Cardiovascular Care - Module 12 Chapter 31 PDF

CHAPTER 16 Cardiovascular Care FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to cardiovascular care necessary to care for the following patients: Coby Pruder, age 40, is to undergo an electrocardiogram as part of his physical examination. Although he consider...

CHAPTER 16 Cardiovascular Care FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to cardiovascular care necessary to care for the following patients: Coby Pruder, age 40, is to undergo an electrocardiogram as part of his physical examination. Although he considers himself healthy, he is nervous. Harry Stebbings, age 67, is admitted to the emergency department for chest pain and cardiac monitoring. Ann Kribell, age 54, is a patient in the cardiac care unit. She has been diagnosed with heart failure and is receiving cardiac monitoring. She needs to have arterial blood samples drawn from her arterial line. LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Obtain a 12-lead ECG. 5. Perform cardiopulmonary resuscitation (CPR). 2. Apply a cardiac monitor. 6. Perform emergency automated external defibrillation. 3. Obtain an arterial blood sample from an arterial line–stopcock system. 7. Perform emergency manual external defibrillation (asynchronous). 4. Remove arterial and femoral lines. 8. Apply and monitor an external pacemaker. KEY TERMS arterial blood gas (ABG): a laboratory test that evaluates the oxygen, carbon dioxide, bicarbonate, and pH of an arterial blood sample, determining metabolic or respiratory alkalosis or acidosis cardiac arrest: sudden cessation of functional circulation of the heart (pulse), such as asystole or defibrillation, typically caused by the occlusion of one or more of the coronary arteries or cardiomyopathy cardiac monitoring: visualization and monitoring of the cardiac electrical activity stimulating the heartbeat cardiopulmonary resuscitation (CPR): also known as basic life support; revival in the absence of spontaneous respirations and heartbeat to preserve heart and brain function while waiting for defibrillation and advanced cardiac life support care. Achieved by manu- 830 ally pumping the heart by compressing the sternum and forcing oxygen into the lungs using mouth-tomouth or rescue breathing. cardioversion: conversion of a pathologic cardiac rhythm to normal sinus rhythm through low doses of electricity, using a device that applies synchronized countershocks to the heart defibrillation: stopping fibrillation of the heart by using an electrical device that applies countershocks to the heart through electrodes on the chest wall. This countershock is given in an attempt to allow the heart’s normal pacemaker to take over. electrocardiogram (ECG/EKG): graphing of the electrical activity of the heart LWBK545_C16_p830-872.qxd 8/6/10 9:50 PM Page 831 Aptara CHAPTER 16 Cardiovascular Care KEY TERMS 831 continued fibrillation: small, local, involuntary contraction of muscle, resulting from spontaneous activation of a single muscle fiber or of an isolated bundle of nerve fibers (Porth & Matfin, 2009) personal protective equipment (PPE): equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear Assessment of heart function commonly involves noninvasive techniques such as auscultation, palpation, and sometimes percussion. Additional basic and important indicators of the heart’s effectiveness are pulse rate, strength, and rhythm; blood pressure; skin color and temperature; and level of consciousness. Noninvasive heart monitoring involves electrocardiography and cardiac monitoring. Arterial blood gases (ABG) are used to measure the oxygen level and pH of the blood, providing information about a patient’s acid–base balance. (Refer to Chapter 18, Laboratory Specimen Collection.) Should the heart stop pumping, it can be manually pumped via cardiopulmonary resuscitation (CPR) until electrical defibrillation and additional medical support arrives. Skill 16-6 discusses defibrillation; other electrical therapy devices are discussed in Fundamentals Review 16-1. This chapter covers selected noninvasive skills to assist the nurse in providing cardiovascular care. Figure 16-1 provides an overview of cardiac anatomy, and Figure 16-2 provides a review of the cardiac conduction system. Figures 16-3 and 16-4 highlight cardiac landmark reference lines and auscultation areas. Invasive techniques, such as pulmonary artery monitoring, Swan-Ganz catheterization, cardiac output determination, and cardiac support via an intra-aortic balloon pump (IABP), typically are used by trained critical care personnel to provide additional monitoring and support. These techniques are beyond the scope of this text. Fundamentals Review 16-1 ELECTRICAL THERAPY DEVICES In addition to defibrillation, electrical therapy may be delivered via the following devices: Implantable cardioverter-defibrillator (ICD) is a sophisticated device that automatically discharges an electric current when it senses ventricular tachyarrhythmias. Patients with a history of ventricular fibrillation, with poor ejection fraction (35%), or with heart failure (New York Heart Association [NYHA] class III or IV) may be candidates for this type of device. Synchronized cardioversion is the treatment of choice for arrhythmias that do not respond to vagal maneuvers or drug therapy, such as atrial tachycardia, atrial flutter, atrial fibrillation, and symptomatic ventricular tachycardia. Cardioversion is performed similarly to defibrillation but is synchronized with the heart rhythm and uses fewer joules. Cardioversion works by delivering an electrical charge to the myocardium at the peak of the R wave. This causes immediate depolarization, interrupting reentry circuits and allowing the sinoatrial node to resume control. Synchronizing the electrical charge with the R wave ensures that the current will not be delivered on the vulnerable T wave and thus disrupt repolarization. It is usually performed in a critical care area, in the presence of a physician, an anesthesiologist, and emergency equipment. The patient is premedicated with pain medicine. Pacemakers are electronic devices that can be used to initiate the heartbeat when the heart’s intrinsic electrical system cannot effectively generate a rate adequate to support cardiac output (Urden et al., 2002). Pacemakers can be temporary: placed on the skin (transcutaneous); via temporary epicardial pacing wires inserted during cardiac surgery; or transvenous, via a pacing electrode wire passed through a vein (often the subclavian or internal jugular) and into the right atrium or right ventricle. Pacemakers can also be permanent surgically implanted devices. Biventricular pacemakers (cardiac resynchronization) use electrical current to improve synchronization of left ventricular contraction. Biventricular pacemakers are used in patients with heart failure (NYHA class III or IV), with an intraventricular conduction delay (QRS 120 ms), and patients with left-ventricular ejection fraction 35%. These devices improve right and left ventricle contraction with a modest increase in left-ventricular ejection fraction (Ermis et al., 2004). LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 832 Aptara 832 UNIT II Promoting Healthy Physiologic Responses Left common carotid artery Brachiocephalic artery Left subclavian artery Right pulmonary artery (branches) Ascending aorta Aortic arch Pulmonary artery Left pulmonary artery (branches) Pulmonic valve Superior vena cava Left pulmonary veins Right pulmonary veins Left atrium Aortic valve Right atrium Tricuspid valve Mitral (bicuspid) valve Inferior vena cava Endocardium Right ventricle Left ventricle Myocardium Blood low in oxygen Epicardium Blood high in oxygen Interventricular septum Apex FIGURE 16-1. Cardiac anatomy. Ascending aorta Superior vena cava Left atrium Sinoatrial node Internodal pathways Right atrium Chordae tendineae Atrioventricular node Papillary muscle Atrioventricular bundle (bundle of His) Left ventricle Right and left bundle branches Right ventricle Purkinje fibers FIGURE 16-2. Cardiac conduction system. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 833 Aptara Midsternal line Left scapular line Right scapular line Right midclavicular line Left midclavicular line A Vertebral line B Anterior axillary line Midaxillary line Posterior axillary line C FIGURE 16-3. Cardiac landmarks: Reference lines. (A) Anterior chest. (B) Posterior chest. (C) Lateral chest. Aortic area Pulmonic area Erb's point Tricuspid area Mitral (apical) area Midsternum Midclavicular line FIGURE 16-4. Cardiac landmarks: Auscultation areas. 833 834 UNIT II 16-1 Promoting Healthy Physiologic Responses Obtaining an Electrocardiogram (ECG) One of the most valuable and frequently used diagnostic tools, electrocardiography (ECG [also abbreviated as EKG in some references]), measures the heart’s electrical activity. Impulses moving through the heart’s conduction system create electric currents that can be monitored on the body’s surface. Electrodes attached to the skin can detect these electric currents and transmit them to an instrument that produces a record (the electrocardiogram) of cardiac activity. The data are graphed as waveforms. ECG can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and drug toxicity. The standard 12-lead ECG uses a series of electrodes placed on the extremities and the chest wall to assess the heart from 12 different views. The 12 leads consist of three standard bipolar limb leads (designated I, II, III), three unipolar augmented leads (aVR, aVL, aVF), and six unipolar precordial leads (V1 to V6). The exact location on the extremities does not matter as long as skin contact is good and bone is avoided. The chest leads are placed in specific locations to ensure accurate recording. The limb leads and augmented leads show the heart from the frontal plane. The precordial leads show the heart from the horizontal plane. Each lead overlies a specific area of the myocardium and provides an electrographic snapshot of electrochemical activity of the cell membrane. The ECG device measures and averages the differences between the electrical potential of the electrode sites for each lead and graphs them over time, creating the standard ECG complex, called PQRST (Box 16-1). Interpreting the ECG requires the following actions: Determine the rhythm. Determine the rate. Evaluate the P wave. Determine the duration of the PR interval. Determine the duration of the QRS complex. Evaluate the T waves. Determine the duration of the QT interval. Evaluate any other components. An ECG is typically accomplished using a multichannel method. All electrodes are attached to the patient at once and the machine prints a simultaneous view of all leads. It is important to reassure the patient that the leads just sense and record and do not transmit any electricity. The patient must be able to lie still and refrain from speaking to prevent body movement from creating artifact in the ECG. Variations of standard ECG include exercise ECG (stress ECG) and ambulatory ECG (Holter monitoring). EQUIPMENT ASSESSMENT Review the patient’s medical record and plan of care for information about the patient’s need for ECG. Assess the patient’s cardiac status, including heart rate, blood pressure, and auscultation of heart sounds. If the patient is already connected to a cardiac monitor, remove the electrodes to accommodate the precordial leads and minimize electrical interference on the ECG tracing. Keep the patient away from objects that might cause electrical interference, such as equipment, fixtures, and power cords. Inspect the patient’s chest for areas of irritation, breakdown, or excessive hair that might interfere with electrode placement. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Decreased Cardiac Output Acute Pain Excess Fluid Volume Deficient Knowledge Ineffective Health Maintenance Activity Intolerance Anxiety ECG machine Recording paper Disposable pregelled electrodes Adhesive remover swabs 4  4 gauze pads Soap and water, if necessary Personal protective equipment (PPE), as indicated Bath blanket LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 835 Aptara CHAPTER 16 Cardiovascular Care BOX 16-1 835 ECG COMPLEX The ECG complex consists of five waveforms labeled with the letters P, Q, R, S, and T. In addition, sometimes a U wave appears. P wave: Represents atrial depolarization (conduction of the electrical impulse through the atria); the first component of ECG waveform. PR interval: Tracks the atrial impulse from the atria through the AV node, from the SA node to the AV node. Measures from the beginning of the P wave to the beginning of the QRS complex. Normal PR is 0.12 to 0.2 seconds. QRS complex: Follows the PR interval and represents depolarization of the ventricles (the time it takes for the impulse to travel through the bundle branches to the Purkinje fibers) or impulse conduction and contraction of the myocardial cells (ventricular systole). The Q wave appears as the first negative deflection in the QRS complex, the R wave as the first positive Atrial depolarization deflection. The S wave appears as the second negative deflection or the first negative deflection after the R wave. Normal QRS is 0.06 to 0.1 seconds. ST segment: Represents the end of ventricular conduction or depolarization and the beginning of ventricular recovery or repolarization; the J point marks the end of the QRS complex and the beginning of the ST segment. T wave: Represents ventricular recovery or repolarization. QT interval: Measures ventricular depolarization and repolarization; varies with the heart rate (i.e., the faster the heart rate, the shorter the QT interval); extends from the beginning of the QRS complex to the end of the T wave. Normal QT is 0.4 seconds, but can vary with heart rate. U wave: Represents the recovery period of the Purkinje fibers or ventricular conduction fibers; not present on every rhythm strip. Ventricular depolarization Ventricular depolarization R Atrial systole Ventricular systole T P Q PR interval S QRS ST segment QT interval Normal ECG waveforms, intervals, and correlation with events of the cardiac cycle. OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve is that a cardiac electrical tracing is obtained without any complications. Other appropriate outcomes may include the following: the patient displays an increased understanding about the ECG, and the patient has reduced anxiety. (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 836 Aptara 836 UNIT II 16-1 Promoting Healthy Physiologic Responses Obtaining an Electrocardiogram (ECG) continued IMPLEMENTATION ACTION R AT I O N A L E 1. Verify the order for an ECG on the patient’s medical record. This ensures that the correct intervention is performed on the correct patient. 2. Gather all equipment and bring to bedside. Having equipment available saves time and facilitates accomplishment of procedure. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on Transmission Precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. As you set up the machine to record a 12-lead ECG, explain the procedure to the patient. Tell the patient that the test records the heart’s electrical activity, and it may be repeated at certain intervals. Emphasize that no electrical current will enter his or her body. Tell the patient the test typically takes about 5 minutes. Ask the patient about allergies to adhesive, as appropriate. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Possible allergies may exist related to adhesive on ECG leads. 6. Place the ECG machine close to the patient’s bed, and plug the power cord into the wall outlet. Having equipment available saves time and facilitates accomplishment of task. 7. If the bed is adjustable, raise it to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Having the bed at the proper height prevents back and muscle strain. 8. Have the patient lie supine in the center of the bed with the arms at the sides. Raise the head of the bed if necessary to promote comfort. Expose the patient’s arms and legs, and drape appropriately. Encourage the patient to relax the arms and legs. If the bed is too narrow, place the patient’s hands under the buttocks to prevent muscle tension. Also use this technique if the patient is shivering or trembling. Make sure the feet do not touch the bed’s footboard. Proper positioning helps increase patient comfort and will produce a better tracing. Having the arms and legs relaxed minimizes muscle trembling, which can cause electrical interference. 9. Select flat, fleshy areas on which to place the electrodes. Avoid muscular and bony areas. If the patient has an amputated limb, choose a site on the stump. Tissue conducts the current more effectively than bone, producing a better tracing. 10. If an area is excessively hairy, clip the hair. Do not shave hair. Clean excess oil or other substances from the skin with soap and water and dry it completely. Shaving causes microabrasions on the chest skin. Oils and excess hair interfere with electrode contact and function. Alcohol, benzoin, and antiperspirant are not recommended to prepare skin. 11. Refer to Figure 1 for lead placement. Apply the limb lead electrodes. The tip of each lead wire is lettered and color coded for easy identification. The white or RA lead goes to the right arm; the green or RL lead to the right leg; the red or LL lead to the left leg; the black or LA lead to the left arm. Peel the contact paper off the self-sticking disposable electrode and apply directly to the prepared site, as recommended by the manufacturer (Figure 2). Position disposable electrodes on the legs with the lead connection pointing superiorly. Having the lead connection pointing superiorly guarantees the best connection to the lead wire. 12. Connect the limb lead wires to the electrodes. Make sure the metal parts of the electrodes are clean and bright. Dirty or corroded electrodes prevent a good electrical connection. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 837 Aptara 837 CHAPTER 16 Cardiovascular Care ACTION R AT I O N A L E Supplemental right precordial leads V5R V4R V3R V2R V1R Mid-clavicle Anterior axillary line Horizontal plane of V4–V6 RA LA V1 V2 V3 V4 V5 ECG strip ECG machine RL LL FIGURE 1. ECG lead placement. Note: V6 (not shown) placed at FIGURE 2. Applying limb lead. 13. Expose the patient’s chest. Apply the precordial lead electrodes (Figure 3). The tip of each lead wire is lettered and color coded for easy identification. The brown or V1 to V6 leads are applied to the chest. Peel the contact paper off the self-sticking, disposable electrode and apply directly to the prepared site, as recommended by the manufacturer. Proper lead placement is necessary for accurate test results. midaxillary line, level with V4. (From Smeltzer, S. C., Bare, B. G., et al. (2010). Brunner and Suddarth’s textbook of medical-surgical nursing. (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins, with permission.) Position chest electrodes as follows (Refer to Figure 1): V1: Fourth intercostal space at right sternal border V2: Fourth intercostal space at left sternal border V3: Halfway between V2 and V4 V4: Fifth intercostal space at the left midclavicular line V5: Fifth intercostal space at anterior axillary line (halfway between V4 and V6) V6: Fifth intercostal space at midaxillary line, level with V4 (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 838 Aptara 838 UNIT II 16-1 Promoting Healthy Physiologic Responses Obtaining an Electrocardiogram (ECG) ACTION continued R AT I O N A L E 14. Connect the precordial lead wires to the electrodes. Make sure the metal parts of the electrodes are clean and bright. Dirty or corroded electrodes prevent a good electrical connection. 15. After the application of all the leads (Figure 4), make sure the paper-speed selector is set to the standard 25 m/second and that the machine is set to full voltage. The machine will record a normal standardization mark—a square that is the height of 2 large squares or 10 small squares on the recording paper. FIGURE 3. Applying chest lead. FIGURE 4. Completed application of 12-lead ECG. 16. If necessary, enter the appropriate patient identification data into the machine. This allows for proper identification of the ECG strip. 17. Ask the patient to relax and breathe normally. Instruct the patient to lie still and not to talk while you record the ECG. Lying still and not talking produces a better tracing. 18. Press the AUTO button. Observe the tracing quality (Figure 5). The machine will record all 12 leads automatically, recording 3 consecutive leads simultaneously. Some machines have a display screen so you can preview waveforms before the machine records them on paper. Adjust waveform, if necessary. If any part of the waveform extends beyond the paper when you record the ECG, adjust the normal standardization to half-standardization and repeat. Note this adjustment on the ECG strip, because this will need to be considered in interpreting the results. Observation of tracing quality allows for adjustments to be made, if necessary. Notation of adjustments ensures accurate interpretation of results. 19. When the machine finishes recording the 12-lead ECG (Figure 6), remove the electrodes and clean the patient’s skin, if necessary, with adhesive remover for sticky residue. Removal and cleaning promote patient comfort. 20. After disconnecting the lead wires from the electrodes, dispose of the electrodes. Return the patient to a comfortable position. Lower bed height and adjust the head of bed to a comfortable position. Proper disposal deters the spread of microorganisms. Positioning with head adjustment promotes patient comfort. Lowering the bed height promotes patient safety. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 839 Aptara CHAPTER 16 Cardiovascular Care ACTION 839 R AT I O N A L E FIGURE 5. Observing tracing quality. FIGURE 6. Normal 12-lead ECG configuration. (From Diepenbrock, N. (2007). Quick reference to critical care. (3rd ed.). Philadelphia, PA: Wolters Kluwer Health: Lippincott Williams & Wilkins, with permission.) 21. Clean ECG machine per facility policy. If not done electronically from data entered into the machine, label the ECG with the patient’s name, date of birth, location, date and time of recording, and other relevant information, such as symptoms that occurred during the recording (Jevon, 2007b). 22. Remove additional PPE, if used. Perform hand hygiene. Cleaning equipment between patient uses decreases risk for transmission of microorganisms. Accurate labeling ensures the ECG is recorded for the correct patient. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 840 Aptara 840 UNIT II 16-1 Promoting Healthy Physiologic Responses Obtaining an Electrocardiogram (ECG) EVALUATION continued The expected outcome is achieved when a quality ECG reading is obtained without any undue patient anxiety or complications or injury. In addition, the patient verbalizes an understanding of the reason for the ECG. DOCUMENTATION Guidelines Sample Documentation Document significant assessment findings, the date and time that the ECG was obtained, and the patient’s response to the procedure. Label the ECG recording with the patient’s name, room number, and facility identification number, if this was not done by the machine. Also record the date and time as well as any appropriate clinical information on the ECG, such as blood pressure measurement, if the patient was experiencing chest pain. 11/10/12 1745 Patient admitted to room 663. Denies pain, nausea, and shortness of breath. Apical heart rate 82 and regular. Blood pressure 146/88. ECG obtained as per admission orders. Copy faxed to Dr. Martin. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS An artifact appears on the tracing: An artifact may be due to loose electrodes or patient movement. Reassess electrode connections and ask the patient to lie extremely still. Redo the ECG, if necessary. Minimal complexes are seen: This may be due to extreme bradycardia. Run longer strips. A wandering baseline is noted, and respirations distort the recording: Ask the patient to hold his or her breath briefly to reduce baseline wander in the tracing. SPECIAL CONSIDERATIONS If self-sticking, disposable electrodes are not used, apply electrode paste or gel to the patient’s skin at the appropriate sites. Rub the gel or paste into the skin. The paste or gel facilitates electrode contact and enhances tracing. Secure electrodes promptly after applying the paste or gel. This prevents drying of the medium, which could impair ECG quality. Never use alcohol or acetone pads in place of the electrode paste or gel. Acetone and alcohol impair electrode contact with the skin and diminish the transmission of electrical impulses. The use of alcohol as a conducting material can result in burns. After disconnecting the lead wires from the electrodes, dispose of (or clean) the electrodes, as indicated. Proper cleaning after use ensures that the machine will be ready for next use. For female patients, place the electrodes below the breast tissue. In a large-breasted woman, you may need to displace the breast tissue laterally and/or superiorly. If necessary trim small areas of hair on the patient’s chest or extremities, but this usually is not necessary (Figure 7). FIGURE 7. Trimming leg hair. 841 CHAPTER 16 Cardiovascular Care If the patient’s skin is exceptionally oily, scaly, or diaphoretic, rub the electrode site with a dry 4  4 gauze or soap and water before applying the electrode to help reduce interference in the tracing. Alcohol, benzoin, and antiperspirant are not recommended to prepare the skin. If the patient has a pacemaker, perform an ECG with or without a magnet, according to the primary care provider’s orders. Note the presence of a pacemaker and the use of the magnet on the strip. Be aware that a new 80-lead ECG system (body surface mapping) is available, which looks at a patient’s heart from 80 views. It can detect up to 15% more cases of myocardial infarction in patients than a standard 12-lead ECG. Additional education regarding use of this technology is required. ECG obtained with body surface mapping can be interpreted in about 5 minutes, using the same skills as the standard 12-lead ECG (Self, et al., 2006). 16-2 Applying a Cardiac Monitor Bedside cardiac monitoring provides continuous observation of the heart’s electrical activity. It focuses on the detection of clinically significant dysrhythmias (Larson & Brady, 2008). Cardiac monitoring is used for patients with conduction disturbances and for those at risk for life-threatening arrhythmias, such as postoperative patients and patients who are sedated. As with other forms of electrocardiography (ECG), cardiac monitoring uses electrodes placed on the patient’s chest to transmit electrical signals that are converted into a tracing of cardiac rhythm on an oscilloscope. Three-lead or five-lead systems may be used (Figure 1). The three-lead–wire monitoring system facilitates monitoring of the patient in any of the limb leads. The five-lead–wire monitoring system facilitates monitoring of the patient in any one of the standard 12 leads. RA LA LA RA C LL Three-lead system LL RL Five-lead system FIGURE 1. Electrode positions for three-lead (left) and five-lead (right) systems. Positions for the three-lead system: RA (white electrode) below right clavicle, second ICS, right midclavicular line LA (black electrode) below left clavicle, second ICS, left midclavicular line LL (red electrode) left lower ribcage, eighth ICS, left midclavicular line Positions for five-lead system: RA (white electrode) below right clavicle, second ICS, right midclavicular line RL (green electrode) right lower ribcage, eighth ICS, right midclavicular line LA (black electrode) below left clavicle, second ICS, left midclavicular line LL (red electrode) left lower ribcage, eighth ICS, left midclavicular line Chest (brown electrode) any V lead position, usually V1 (fourth ICS, right sternal border) (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 842 Aptara 842 UNIT II Promoting Healthy Physiologic Responses 16-2 Applying a Cardiac Monitor continued Two types of monitoring may be performed: hardwire or telemetry. In hardwire monitoring, the patient is connected to a monitor at the bedside. The rhythm display appears at the bedside but may also be transmitted to a console at a remote location. Telemetry uses a small transmitter connected to the ambulatory patient to send electrical signals to another location, where they are displayed on a monitor screen. Battery-powered and portable, telemetry frees patients from cumbersome wires and cables and lets them be comfortably mobile. Telemetry is especially useful for monitoring arrhythmias that occur during sleep, rest, exercise, or stressful situations. Wireless telemetry devices are also being introduced, using microchips to record patient data, eliminating the need for new leads each time the patient is moved to a different location (Goulette, 2008). Regardless of the type, cardiac monitors can display the patient’s heart rate and rhythm, produce a printed record of cardiac rhythm, and sound an alarm if the heart rate exceeds or falls below specified limits. Monitors also recognize and count abnormal heartbeats as well as changes. Gel foam electrodes are commonly used. Electrodes should be changed every 24 hours, or according to facility policy, to prevent skin irritation. Hypoallergenic electrodes are available for patients with hypersensitivity to tape or adhesive. Any loose or nonadhering electrode should be replaced immediately to prevent inaccurate or missing data. EQUIPMENT ASSESSMENT Review the patient’s medical record and plan of care for information about the patient’s need for cardiac monitoring. Assess the patient’s cardiac status, including heart rate, blood pressure, and auscultation of heart sounds. Inspect the patient’s chest for areas of irritation, breakdown, or excessive hair that might interfere with electrode placement. Electrode sites must be dry, with minimal hair. The patient may be sitting or supine, in a bed or chair. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Decreased Cardiac Output Excess Fluid Volume Impaired Gas Exchange Deficient Knowledge Acute Pain Activity Intolerance Anxiety OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when performing cardiac monitoring is that a clear waveform, free from artifact, is displayed on the cardiac monitor. Other appropriate outcomes may include the following: the patient displays an understanding of the reason for monitoring, and the patient experiences reduced anxiety. Lead wires Pregelled (gel foam) electrodes (number varies from 3 to 5) Alcohol pads Gauze pads Patient cable for hardwire cardiac monitoring Transmitter, transmitter pouch, and telemetry battery pack for telemetry PPE, as indicated IMPLEMENTATION ACTION R AT I O N A L E 1. Verify the order for cardiac monitoring on the patient’s medical record. This ensures that the correct intervention is performed on the correct patient. 2. Gather all equipment and bring to bedside. Having equipment available saves time and facilitates accomplishment of procedure. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 843 Aptara 843 CHAPTER 16 Cardiovascular Care ACTION 4. Identify the patient. R AT I O N A L E Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain the procedure to the patient. Tell the patient that the monitoring records the heart’s electrical activity. Emphasize that no electrical current will enter his or her body. Ask the patient about allergies to adhesive, as appropriate. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Possible allergies may exist related to adhesive on ECG leads. 6. For hardwire monitoring, plug the cardiac monitor into an electrical outlet and turn it on to warm up the unit while preparing the equipment and the patient. For telemetry monitoring, insert a new battery into the transmitter. Match the poles on the battery with the polar markings on the transmitter case. Press the button at the top of the unit, test the battery’s charge, and test the unit to ensure that the battery is operational. Proper setup ensures proper functioning. Not all models have a test button. Test according to manufacturer’s directions. 7. Insert the cable into the appropriate socket in the monitor. Proper setup ensures proper functioning. 8. Connect the lead wires to the cable. In some systems, the lead wires are permanently secured to the cable. For telemetry, if the lead wires are not permanently affixed to the telemetry unit, attach them securely. If they must be attached individually, connect each one to the correct outlet. Proper setup ensures proper functioning. 9. Connect an electrode to each of the lead wires, carefully checking that each lead wire is in its correct outlet. Proper setup ensures proper functioning. 10. If the bed is adjustable, raise it to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Having the bed at the proper height prevents back and muscle strain. 11. Expose the patient’s chest and determine electrode positions, based on which system and leads are being used. (Refer to Figure 1.) If necessary, clip the hair from an area about 10 cm in diameter around each electrode site. Clean the area with soap and water and dry it completely to remove skin secretions that may interfere with electrode function. These actions allow for better adhesion of the electrode and thus better conduction. Alcohol, benzoin, and antiperspirant are not recommended to prepare the skin. 12. Remove the backing from the pregelled electrode. Check the gel for moistness. If the gel is dry, discard it and replace it with a fresh electrode. Apply the electrode to the site and press firmly to ensure a tight seal. Repeat with the remaining electrodes to complete the three-lead or five-lead system (Figures 2 and 3). Gel acts as a conduit and must be moist and secured tightly. 13. When all the electrodes are in place, connect the appropriate lead wire to each electrode. Check waveform for clarity, position, and size. To verify that the monitor is detecting each beat, compare the digital heart rate display with an auscultated count of the patient’s heart rate. If necessary, use the gain control to adjust the size of the rhythm tracing, and use the position control to adjust the waveform position on the monitor. This ensures accuracy of reading. 14. Set the upper and lower limits of the heart rate alarm, based on the patient’s condition or unit policy. Setting the alarm allows for audible notification if the heart rate is beyond limits. The default setting for the monitor automatically turns on all alarms; limits should be set for each patient. (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 844 Aptara 844 UNIT II 16-2 Promoting Healthy Physiologic Responses Applying a Cardiac Monitor ACTION continued R AT I O N A L E FIGURE 2. Applying the electrodes for three-lead monitoring FIGURE 3. Applying electrodes for five-lead monitoring system. system. 15. For telemetry, place the transmitter in the pouch in the hospital gown. If not available in gown, use a portable pouch. Tie the pouch strings around the patient’s neck and waist, making sure that the pouch fits snugly without causing discomfort. If no pouch is available, place the transmitter in the patient’s bathrobe pocket. Patient comfort leads to compliance. 16. To obtain a rhythm strip, press the RECORD key either at the bedside for monitoring or at the central station for telemetry. Label the strip with the patient’s name and room number, date, time, and rhythm identification. Analyze the strip, as appropriate. Place the rhythm strip in the appropriate location in the patient’s chart. A rhythm strip provides a baseline. 17. Return the patient to a comfortable position. Lower bed height and adjust the head of bed to a comfortable position. Repositioning promotes patient comfort. Lowering the bed promotes patient safety. 18. Remove additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. The expected outcome is achieved when the cardiac monitoring waveform displays the patient’s cardiac rhythm, with a waveform that is detecting each beat, and is appropriate for clarity, position, and size. In addition, the patient demonstrates no undue anxiety and remains free of complications or injury. DOCUMENTATION Guidelines Sample Documentation Record the date and time that monitoring begins and the monitoring lead used in the medical record. Document a rhythm strip at least every 8 hours and with any changes in the patient’s condition (or as stated by facility’s policy). Label the rhythm strip with the patient’s name and room number, date, and time. 12/3/12 1615 Patient admitted to room. Cardiac telemetry monitor in place; monitoring in lead II. See flow sheet for assessment data and initial rhythm strip. —T. Shah, RN LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 845 Aptara CHAPTER 16 Cardiovascular Care UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS 845 False high-rate alarm sounds: Assess for monitor that is interpreting large T waves as QRS complexes, thus doubling the rate, or for skeletal muscle activity. Reposition electrodes to a lead where the QRS complexes are taller than the T waves, and place electrodes away from major muscle masses. Change lead view on monitor. Use “relearn” feature, if available, to identify where the normal complexes are. False low-rate alarm sounds: Assess for a shift in the electrical axis due to patient movement, making QRS complexes too small to register; low amplitude of QRS; or poor contact between skin and electrode. Reapply electrodes. Set gain so that the height of complex is greater than 1 mV. Low amplitude: Assess for gain dial set too low; poor contact between skin and electrodes; dried gel; broken or loose lead wires; poor connection between patient and monitor; or malfunctioning monitor. Check connections on all lead wires and monitoring cable. Replace electrodes, as necessary. Reapply electrodes, if required. Wandering baseline: Assess for poor position or contact between electrodes and skin, or thoracic movement with respirations. Reposition or replace electrodes. Artifact (waveform interference): Assess for patient movement, improperly applied electrodes, or static electricity. Attach all electrical equipment to a common ground. Check plugs to make sure prongs are not loose. Skin excoriation under electrodes: Assess for allergic reaction to electrode adhesive or electrodes being left on the skin too long. Remove electrodes and apply hypoallergenic electrodes and hypoallergenic tape, or remove electrode, clean site, and reapply electrode at new site. SPECIAL CONSIDERATIONS General Considerations Make sure all electrical equipment and outlets are grounded to avoid electric shock and interference (artifacts). Avoid opening the electrode packages until just before using to prevent the gel from drying out. Avoid placing the electrodes on bony prominences, hairy locations, areas where defibrillator pads will be placed, or areas for chest compression. If the patient’s skin is very oily, scaly, or diaphoretic, rub the electrode site with a dry 4  4 gauze pad before applying the electrode to help reduce interference in the tracing. Assess skin integrity and examine the leads every 8 hours. Replace and reposition the electrodes, as necessary. If the patient is being monitored by telemetry, show him or her how the transmitter works. If applicable, identify the button that will produce a recording of the ECG at the central station. Instruct the patient to push the button whenever symptoms occur; this causes the central console to print a rhythm strip. Also, advise the patient to notify the nurse immediately if symptoms occur. If a medical order is in place, tell the patient to remove the transmitter during showering or bathing, if appropriate, but stress that he or she should let the nurse know the unit is being removed. Infant and Child Considerations Having the infant or child wear a snug undershirt over the leads helps to keep the leads in place (Kyle, 2008). EVIDENCE FOR PRACTICE Many patients admitted to the hospital with cardiac, respiratory, and other acute health problems are placed on electrocardiographic monitoring. This monitoring allows the healthcare providers, including nurses, to monitor the patient for the development of cardiac dysrhythmias. Cardiac monitoring is invaluable for certain patients, but may be overused and may not be indicated in many instances. Is this type of monitoring being used effectively? Related Research Larson, T., & Brady, W. (2008). Electrocardiographic monitoring in the hospitalized patient: A diagnostic intervention of uncertain clinical impact. American Journal of Emergency Medicine, 26(9), 1047–1055. This literature review discusses the use of inpatient telemetry and its impact and suggests highyield criteria for its application among inpatient populations. The authors conclude that cardiac monitoring is useful for certain high-risk patients and that it is often over used with low-risk patients. Over use contributes to overcrowding (lack of inpatient bed space on monitored units), (continued) 846 UNIT II Promoting Healthy Physiologic Responses 16-2 Applying a Cardiac Monitor continued resource demand (missed adverse events), and increased financial burden for hospitals. The article provides criteria to identify low-risk patient populations and suggests healthcare providers refrain from using cardiac monitoring with these patients to reduce unnecessary cardiac monitoring. An example of a patient who can be treated in the hospital without cardiac monitoring includes one with atypical chest pain without associated symptoms and normal ECG findings and normal biomarkers. Relevance for Nursing Practice 16-3 As primary care providers, nurses have the opportunity to screen patients for the appropriateness of cardiac monitoring and act as an advocate to ensure the best care for individual patients. Obtaining an Arterial Blood Sample From an Arterial Line–Stopcock System Obtaining an arterial blood sample requires percutaneous puncture of the brachial, radial, or femoral artery (see Chapter 18: Laboratory Specimen Collection). However, an arterial blood sample can also be obtained from an arterial line. When collected, the sample can be analyzed to determine arterial blood gas (ABG), laboratory specimens, or other values. The procedure below describes obtaining a sample from an open system. For information on obtaining an arterial blood sample from a closed reservoir system, please see the Skill Variation at the end of the skill. EQUIPMENT ASSESSMENT Review the patient’s medical record and plan of care for information about the patient’s need for an arterial blood sample. Assess the patient’s cardiac status, including heart rate, blood pressure, and auscultation of heart sounds. Also assess the patient’s respiratory status, including respiratory rate, excursion, lung sounds, and use of oxygen, if ordered. Check the patency and functioning of the arterial line. Determine the dead-space volume of the arterial line system immediately before withdrawing the laboratory sample (see Step 8 below). The dead space is the volume of the space from the tip of the catheter to the sampling port of the stopcock; it depends on the gauge and length of the catheter, the length of the connecting tubing, and the number of stopcocks in the system. A sufficient amount of discard volume needs to be withdrawn before obtaining the blood sample to be tested in the laboratory. If an insufficient amount of discard volume is withdrawn, the specimen may be diluted and contaminated with flush solution. If an excessive amount of discard volume is withdrawn, the patient may experience an iatrogenic (treatment-induced) blood loss. Assess the patient’s understanding about the need for specimen collection. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Gas Exchange Risk for Infection Decreased Cardiac Output Risk for Injury Excess Fluid Volume Anxiety Arterial blood gas (ABG) syringe with needleless cannula, if ABG is ordered Gloves Goggles Additional PPE, as indicated Two 5-mL syringes Vacutainer with needleless adapter and appropriate blood collection tubes for ordered tests Alcohol swabs or chlorhexidine, per facility policy Rubber cap for ABG syringe hub Ice-filled plastic bag or cup Label with patient identification information and test order number Laboratory request form, if necessary Biohazard bag LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 847 Aptara CHAPTER 16 Cardiovascular Care OUTCOME IDENTIFICATION AND PLANNING 847 The expected outcome to achieve when obtaining an arterial blood sample is that a specimen is obtained without compromise to the patency of the arterial line. In addition, the patient experiences minimal discomfort and anxiety, remains free from infection, and demonstrates an understanding about the need for the specimen collection. IMPLEMENTATION ACTION R AT I O N A L E 1. Verify the order for laboratory testing on the patient’s medical record. This ensures that the correct intervention is performed on the correct patient. 2. Gather all equipment and bring to bedside. Having equipment available saves time and facilitates accomplishment of procedure. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain the procedure to the patient. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. 6. Compare specimen label with patient identification bracelet. Label should include patient’s name and identification number, time specimen was collected, route of collection, identification of the person obtaining sample, and any other information required by agency policy. Verification of the patient’s identity validates that the correct procedure is being done on the correct patient, and the specimen is accurately labeled. 7. Put on gloves and goggles or face shield. Gloves and goggles (or face shield) prevent contact with blood and body fluids. 8. Turn off or temporarily silence the arterial pressure alarms, depending on facility policy. The integrity of the system is being altered, which will cause the system to sound an alarm. Facility policy may require the alarm be left on. 9. Locate the stopcock nearest the arterial line insertion site (Figure 1). Use the alcohol swab or chlorhexidine to scrub the sampling port on the stopcock. Allow to air dry. Cleansing prevents contamination from microorganisms on sampling port. 10. Attach a 5-mL syringe into the sampling port on the stopcock to obtain the discard volume (Figure 2). Turn off the stopcock to the flush solution. Aspirate slowly until blood enters the syringe. Stop aspirating. Note the volume in the syringe, which is the dead-space volume. Continue to aspirate until the dead-space volume has been withdrawn a total of three times. For example, if the dead-space volume is 0.8 mL, aspirate 2.4 mL of blood. A sufficient amount of discard volume needs to be withdrawn before obtaining the blood sample to be tested in the laboratory. This sample is discarded because it is diluted with flush solution, possibly leading to inaccurate test results. The dead space is the volume of the space from the tip of the catheter to the sampling port of the stopcock. The dead-space volume will depend on the gauge and length of the catheter, the length of the connecting tubing, and the number of stopcocks in the system. If an insufficient amount of discard volume is withdrawn, the specimen may be diluted and contaminated with flush solution. If an excessive amount of discard volume is withdrawn, the patient may experience an iatrogenic (treatment-induced) blood loss. 11. Turn the stopcock to the halfway position between the flush solution and the sampling port to close the system in all directions. Turning the stopcock off maintains the integrity of the system. 12. Remove the discard syringe and dispose of appropriately. Observe Standard Precautions. Diluted blood still poses a risk for infection transmission. (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 848 Aptara 848 UNIT II 16-3 Promoting Healthy Physiologic Responses Obtaining an Arterial Blood Sample From an Arterial Line–Stopcock System continued ACTION R AT I O N A L E Arterial line tubing Stopcock and sampling port Radial artery catheter OFF FIGURE 1. Locating stopcock. (From Spring house , FIGURE 2. Attaching a 5-mL syringe to the sampling port on the Cardiovascular Care Made Incredibly Visual!) stopcock. 13. Place the syringe for the laboratory sample or the Vacutainer in the sampling port of the stopcock. Turn the stopcock off to the flush solution, and slowly withdraw the required amount of blood. For each additional sample required, repeat this procedure. If coagulation tests are included in the required tests, obtain blood for this from the final sample. Turning the stopcock off to the flush solution prevents dilution from the flush device. 14. Turn the stopcock to the halfway position between the flush solution and the sampling port to close the system in all directions. Remove the syringe or Vacutainer. Apply the rubber cap to the ABG syringe hub, if necessary. Turning the stopcock off maintains the integrity of the system. 15. Insert a 5-mL syringe into the sampling port of the stopcock. Turn off the stopcock to the patient. Activate the in-line flushing device. Flush through the sampling port into the syringe to clear the stopcock and sampling port of any residual blood. Turning the stopcock off and in-line flushing maintains the integrity of the system, preventing clotting and infection. 16. Turn off the stopcock to the sampling port; remove the syringe. Remove sampling port cap and replace with new sterile one. Intermittently flush the arterial catheter with the in-line flushing device until the tubing is clear of blood. Turning the stopcock off and in-line flushing maintains the integrity of the system, preventing clotting and infection. 17. Remove gloves. Reactivate the monitor alarms. Record date and time the samples were obtained on the labels, as well as the required information to identify the person obtaining the samples. If ABG was collected, record oxygen flow rate (or room air) on label. Apply labels to the specimens, according to facility policy. Place in biohazard bags; place ABG sample in bag with ice. Removing gloves properly reduces the risk for infection transmission and contamination of other items. Reactivating the system ensures proper functioning. Proper labeling prevents error. Recording oxygen flow rate ensures accurate interpretation of results of ABG. Use of biohazard bag prevents contact with blood and body fluids. Ice maintains integrity of the sample. 18. Check the monitor for return of the arterial waveform and pressure reading. This ensures proper functioning and integrity of the system. 19. Return the patient to a comfortable position. Lower bed height, if necessary, and adjust head of bed to a comfortable position. Repositioning promotes patient comfort. Lowering the bed promotes patient safety. 20. Remove goggles and additional PPE, if used. Perform hand hygiene. Send specimens to the laboratory immediately. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. Specimens must be processed in a timely manner to ensure accuracy. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 849 Aptara CHAPTER 16 Cardiovascular Care EVALUATION 849 The expected outcome to achieve when obtaining an arterial blood sample is that a specimen is obtained without compromise to the patency of the arterial line. In addition, the patient experiences minimal discomfort and anxiety, remains free from infection, and demonstrates an understanding about the need for the specimen collection. DOCUMENTATION Guidelines Document any pertinent assessments, the laboratory specimens obtained, date and time specimens were obtained, and disposition of specimens. Sample Documentation 10/20/12 0230 Continuous heparin IV infusion at 900 U via left subclavian central catheter. Blood specimens for repeat PT/PTT, CBC, and BMP obtained via right radial arterial line per order. Line flushed per policy; specimens sent to the laboratory. —R. Chin, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS The specimen obtained is dark: Dark blood means a vein may have been accessed, or the blood may be poorly oxygenated. Ensure that the line from which you are obtaining the specimen is indeed an arterial line. Also, check the patient’s oxygen saturation level to evaluate for possible hypoxemia. When retracting the syringe for the discarded sample, you feel resistance: Reposition the affected extremity and check the insertion site for obvious problems (e.g., catheter kinking). Then attempt to obtain the sample to be discarded. If resistance is still felt, notify the primary care provider. After obtaining the specimen and reactivating the arterial pressure monitoring system, no waveform is noted: Check the stopcock to make sure that it is open to the patient and recheck all connections and components of the system to ensure proper setup. If necessary, rebalance the transducer or replace the system, as necessary. If problem persists, suspect a clotted catheter tip. Follow facility policy to troubleshoot a potentially clotted arterial line and notify the primary care provider. SPECIAL CONSIDERATIONS If the patient is receiving oxygen, make sure that this therapy has been underway for at least 15 minutes before collecting an arterial blood sample for ABG analysis. Indicate on the laboratory request slip the amount and type of oxygen therapy the patient is receiving. Also note the patient’s current temperature, most recent hemoglobin level, and current respiratory rate. If the patient is receiving mechanical ventilation, note the fraction of inspired oxygen and tidal volume. If the patient is not receiving oxygen, indicate that he or she is breathing room air. If the patient has just received a nebulizer treatment, wait about 20 minutes before collecting the sample for ABG analysis. Skill Variation Obtaining an Arterial Blood Sample From a Closed Reservoir System 1. Gather all equipment and bring it to the bedside. 2. Perform hand hygiene. Put on PPE, as indicated. 3. Check the patient’s identification. Compare the specimen label with the patient’s identification. 4. Explain the procedure to the patient. Close curtains around bed and close the door to the room, if possible. 5. If the bed is adjustable, raise it to a comfortable working height. 6. Put on gloves and goggles. 7. Locate the closed-system reservoir and blood-sampling site. Deactivate or temporarily silence monitor alarms (some facilities require that alarms be left on). 8. Clean the sampling site with an alcohol swab or chlorhexidine. 9. Holding the reservoir upright, grasp the flexures, and slowly fill the reservoir with blood over a 3- to 5-second period. If you feel resistance, reposition the extremity and check the catheter site for obvious problems (e.g., kinking of the tubing). Then continue with blood withdrawal. (continued) 850 UNIT II 16-3 Promoting Healthy Physiologic Responses Obtaining an Arterial Blood Sample From an Arterial Line–Stopcock System continued an Arterial Blood Sample From a Skill Variation Obtaining Closed Reservoir System continued 10. Turn off the one-way valve to the reservoir by turning the handle perpendicular to the tubing. Using a syringe with attached cannula, insert the cannula into the sampling site. Slowly fill the syringe. Then grasp the cannula near the sampling site and remove the syringe and cannula as one unit. Repeat the procedure, as needed, to fill the required number of syringes. If coagulation tests have been ordered, obtain blood for those tests from the final syringe. 11. After filling the syringes, turn the one-way valve to its original position, parallel to the tubing. Push down evenly on the plunger until the flexures lock in place in the fully closed position and all fluid has been re-infused. The fluid should be re-infused over a 3- to 5-second period. Activate the fastflush release. 16-4 12. Clean the sampling site with an alcohol swab or chlorhexidine. Reactivate the monitor alarms. Transfer blood samples to the appropriate specimen tubes, if necessary. Record on the labels the date and time the samples were obtained, as well as the required information to identify the person obtaining the samples. Apply labels to the specimens according to facility policy. Place in biohazard bags; place ABG sample in bag with ice. Remove gloves. 13. Check the monitor for return of the arterial waveform and pressure reading. 14. Remove any remaining equipment. Remove goggles and additional PPE, if used. Perform hand hygiene. Send specimens to the laboratory immediately. Removing Arterial and Femoral Lines Arterial and femoral lines are used for intensive and continuous cardiac monitoring and intra-arterial access. Once the lines are no longer necessary or have become ineffective, they need to be removed. Consult facility policy to determine whether nurses are permitted to perform this procedure. Two nurses should be at the bedside until bleeding is controlled, and are available to give emergency medications, if necessary. The patient should be kept NPO until the catheter is removed in case of nausea with a vasovagal response. EQUIPMENT ASSESSMENT Review the patient’s medical record and plan of care for information about discontinuation of the arterial or femoral line. Assess the patient’s coagulation status, including laboratory studies, to reduce the risk of complications secondary to impaired clotting ability. Assess the patient’s understanding of the procedure. Inspect the site for leakage, bleeding, or hematoma. Assess skin color and temperature and assess distal pulses for strength and quality. Mark distal pulses with an ‘X’ for easy identification after the procedure. Assess the patient’s blood pressure; systolic blood pressure should be less than 180 mm Hg before the catheter is removed. Sterile gloves Clean gloves Goggles or face shield Sterile gauze pads Waterproof protective pad Sterile suture removal set Transparent dressing Alcohol pads Hypoallergenic tape For femoral line: small sandbag (5 to 10 pounds), wrapped in a towel or pillowcase Emergency medications (e.g., atropine, for a vasovagal response with femoral line removal) for emergency response, per facility policy and guidelines Indelible pen LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 851 Aptara 851 CHAPTER 16 Cardiovascular Care NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Injury Risk for Infection Impaired Skin Integrity Anxiety OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when removing an arterial or femoral line is that the line is removed intact and without injury to the patient. In addition, the site remains clean and dry, without evidence of infection, bleeding, or hematoma. IMPLEMENTATION ACTION R AT I O N A L E 1. Verify the order for removal of arterial or femoral line in the patient’s medical record. This ensures that the correct intervention is performed on the correct patient. 2. Gather all equipment and bring to bedside. Having equipment available saves time and facilitates accomplishment of procedure. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Explain the procedure to the patient. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. 6. Ask the patient to empty his or her bladder. Maintain an IV infusion of normal saline via another venous access during the procedure, as per medical orders or facility guidelines. Emptying the bladder ensures patient comfort. IV access may be needed in case of hypotension or bradycardia. 7. If the bed is adjustable, raise it to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Having the bed at the proper height prevents back and muscle strain. 8. Put on clean gloves, goggles, and gown. These prevent contact with blood and body fluids. 9. If the line being removed is in a femoral site, use Doppler ultrasound to locate femoral artery 1 to 2 inches above the entrance site of the femoral line. Mark with ‘X’ using indelible pen. This ensures accurate location of femoral artery. 10. Turn off the monitor alarms and then turn off the flow clamp to the flush solution. Carefully remove the dressing over the insertion site. Remove any sutures using the suture removal kit; make sure all sutures have been removed. These measures help prepare for withdrawal of line. 11. Withdraw the catheter using a gentle, steady motion. Keep the catheter parallel to the blood vessel during withdrawal. Watch for hematoma formation during catheter removal by gently palpating surrounding tissue. If hematoma starts to form, reposition your hands until optimal pressure is obtained to prevent further leakage of blood. Using a gentle, steady motion parallel to the blood vessel reduces the risk for traumatic injury. 12. Immediately after withdrawing the catheter, apply pressure 1 or 2 inches above the site at the previously marked spot with a sterile 4  4 gauze pad. Maintain pressure for at least 10 minutes, or per facility policy (longer if bleeding or oozing persists). Apply additional pressure to a femoral site or if the patient has coagulopathy or is receiving anticoagulants. If sufficient pressure is not applied, a large, painful hematoma may form. (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 852 Aptara 852 UNIT II 16-4 Promoting Healthy Physiologic Responses Removing Arterial and Femoral Lines ACTION continued R AT I O N A L E 13. Assess distal pulses every 3 to 5 minutes while pressure is being applied. Note: dorsalis pedis and posterior tibial pulses should be markedly weaker from baseline if sufficient pressure is applied to the femoral artery. Assessment of distal pulses determines blood flow to the extremity. Pulses should return to baseline after pressure is released. 14. Cover the site with an appropriate dressing and secure the dressing with tape. If stipulated by facility policy, make a pressure dressing for a femoral site by folding four sterile 4  4 gauze pads in half, and then applying the dressing. Sufficient pressure is needed to prevent continued bleeding and hematoma formation. 15. Cover the dressing with a tight adhesive bandage, per policy, and then cover the femoral bandage with a sandbag. Remove gloves. Maintain the patient on bed rest, with the head of the bed elevated less than 30º, for 6 hours with the sandbag in place. Lower the bed height. Remind the patient not to lift his or her head while on bed rest. Sufficient pressure is needed to prevent continued bleeding and hematoma formation. Removing gloves properly reduces the risk for infection transmission and contamination of other items. Raising the head increases intra-abdominal pressure, which could lead to bleeding from the site. 16. Remove additional PPE. Perform hand hygiene. Send specimens to the laboratory immediately. 17. Observe the site for bleeding. Assess circulation in the extremity distal to the site by evaluating color, pulses, and sensation. Repeat this assessment every 15 minutes for the first 1 hour, every 30 minutes for the next 2 hours, hourly for the next 2 hours, then every 4 hours, or according to facility policy. Use log rolling to assist the patient in using the bedpan, if needed. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. Specimens must be processed in a timely manner to ensure accuracy. Continued assessment allows for early detection and prompt intervention should problems arise. The expected outcome is met when the patient exhibits an arterial or femoral line site that is clean and dry without evidence of injury, infection, bleeding, or hematoma. In addition, the patient demonstrates intact peripheral circulation and verbalizes a reduction in anxiety. DOCUMENTATION Guidelines Sample Documentation Document the time the line was removed and how long pressure was applied. Document site assessment every 5 minutes while pressure is being applied (second nurse can do this). Document assessment of peripheral circulation, appearance of site, type of dressing applied, the timed assessments, patient’s response, and any medications given. 12/20/12 1830 Right upper extremity arterial line removed per order. Pressure applied to site for 10 minutes. Site intact without signs of hematoma; radial pulse present, 2 and regular. Hand warm and dry; hand skin tone consistent with left hand. Pressure dressing applied to site. Patient denies pain, nausea, shortness of breath. Vital signs stable before, during and after procedure. See flow sheet. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Assessment reveals fresh blood on the site dressing: Apply pressure. If bleeding continues, notify the primary care provider. The patient has a history of peripheral vascular disease: Assess the peripheral circulation for changes; if necessary, apply slightly decreased pressure at the insertion site. Affected extremity is cold and/or pulseless: Immediately notify primary care provider. Patient complains of severe back pain or noted to be hypotensive: Symptoms may be due to retroperitoneal bleeding. Notify primary care provider immediately. SPECIAL CONSIDERATIONS Sometimes, a culture of the catheter tip is ordered to aid in identifying the source of infection. If ordered, place the catheter tip on a 4  4 sterile gauze pad. After the bleeding is under control and the dressing is secure, hold the catheter over the sterile container. Cut the tip of the catheter with sterile scissors and allow it to fall into the sterile container. Label the specimen and send it to the laboratory. 853 CHAPTER 16 Cardiovascular Care 16-5 Performing Cardiopulmonary Resuscitation (CPR) Cardiopulmonary resuscitation (CPR), also known as basic life support, is used in the absence of spontaneous respirations and heartbeat to preserve heart and brain function while waiting for defibrillation and advanced cardiac life-support care. It is a combination of chest compressions, which manually pump the heart to circulate blood to the body systems, and “mouth-to-mouth” or rescue breathing, which supplies oxygen to the lungs. Assess the patient, activate the emergency response system, and perform the ABCD of CPR. Remember the ABCD of CPR—airway, breathing, and circulation—followed by the ‘D’ of defibrillation to manage sudden cardiac death (American Heart Association [AHA], 2006). In the hospital setting, it is imperative that personnel be aware of the patient’s stated instructions regarding a wish not to be resuscitated. This should be clearly expressed and documented in the patient’s medical record. In 2008, the American Heart Association (AHA) instituted changes in their suggestions regarding emergency interventions outside of healthcare facilities. Learning conventional CPR is still recommended. However, the AHA alternately recommends when an adult suddenly collapses, persons near the victim should call 911 (activate the emergency response system), and push hard and fast in the center of the victim’s chest. Studies of real emergencies that have occurred in homes, at work, or in public locations, show that these two steps, called Hands-Only CPR, can be as effective as conventional CPR. Providing Hands-Only CPR to an adult who has collapsed from a sudden cardiac arrest can more than double that person’s chance of survival (AHA, 2008). EQUIPMENT Personal protective equipment, such as a face shield or one-way valve mask and gloves, if available Ambu-bag and oxygen, if available ASSESSMENT Assess the patient’s vital parameters and determine the patient’s level of responsiveness. Check for partial or complete airway obstruction. Assess for the absence or ineffectiveness of respirations. Assess for the absence of signs of circulation and pulses. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Decreased Cardiac Output Ineffective Airway Clearance Risk for Ineffective Cerebral Tissue Risk for Aspiration Perfusion Risk for Injury Impaired Gas Exchange Impaired Spontaneous Ventilation OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when performing CPR is that CPR is performed effectively without adverse effect to the patient. Additional outcomes include the following: the patient regains a pulse and respirations; the patient’s heart and lungs maintain adequate function to sustain life; and advanced cardiac life support is initiated. Another appropriate outcome may be that the patient does not experience injury. IMPLEMENTATION ACTION R AT I O N A L E 1. Assess responsiveness. If the patient is not responsive, call for help, pull call bell, and call the facility emergency response number. Call for the automated external defibrillator (AED). Assessing responsiveness prevents starting CPR on a conscious victim. Activating the emergency response system initiates a rapid response. 2. Put on gloves, if available. Position the patient supine on his or her back on a firm, flat surface, with arms alongside the body. If the patient is in bed, place a backboard or other rigid surface under the patient (often the footboard of the patient’s bed). Gloves prevent contact with blood and body fluids. The supine position is required for resuscitative efforts and evaluation to be effective. Backboard provides a firm surface on which to apply compressions. If the patient must be rolled, move as a unit so the head, shoulders, and torso move simultaneously without twisting. (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 854 Aptara 854 UNIT II 16-5 Promoting Healthy Physiologic Responses Performing Cardiopulmonary Resuscitation (CPR) ACTION 3. Use the head tilt–chin lift maneuver to open the airway (Figure 1). Place one hand on the victim’s forehead and apply firm, backward pressure with the palm to tilt the head back. Place the fingers of the other hand under the bony part of the lower jaw near the chin and lift the jaw upward to bring the chin forward and the teeth almost to occlusion. If trauma to the head or neck is present or suspected, use the jaw-thrust maneuver to open the airway (Figure 2). Place one hand on each side of the patient’s head. Rest elbows on the flat surface under the patient, grasp the angle of the patient’s lower jaw, and lift with both hands. FIGURE 1. Using the head tilt–chin lift method to open the continued R AT I O N A L E This maneuver may be sufficient to open the airway and promote spontaneous respirations. FIGURE 2. Using the jaw-thrust maneuver to open the airway. airway. 4. Look, listen, and feel for air exchange. Take at least 5 seconds and no more than 10 seconds (AHA, 2006). These techniques provide information about the patient’s breathing and the need for rescue breathing. 5. If the patient resumes breathing or adequate respirations and signs of circulation are noted, place the patient in the recovery position. The recovery position maintains alignment of the back and spine while allowing for continued observation and maintains access to the patient. 6. If no spontaneous breathing is noted, seal the patient’s mouth and nose with the face shield, one-way valve mask (Figure 3A), or Ambu-bag (handheld resuscitation bag), if available (Figure 3B). If not available, seal the patient’s mouth with rescuer’s mouth. Sealing the patient’s mouth and nose prevents air from escaping. Devices such as masks reduce the risk for transmission of infections. 7. Instill two breaths, each lasting 1 second, making the chest rise. Breathing into the patient provides oxygen to the patient’s lungs. Hyperventilation results in increased positive chest pressure and decreased venous return. Blood flow to the lungs during CPR is only about 25% to 33% normal; patient requires less ventilation to provide oxygen and remove carbon dioxide. Longer breaths reduce the amount of blood that refills the heart, reducing blood flow generated by compressions. Delivery of large, forceful breaths may cause gastric inflation and distension. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 855 Aptara 855 CHAPTER 16 Cardiovascular Care ACTION A R AT I O N A L E B FIGURE 3. A. Using a one-way valve mask. B. Using a handheld resuscitation bag. (Photo courtesy B. Proud.) 8. If you are unable to ventilate or the chest does not rise during ventilation, reposition the patient’s head and reattempt to ventilate. If still unable to ventilate, begin CPR. Each subsequent time the airway is opened to administer breaths, look for an object. If an object is visible in the mouth, remove it. If no object is visible, continue with CPR. Inability to ventilate indicates that the airway may be obstructed. Repositioning maneuvers may be sufficient to open the airway and promote spontaneous respirations. It is critical to minimize interruptions in chest compressions, to maintain circulatory perfusion. 9. Check the carotid pulse, simultaneously evaluating for breathing, coughing, or movement. This assessment should take at least 5 seconds and no more than 10 seconds. Place the patient in the recovery position if breathing resumes (Figure 4). Pulse and other assessments evaluate cardiac function. The femoral pulse may be used for the pulse check. 10. If patient has a pulse, but remains without spontaneous breathing, continue rescue breathing at a rate of one breath every 5 to 6 seconds, for a rate of 10 to 12 breaths per minute. Rescue breathing maintains adequate oxygenation. 11. If the patient is without signs of circulation, position the heel of one hand in the center of the chest between the nipples, directly over the lower half of the sternum. Place the other hand directly on top of the first hand. Extend or interlace fingers to keep fingers above the chest. Straighten arms and position shoulders directly over hands. Proper hand positioning ensures that the force of compressions is on the sternum, thereby reducing the risk of rib fracture, lung puncture, or liver laceration. 12. Perform 30 chest compressions at a rate of 100 per minute, counting “one, two, etc.” up to 30, keeping elbows locked, arms straight, and shoulders directly over the hands. Chest compressions should depress the sternum 11⁄2 to 2 inches. Push straight down on the patient’s sternum. Allow full chest recoil (re-expand) after each compression (Figure 5). Direct cardiac compression and manipulation of intrathoracic pressure supply blood flow during CPR. Compressing the chest 11⁄2 to 2 inches ensures that compressions are not too shallow and provides adequate blood flow. Full chest recoil allows adequate venous return to the heart. 13. Give two rescue breaths after each set of 30 compressions. Do five complete cycles of 30 compressions and two ventilations. Breathing and compressions simulate lung and heart function, providing oxygen and circulation. 14. Defibrillation should be provided at the earliest possible moment, as soon as AED becomes available. Refer to Skill 16-6: Automated External Defibrillation and Skill 16-7: Manual External Defibrillation. The interval from collapse to defibrillation is the most important determinant of survival from cardiac arrest (AHA, 2005b). (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 856 Aptara 856 UNIT II 16-5 Promoting Healthy Physiologic Responses Performing Cardiopulmonary Resuscitation (CPR) ACTION continued R AT I O N A L E 11/2 – 2 inches FIGURE 4. Recovery position. (Photo by B. Proud.) FIGURE 5. Using correct body alignment for chest compressions. Depress the sternum 11⁄2 to 2 inches. 15. Continue CPR until advanced care providers take over, the patient starts to move, you are too exhausted to continue, or a physician discontinues CPR. Advanced care providers will indicate when a pulse check or other therapies are appropriate (AHA, 2006, p. 34). 16. Remove gloves, if used. Perform hand hygiene. EVALUATION Once started, CPR must continue until one of these conditions is met. In a hospital setting, help should arrive within a few minutes. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. The expected outcome is achieved when CPR is performed effectively without adverse effect to the patient; the patient regains a pulse and respirations; the patient’s heart and lungs maintain adequate function to sustain life; advanced cardiac life support is initiated; and the patient does not experience serious injury. DOCUMENTATION Guidelines Sample Documentation Document the time you discovered the patient unresponsive and started CPR. Continued intervention, such as by the code team, is typically documented on a code form, which identifies the actions and drugs provided during the code. Provide a summary of these events in the patient’s medical record. 07/06/12 2230 Called to patient’s room by wife. Patient noted to be without evidence of respirations or circulation. Emergency response system activated, CPR initiated. See code sheet. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS When performing chest compression, there is an audible crack: Be aware that this sound most commonly indicates cracking of the ribs. Recheck hand position. Then continue compressions. You come upon a patient lying on the floor: Determine the patient’s level of responsiveness. If the patient is unresponsive, quickly clear an area, call for assistance and AED, and begin CPR. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 857 Aptara CHAPTER 16 Cardiovascular Care 857 SPECIAL CONSIDERATIONS General Considerations If the arrest is out of hospital and not witnessed, approximately 2 minutes of CPR (five cycles) should be given before applying the AED, checking the ECG rhythm, and attempting defibrillation (Brunetti, 2008; AHA, 2006). If unsure whether the patient has a pulse, initiate CPR. Unnecessary CPR is less harmful than not performing CPR when it is truly needed (AHA, 2006, p. 12). Every effort should be taken to minimize interruptions in chest compressions. Causes for not providing compressions may include prolonged pulse checks, taking too long to give breaths, moving the patient, and using the AED. Try to limit interruptions to less than 10 seconds, except for intubation, defibrillation, or moving the patient from danger (AHA, 2006). Perform CPR in the same manner if the patient is obese. Perform CPR for pregnant patients using the same guidelines, with a few additional measures. Before initiating chest compressions, the patient must be placed in a 30-degree left lateral tilt position, which reduces vena cava compression and resulting decreased cardiac output (Castle, 2007). The left lateral tilt position is accomplished by using a foam wedge or other firm device behind the patient’s back. The rescuer’s hands are placed in the center of the patient’s chest and compressions directed to move the sternum toward the spine, not vertically downward. Use additional pressure with chest compressions. Pregnancy-related decreased chest-wall compliance decreases the efficiency of chest compressions. Anteroposterior placement of electrode pads can avoid difficulties associated with increased breast size (Castle, 2007). If it is not possible to completely seal the patient’s mouth for reasons such as oral trauma, perform mouth-to-nose breathing. If the patient has a tracheostomy, provide ventilations through the tracheostomy instead of the mouth. Be aware that in 2008, the American Heart Association instituted changes in their suggestions regarding emergency interventions outside of healthcare facilities. Learning conventional CPR is still recommended. However, the AHA alternately recommends when an adult suddenly collapses, persons near the victim should call 911 (activate the emergency response system), and push hard and fast in the center of the victim’s chest. Studies of real emergencies that have occurred in homes, at work or in public locations, show that these two steps, called Hands-Only CPR, can be as effective as conventional CPR. Providing Hands-Only CPR to an adult who has collapsed from a sudden cardiac arrest can more than double that person’s chance of survival (AHA, 2008). Know that Hands-Only CPR is not recommended for victims of drowning, trauma, airway obstruction, and acute respiratory distress (AHA, 2008). Infant and Child Considerations Once a child reaches puberty (breast development on the female; underarm, chest, and facial hair on the male), use adult CPR guidelines for resuscitation (AHA, 2006). As soon as it is determined that an infant or child is unresponsive, shout for help. If you are alone, initiate CPR immediately for approximately 2 minutes (about five cycles of CPR) at the rate of 100 compressions per minute (compression-to-ventilation ratio 30 to 2), before leaving the infant/child to activate the emergency response system. If the child is small and it is safe to do so, consider carrying the child with you to activate the emergency response system. If the child suddenly collapses, first activate the emergency response system and get an AED, if available, then begin CPR. If the victim is age 1 to puberty, use the heel of one or two hands to provide chest compressions, based on child’s body size. Depth of compressions is one-third to one-half the depth of the chest. For an infant under 1 year of age, use two or three fingers placed in the midline one fingerbreadth below the nipple line and compress one-third to one-half the depth of the chest. To open the airway of a child, place one hand on the child’s forehead and gently lift the chin with the other hand (called the sniffing position in infants). If head or neck injury is suspected, use the jaw-thrust method. If available, use a one-way valve mask over the child’s nose and mouth when performing CPR. Perform rescue breathing for infants and children with a pulse at a rate of one breath every 3 to 5 seconds, to deliver 12 to 20 breaths per minute. Be aware that Hands-Only CPR is not recommended for unresponsive infants and children (AHA, 2008). (continued) 858 UNIT II 16-5 EVIDENCE FOR PRACTICE 16-6 Promoting Healthy Physiologic Responses Performing Cardiopulmonary Resuscitation (CPR) continued The American Heart Association provides guidelines for cardiopulmonary resuscitation and emergency cardiac care and has incorporated these guidelines into the Basic Life Support and Advanced Life Support education for healthcare providers who respond to cardiovascular and respiratory emergencies. American Heart Association (AHA). (2005a). Advanced life support: 2005 International consensus conference on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation, 112(22 Suppl.), III25–III54. American Heart Association (AHA). (2006). BLS for healthcare providers. Dallas, TX: Author. Performing Emergency Automated External Defibrillation The most frequent initial cardiac rhythm in witnessed sudden cardiac arrest is ventricular fibrillation (AHA, 2005b). Electrical defibrillation is the most effective treatment for ventricular fibrillation. Electrical therapy can be administered by defibrillation, cardioversion, or a pacemaker. (See Fundamentals Review 16-1 at the beginning of the chapter.) Early defibrillation is critical to increase patient survival (AHA, 2006). Defibrillation delivers large amounts of electric current to a patient over brief periods of time. It is the standard treatment for ventricular fibrillation (VF) and is also used to treat pulseless ventricular tachycardia (VT). The goal is to depolarize the irregularly beating heart temporarily and allow more coordinated contractile activity to resume. It does so by completely depolarizing the myocardium, producing a momentary asystole. This provides an opportunity for the natural pacemaker centers of the heart to resume normal activity. The automated external defibrillator (AED) is a portable external defibrillator that automatically detects and interprets the heart’s rhythm and informs the operator if a shock is indicated. AEDs are appropriate for use in situations where the patient is unresponsive, not breathing, and has no pulse (AHA, 2006). The defibrillator responds to the patient information by advising ‘shock’ or ‘no shock.’ Fully automatic models automatically perform rhythm analysis and shock, if indicated. These are usually found in out-of-hospital settings. Semiautomatic models require the operator to press an ‘Analyze’ button to initiate rhythm analysis and then press a ‘Shock’ button to deliver the shock, if indicated. Semiautomatic models are usually found in the hospital setting. AED will not deliver a shock unless the electrode pads are correctly attached and a shockable rhythm is detected. Some AEDs have motion-detection devices that ensure the defibrillator will not discharge if there is motion, such as motion from personnel in contact with the patient. The strength of the charge is preset. Once the pads are in place and the device is turned on, follow the prompts given by the device. The following guidelines are based on the American Heart Association (AHA, 2005a) guidelines. AHA guidelines state that these recommendations may be modified for the in-hospital setting, where continuous electrocardiographic or hemodynamic monitoring may be in place. Current recommendations call for the application of the AED as soon as it is available, allowing for analysis of cardiac status and delivery of an initial shock, if indicated, for adults and children. After an initial shock, deliver five cycles of chest compressions/ventilations (30/2), and then reanalyze cardiac rhythm. Provide sets of one shock alternating with 2 minutes of CPR until the AED indicates a ‘no shock indicated’ message or until ACLS is available (AHA, 2006). In the hospital setting, it is imperative that personnel be aware of the patient’s stated instructions regarding a wish not to be resuscitated. This should be clearly expressed and documented in the patient’s medical record. EQUIPMENT Automated external defibrillator (AED) Self-adhesive, pregelled monitor-defibrillator pads (6) Cables to connect the pads and AED Razor Towel Some models have the pads, cables, and AED preconnected. LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 859 Aptara CHAPTER 16 Cardiovascular Care ASSESSMENT BOX 16-2 859 Assess the patient for unresponsiveness, effective breathing, and signs of circulation. Assess the patient’s vital parameters and determine the patient’s level of responsiveness. Check for partial or complete airway obstruction. Assess for the absence or ineffectiveness of respirations. Assess for the absence of signs of circulation and pulses. AED should be used only when a patient is unresponsive, not breathing, and without signs of circulation (pulseless, lack of effective respirations, coughing, moving). Determine the age of the patient; some AED systems are designed to deliver both adult and child shock doses. Choose correct electrode pad for size/age of patient. If available, use child pads or a child system for children less than 8 years of age. Determine whether special situations exist that require additional actions before the AED is used or contraindicate for its use. (Refer to Box 16-2, Special Situations Related to AED, for details of these situations and appropriate actions.) SPECIAL SITUATIONS RELATED TO AUTOMATED EXTERNAL DEFIBRILLATION (AED) The patient is in or near standing water. Water is a good conductor of electricity. Defibrillation administered to a patient in water could result in shocking the AED operator and bystanders. Another possible effect is that water on the patient’s skin will provide a direct path for the electrical current from one electrode to the other. The arcing of the electrical current between the electrodes bypasses the heart, resulting in the delivery of inadequate current to the heart. Patients should be removed from standing water and the chest quickly dried before initiating AED. The patient has an implanted pacemaker. Place the AED electrode pad at least 1 inch to the side of the implanted device. If an AED electrode pad is placed directly over an implanted device, the device may block delivery of the shock to the heart. If the implanted device is delivering shocks to the patient (observed external chest muscle contractions), wait 30 to 60 seconds for the device to complete the treatment cycle before delivering a shock from the AED. A transdermal medication patch or other object is located on the patient’s skin where the electrode pads are to be placed. Remove the patch and wipe the area clean before attaching the electrode pads. Do not place the electrode pad directly on top of a medication patch. The patch may block the delivery of energy to the heart. (Adapted from American Heart Association.. BLS for healthcare providers. Dallas, TX: Author.) NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Decreased Cardiac Output Impaired Gas Exchange Ineffective Airway Clearance Risk for Ineffective Cerebral Tissue Perfusion Impaired Spontaneous Ventilation Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when performing automatic external defibrillation is that it is performed correctly without adverse effect to the patient, and the patient regains signs of circulation, with organized electrical rhythm and pulse. Additional outcomes include the following: the patient regains respirations; the patient’s heart and lungs maintain adequate function to sustain life; the patient does not experience serious injury; and advanced cardiac life support is initiated. IMPLEMENTATION ACTION R AT I O N A L E 1. Assess responsiveness. If the patient is not responsive, call for help and pull call bell, and call the facility emergency response number. Call for the AED. Put on gloves, if available. Perform cardiopulmonary resuscitation (CPR) until the defibrillator and other emergency equipment arrive. Assessing responsiveness prevents starting CPR on a conscious victim. Activating the emergency response system initiates a rapid response. Gloves prevent contact with blood and body fluids. Initiating CPR preserves heart and brain function while awaiting defibrillation. 2. Prepare the AED. Power on the AED. Push the power button. Some devices will turn on automatically when the lid or case is opened. Proper setup ensures proper functioning. (continued) LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 860 Aptara 860 UNIT II 16-6 Promoting Healthy Physiologic Responses Performing Emergency Automated External Defibrillation continued ACTION R AT I O N A L E Proper setup ensures proper functioning. 4. Stop chest compressions. Peel away the covering from the electrode pads to expose the adhesive surface. Attach the electrode pads to the patient’s chest. Place one pad on the upper right sternal border, directly below the clavicle. Place the second pad lateral to the left nipple, with the top margin of the pad a few inches below the axilla (Figure 1). Proper setup ensures proper functioning. The use of self-adhesive pads allows hands-free defibrillation and excellent skin–electrode contact, which provides lower impedance, less artifact, and greater user safety (Dwyer et al., 2004). 5. Once the pads are in place and the device is turned on, follow the prompts given by the device. Clear the patient and analyze the rhythm. Ensure no one is touching the patient. Loudly state a “Clear the patient” message. Press ‘Analyze’ button to initiate analysis, if necessary. Some devices automatically begin analysis when the pads are attached. Avoid all movement affecting the patient during analysis. Movement and electrical impulses cause artifact during analysis. Avoidance of artifact ensures accurate rhythm analysis. Avoidance of contact with patient avoids accidental shock to personnel. 6. If ventricular tachycardia or ventricular fibrillation is present, the device will announce that a shock is indicated and begin charging. Once the AED is charged, a message will be delivered to shock the patient. Shock message is delivered through a written or visual message on the AED screen, an auditory alarm, or a voice-synthesized statement. 7. Before pressing the ‘Shock’ button, loudly state a “Clear the patient” message. Visually check that no one is in contact with the patient (Figure 2). Press the ‘Shock’ button. If the AED is fully automatic, a shock will be delivered automatically. Ensuring a clear patient avoids accidental shocking of personnel. FIGURE 1. AED electrode pad placement. FIGURE 2. Clearing the patient. A 3. Attach AED connecting cables to the AED (may be preconnected). Attach AED cables to the adhesive electrode pads (may be preconnected). E D LWBK545_C16_p830-872.qxd 8/6/10 8:48 PM Page 861 Aptara CHAPTER 16 Cardiovascular Care ACTION R AT I O N A L E 8. Immediately resume CPR, beginning with chest compressions. After five cycles (about 2 minutes), allow the AED to analyze the heart rhythm. If a shock is not advised, resume CPR, beginning with chest compressions. Do not recheck to see if there is a pulse. Follow the AED voice prompts. Continue until advanced care providers take over, the patient starts to move, you are too exhausted to continue, or a physician discontinues CPR. Advanced care providers will indicate when a pulse check or other therapies are appropriate (AHA, 2006, p. 34). 9. Remove gloves, if used. Perform hand hygiene. EVALUATION 861 Resuming CPR provides optimal treatment. CPR preserves heart, and neurologic function (based on AHA 2006 recommended guidelines). Even when a shock eliminates the dysrhythmia, it may take several minutes for a heart rhythm to establish and even longer to achieve perfusion. Chest compressions can provide coronary and cerebral perfusion during this period (Zed, et al., 2008). Some AEDs in the community for use by lay persons are automatically programmed to cycle through three analysis/shock cycles in one set. This would necessitate turning the AED off after the first shock and turning it back on for future analysis and defibrillation. Be familiar with the type of AED available for use. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms. The expected outcome is achieved when automatic external defibrillation is applied correctly without adverse effect to the patient and the patient regains signs of circulation. Additional outcomes may include the following: the patient regains respirations; the patient’s heart and lungs maintain adequate function to sustain life; the patient does not experience injury; and advanced cardiac life support is initiated. DOCUMENTATION Guidelines Sample Documentation Document the time you discovered the patient unresponsive and started CPR. Document the time(s) AED shocks are initiated. Continued intervention, such as by the code team, is typically documented on a code form, which identifies the actions and drugs provided during the code. Provide a summary of these events in the patient’s medical record. 07/06/12 2230 Called to patient’s room by wife. Patient noted to be without evidence of respirations or circulation. Emergency response system activated, CPR initiated. AED applied at 2232. See code sheet. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS A ‘Check pads’ or ‘Check electrodes’ message appears on the AED: The electrode pads are not securely attached to the chest or the cables are not securely fastened. Check that the pads are firmly and evenly adhered to the patient’s skin. Verify connections between the cables and the AED and the cables and electrode pads. Check that the patient is not wet or diaphoretic, or has excessive chest hair. See actions below for appropriate interventions in these situations. The patient has a hairy chest: The adhesive electrode pads may stick to the hair of the chest instead of the skin, preventing adequate contact with the skin. Press firmly on the current pads to attempt to provide sufficient adhesion. If unsuccessful, briskly remove the current pads to remove a good portion of the chest hair. If a significant amount of hair remains, shave the area with the razor in the AED case. Apply a second set of electrode pads over the same sites. Continue with the procedure. The patient is noticeably diaphoretic or the skin is wet: The electrode pads will not attach firmly to wet or diaphoretic skin. Dry the chest with a cloth or towel before attaching the electrode pads. SPECIAL CONSIDERATIONS General Considerations Appropriate maintenance of the AED is crit