M1P8.pdf

1/9/24, 1:55 AM herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9a… Premature Atrial Complex Medical Management If PACs are infrequent; no treatment is necessary. If they are frequent (more than six per minute), this may herald...

1/9/24, 1:55 AM herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9a… Premature Atrial Complex Medical Management If PACs are infrequent; no treatment is necessary. If they are frequent (more than six per minute), this may herald a worsening disease state or the onset of more serious arrhythmias, such as atrial fibrillation. Medical management is directed toward treating the underlying cause (e.g., reduction of caffeine intake, correction of hypokalemia). Atrial Fibrillation Medical Management Treatment of atrial fibrillation depends on the cause, pattern, and duration of the arrhythmia, the ventricular response rate, as well as the presence of structural or valvular heart disease and other cardiac conditions such as coronary artery disease or heart failure. Strategies for both rhythm control (i.e., conversion to sinus rhythm) and rate control are dependent on shared clinical decision making between the patient and primary provider. In some cases, atrial fibrillation spontaneously converts to sinus rhythm within 24 to 48 hours and without treatment. However, in instances where atrial fibrillation is concomitant with significant other morbid conditions (e.g., severe heart failure), the atrial fibrillation may be classified as “permanent,” meaning that the patient and primary provider have made a joint decision to stop further attempts to restore or maintain sinus rhythm. Therefore, management of atrial fibrillation may not only be different in different patients, but it also may change over time for any one patient. Medical management revolves around preventing embolic events such as stroke with anticoagulant medications, controlling the ventricular rate of response with antiarrhythmic agents, and treating the arrhythmia as indicated so that it is converted to a sinus rhythm (i.e., cardioversion). Electrical Cardioversion for Atrial Fibrillation Electrical cardioversion is indicated for patients with atrial fibrillation who are hemodynamically unstable (e.g., acute alteration in mental status, chest discomfort, hypotension) and do not respond to medications (January et al., 2014, 2019). Flecainide, propafenone, amiodarone, dofetilide, or sotalol may be given prior to cardioversion to enhance the success of cardioversion and maintain sinus rhythm (January et al., 2014, 2019). Quality and Safety Nursing Alert The patient with atrial fibrillation is at high risk for thrombus formation. When electrical cardioversion is indicated, the nurse may anticipate that a tra performed to evaluate for possible atrial thrombi. Because atrial function may be impaired for several weeks after cardioversion, antithrombotic therapy (e.g., warfarin) is indicated for at least 4 weeks after the procedure (January et al., 2014, 2019). Repeated attempts at electrical cardioversion may be made, following administration of an antiarrhythmic medication. Cardiac Rhythm Therapies Atrial fibrillation that does not respond to medications or electrical cardioversion may be treated by cardiac rhythm therapies, including catheter ablation, maze or mini-maze procedure, or convergent procedure. Catheter Ablation Therapy Catheter ablation destroys specific cells that are the cause of a tachyarrhythmia. Catheter ablation is performed most often today for atrial fibrillation, although it may also be useful in treating atrioventricular nodal reentry tachycardia (AVNRT) and recurrent ventricular tachycardia (VT) (see later discussion of these arrhythmias). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9aojXmGqF3r… 1/5 1/9/24, 1:55 AM herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9a… Atrial fibrillation is associated with intrinsic cardiac autonomic nervous system activity to the pulmonary veins. Ablation involves a procedure similar to a cardiac catheterization; however, in this instance, a special catheter is advanced at or near the origin of the arrhythmia, where high-frequency, low-energy sound waves are passed through the catheter, causing thermal injury, localized cell destruction, and scarring. The tissue damage is more specific to the arrhythmic tissue, with less trauma to the surrounding cardiac tissue. Ablation may also be accomplished using a special catheter to apply extremely cold temperature to destroy selected cardiac cells, called cryoablation. The goal of each of these ablation procedures is to eliminate the arrhythmia, by preventing the ectopic activity arising from the pulmonary veins from reaching the atria, thereby stopping fibrillation (Weber, Sagerer-Gerhardt, & Heinze, 2017). An EPS (see later discussion) may be performed to induce the arrhythmia prior to the catheter ablation. During the ablation procedure, defibrillation pads, an automatic blood pressure cuff, and a pulse oximeter are used. The patient is usually given moderate sedation (see Chapter 15) and IV heparin to reduce the risk of periprocedural thromboembolism. Immediately postablation, the patient is monitored for another 30 to 60 minutes and then retested to ensure that the arrhythmia does not recur. Successful ablation is achieved when the arrhythmia cannot be induced. Major risks of catheter ablation include pericardial effusion and tamponade, phrenic nerve injury, stroke, hematoma, retroperitoneal bleeding, pulmonary vein stenosis, and atrioesophageal fistulas (Canpolat, Kocyigit, & Aytemir, 2017). Nursing Management. Postprocedural care on a step-down unit for the patient who has had ablation is similar to the nursing management of a patient who has had a cardiac catheterization; the patient is monitored closely to ensure recovery from sedation. Postprocedural nursing interventions include frequent monitoring for arrhythmias and for signs and symptoms of a stroke and vascular access site complications. Because of the prolonged time required for the procedure as well as the time needed in bed to obtain hemostasis at the vascular access site, it is not unusual for the patient to have back discomfort. In addition to administering any pain medications, the nurse may help to alleviate this pain by placing rolled towels under the patient’s knees and waist. Nursing Management Postprocedural care on a step-down unit for the patient who has had ablation is similar to the nursing management of a patient who has had a cardiac catheterization; the patient is monitored closely to ensure recovery from sedation. Postprocedural nursing interventions include frequent monitoring for dysrhythmias and signs and symptoms of a stroke, vascular access site complications, and fluid imbalance (Hoke & Steletsky, 2015). Because of the prolonged time required for the procedure as well as the time needed in bed to obtain hemostasis at the vascular access site, it is not unusual for the patient to have back discomfort. In addition to administering any pain medications, the nurse may help to alleviate this pain by placing rolled towels under the patient's knees and waist. Maze and Mini-Maze Procedures The maze procedure is an open heart surgical procedure for refractory atrial fibrillation. Small transmural incisions are made throughout the atria. The resulting formation of scar tissue prevents reentry conduction of the aberrant electrical impulse. Because the procedure requires significant time and cardiopulmonary bypass, its use is reserved only for those patients undergoing cardiac surgery for another reason (e.g., coronary artery bypass; January et al., 2014, 2019). Some patients may need a permanent pacemaker after this surgery because of subsequent injury to the SA node. A modification of the maze procedure, minimally invasive maze surgery, or mini-maze, may be performed by making small incisions between the ribs, through which video-guided instruments are inserted. The pulmonary veins are encircled with surgical incisions within the left atrium. This surgery eliminates the need for opening the sternum, heart–lung bypass, and the use of cardioplegia. This results in a shorter recovery time and a lower risk of infection (January et al., 2014, 2019). Convergent Procedure The convergent procedure utilizes a hybrid approach to ablation, requiring the skills of both a cardiothoracic surgeon and an electrophysiologist, a cardiologist with specialized training. This procedure is associated with lower rates of arrhythmia recurrence than catheter ablation, but more complications within 30 days of the procedure (e.g., infections, bleeding) (Jan, Zizek, Gersak, et al., 2018). The surgeon creates a few small incisions in the abdomen so that a special catheter that allows visualization can be inserted through the diaphragm and toward the posterior wall of the heart. The surgeon performs ablation of the epicardial wall in the area around the pulmonary veins and the electrophysiologist performs ablation around the endocardial area of the pulmonary veins. Because of the incisions, the patient usually has a 3-day hospital length of stay (Elrod, 2014). The patient may experience mild dull chest pain caused by the resulting inflammation from the ablation that usually resolves within a few days (Elrod, 2014). This pain is usually alleviated by treatment with acetaminophen as needed. In addition, if the phrenic nerve was affected, the patient may experience shortness of breath that may take days to weeks to resolve (Elrod, 2014). Left Atrial Appendage Occlusion (LAAO) LAAO is an alternative to antithrombotic medications for stroke prevention in patients with nonvalvular atrial fibrillation (Masoudi, Calkins, Kavinsky, et al., 2015). As noted previously, the LAA is the area where the majority of stroke-causing blood clots form in patients with https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9aojXmGqF3r… 2/5 1/9/24, 1:55 AM herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9a… nonvalvular atrial fibrillation. However, concerns about the risk of long-term anticoagulant use and the risk of bleeding can complicate effective management (Ojo, Yandrapalli, Veseli, et al., 2020). Candidates for LAAO include those patients with increased risk of stroke based on CHA2DS2-VASC scores of one or higher and those patients seeking a nonpharmacologic alternative to treatment (Masoudi et al., 2015). Commonly used is the WATCHMAN, a device typically inserted while the patient is under general anesthesia. Similar to a percutaneous coronary intervention (PCI) procedure, a small incision is made in the femoral area and a catheter is then inserted that guides the device into position. The parachute-shaped device is threaded through to the opening of the LAA, sealing it off and preventing it from releasing clots. Patients typically stay in the hospital overnight after placement of a WATCHMAN device. The nursing management of patients who received this device is similar to that of patients post cardiac catheterization. Patients are prescribed aspirin and warfarin post procedure; approximately 6 weeks post procedure, they should return to the cardiology clinic for a TEE to confirm that the device has effectively occluded the LAA. If LAAO has occurred, then the patient may stop taking warfarin and is prescribed clopidogrel, an antiplatelet medication. After 6 months, the patient may stop taking clopidogrel but must continue taking daily aspirin indefinitely (Carlson & Doshi, 2017). Wolff–Parkinson–White Syndrome In the patient with atrial fibrillation, if the QRS is wide and the ventricular rhythm is very fast and irregular, an accessory pathway should be suspected. An accessory pathway is typically congenital tissue between the atria, bundle of His, AV node, Purkinje fibers, or ventricular myocardium. This anomaly is known as Wolff-Parkinson-White (WPW) syndrome. Electrical cardioversion is the treatment of choice for atrial fibrillation in the presence of WPW syndrome that causes hemodynamic instability. Medications that block AV conduction (e.g., digoxin, diltiazem, verapamil) should be avoided in WPW because they can increase the ventricular rate. If the patient is hemodynamically stable, procainamide, propafenone, flecainide, or amiodarone are recommended to restore sinus rhythm (January et al., 2014, 2019). Catheter ablation is performed for long-term management. Atrial Flutter Medical Management https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9aojXmGqF3r… 3/5 1/9/24, 1:55 AM herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9a… Atrial flutter can cause serious signs and symptoms, such as chest pain, shortness of breath, and low blood pressure. Medical management involves the use of vagal maneuvers (see previous discussion under Sinus Tachycardia) or a trial administration of adenosine, which causes sympathetic block and slowing of conduction through the AV node. This may terminate the tachycardia; optimally, it will facilitate visualization of flutter waves for diagnostic purposes. Adenosine is given IV by rapid administration, and immediately followed by a 20-mL saline flush and elevation of the arm with the IV line to promote rapid circulation of the medication. Example Youtube: Electrocardioversion | Circulatory System and Disease | NCLEX-RN | Khan Academy Youtube: Ablation | Circulatory System and Disease | NCLEX-RN | Khan Academy Summary Dysrhythmias result from disorders of impulse formation, conduction of impulses, or both. The heart has specialized cells in the SA node, atria, AV node, and bundle of His and Purkinje fibers (His-Purkinje system), which can fire (discharge) spontaneously. Atrial rhythms originate in the atria rather than in the SA node. The P wave will be positive, but its shape can differ from a normal sinus rhythm because the electrical impulse follows a different path to the AV (atrioventricular) node. PACs occur due to the premature discharge of an electrical impulse in an irritable area of the atria, causing a premature contraction. A PAC is premature because they occur earlier than the next regular beat should have occurred. There are abnormally shaped P waves, but the QRS complex is not affected. The most common symptom is palpitations, often reported as “missing" or "skipping" the heartbeat. Atrial fibrillation is the irregular and rapid atrial contraction, resulting in a quivering of the atria rather than contract at a rate greater than 400/min. The ventricular rate depends on the number of https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9aojXmGqF3r… 4/5 1/9/24, 1:55 AM herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9a… impulses conducted through the AV node. Atrial flutter is when the atrial ectopic pacer fires at a rate of 250-400/ min and occurs in a variety of heart diseases- rheumatic, coronary, hypertensive, cardiomyopathy, hypoxia, and heart failure. Review Premature Atrial Contraction are ectopic beats that originate from the atria and are not rhythms. Cells in the heart start to fire or go off before the normal heartbeat is supposed to occur. These are called heart palpitations and have the following characteristics: Premature and abnormal-looking P waves that differ in configuration from normal P waves QRS complex after P waves except in very early or blocked PACs P waves often buried in the preceding T wave or identified in the preceding T wave. Causes include coronary or valvular heart diseases, atrial ischemia, coronary artery atherosclerosis, heart failure, COPD, electrolyte imbalance, and hypoxia. Usually there is no treatment needed, but it may include procainamide and quinidine administration (antidysrhythmic drugs) and carotid sinus massage. Atrial flutter is an abnormal rhythm that occurs in the atria of the heart. Atrial flutter has an atrial rhythm that is regular but has an atrial rate of 250 to 400 beats/minute. It has saw tooth appearance. QRS complexes are uniform in shape but often irregular in rate. Normal atrial rhythm Abnormal atrial rate: 250 to 400 beats/minute Saw tooth P wave configuration QRS complexes uniform in shape but irregular in rate Causes include heart failure, tricuspid valve or mitral valve diseases, pulmonary embolism, cor pulmonale, inferior wall MI, carditis, and digoxin toxicity. In management if the patient is unstable with ventricular rate of greater than 150 bpm, prepare for immediate cardioversion. If the patient is stable, drug therapy may include calcium channel blocker, beta-adrenergic blockers, or antiarrhythmic. Anticoagulation may be necessary as there would be pooling of blood in the atria. Atrial fibrillation is disorganized and uncoordinated twitching of atrial musculature caused by overly rapid production of atrial impulses. This arrhythmia has the following characteristics: Atrial Rate: 350 to 600 bpm Ventricular Rate: 120 to 200 bpm P wave is not discernible with an irregular baseline PR interval is not measurable QRS complex is normal Rhythm is irregular and usually rapid unless controlled. Causes include atherosclerosis, heart failure, congenital heart disease, chronic obstructive pulmonary disease, hypothyroidism, and thyrotoxicosis. Atrial fibrillation may be asymptomatic, but the clinical manifestation may include palpitations, dyspnea, and pulmonary edema. The nursing goal is towards the administration of prescribed treatment to decrease ventricular response, decrease atrial irritability, and eliminate the cause (Iheduru-Anderson, 2016). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zbusjeLUzRyumZIEGwikvZDA89aMIS3TVE3sojJO9aojXmGqF3r… 5/5