Chapter 27 Management of Patients With Dysrhythmias and.pdf

Chapter 27 Management of Patients With Dysrhythmias and Conduction Problems Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Dysrhythmias ‫عدم انتظام ضربات القلب‬ Disorders of formation or conduction (or both) of...

Chapter 27 Management of Patients With Dysrhythmias and Conduction Problems Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Dysrhythmias ‫عدم انتظام ضربات القلب‬ Disorders of formation or conduction (or both) of electrical impulses within heart ‫اضطرابات تكوين أو توصيل )أو كليهما( النبضات الكهربائية داخل القلب‬ Can cause disturbances of – Rate – Rhythm – Both rate, rhythm Potentially can alter blood flow, cause hemodynamic changes Diagnosed by analysis of electrographic waveform Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Relationship of ECG Complex, Lead System, and Electrical Impulse Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins ECG Electrode Placement Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins ECG Graph and Commonly Measured Components Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Heart Rate Determination Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Heart Rate Determination- continu… The RR interval is used to determine ventricular rhythm and the PP interval to determine atrial rhythm. If the intervals are the same or if the difference between the intervals is less than 0.8 seconds throughout the strip, the rhythm is called regular. If the intervals are different, the rhythm is called irregular. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal Sinus Rhythm Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Ventricular and atrial rate: 60 to 100 bpm in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P:QRS ratio: 1:1 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Sinus Bradycardia Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Sinus bradycardia occurs; when the SA node creates an impulse at a slower-than-normal rate. HR less than 60 beats per minute. Causes include lower metabolic needs (e.g.,sleep, athletic training, hypothyroidism), vagal stimulation (e.g., from vomiting, suctioning, severe pain), medications (e.g., calcium channel blockers (e.g., nifedipine [Procardia]), amiodarone [Cordarone], betablockers (e.g., metoprolol [Lopressor]), idiopathic sinus node dysfunction, increased intracranial pressure, and coronary artery disease, especially myocardial infarction (MI) of the inferior wall. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Sinus Tachycardia Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate. Causes may include the following: Physiologic or psychological stress (e.g., acute blood loss, anemia, shock, hypervolemia, hypovolemia, heart failure, pain, hypermetabolic states, fever, exercise, anxiety. Ventricular and atrial rate: Greater than 100 bpm in the adult, but usually less than 120 bpm Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Sinus Arrhythmia Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Premature Atrial Complexes Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Atrial Flutter Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Atrial flutter occurs because of a conduction defect in the atrium and causes a rapid, regular atrial impulse at a rate between 250 and 400 bpm. Because the atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node. Atrial flutter has the following characteristics Ventricular and atrial rate: Atrial rate ranges between 250 and 400 bpm; ventricular rate usually ranges between 75 and 150 bpm. Ventricular and atrial rhythm: The atrial rhythm is regular; the ventricular rhythm is usually regular but may be irregular because of a change in the AV conduction. QRS shape and duration: Usually normal, but may be abnormal or may be absent. P wave: Saw-toothed shape; these waves are referred to as F waves. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Atrial Fibrillation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Atrial fibrillation has the following characteristics ; Ventricular and atrial rate: Atrial rate is 300 to 600 bpm; ventricular rate is usually 120 to 200 bpm in untreated atrial fibrillation. Ventricular and atrial rhythm: Highly irregular QRS shape and duration: Usually normal, but may be abnormal P wave: No noticeable P waves; irregular undulating-means having a smooth rising & falling waves that vary in amplitude and shape are seen and referred to as fibrillatory or f waves PR interval: Cannot be measured P:QRS ratio: Many:1 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Multifocal PVCs-Quadrigeminy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Ventricular Tachycardia Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  VT is Ventricular and atrial rate: Ventricular rate is 100 to 200 bpm; atrial rate depends on the underlying rhythm (e.g., sinus rhythm). Ventricular and atrial rhythm: Usually regular; atrial rhythm may also be regular. QRS shape and duration: Duration is 0.12 seconds or more; bizarre, abnormal shape. P wave: Very difficult to detect, so the atrial rate and rhythm may be indeterminable. PR interval: Very irregular, if P waves are seen P:QRS ratio: Difficult to determine, but if P waves are apparent, there are usually more QRS complexes than P waves. defined as three or more PVCs in a row, occurring at a rate exceeding 100 bpm. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Ventricular Fibrillation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  The most common dysrhythmia in patients with cardiac arrest is ventricular fibrillation, which is a rapid, disorganized ventricular rhythm. The most common cause of ventricular fibrillation is coronary artery disease and resulting acute MI. Ventricular rate: Greater than 300 bpm Ventricular rhythm: Extremely irregular, without a specific pattern QRS shape and duration: Irregular, undulating waves with changing amplitudes. There are no recognizable QRS complexes. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Asystole Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins First Degree AV Block Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  First-degree AV block occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: Depends on the underlying rhythm QRS shape and duration: Usually normal, but may be abnormal P wave: In front of the QRS complex; shows sinus rhythm, regular shape PR interval: Greater than 0.20 seconds; PR interval measurement is constant. P:QRS ratio: 1:1 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Second Degree AV Block, Type I Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Second-degree AV block, type I, occurs when there is a repeating pattern in which all but one of a series of atrial impulses are conducted through the AV node into the ventricles (e.g., every four of five atrial impulses are conducted). Each atrial impulse takes a longer time for conduction than the one before, until one impulse is fully blocked. Because the AV node is not depolarized by the blocked atrial impulse, the AV node has time to fully repolarize so that the next atrial impulse can be conducted within the shortest amount of time. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Second Degree AV Block, Type II Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Second-degree AV block, type II, occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. Ventricular and atrial rate: Depends on the underlying rhythm, but the ventricular rate is lower than the atrial rate. Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm. The RR interval is usually regular but may be irregular, depending on the P:QRS ratio. QRS shape and duration: Usually abnormal, but may be normal P wave: In front of the QRS complex; shape depends on underlying rhythm. PR interval: The PR interval is constant for those P waves just before QRS complexes. P:QRS ratio: 2:1, 3:1, 4:1, 5:1, and so forth Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Third Degree AV Block Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Third-degree AV block occurs when no atrial impulse is conducted through the AV node into the ventricles. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Nursing Process: Care of the Patient with a Dysrhythmia - Assessment Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness Physical assessment include – Rate, rhythm of apical, peripheral pulses – Heart sounds – Blood pressure, pulse pressure – Signs of fluid retention Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Care of the Patient with a Dysrhythmia – Assessment (cont’d) Health history: include presence of coexisting conditions, indications of previous occurrence Medications Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Care of the Patient with a Dysrhythmia - Diagnoses Decrease cardiac output Anxiety Deficient knowledge Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Collaborative Problems/Potential Complications Cardiac arrest Heart failure Thromboembolic event, especially with atrial fibrillation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Nursing Process: Care of the Patient with a Dysrhythmia - Planning Goals – Eradicating or decreasing occurrence of dysrhythmia to maintain cardiac output – Minimizing anxiety – Acquiring knowledge about dysrhythmia, its treatment Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Decreased Cardiac Output Monitoring – ECG monitoring – Assessment of signs, symptoms Administration of medications,(Inj. Atropine-Increases the heart rate and improves the av conduction by blocking parasympathetic influences on the heart) assessment of medication effects Adjunct therapy: cardioversion, defibrillation, pacemakers Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Other Interventions Anxiety – Use calm, reassuring manner – Measures to maximize patient control to make episodes less threatening – Communication, teaching Teaching self-care – Include family in teaching Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Pacemakers Electronic device that provides electrical stimuli to heart muscle Types – Permanent – Temporary NASPE-BPEG code for pacemaker function (North American Society of Pacing and Electrophysiology and the British Pacing and Electrophysiology Group) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Implanted Transvenous Pacemaker Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Transcutaneous Pacemaker Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Permanent pacemaker generators are insulated to protect against body moisture and warmth and have filters that protect them from electrical interference from most household devices, motors, and appliances. Lithium cells are most commonly used; they last approximately 6 to 12 years, depending on the type of pacemaker, how it is programmed, and how often it is used. Most pacemakers have an elective replacement indicator (ERI), If a patient suddenly develops a bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins ECG-On Demand Pacing Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Complications of Pacemaker Use Infection Bleeding or hematoma formation Dislocation of lead Skeletal muscle or phrenic nerve stimulation Cardiac tamponade Pacemaker malfunction Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Care of the Patient with an Implanted Cardiac Device - Assessment Device function: ECG Cardiac output, hemodynamic stability Incision site Coping Patient, family knowledge Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process: Care of the Patient with an Implanted Cardiac Device - Diagnoses Risk for infection Risk for ineffective coping Knowledge deficient Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Nursing Process: Care of the Patient with an Implanted Cardiac Device - Planning Goals – Absence of infection – Adherence to self-care program – Effective coping – Maintenance of device function Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Interventions Risk for ineffective coping – Support of patient, family coping – Setting of realistic goals – Allow patient to talk, share feelings, experiences – Support groups or referral – Stress-reduction techniques Knowledge deficient – Patient, family teaching Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Cardioversion and Defibrillation Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial cells – When cells repolarize, sinus node usually able to recapture role as heart pacemaker In cardioversion, current delivery synchronized with patient’s ECG In defibrillation, current delivery is unsynchronized Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Safety Measures Assure good contact between skin, pads or paddles – Use conductive medium, 20 to 25 pounds of pressure Place paddles so they do not touch bedding or clothing, are not near medication patches or oxygen flow If cardioverting, turn synchronizer on If defibrillating, turn synchronizer off Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Safety Measures (cont’d) Do not charge device until ready to shock Call “clear” three times; follow checks required for clear – Assure no one is in contact with patient, bed, or equipment Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Paddle Placement for Defibrillation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Implantable Cardioverter Defibrillator (ICD) Device that detects, terminates life-threatening episodes of tachycardia or fibrillation NASPE-BPEG code Antitachycardia pacing Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins ICD-Implantable cardioverter defibrillator Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias An EP study is an invasive Electrophysiologic studies; procedure used to evaluate and treat various chronic dysrhythmias that have caused cardiac arrest or significant symptoms. Cardiac conduction surgery – Maze procedure – Catheter ablation therapy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  The patient is conscious but lightly sedated. Usually, a catheter with multiple electrodes is inserted through a small incision in the femoral vein, threaded through the inferior vena cava, and advanced into the heart; however, depending on the type of study and the information needed, a second catheter may be inserted into the femoral artery. The electrodes are positioned within the heart at specific locations —for instance, in the right atrium near the sinus node, in the coronary sinus, near the tricuspid valve, and at the apex of the right ventricle. The number and placement of electrodes depend on the type of study being conducted. These electrodes allow the electrical signal to be recorded from within the heart (intracardiogram). Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Reference; Kindly consult your course book Brunner and Siddharth, The medical and surgical nursing, 14th Edition; 2018 p.no.1952-2035 for more details and exams preparation. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins