Critical Care Nursing PDF

NCM 118: Medical CRITICAL CARE NURSING ▪ At the same time, general ICU’s developed for sick and ▪ The care of seriously ill clients from point of injury or illness postoperative patients until discharge from intensive care...

NCM 118: Medical CRITICAL CARE NURSING ▪ At the same time, general ICU’s developed for sick and ▪ The care of seriously ill clients from point of injury or illness postoperative patients until discharge from intensive care History Continued ▪ Deals with human responses to life threatening problems - ▪ Collaboration between nurses and physicians trauma /major surgery (Mary,L.S., Deborah, G.K. & Marthe, ▪ 1950’s & 1960’s – CV Disease most common diagnosis J.M. 2005) ▪ 1960’s – 30-40% m0rtality rate for MI ▪ Care for clients who are very ill ▪ 1965 – 1st specialized ICU – The Coronary Care Unit ▪ Provide direct one to one care ▪ Emergence of Specialized ICU’s ▪ Responsible for making life-and death decision ▪ At high risk of injury or illness from possible exposure to IDEAL ICU infections ▪ Communication skill is of optimal importance Multidisciplinary & Collaborative Approach to ICU Care ▪ At high risk for actual or potential life-threatening ▪ Medical & nursing directors: ▪ health problems ▪ Co-responsibility for ICU management ▪ More ill ▪ A team approach: doctors, nurses, R/T, pharmacist ▪ Required more intensive and careful nursing care ▪ Use of standard, protocol, guideline consistent approach to all issues Term Definition ▪ Dedication to coordination and communication for all aspects Critical Care A term used to describe as the care of patients of ICU management who are extremely ill and whose clinical ▪ Emphasis on research, education, ethical issues, patient condition is unstable or potentially unstable advocacy Team Dynamics Critical Care Defined as the unit in which comprehensive Unit care of a critically ill patient which is deemed ▪ A multidisciplinary team to effectively attain specified to recoverable stage is carried out objective ▪ Physician team leader & critical care nurse manager Critical Care Refers to those comprehensive, specialized Nursing and individualized nursing care services which are rendered to patient with life threatening CRITICAL CARE PRACTICE PATTERN conditions and their families 1. Open Units Any attending physician with hospital admitting Critical Care Technology privileges can be the physician of record and direct ICU care. (All ▪ ECG Monitoring other physicians are consultants) ▪ Arterial Lines Disadvantage: ▪ Oxygen Saturation ▪ Lack of a cohesive plan ▪ Ventilation ▪ Inconsistent night coverage ▪ Intracranial Pressure Monitoring ▪ Duplication of services ▪ Temperature 2. Closed Units ▪ Pulmonary Artery Catheter An intensivist is the physician of record for ICU patients. ▪ IABP (other physicians are consultants), All orders & procedures carried ▪ Extensive use of pharmaceuticals out by ICU staff Advantage: Historical Background ▪ Improved efficiency World War II ▪ Standardized protocol for care ▪ Shock wards establish for resuscitation Disadvantage: ▪ Transfusion practices in early stages ▪ Potential to lock out private physician ▪ After World war-II, nursing shortage forced grouping of ▪ Increase physician conflict postoperative patients in recovery areas. 3. Transitional Units Combines elements of both open and closed units. In this model, the intensivist and the admitting doctor share responsibility for the patient’s care in the ICU. Advantage: ▪ Reduce Physician conflict ▪ Standard Policies ▪ Policies usually present Disadvantage: ▪ Confusion and conflict regarding final authority & responsibilities for patient care decision A GOOD ICU Polio Epidemic Well Organized ▪ 1950’s: use of mechanical ventilation (“iron lung”) for ▪ Trust treatment of polio ▪ Coordinated care ▪ Development of respiratory intensive care units 1 marga ^ ^  ▪ Full-time intensivist: daily round records, which may be on paper or as part of the ▪ Protocol & policies electronic medical record which can be assessed by all ▪ Bedside nurses (master degree) members of the health care team. ▪ No intern A TEAM Classification of Critical Care Units ▪ Doctors, nurses, R/T, pharmacists Level – I: ▪ Led by full time intensivists ▪ Provides monitoring, observation and short term ventilation. - critical care trained Nurse patient ratio is 1.3 and the medical staff are not present - available in a timely fashion (24hr/day) in the unit all the time. - no competing clinical responsibilities during duty Level – II: - closed units, if resources allow ▪ Provides observation, monitoring and long term ventilation with resident doctors. The nurse-patient ratio is 1:2 and junior What are the conditions considered as Critical? medical staff is available in the unit all the time and consultant medical staff is available if needed. 1. Any Person with life threatening condition Level – III: 2. Patients with: - ARF ▪ Provides all aspects of intensive care including invasive - AMI hemodynamic monitoring and dialysis nurse patient ratio is 1:1 - CARDIAC TAMPONADE Classification of Critical Care Patients - SEVERE SHOCK Level 0: - HEART BLOCK - ACUTE RENAL FAILURE ▪ Normal ward care Level 1: - POLY TRAUMA, MULTIPLE ORGAN FAILURE AND ORGAN DYSFUNCTION ▪ At risk of deteriorating, support from critical care team - SEVERE BURNS Level 2: ▪ More observation or intervention, single failing organ or post- Nursing Assessment operative care Level 3: - It is the first stage of nursing process in which the nurse should carry out a complete and holistic nursing assessment ▪ Advanced respiratory support or basic respiratory support, of every patient’s needs, regardless of the reason for the multiorgan, failure encounter. High Dependency Care Components of Nursing Assessment ▪ Coronary care units (CCU) 1. NURSING HISTORY: Taking a nursing history prior to the ▪ Renal high dependency unit (HDU) physical examination allows a nurse to establish a rapport ▪ Post-operative recovery room with the patient and family ▪ Accident and emergency departments (A&E) Elements of the history include – ▪ Intensive care units (ICU) ▪ Health Status ▪ Cause of present illness including symptoms Types of ICU ▪ Current management of illness General ▪ Past medical history including family’s medical history Medical Intensive Care Unit (MICU) ▪ Social history Surgical Intensive Care Unit ▪ Perception of illness Medical Surgical Intensive Care Unit (MSICU) 2. PSYCHOLOGICAL AND SOCIAL EXAMINATION Specialized ▪ Client’s perception Neonatal Intensive Care Unit (NICU) ▪ Emotional health Special Care Nursery (SCN) ▪ Physical health Pediatric Intensive Care Unit (PICU) ▪ Spiritual health Coronary Care Unit (CCU) ▪ Intellectual health Cardiac Surgery Intensive Care Unit (CSICU) 3. PHYSICAL EXAMINATION Neuro-Surgery Intensive Care Unit (NSICU) ▪ A nursing assessment includes physical examination, Burn Intensive Care Unit (BICU) where the observation or measurement of signs, Trauma Intensive Care Unit which can be observed or measured, or symptoms such as nausea or vertigo, which can be felt by the Principles of Critical Care Nursing patient. ANTICIPATION ▪ The techniques used may include Inspection, Palpation, auscultation and Percussion in addition to ▪ The first principle in critical care is Anticipation. One has to the vital signs like temperature, pulse, respiration, BP recognize the high-risk patients and anticipate the and further examination of the body systems such as requirements, complications and be prepared to meet any the cardiovascular or musculoskeletal systems. emergency. Unit is properly organized in which all necessary ▪ Documentation of Assessment: The Assessment is equipments and supplies are mandatory for smooth running documented in the patient’s medical or nursing of the unit. 2 marga ^ ^  ▪ 225-250 sq. ft per bed if in a single room. EARLY DETECTION AND PROMPT ACTION ▪ Beds should be adjustable, no head board, with side rails and ▪ The prognosis of the patient depends on the early detection wheels. of variation, prompt and appropriate action to prevent or ▪ Keep bed 2 ft away from head wall. combat complication. Monitoring of cardiac respiratory ACCESSORIES function is of prime importance in assessment. ▪ 3 O2 outlets, 3 suction outlets (gastric, tracheal and Collaborative Practice underwater seal), 2 compressed air outlets and 16 power ▪ Critical Care, which has originated as technical sub-specialized outlets per bed. body of knowledge has evolved into a comprehensive ▪ Storage by each bedside. discipline requiring a very specialized body of knowledge for ▪ Hand rinse solution by each bedside. the physicians and nurses working in the critical care unit ▪ Equipment shelf at the head end. fosters a partnerships for decision making and ensures ▪ Hooks and devices to hang infusions/ blood bags, extended quality and compassionate patient care. from the ceiling with a sliding rail to position. ▪ Collaborate practice is more and more warranted for critical ▪ Infusion pumps to be mounted on stand or poles. care more than in any other field. ▪ Level II ICUs may require multi-channel invasive monitors. Communication ▪ 8. ventilators, infusion pumps, portable X ray unit, fluid and bed warmers, portable light, defibrillators, anaesthesia ▪ Intra professional, inter departmental and inter-personal machines and difficult airway management equipments are communication has a significant importance in the smooth necessary. running of unit. Collaborative practice of communication STAFFING : model Prevention of Infection ▪ Medical Staff – the best senior medical staff to be appointed as an Intensive Care Director or Intensivist. Less preferred are ▪ Nosocomial infection cost a lot in the health care services. other specialists from anaesthesia / medicine who has clinical Critically ill patients requiring intensive care are at a greater commitment elsewhere. Junior staff are intensive care risk than other patients due to the immunocompromised trainers and trainees on deputation from other disciplines. state with the antibiotic usage and stress, invasive lines, ▪ Nursing staff mechanical ventilators, prolonged stay and severity of illness and environment of the critical unit itself. - The major teaching tertiary care ICU requires trained Crisis Intervention and Stress Reduction nurses in critical care. - The no. of nurses ideally required for such unit is 1:1 ▪ Partnerships are formulated during crisis. Bonds between ratio, however it might not be possible to have such nurses, patients and families are stronger during members in our set up. So 1 nurse for 2 patients is hospitalization. As patient advocated, nurses assist the acceptable. The no of trained nurses should also be patient to express fear and identify their grieving pattern and worked out by the type of ICU, the workload and work provide avenues for positive coping. statistics and type of patient load. ▪ Allied Services – Respiratory services, Nutritionist, ORGANIZATION OF ICU Physiotherapist, Biomedical engineer, technicians, computer Design of ICU: programmer, clinical pharmacist, social worker / counsellor ▪ Should be at a geographically distinct area within the and other support staff, guards and grade IV workers. hospital, with controlled access. ▪ There should be a single entry and exit. However, it is Prime Responsibilities of a Critical Care Nurse required to have emergency exit points in case of emergency and disaster. ▪ Continuous monitoring ▪ There should not be any through traffic of goods or hospital ▪ Keep ready emergency trolley/crash Cart staff. Supply and professional traffic should be separated ▪ Efficient Individualized Care from public/visitor traffic. ▪ Counseling and information to family ▪ Safe, easy, fast transport of a critically sick pt. should be a ▪ Application of policies and procedures priority in planning its location. Therefor, the ICU should be ▪ Proper records of all activities located in close proximity or ER, OT, trauma ward etc. ▪ Maintain infection control principles ▪ Corridors, lifts and ramps should be spacious enough to ▪ Keep update with advance information provide easy movement of bed/trolly of a critically sick patient. Quick Reference Protocol for Managing Emergency in ICU ▪ Close, easy proximity is also desirable to diagnostic facilities, ▪ Quickly review the patient–Identity, History, Physical Exam blood bank, pharmacy etc. ▪ Be with the patient, ask for help BED STRENGTH: ▪ Place the patient in a suitable position ▪ It is recommended that total bed strength in ICU should be ▪ Attach the cardiac monitor and call for crash cart between 8-12 and not less than 6 or not more than 24 in any ▪ Maintain ABC along with the expert team case. ▪ Introduce IV, CV line ▪ 3-5 beds per 100 hospital beds for a Level III ICU or 2 to 20% of ▪ Administer medication as needed the total no of hospital beds. ▪ Carry on Investigations – ABG, ECG, Urea, Creatinine, Blood ▪ 1 isolation bed for every ICU beds. Sugar, Cardiac enzymes BED AND ITS SPACE: ▪ Maintain Fluid and Electrolytes ▪ 150-200 sq. ft per open bed with 8 ft in between beds. ▪ Record right things at right time rightly 3 marga ^ ^ Family Need of the Critical Patient ▪ Hemodynamic monitoring ▪ Information – major source of anxiety and litigation (legal ▪ Environmental injuries (lightning, near drowning, issues) hypo/hyperthermia) ▪ Reassurance – can reassure care is being given ▪ Convenience – access to the patient Admission Criteria in ICU - The ICU admission decision may be based on several models Critical illness are grouped by the system of the body; utilizing prioritization, diagnosis, and objective parameters A. Cardiac System models ▪ Acute myocardial infarction with complications A. Prioritization Model ▪ Cardiogenic shock ▪ This system defines those that will benefit most from the ICU ▪ Complex arrhythmias requiring close monitoring and (Priority 1) to those that will not benefit at all (Priority 4) from intervention ICU admission. ▪ Acute congestive heart failure with respiratory failure and/or Priority 1: requiring hemodynamic support These are critically ill, unstable patients in need of intensive ▪ Hypertensive emergencies treatment and monitoring that cannot be provided outside of ▪ Unstable angina, particularly with dysrhythmias, the ICU. Usually, these treatments include ventilator support, hemodynamic instability, or persistent chest pain continuous vasoactive drug infusions. Examples of these ▪ Cardiac tamponade or constriction with hemodynamic patients may include post-operative or acute respiratory instability failure patients requiring mechanical ventilatory support and ▪ Dissecting aortic aneurysms shock or hemodynamically unstable patients receiving ▪ Complete heart block invasive monitoring and/or vasoactive drugs. B. Pulmonary System Priority 2: ▪ Acute respiratory failure requiring ventilatory support These patients require intensive monitoring and may ▪ Pulmonary emboli with hemodynamic instability potentially need immediate intervention. Examples include ▪ Massive hemoptysis patients with chronic comorbid conditions who develop acute C. Neurologic disorder sever medical or surgical illness. ▪ Intracranial hemorrhage Priority 3: ▪ Meningitis with altered mental status or respiratory These unstable patients are critically ill but have a reduced compromise likelihood of recovery because of underlying likelihood of ▪ Central nervous system or neuromuscular disorders with recover because of underlying disease or nature of their acute deteriorating neurologic or pulmonary function illness. Examples include patients with metastatic malignancy ▪ Status epilepticus complicated by infection, cardiac tamponade, or airway ▪ Severe head injured patients obstruction. D. Drug Ingestion and Drug Overdose ▪ Hemodynamically unstable drug ingestion Team of Critical Care Unit ▪ Drug ingestion with significantly altered mental status with Physicians inadequate airway protection ▪ The Most Responsible Physician (MRP) is the physician in ▪ Seizures following drug ingestion charge of the patient's care during the current E. Gastrointestinal Disorders hospitalization. He or she communicates with other members ▪ Life threatening gastrointestinal bleeding including of the team on a daily basis. hypotension, angina, continued bleeding, or with comorbid Nurses conditions ▪ Intensive Care Nurses are the minute-to-minute critical care ▪ Hepatic failure providers. They not only help to provide, but also coordinate ▪ Severe pancreatitis most aspects of care delivery. They have received specialized F. Endocrine training in caring for critically ill patients. ▪ Diabetic ketoacidosis complicated by hemodynamic Respiratory Therapists instability, altered mental status, respiratory insufficiency, or ▪ Respiratory therapists have special training and experience in sever acidosis caring for patients with breathing problems. They work ▪ Severe hypercalcemia with altered mental status, requiring closely with the physician to develop a plan to support a hemodynamic monitoring patient’s breathing. They set up, monitor and maintain the ▪ Hypo or Hypernatremia seizures, altered mental status breathing machines (mechanical ventilators), and they adjust ▪ Hypo 0 Hypermagnesemia with hemodynamic compromise or these machines minute by minute and hour by hour to best dysrhythmias meet the patient’s needs. ▪ Hypo or Hyperkalemia with dysrhythmias or muscular Pharmacists weakness ▪ Hypophosphatemia with muscular weakness ▪ Pharmacists consult with the physician in selecting the right G. Surgical medicines at the correct dose for patients and also in monitoring drug levels in the body. Pharmacists also help to ▪ Post-operative patients requiring hemodynamic decrease medication side effects and provide valuable monitoring/ventilatory support or extensive nursing care information to the team members. H. Miscellaneous Physical Therapists ▪ Septic shock with hemodynamic instability 4 marga ^ ^ ▪ They help prevent disabilities and facilitate rehabilitation as Morphine soon as possible ▪ Reduces pain Dieticians ▪ Chiefly used in MI ▪ Dieticians calculate the nutritional needs of the critically ill ▪ 2-4 mg dissolved in 10 ml NS patients and consult with the physician with the physician to ▪ Antidote: Naloxone provide the patient with the best possible diet, whether ▪ Supplied by hospital orally or through a feeding tube. Acetaminophen and NSAIDs Medical Radiation Technologist ▪ Often more effective than opioids in reducing pain from pleural or pericardial rubs, a pain that responds poorly to Medical Laboratory Technologist opioids. ▪ particularly effective in reducing muscular and skeletal pain Trauma Coordinator ▪ Tab form: 500mg OD ▪ The Trauma Coordinator reviews the plan of care for each trauma patient and in consultation with the ICU Care Team, SEDATIVES makes suggestions regarding patient needs. She also works Benzodiazepines closely with the patient and family about the patient’s 1. Midazolam progress and expected outcomes. ▪ Short acting sedatives and hypnotics Social Worker ▪ In intubated patients ▪ Social workers provide professional assistance with the needs ▪ Dose 0.01- 0.05 mg/Kg for several hours of patients and families. They can help to assess and 2. Diazepam determine what resources patients and families might be ▪ Adult dose = 0.2 – 0.5 mg/ Kg lacking, providing them with information on agencies to ▪ Not given in MI patients assist with various needs and generally assisting with other Dissociative Anaesthesia family difficulties. 1. Ketamine Clinical Educator ▪ Adult dose = 1-3 mg/kg IV ▪ Clinical Educators are nurses who provide ongoing education 2. Propofol for ICU nurses on new practices, protocols and on new ▪ Arousal is rapid 10- 15 min equipment. They are up-to-date with the best practices in ICU ▪ Used in neuro cases and those with increased ICP, and communicate with the Manager and with ICU nurses during tracheostomy procedure about all aspects of nursing practice and education. As an important part of their role, they provide a comprehensive INOTROPES orientation to nurses new to the ICU Care Team as well as Dopamine providing continuing advice, support and education for all Dobutamine nurses in ICU. Nor- adrenaline Ward Clerk ▪ ICU Ward Clerk help with communication by answering the THROMBOLYTIC AGENTS phones, processing physician orders and coordinating some of the patient activities in the ICU. TEDS compressive stocking Pastoral Care SCD (Systematic Compressive Device) LMWX ▪ Chaplains are available to minister to the spiritual needs of Heparin flush patients and families Manager Infection Control ▪ Nurse Manager are nurses with additional experience and ▪ Hand washing before, during and after the procedure education, who are responsible for the day to day operations ▪ Sterility maintenance during procedures of the ICU. In addition to managing the ICU nursing staff, the ▪ Use of disinfectants ICU Nurse Manager is responsible for the ICU budget and ▪ Weekly high wash nursing practices. Nurse Managers are responsible for ▪ Monthly culture test of health personnel, equipments and ensuring that the care in the ICU is safe. She/he hires ICU infrastructures nurses and ensures that all nursing staff members meet the ▪ Regular inspection by infection control team standards established for their performance. She is also there ▪ Each shift CVP dressing to assist family members with their needs. CRITICAL CARE COMMON DRUGS ANALGESICS Fentanyl ▪ It works 600 times more effectively than Morphine and reduces the pain and increases the pain threshold ▪ Used in moderate and severe pain ▪ In ICU 50 – 100 µg per Kg ▪ Antidote Naloxone 0.05 mg/ Kg 5 marga ^ ^  CENTRAL VENOUS (CVC) or CENTRAL LINE CATHETER HEMODYNAMIC MONITORING ▪ Insertion of catheter to the large vein (superior vena cava and ▪ ‘HEMO’ – Blood Inferior vena cava) through subclavian, intra-jugular and ▪ ‘DYNAMIC’ – Movement femoral. ▪ A procedure that checks your blood circulation and evaluates ▪ For “E” HD – Emergency Hemodialysis how well your heart is working Indication ▪ Movement of blood throughout the body C - Chemotherapy ▪ Test to determine how many O2 that the body needs to A - Antibiotics prevent hypoxia T – Total Parenteral Nutrition (TPN) 2 Types of Hemodynamic Monitoring H – Hemodialysis 1. NON-INVASIVE MONITORING Types of CVC ▪ Supine, Mid Axillary 1. Peripherally Inserted Central Catheter (PICC) Signs and Symptoms: ▪ PICCs are placed through the basilic (right basilic vein - vein ▪ Skin: Diaphoresis Pale, Cyanotic of choice due to its larger size), brachial, cephalic or the ▪ GI: Constipation, NGT Secretions medial cubital vein of the arm. ▪ Kidney: Decrease Urine Output (Less than 30cc) ▪ Has the straightest route, as it courses through the Increased BUN & CREATINE subclavian, and finally settles in Superior Vena Cava ▪ Liver: AST and ALT (Liver Enzyme, Hepatitis, Liver Cirrhosis) ▪ Lungs: 0.12s ▪ Immediate Defibrillation - Early defibrillation is the most ▪ Followed by compensatory pause critical intervention. CAUSES OF PVC ▪ CPR: High-quality chest compressions. ▪ Stress or anxiety ▪ Epinephrine: 1 mg IV every 3-5 minutes. ▪ Electrolyte imbalances ▪ Amiodarone: 300 mg IV after defibrillation if VF persists. ▪ (hypokalemia, hypomagnesemia) ▪ Consider Magnesium Sulfate - If torsades de pointes (a ▪ 3. Stimulants (caffeine, nicotine) specific form of VFib) is suspected. ▪ 4. Myocardial ischemia ▪ 5. Heart failure Ventricular Tachycardia SIGNS AND SYMPTOMS ▪ Palpitations ▪ Asymptomatic ▪ Dizziness or syncope CLASSIFICATION: 1. SITE OF ORIGIN 2 marga^^ CHARACTERISTICS: ▪ P Wave = Absent ▪ QRS Complex = Wide, Bizaare ▪ PR Interval = Non-discernable ▪ Rate = 100-200 bpm ▪ Rhythm = Regular/Irregular CAUSES OF VTACH ▪ Myocardial infarction ▪ Severe electrolyte imbalances ▪ (especially potassium and magnesium) ▪ Heart Failure ▪ Cardiomyopathy SIGNS AND SYMPTOMS ▪ Palpitations ▪ Dizziness or syncope ▪ Chest pain ▪ Shortness of breath ▪ Hemodynamic instability (low BP, shock) MANAGEMENT OF VTACH ▪ Stable VT (with pulse): - Antiarrhythmic Drugs - Amiodarone (Cordarone) 150 mg IV bolus over 10 minutes. - Lidocaine (Xylocaine) 1-1.5 mg/kg IV bolus. ▪ Unstable VT (with pulse) - Synchronized Cardioversion. ▪ Pulseless VT - CPR and Defibrillation. - Epinephrine 1 mg IV every 3-5 minutes. - Amiodarone 300 mg IV bolus after defibrillation. Interpret this ECG Strip: 1. d 2. d 3 marga^^  HEART BLOCKS CHARACTERISTICS: 1. First-Degree Heart Blocks/First Degree Atrioventricular ▪ Consistent PR intervals with sudden, unpredictable dropped Blocks QRS complexes ▪ More dangerous than Type I as it may progress to complete heart block. CAUSES: ▪ Anterior wall myocardial infarction. ▪ Fibrosis or scarring of the conduction system. ▪ Cardiomyopathy or structural heart disease. SIGNS & SYMPTOMS: CHARACTERISTICS: ▪ Dizziness, fatigue, syncope, or chest pain ▪ Prolonged PR interval (>0.20 seconds), consistent across ▪ May progress to decreased cardiac output or complete heart beats. block. ▪ P wave followed by a QRS complex. MANAGEMENT: CAUSES: ▪ Immediate intervention required, often with pacemaker ▪ Increased vagal tone. implantation ▪ Medications (beta-blockers, calcium channel blockers, digoxin). ▪ Temporary pacing in acute settings ▪ Electrolyte imbalances (hyperkalemia). ▪ Avoid medications that further slow AV conduction ▪ Myocardial ischemia or infarction. ▪ Permanent pacemaker recommended for most cases. SIGNS & SYMPTOMS: ▪ Usually asymptomatic. 4. Third-Degree AV Block (Complete Heart Block) ▪ Occasionally, patients may experience mild fatigue or dizziness. MANAGEMENT: ▪ Often requires no treatment if asymptomatic. ▪ Correct underlying causes (adjust medications or manage electrolyte imbalances). ▪ Monitor regularly for progression to more severe blocks. 2. Second Degree Heart Blocks Type I (WENCKEBACK)/Mobitz I CHARACTERISTICS: ▪ Complete dissociation between atrial (P waves) and ventricular (QRS complexes) activity ▪ Ventricular rhythm is typically slow and regular, with a bradycardic heart rate. CAUSES: ▪ Extensive myocardial infarction ▪ Fibrosis or degeneration of the conduction system. CHARACTERISTICS: ▪ Drug toxicity (digoxin, beta-blockers, calcium channel ▪ Progressive lengthening of the PR interval followed by a blockers). dropped QRS complex. ▪ Cardiac surgeries or congenital heart conditions ▪ Irregular rhythm due to the dropped beats. SIGNS & SYMPTOMS: CAUSES: ▪ Severe bradycardia, hypotension ▪ Medications that slow AV conduction (digoxin, beta-blockers) ▪ Fatigue, dizziness, syncope, and signs of heart failure ▪ Ischemic heart disease, especially in the inferior wall. ▪ Can lead to reduced cardiac output and shock. ▪ Increased vagal tone. MANAGEMENT: SIGNS & SYMPTOMS: ▪ Immediate: Temporary transcutaneous or transvenous ▪ Often asymptomatic pacing in emergencies ▪ In some cases, lightheadedness or syncope due to the ▪ Long-term: Permanent pacemaker insertion is typically irregular heart rate. required MANAGEMENT: ▪ Discontinue medications that contribute to AV block. ▪ Observation if asymptomatic. ▪ Atropine may be administered if symptomatic ▪ Address reversible causes (ischemia, medications) CARDIOGENIC SHOCK ▪ Temporary pacemaker if symptoms persist or worsen. ▪ cardiogenic shock occurs when the heart fails to pump adequately, resulting in a decrease in cardiac output and 3. Second-Degree AV Block Type II (Mobitz II) impaired tissue perfusion. Causes ▪ Myocardial infarction (most common cause) ▪ Severe heart failure ▪ Cardiomyopathy ▪ Severe valvular disease (mitral regurgitation, aortic stenosis) 1 marga^^ ▪ Cardiac arrhythmias (ventricular tachycardia, ventricular ▪ Complications of myocardial infarction fibrillation) ▪ Pericarditis (inflammatory diseases like lupus, rheumatoid ▪ Cardiac tamponade. arthritis) Signs & Symptoms ▪ Cardiac surgery ▪ Hypotension (systolic blood pressure