscious

Evaluate if Pacemaker is Operating Properly

• Check for Pacing spikes followed by QRS complexes (Capture achieved) on the ECG
• Assess if there are any prolonged pauses or asystole
• Monitor for Stable rhythm without persistent bradycardia
• Check for Stable blood pressure, pulse and mental status
• Check and make sure there are no signs of Syncope, dizziness, or signs of poor perfusion

VVI Pacemaker Letters

• V → Ventricular paced, which stimulates the ventricle
• V → Ventricular sensed and detects intrinsic ventricular activity
• I → Inhibited mode, the pacemaker fires only if needed, and not if an intrinsic beat is detected

ECG Capture Check

• Each pacing spike is followed by a wide QRS Complex, which indicated effective depolarization
• Loss of capture = pacing spike with no QRS

Pacemaker Sensing

• Pacemaker detects intrinsic beats and inhibits the firing if unnecessary.
• Undersensing: PM doesn't detect intrinsic activity and fires inappropriately
• Oversensing: PM detects false signals (e.g. artifact) and doesn't fire when needed

Nursing Actions for Sudden ECG Changes

• For showing signs/symptoms of hypotension, syncope, or LOC changes
• Check pacemaker settings & battery
• Ensure lead connections are intact
• Increase pacing output if loss of capture
• Prepare for external pacing (TCP) if needed
• Notify cardiology immediately

Discharge Teaching

• Monitor ECG to ensure that pacing and sensing are functioning
• Assess insertion site to check for bleeding, infection and hematoma
• Keep affected arm immobilize initially to prevent lead dislodgement
• Monitor for pneumothorax using a chest X-ray post procedure
• Post procedure, report immediately if: There are signs of lead dislodgement; Signs of infection; Chest pain, dizziness, syncope, as they may indicate malfunction

Discharge Teaching

• Avoid lifting arm above shoulder on pacemaker side for 4-6 weeks
• Avoid zero heavy lifting over 10 lbs until cleared by provider
• Avoid strong magnets and electromagnetic fields (MRI, Welding Equipment)
• Always carry a pacemaker ID card
• Check pulse daily and report if slow
• Regular follow-ups for pacemaker checks