Introduction to Critical Care Nursing (Emergency Care) PDF

LESSON 2: INTRODUCTION TO CRITICAL CARE NURSING (EMERGENCY CARE - HOSPITAL SET-UP) (Prepared By: Elaine Joy A. Kahulugan, RN) Learning Objectives After 4 hours of lecture-discussion, the students will be able to: 1. Define the philosophy, concept, scop...

LESSON 2: INTRODUCTION TO CRITICAL CARE NURSING (EMERGENCY CARE - HOSPITAL SET-UP) (Prepared By: Elaine Joy A. Kahulugan, RN) Learning Objectives After 4 hours of lecture-discussion, the students will be able to: 1. Define the philosophy, concept, scope and principles of emergency care nursing practice; 2. Identify the qualifications and qualities of an emergency room nurse as care provider; and 3. Familiarize Emergency Room assessment and the safety and infection control. Topic Outline: Philosophy ⚫ Care is provided in any setting to persons. Of all ages with actual or perceived alterations in physical or emotional health. ⚫ Respond to any trauma or sudden illness that requires immediate intervention to prevent imminent severe damage or death. ⚫ Emergency nursing is the provision of immediate nursing care to people who have identified their problem as an emergency or where nursing intervention may prevent an emergency arising. ⚫ The emergency nurse must lead, initiate, and coordinate patient care that includes rapid patient assessment, prioritizing care, appropriate intervention- based on assessment, ongoing evaluation, and discharge or referral to other sources including discharge education. Concept of Emergency Nursing ⚫ The term emergency is used for those patients who require immediate action to prevent further deterioration or stabilizing the condition until the availability of the services close to the patients. ⚫ “ Emergency has been defined as a condition determined clinically or considered by the patient or his/her relatives as requiring urgent medical services, failing which, it could result in loss of life or limb”.-Who ⚫ Medical emergency is a situation when patient requires urgent & high quality medical care to prevent loss of life or limb and/or to initiate action for the restoration of normal healthy life. ⚫ Emergency care can be defined as the episodic and crisis-oriented care provided to patients with conditions ranging from minor to serious or life-threatening injuries or illnesses. ⚫ Emergency management traditionally refers to urgent and critical care needs; however, the ED has increasingly been used for non-urgent problems, and emergency management has  broadened to include the concept that an emergency is whatever the patient or family considers it to be. ⚫ Emergency nursing is a specialty within the field of professional nursing focusing on the care of patients with medical emergencies, that is, those who require prompt medical attention to avoid long-term disability or death. Scope and Practice of Emergency Nursing Emergency management traditionally refers to urgent and critical care needs. The Emergency Department (ED) has increasingly been used for non- urgent problems Emergency management has broadened to include that an emergency is whatever the patient or family considers it to be. The emergency room staff work as a team. Principles of Emergency Care ⚫ Quick assessment of patient to institute life saving measures. ⚫ Keep patient casualty in dorsal position and cover his/her body with whatever cloth is available to prevent heat loss. ⚫ Avoid unnecessary handling except to remove the patient from additional danger. ⚫ Give first aid to the injured part. ⚫ Observed and keep a medical record of the patient’s initial condition ⚫ Reassurance should be given to the patient and relatives that he/she is in safe hands. ⚫ Maintain patent airway & provide adequate ventilation employing resuscitation measures when necessary ⚫ Control hemorrhage & its consequences ⚫ Evaluate and restore cardiac output ⚫ Prevent and treat shock, maintain or restore effective circulation ⚫ Carry out a rapid initial and ongoing physical examination ⚫ Assess the patient consciousness, whether the patient can follow commands or not, evaluate the size & reactivity of pupils ⚫ Start ECG monitoring if appropriate ⚫ Apply splint of suspected fractures sites including cervical spines in patients with head injuries ⚫ Protect wounds with sterile dressings ⚫ Start a flow sheet of patient’s vital sign, neurological state, to guide in decision-making  ⚫ Prevent people crowding near the patient; allow fresh air to circulate around the patient ⚫ Do not give water to drink to the patient with abdominal injuries as it may requiring immediate surgery and or to patient who is in respiratory distress Qualifications of Emergency Room Nurse A graduate of Bachelor of Science in Nursing A registered nurse Knowledgeable and skillful for technology and equipment used in emergency care setting Must have a basic understanding of triage nursing Must be calm and collected under pressure and must be sympathetic to patients and their families. Must be detailed-oriented, as doctor’s orders must be carried out instantly and correctly in emergency rooms. Must also be able to emotionally handle the daily sight of physical suffering and the reality that some patients may not be able to saved, despite everyone’s best efforts. Qualities of Emergency Room Nurse The nurses working in emergency or trauma units must have specialized skills in handling emergencies. Some of these skills are: Observation and assessment skills Quick decision making skills Patient care skills in emergency situations. Emotional stability Self-confidence with ability to lead and control the patients as well as attendants. Recording and reporting skills. Safety and Infection Control Disease can be directly transmitted in two ways: A. Vertical disease transmission- passing a disease causing agent vertically from parent to offspring, such as perinatal transmission. Example: ⚫ HIV  ⚫ Varicella zoster virus ⚫ Rubella ⚫ Herpes viruses B. Horizontal disease transmission- the spread of an infectious agent from one individual to another, usually through contact with bodily excretions or fluids, such as sputum or blood, that contain the agent. 1. Airborne Transmission Occurs when bacteria or viruses travel on dust particles or on small respiratory droplets that may become aerosolized when people sneeze, cough, laugh, or exhale. They hang in the air much like invisible smoke. They can travel on air currents over considerable distances. Examples: Anthrax(inhalation), Smallpox, Tuberculosis, Measles, Chickenpox Precautions: a. Be in a different room from the person who is ill, with a closed door in between. b. If you need to be in the same room, wearing a mask may help for a brief exposure. c. Covering the mouth or nose when coughing or sneezing decrease the risk of transmission. 2. Droplet Precaution Occurs when the bacteria or viruses travel on relatively large respiratory droplets that people sneeze, cough, drip, or exhale. They travel only short distance before settling, usually less than 3 feet. They can be spread directly if people are close enough to each other. The droplets land on hands, toys, tables, mats, or other surface, where they sometimes remain infectious for hours. Examples: Common colds, Diphtheria, Influenza, Meningitis, Mumps, Pertussis (whooping cough), Sars ncov-2 (covid 19) Precautions: a. Frequent hand washing help prevent transmission. b. Covering mouth or nose when coughing or sneezing decrease droplet transmission  c. Using of face mask and face shield at all times. d. Cleaning or disinfecting commonly touched infected surface (doorknobs, shared toys, cellphone, keys and etc.) Can also help. 3. Contact Precaution Requires some form of touch to spread an infection. It is divided into two: A. Direct contact transmission- involves immediate contact between two people (or with an animal). B. Indirect contact transmission- involves fomites; an object that becomes contaminated by touch then spreads the infection by touch. Examples: Abscess, Diphtheria (cutaneous), Lice, Scabies, Athlete’s foot, Conjunctivitis (“pink eye”) Precautions: a. Avoid direct contact with infected person especially when there is a break in the skin. b. Frequent hand washing c. Surface disinfecting can interrupt some disease transmission. d. Avoid sharing hairbrushes, combs, and hats. 4. Reverse Transmission The patient is being protected from nurse and all the people in contact with the patient. Examples: Immunocompromised patients, Cancer patients undergoing chemotherapy Assessment in ER ⚫ The Primary Survey- focuses on stabilizing life-threatening conditions; employs the ABCD method. Airway- establish the airway Breathing- provide adequate ventilation Circulation- evaluate & restore cardiac output by controlling hemorrhage, preventing & treating shock, and maintaining or restoring effective circulation Disability- determine neurologic disability by assessing neuro function using the Glasgow coma scale (GCS)  Generally, brain injury is classified as: Severe GCS ≤ 8, Moderate GCS 9–12, Minor GCS ≥ 13 and above The GCS has limited applicability to children, especially below the age of 36 months (where the verbal performance of even a healthy child would be expected to be poor). Pediatric Glasgow coma scale- a separate yet closely related scale, was developed for assessing younger children. ADULT GLASCOW COMA SCALE ⚫ The Secondary Survey is to assess and intervene. Includes the following: ⚫ A complete health history & head- to- toe assessment ⚫ Diagnostic & laboratory testing ⚫ Application of monitoring devices ⚫ Splinting of suspected fractures ⚫ Cleaning & dressing of wounds ⚫ Performance of other necessary interventions based on the patient’s condition. Emergency Cart (E-Cart or Crash Cart) ⚫ A cart stocked with emergency medical equipment, supplies, and drugs for use by medical personnel especially during efforts to resuscitate a patient experiencing cardiac arrest. ⚫ Located in designated areas where medical emergencies and resuscitation is needed ⚫ Purpose: to maximize the efficiency in locating medications/supplies needed for emergency situations. ⚫ Example of E-Cart Arrangement Upper portion: cardiac monitor, face shields Drawer 1: laryngoscope (adult & pedia ), guide wires, surgical types Drawer 2 & 3 : contains medication needed during a code such as epinephrine, atropine, lidocaine spray or lidocaine polyamp, sodium bicarbonate, dopamine amp, dobutamine amp, activated charcoal, amiodarone, d50 50 water, syringes (50ml, 25ml, 10ml, 5ml, 3ml, 1ml), and etc. Drawer 4:endotracheal tube size & color (8.5, 8, 7.5, 7,6.5, 6, 5.5, 5, 4.5, 4, 3.5, 3, 2.5, 2), nasogastric tube size & color (16 orange, 14 green, 12 white, 10 black, 8 blue, 5 grey), asepto syringe, oropharyngeal airway size & color (4 red, 3 yellow, 2 green, 1 white, 0 grey, 00 blue, 000 pink), foley catheter tubes size and color (20 violet, 18 red, 16 orange, 14 green, 12 white, 8 black), urobag, oxygen tubings adult & pedia (nasal, face mask, non-rebreather mask. Drawer 5: iv fluids 1l & 500ml (pnss green, plr blue, d5 0.3nacl baby blue, d5nm orange, d5 water red ,d5nss yellow, d5nr yellow green, d5 imb violet), gelofusine 500ml, premix dobutamine 500/250,250/250, dopamine 200/250, 400/250, bag-valve-mask adult and pedia, anchor fast, 4 & 2 way restraints, aprons. Side or back of the cart: cardiac board. LESSON 1: INTRODUCTION TO CRITICAL CARE NURSING (INTENSIVE CARE) (Prepared By: Elaine Joy A. Kahulugan, RN) Learning Objectives After 4 hours of lecture-discussion, the students will be able to: 1. Determine the philosophy, goals, and scope of critical care nursing practice; 2. Distinguish the roles of critical care nurses as care provider; and 3. Value professionalism in critical care nursing through the competencies, standards, specialization, and ethics in the practice. Topic Outline: Philosophy Critical care nursing reflects a holistic approach It places great emphasis on the caring of the bio-psycho-social-spiritual nature and responses to illnesses rather than salary on the disease process. It helps maintain the individual patient’s identity and dignity. The focus of caring includes preventive care, risk factor modification and education to decrease future patient admissions to acute care facilities. In the Critical Care Units, each patient is viewed as a unique individual with dignity and worth. The critically ill patient should receive comfort and provided privacy in a highly technological environment. In collaboration with other health care team members, critical care nurses provide high level of patient care which includes patient and family education, health promotion and rehabilitation. To achieve this holistic care process, participation by the patient and his/her family is always emphasized. At the forefront of critical care science and technology, critical care nurses maintain professional competence based on a broad base of knowledge and experience through continuous education and evidence-based research. With the advances in sophisticated biomedical technology and knowledge, critical care nurses are able to continuously monitor and observe patients for physiological changes to confront problems proactively and to assist patients achieve and maintain an optimum level of functioning or a peaceful death. Goals To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the physiological dysfunction as well as the psychological stress in the ICU are under control To care for the critically ill patients with a holistic approach, considering the patient's biological, psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting. To use relevant and up-to-date knowledge, caring attitude and clinical skills, supported by advanced technology for prevention, early detection and treatment of complications in order to facilitate recovery. To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to the patients and families to go through the painful sufferings. On the whole, critical care nursing should be patient-centered, safe, effective, and efficient. The nursing interventions are expected to be delivered in a timely and equitable manner. Scope Constant intensive assessment, timely critical care interventions and continuous evaluation of management through multidisciplinary efforts are required to restore stability, prevent complications, and achieve optimal health. Palliative care should be instituted to alleviate pain and sufferings of the patient and family in situations where death is imminent. The scope of critical care nursing is defined by the dynamic interaction of the critically ill patient, the critical care nurse and the critical care environment in order to bring about optimal patient outcomes through nursing proficiency within an environment conducive to the provision of this highly specialized care. Critical Care Nurses are registered nurses, who are trained and qualified to practice critical care nursing. They possess the standard critical care nursing competencies in assuming specialized and expanded roles in caring for the critically ill patients and their family. Likewise, the critical care nurse is personally responsible and committed to continues learning and updating of knowledge and skills. The critical care nurses carry out interventions and collaborates patient care activities to address life-threatening situations that will meet patient's biological, psychological, cultural and spiritual needs. The critical care environment constantly supports the interaction between the critically ill patients, their family and the critical care nurses to achieve desired patient outcomes. It entails readily available and accessible emergency equipment, sufficient supplies and effective supporting system to ensure quality patient care as well as staff safety and productivity. Role of Critical Care Nurse The critical care nurses execute their practice roles 24-hours a day to provide high quality care to the critically ill patient. Care Provider Direct Patient Care Indirect Patient Care A. Direct Patient Care Detects and interprets indicators that signify the varying conditions of the critically ill with the assistance of advanced technology and knowledge; Plans and initiates nursing process to its full capacity in a need driven and proactive manner; Acts promptly and judiciously to prevent or halt deterioration of patients’ condition when conditions warrant, and Co-ordinates with other healthcare providers in the provision of optimal care to achieve the best possible outcomes. B. Indirect patient care – Care of the Family Understands family needs and provide information to allay fears and anxieties and Assists family to cope with the life-threatening situation and/or patient’s impending death. Critical care nurses have roles beyond their professional boundary. With proper training and in accordance with established guidelines, algorithms, and protocols that are continuously reviewed and updated, critical care nurses also perform procedures and therapies that are otherwise done by doctors. Such procedures and therapies are: a. Sampling and analyzing arterial blood gases; b. Weaning patients off ventilators; c. Adjusting intravenous analgesia / sedations; e. Performing and interpreting ECGs; f. Titrating intravenous and central line medicated infusion and nutrition support; g. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular tachycardia; h. Removal of pacer wire, femoral sheaths and chest tubes, and  i. Other procedures deemed necessary in their respective institutions under a clinical protocol. Competencies/Standards of Critical Care Nursing Practice Competencies The competence of critical care nurses together with established nursing standards and the identified core competencies for registered nurses will result to excellence in critical care nursing practice. This three-pronged holistic framework ensures quality performance through: a. an adherence to nursing standards, b. the demonstration of competencies, and c. the integration of appropriate nursing model/s into the health care delivery process. To achieve safe and quality client-centered care, nurses working in the critical care units are envisioned to adopt not only the stated core competencies of registered nurses but also the specific competencies stipulated in the following eleven major key responsibility areas: Safe and Quality Nursing Care Management of Resources Legal Responsibilities Ethico-Moral Responsibilities Collaboration and Teamwork Personal and Professional Development Communication Health Education Quality Improvement Research Record Management Standards Care standards for critical care nursing provide measures for determining the quality of care delivered, and also serve as means for recognizing the competencies of nurses in intensive care specialty. Procedures standards for critical care nursing practice provide a step-by-step guideline for nurses to carry out day-to-day nursing procedure in a most appropriate manner. 11 Standards 1. The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice. 2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis. 3. The critical care nurse practices current critical care nursing competently. 4. The critical care nurse delivers nursing care in a way that can be ethically justified. 5. The critical care nurse demonstrates accountability for his/her professional judgment and actions. 6. The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff. 7. The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients. 8. The critical care nurse protects the patients from developing environmental induced infection. 9. The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care. 10. The critical care nurse carries out health education for promotion and maintenance of health. 11. The critical care nurse acts to enhance the professional development of self and others. Challenges in Critical Care Nursing The challenging needs from the critical care nursing service and its environments demand the nurses: To develop, foster and maintain a level of knowledge about the norms, values, beliefs, patterns of ill health and care needs of the people; To analyze and evaluate specialist skills and criticize their evolving roles; To review current studies and researches and to examine contextual issues thus enabling evaluation and synthesis of new knowledge, traditional techniques, religious and cultural influences to be applied in nursing practice, particularly, evidence-based nursing practice; and To exercise professional judgments expected of them in the critical care clinical setting. Critical Care Environment Categories of Care The Critical Care Unit can be categorized according to patients’ age group or medical specialties. A. Age Group Neonatal Pediatric Adult B. Specialty Medical Surgical Cardio-thoracic Cardiac Respiratory Neurosurgical Trauma Ethics in Critical Care Informed Consent It is common for healthcare providers and family members to question the decision-making ability of critically ill patients due to: being intubated experiencing pain depressed and not capable of thinking clearly. Whenever possible, patients should be allowed to participate in the consent process, and it has been shown that they remember and value the participation (Sims, 2008). However, many critically ill patients lack the capacity to give informed consent. A determination of incapacity does not require a legal proceeding; it is a clinical judgment that can be assessed during conversation with the patient. During the period of incapacity, a surrogate healthcare decision maker might be requested to consent to treatment for the patient.  If a surrogate decision maker is having difficulty determining what ought to be done, the nurse might explain that there are two common ethically accepted modes for making surrogate decisions. First Method: Best Interest Standard the decision maker decides what he believes is in the best interests of the patient. For example, following his wife’s stroke a husband might decide that she would consent to administration of rTPA because it would be in her best interests to have minimal neurological impairment. The Second Method: Substituted Judgment The surrogate decides what he thinks the patient would have decided had she been able to make the decision. For example, a husband might realize that his wife had been in atrial fibrillation and heart failure prior to her stroke and had been saying for months that she could not go on anymore. He might decide that she would not have consented to the treatment, so he would make that decision for her. Whether it is the patient or a surrogate who is making the decision, it is essential that the decision maker have adequate information about the possible treatment(s) to make a decision. Although the nurse does not usually provide the initial information for the informed consent, it is the nurse who consistently reinforces the teaching and ensures that the decision maker understands. Assisting a critically ill patient or the patient’s surrogate to make a decision is not easy. As Rosenbaum (2015) notes, it is possible to provide too much information to the decision maker leading to cognitive overload and a poor decision. When the patient is critically ill, the decision maker may be in crisis, emotionally overwhelmed and unable to process information. It is imperative that the nurse calm the decision maker, then explain the information repeatedly and listen to determine if it has been understood. Conflict is more likely to develop when healthcare providers, patients and families, or decision makers do not have a common understanding of the proposed treatment(s), or when they disagree about what the patient would have wanted or what is in the patient’s best interests. Use of Restraints Nurses’ primary motivation in restraining these patients was beneficence, acting to prevent patients from the harm they might incur if they tried to: pull out an endotracheal tube or IV, move around in bed unassisted, or inadvertently disconnect ventilator tubing.  However, ethicists have been deeply concerned about the practice. They believe that the principle of nonmaleficence (or not harming a patient) should always take precedence over beneficence (attempting to do good for a patient). As researchers studied restraints, nurses learned that restraining a patient causes physical harm. When people are restrained, they become: weak, incontinent, constipated, and to develop nosocomial infections recover more slowly Studies determined that the main factors in the nurses’ decisions to use restraints were the: Glasgow Coma Scale score, restless behavior, emotional state, discomfort factors, medical devices, and life-sustaining devices Alternative: Sedation This is concerning because patients who are more sedated have been demonstrated to spend more time on a ventilator, in the ICU, and in the hospital. Cho et al. (2006) concluded and Chang et al. (2008) reaffirmed that better guidelines on the use of restraints should be developed, taught, and followed. Until then, nurses need to make the decision to restrain patients carefully, obtain consent, if possible, follow available guidelines, and be diligent in their efforts to prevent untoward effects. LESSON 3: CARE OF CRITICALLY ILL CLIENTS WITH PROBLEMS IN RESPIRATORY SYSTEM (Prepared By: Elaine Joy A. Kahulugan, RN) Learning Objectives After 4 hours of lecture-discussion, the students will be able to: Define the meaning of Respiratory Failure and its classification; Identify different respiratory modalities; and Familiarize the different Mechanical ventilator alarm codes. Topic Outline: 1. Respiratory Failure 2. Respiratory Modalities for Respiratory Failure 3. ABG RESPIRATORY FAILURE - It is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. - TYPES: 1. Acute Respiratory Failure: - The loss of the ability to ventilate adequately or to provide sufficient oxygen to the blood and systemic organs. The pulmonary system is no longer able to meet the metabolic demands of the body with respect to oxygenation of the blood and/or CO2 elimination. 2. Chronic respiratory failure - Chronic respiratory failure usually happens when the airways that carry air to the lungs become narrow and damaged. This limits air movement through the body, which means that less oxygen gets in and less carbon dioxide gets out. - is a serious illness that gets worse over time. As the condition increases in severity, people may develop an abnormal heart rhythm, stop breathing, or slip into a coma. -Causes (Diseases and conditions that commonly lead to chronic respiratory failure): - chronic obstructive pulmonary disease (COPD) -complicated pneumonia -cystic fibrosis -spinal cord injuries -stroke -muscular dystrophy -ALS (Lou Gehrig’s disease) -injury to the chest -drug or alcohol misuse -smoking  -Signs and symptoms: -difficulty breathing or shortness of breath, especially when active-coughing up mucous-wheezing-bluish tint to the skin, lips, or fingernails-rapid breathing-fatigue- anxiety-confusion-daily headache -Treatment Chronic respiratory failure may be managed at home, depending on its cause. In severe cases, medical professionals can help you manage the condition in a long-term healthcare center. -Treatment options include: a. treating the underlying cause of respiratory failure b. removing excess carbon dioxide from the blood c. increasing oxygen levels in the blood - CLASSIFICATION: Type I Respiratory Failure (hypoxemic) - Hypoxemic respiratory failure. This means that a person is not exchanging oxygen properly in its lungs. This may be due to swelling or damage to the lungs. - A person with type 1 acute respiratory failure has very low oxygen levels. - Therapies for acute hypoxemic respiratory failure include; -Oxygen -PEEP (Positive end-expiratory pressure) -Diuresis -Prone Position -Permissive hypercapnia -Inverse Ratio Ventilation or Pressure Control Ventilation Type II Respiratory Failure (hypercapnic) - In a person with type 2 acute respiratory failure, the lungs are not removing enough carbon dioxide, which is a gas and a waste product. The lungs usually exchange carbon dioxide for fresh oxygen.- This type of respiratory failure causes carbon dioxide levels to be high. It may result from a drug overdose that has caused a person to breathe too slowly, or because of lung damage from smoking, which causes COPD. - There are two concepts that we need to understand: 1. Ventilatory supply - The maximum ventilation that the body can sustain without developing respiratory muscle fatigue. 2. Ventilatory demand -This is the amount of ventilation needed to keep the PaO2 within normal limits. -Respiratory supply > Respiratory demand -16-20 breaths/min -During exercise this increases about 40-50 breaths/min. Even with that sudden increase the supply is still always greater than the demand. - Obstructive disease 1. COPD 2. Bronchitis  - Because of the obstruction: Less CO2 is exhaled out of the body Body breaths double time in attempt to release the “excess” CO2 The respiratory demand exceeds respiratory supply. Exceeding respiratory supply causes the respiratory muscles to fatigue, which eventually will lead to RESPIRATORY FAILURE! SIGNS AND SYMPTOMS OF SIGNS AND SYMPTOMS OF HYPOXEMIA HYPERCAPNIA Dyspnea, irritability Headache Confusion, somnolence, fits Change of behavior Tachycardia, arrhythmia Coma Tachypnea Papilledema Cyanosis Warm extremities -Detecting Type I and Type II Respiratory Failure - Blood gas analysis: helps professionals identify the type of respiratory failure, which is crucial to indicate what respiratory support may be needed. Blood gas analysis will also be useful in monitoring the clinical condition throughout treatment and recovery. - Pulse oximetry: gives a continuous measure of blood oxygen saturation. - ECG: to monitor cardiac function as tachycardia and cardiac arrhythmias may result from hypoxemia and acidosis. -Capnography: provides a continuous reading of respiratory function and end tidal CO2. Type III Respiratory Failure - Doctors refer to this as perioperative respiratory failure. It occurs when a person has had surgery, and the small airways in the lungs have closed in greater numbers -Factors such as pain or stomach surgery, which places higher pressure on the lungs, can also contribute to this type of respiratory failure. -Causes: - Decreased Functional Residual Capacity (FRC) - Supine/ obese/ ascites - Anesthesia - Upper abdominal incision - Airway secretions -Therapy reversing atelectasis: - Turn patient q1-2h - Chest physiotherapy - Incentive spirometry - Treat incisional pain (may include epidural anesthesia or patient controlled analgesia) - Ventilate at 45 degrees upright - Drain ascites - Re-expansion of lobar collapse - Avoid overhydration  Type IV Respiratory Failure - It is a shock state. The body cannot adequately provide oxygen and maintain blood pressure on its own. - This can result from serious illness or injury, such as when a person loses too much blood. - Hypoperfusion can lead to respiratory failure. Ventilator therapy is often instituted in order to minimize the steal of the limited cardiac output by the overworking respiratory muscles until the etiology of the hypoperfusion state is identified and corrected. a. Cardiogenic - Is a life-threatening condition where your heart suddenly stops pumping enough oxygen-rich blood to your body b. Hypovolemic - Is an emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body. This type of shock can cause many organs to stop working. c. Septic - Is a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection. Any type of bacteria can cause the infection. - Etiology - ARF can result from a variety of etiologies. It can result from primary pulmonary pathologies or can be initiated by extra-pulmonary pathology. Causes are often multifactorial. Acute respiratory failure can be caused by abnormalities in: 1. CNS (drugs, metabolic encephalopathy, CNS infections, increased ICP, OSA, Central alveolar hypoventilation). 2. spinal cord (trauma, transverse myelitis) 3. neuromuscular system (polio, tetanus, M.S., M.Gravis, Guillain-Barre, critical care or steroid myopathy) 4. chest wall (Kyphoscoliosis, obesity) 5. upper airways (obstruction from tissue enlargement, infection, mass; vocal cord paralysis, tracheomalacia) 6. lower airways (bronchospasm, CHF, infection) 7. lung parenchyma (infection, interstitial lung disease) 8. cardiovascular system - Nursing Intervention NURSING INTERVENTION RATIONALE Observe for changes in the level of Early signs of hypoxia include disorientation, consciousness. irritability, and restlessness. While lethargy, stupor, and somnolence are considered as late signs. Assess the client’s respiratory rate, depth, and Changes in the respiratory rate and rhythm are pattern, including the use of accessory muscles. early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions. Assess the client’s heart rate and blood pressure. Tachycardia may result from hypoxia; Increased in blood pressure happen in the initial phases then followed by lowered blood pressure as the  condition progresses. Auscultate the lung for normal or adventitious Adventitious breath sounds such as wheezes and breath sounds. crackles are an indication of respiratory difficulties. Quick assessment allows for early detection of deterioration or improvement. Assess the skin color, examine the lips and Bluish discoloration of the skin (cyanosis) nailbeds for cyanosis. indicates an excessive concentration of deoxygenated blood and that breathing pattern is ineffective to maintain adequate tissue oxygenation. Monitor oxygen saturation using pulse oximetry. Pulse oximetry is useful in detecting early changes in oxygen. Oxygen saturation levels should be between 92% and 98% for an adult without any respiratory difficulties. Monitor arterial blood gases (ABGs) as indicated. Increasing Paco2 and decreasing PaO2 indicates respiratory failure. If the client’s condition begins to fail, the respiratory rate and depth decreases and Paco2 begin to rise. RESPIRATORY MODALITIES FOR RESPIRATORY FAILURE Mechanical Ventilation - a treatment to help a person breathe when they find it difficult or are unable to breathe on their own. Mechanical ventilator - pushes airflow into the patient’s lungs to help them breathe Types: Positive-pressure ventilation - pushes the air into the lungs. Negative-pressure ventilation - sucks the air into the lungs by making the chest expand and contract. Mechanical Ventilation: 1. Non-invasive ventilation - can be used at home by people with respiratory difficulties. -come with masks -The two kinds: a. Continuous positive airway pressure (CPAP) - delivers constant and steady air pressure. - CPAP is the most basic level of support and provides constant fixed positive pressure throughout inspiration and expiration, causing the airways to remain open and reduce the work of breathing. - Types of CPAP Mask 1. Nasal pillow mask. This type of mask has a small cushion that caps over your nostril area. It may also have prongs that fit into your nostrils. This mask allows you to wear your glasses easily. It also works well if you have lots of facial hair that may prevent a larger mask from fitting snugly. 2. Nasal mask. This type is a cushioned mask that covers your whole nose area. It may be a better option if you tend to move around in your sleep. It can deliver a high-pressure airstream. 3. Full mask. This type is shaped like a triangle and covers your mouth and nose. Your doctor might prescribe this kind of mask if you breathe through your mouth when you sleep or if you have a blockage of some kind in your nose.  b. Bilevel positive airway pressure (BiPAP) - delivers air with different pressures for inhalation and exhalation. - BiPAP is the trade name. - Type II Respiratory Failure OTHER NON- INVASIVE VENTILATION a. Nasal Cannula -Flow rate is 1-6L/min -FIO2 is 22-45% -Set up for low flow -High flow can cause nosebleed b. Simple Face Mask -Flow rate: 5-10L/min -FIO2 is 35-50% -Low flow device -Flow must be at 5L/min or above to flush out carbon dioxide. c. Non-rebreather Mask -Low flow -FIO2: 60-100% -Flow rate 6-15L/min -Bag must always remain inflated -Low flow device -Need enough flow to wash CO2  d. Venturi Mask -Flow rate goes to whatever the adaptors says -FIO2 28-100% -Make sure do not cover the air entrainment port with bed linen or clothes- this will alter the FIO2 2. Invasive ventilation - with a tube inserted into the patient’s airway, performed in the intensive care unit in the hospital. -Endotracheal intubation -Tracheostomy -Types: 1. Elective Tracheostomy 2. Emergency Tracheostomy 3. Mini Tracheostomy 4. High, Mid and Low Tracheostomy 5. Temporary tracheostomy or Permanent - Nursing management for ventilated patient: 1. Promote respiratory function 2. Monitor for Complication 3. Prevent infections 4. Provide adequate nutrition 5. Monitor GI bleeding 6. Maintain patent airway Suctioning - To maintain a patent airway - To improve gas exchange. - To obtain tracheal aspirate specimen. - To prevent effect of retained secretions. (It’s important to Oxygenate before and after suctioning) VENTILATOR ALARMS Ventilator Alarms Alarm Potential Causes Interventions High peak inspiratory Blockage of ET tube Assess lung sounds. pressure (PIP) (secretions, food, kinked Suction airway for secretions tubing, patient biting on ET Insert bite block or administer tube) sedation per orders if patient is Bronchospasm agitated or biting on ET tube. Lower airway obstruction Assess breath sounds for Pulmonary edema increased consolidation, Pneumothorax wheezing, and bronchospasm; Ventilator/patient treat as ordered. dyssynchrony Low pressure alarm Air leak in ventilator circuit Check the tube connections. or in the ET tube cuff Reconnect patient to the Disconnection of the tube, ventilator. or the patient stops to Replace leaking tubes by breath. manually ventilating the patient. Auscultate patient’s lung fields for bilateral lung sounds. Monitor respiratory rate and breathing patterns. Evaluate cuff pressure. Reinflate if needed High Pressure alarm Indicate displacement of the Assess your patient. ET tube Auscultate lung fields for Increased secretions, secretions. This should be done obstruction in the tube, at least every 2 hours or more. bronchospasms Suction secretions as needed. the patient is coughing or Oxygenate patient manually biting the tube before suctioning. If patient is biting the tube, provide bite block. Sedate patient, if necessary, especially when patient is fighting the vent. Make sure this is ordered by the attending physician or hospitalist on duty. Monitor pulse oximeter continuously if cardiac monitor and pulse oximeter devices are present. ARTERIAL BLOOD GAS (ABG) -A test measures the oxygen and carbon dioxide levels in your blood as well your blood's pH balance. Topic 6: Lesson Guide Care of Critically Ill Clients with Dysrhythmias Topic Outline: Review of CArdiac Anatomy and Physiology A. Electrocardiography B. Arrhythmias 1. Sinoatrial (SA) Node 2. Atrial 3. Junctional 4. Ventricular 5. Atrioventricular Blocks 6. Serum Electrolytes C. Adjunctive Modalities and Management 1. Cardioversion 2. Pacemaker Therapy 3. Defibrillators Review of Cardiac Anatomy and Physiology Heart – a hollow, muscular organ situated in the anterior thoracic cavity behind the sternum and above the diaphragm. Layers of the Heart Pericardium – a fluid-field sac that acts as a tough protective covering enveloping the heart Epicardial fat – a layer of adipose tissue beneath the myocardium Epicardium – the outermost layer consists of squamous epithelial cells overlying connective tissue Myocardium – a thick, muscular layer that forms the largest portion of the heart’s wall. In this layer, muscle tissue contracts with each heartbeat. Endocardium – the innermost layer of the heart. It is a thin layer of endothelium and connective tissue lining inside the heart. Cardiac Chambers Atrium - serves as volume reservoir for the blood being transported into the ventricles. o Right Atrium – receives blood from pulmonary arteries o Left Atrium – receive blood from vena cava Ventricles – serve as the pumping chambers of the heart o Right Ventricle – receives blood from the right atrium o Left Ventricle - forms the heart’s apex, has a thicker wall because it works harder in pumping the heart against the higher pressure of the aorta Heart Valves – The function of the valves is to keep the blood flowing through the heart in a forward direction, and prevent backflow or 1  regurgitation from one chamber to another. It is associated with heart sounds Atrioventricular valves – o Mitral valve (Bicuspid valve) o Tricuspid valve Aortic valves Pulmonary valves Cardiac cycle Cardiac output = Heart rate x Stroke Volume (usually 70ml). The normal cardiac output is 4 to 8 L/ min Phases of Cardiac Cycle o Isovolumetric ventricular contraction o Ventricular ejection o Isovolumetric relaxation o Ventricular filling o Atrial systole Preload - a stretching exerted by blood on the ventricular muscle fibers at the end of diastole. Afterload – the pressure that the ventricles need to generate to overcome higher pressure in the aorta to eject blood into the systemic circulation. Depolarization and repolarization Phase 0 Rapid o Cardiac cell receives stimulus depolarization o Sodium and calcium move rapidly into the cell o Myocardial contraction occurs Phase 1 Early o Sodium channel closes repolarization o Transmembrane potential fails slightly Phase 2 Plateau phase o Little change occurs in the cell’s transmembrane potential o Calcium continues to flow in o Potassium flows out of the cell Phase 3 Rapid o Calcium channel close repolarization o Potassium flows in rapidly o The cell returns to its original state Phase 0 Resting phase o Active transport through the sodium-potassium pump begins restoring potassium to the inside of the cells and sodium to the outside 2  o Cell membrane becomes impermeable sodium o Potassium may move out of the cell. o The cell is ready for another stimulus Conduction System of the Heart SA node – the normal pacemaker of the heart Bachmann’s bundle Internodal tract- Posterior (Thorel’s), Middle ( Wenckebach’s) , Anterior Atrioventricular node - doesn’t possess pacemaker cells - It has junctional tissue with pacemaker cells Bundle of His -conduction occurs leading to a heart rate between 40 to 60/min Right bundle branch- extends down to the right ventricles Left bundle branch- impulses travel faster down in this area to feed the larger, thicker-walled left ventricle Purkinje fibers – automatic firing rate ranges from 20 to 40/min A. ELECTROCARDIOGRAPHY (ECG/EKG) - It is one of the most essential diagnostic tools that records the heart’s electrical activity as waveforms - It helps identify rhythm disturbance, conduction abnormalities, and electrolyte imbalances - Changes in the rhythm can indicate structural, mechanical, or electrical issues. Types of ECG recording: a. 12-lead ECG (most common) - it records information from 12 different views of the heart 1. Frontal plane – Six limb leads such as I, II, III, augmented vector right (aVR), augmented vector left (aVL), augmented vector foot (aVF) o Bipolar leads - Lead I, II and III – require positive and negative electrode o Augmented leads – unipolar. requires positive electrodes 2. Horizontal plane- Six precordial leads – V1, V2, V3, V4, V5 V6 - unipolar b. Rhythm strip – provides continuous information about the heart’s electrical activity commonly, lead II, V1 and V6 3 Electrode Placement Standard limb leads Electrode Placement Area RA Right arm LA Left arm LL Left leg RL Right leg V1 Fourth intercostal space to the right of the sternum. V2 Fourth intercostal space to the left of the sternum. V3 Directly between leads V2 and V4. V4 Fifth intercostal space at midclavicular line. V5 Level with V4 at left anterior axillary line. V6 Level with V5 at the midaxillary line. (Directly under the midpoint of the armpit) ECG Grid- represents the horizontal axis and vertical axis and their corresponding values. 4 Rhythm strip and interpretation PARAMETER DEFINITION LOCATION AMPLITUDE DURATION CONFIGURATION DISORDER P wave- The first component Precedes the 2 to 3 mm high 0.06 – 0.12 Usually round and Peak P wave – represents of a normal ECG. QRS seconds upright atrial hypertrophy or The P wave occurs enlargement (COPD, during atrial pulmonary emboli, valvular depolarization, which disease, heart failure) causes the atria to Inverted P wave contract. PR interval The represents the From the start 0.12 to 0.20 If less than 0.12 sec, it is amount of time for of P wave to seconds associated with junctional the impulse to travel the beginning arrhythmias and from the SA node in of the QRS preexcitation syndromes. the atria through AV complex node, bundle of His If more than 0.20 sec, may and right and left indicate digoxin toxicity or 5  bundle, until it heart block. reaches the ventricles QRS complex Represents Follows the 5 to 30 mm high, 0.08 to 0.12 Consist of Q wave Deep wide Q waves may ventricular PR interval but may differ in seconds (negative represent myocardial depolarization – other leads deflection), R infarction. Missing QRS ventricles contract wave (positive complex may indicate an deflection), and S atrioventricular block or wave ( negative ventricular standstill. deflection) QT Interval The length of time it 0.36 to 0.44 If elongated, may represent takes the electrical seconds Torsades or Ventricular impulse to go from Fibrillation the beginning of the ventricles – until the ventricles completely repolarize and are ready for another contraction. ST segment Known as J point, Extend from Not observed 0.08 to 0.12 Change may indicate represents the end of the S wave to (isoelectric line) seconds myocardial injury or ventricular the beginning ischemia conduction or of the T wave depolarization and the beginning of ventricular recovery or repolarization T wave The last wave and its Follows the 0.5mm in leads I, II, 0.16 Round and smooth A tall T wave may indicate wave’s peak ST segment III and up to 10mm seconds Myocardial injury or represent ventricular in precordial leads electrolyte imbalances repolarization such as hyperkalemia. Hypokalemia leads to a flattened T wave. 6  U wave It represents the.16 to 0.20 Bradycardia, hypokalemia, repolarization of the seconds hyperkalemia, Digoxin Purkinje fibers within toxicity the Ventricles. Ectopic Beats – The beats that originate outside of the SA node. It represents ischemia or damage. It may or may not actually cause contraction of the heart. It causes palpitation or skipped beats eg. Premature Ventricular Contractions (Bigeminy, trigeminy, quadrigeminy), Premature Atrial Contractions, Premature Junctional Contractions Steps in Rhythm Interpretation 1. Determine Regularity 2. Determine Rate 3. P waves and PR interval 4. QRS AND QT Interval 5. ST segment and T wave 6. Ectopic Beats Common Monitor Problems Artifacts – also called as waveform interference False high-rate alarm Weak signals Wandering baseline Fuzzy baseline B. ARRHYTHMIA - The absence of cardiac rhythm DYSRHYTHMIA - The abnormal cardiac rhythm 1. Normal Sinus Rhythm - occurs when an impulse starts in the SA node to the atria and progresses to the ventricles through a normal conduction pathway. Rhythm: regular Rate: 60- 100beats /min P wave: Normal, similar in shape and size PR interval: Normal, 0.12 to 0.20 second QRS complex: 0.08 to 0.12 second T wave: Normal, upright and rounded shape in lead II 7  QT interval: Normal, 0.36 to 0.44 sec Other: no ectopic or aberrant beats Note: For older adult, ECG changes increased in PR, QRS, and QT interval, decreased amplitude of the QRS complex, and a shift of the QRS axis to the left. 2. Sinoatrial (SA) Node Arrhythmias- The alteration brought by changes in the automaticity of the sinus node, blood supply, and autonomic nerve system. The SA node acts as the primary pacemaker. The SA node's blood supply comes from the right coronary artery. SINUS BRADYCARDIA SINUS TACHYCARDIA Parameters Rhythm: Regular Rhythm: Regular Rate: less than 60 beats/min Rate: 100 to 160 beats/min P wave: Normal P wave: Normal but may increase in amplitude PR interval: Normal and constant PR interval: Normal QRS complex: Normal QRS complex: Normal T wave: Normal T wave: Normal QT interval: Normal, may be prolonged QT interval: Normal, but commonly shortened Others: None Other: None 8 Nursing Asymptomatic - treatment isn't necessary Check the level of consciousness to assess cerebral perfusion Interventions Evaluate the rhythm at rest and with activity Provide a calm environment Review the patient’s medications Help reduce fear and anxiety If symptomatic, treat the underlying cause. Prevent injury of the heart by monitoring the signs of heart failure, and May administer drugs, such as atropine, treat with drugs to slow the heart rate. Drug of choice: Beta-adrenergic epinephrine or dobutamine. blockers (metoprolol and atenolol), and calcium blockers ( verapamil Pacemaker and diltiazem) If caused by hemorrhage, treatment includes replacing blood and fluid losses and stopping the bleeding. Monitor intake and output, along with daily weight. Check patient's medical history. Over-the-counter sympathomimetics (nose drops and cold formulas) may contribute to sinus tachycardia. Avoid caffeinated foods, smoking, and drugs like cocaine and amphetamines Note: Tachycardia is initially a sign of pulmonary embolism for patients with predisposing risk factors for thrombotic emboli. SINUS ARRHYTHMIA Rhythm: Irregular Rate: 60 to 100 beats/min P wave: Normal 9  PR interval: Normal QRS complex: Normal T wave: Normal QT interval: Normal Other: Phasic slowing and quickening Sinus Arrhythmia results from an inhibition of reflex vagal activity, or tone. The cyclic irregular rhythm varies with the respiratory cycle Nursing If sinus arrhythmia is unrelated to respiration it may require treatment Interventions Monitor heart rhythm during respiration If sinus arrhythmia is induced by drugs, the practitioner may decide to continue it because the condition may be worsened if discontinued. If taking digoxin, notify the physician immediately. It may be experiencing digoxin toxicity. 3. Atrial arrhythmias - also called supraventricular arrhythmia, begins in the upper chambers of the heart. PREMATURE ATRIAL CONTRACTIONS (PAC) ATRIAL TACHYCARDIA Parameters Rhythm: Irregular Rhythm: Regular Rate: 60- 100 beats/min Rate: 150 to 250 beats/min P wave: Abnormal, may be hidden in the preceeding T wave P wave: Almost hidden PR interval: Normal PR interval: Not measurable QRS complex: Normal QRS complex: Normal T wave: Normal or distorted T wave: abnormal, with some embedded P waves QT interval: Normal QT interval: Normal or shortened The presence of three or more PAC is called atrial tachycardia 10 Nursing Avoid caffeinated drinks and alcohol Monitor serum digoxin level. Interventions Stress reduction activities Valsalva maneuver or carotid sinus massage may Ask patient factors that could trigger ectopic beats be applied for paroxysmal atrial tachycardia (PAT) Monitor signs of heart failure Monitor the cardiac rhythm and chest pain Drug of choice: Beta-adrenergic blockers and calcium Monitor patient for signs of heart failure and MI channel blockers Drug therapy (amiodarone, digoxin, beta-blockers, calcium channel blockers If the patient is unstable, synchronized cardioversion may be used. Pacemaker, atrial overdrive pacing, radiofrequency ablation ATRIAL FLUTTER ATRIAL FIBRILLATION Parameter Rhythm: Atrial – regular, Ventricular - varies Rhythm: Irregularly irregular Rate: Atrial – 250 to 350 beats/min, Ventricular - 60 to 100 Rate: Atrial – Indiscernible, Ventricular – 100 to 150 beats/min but may accelerate up to 150 beats/min beats/min P wave: classic sawtooth appearance P wave: Absent, replaced by fibrillatory waves PR interval: Unmeasurable PR interval: Indiscernible QRS complex: Normal QRS complex: Normal T wave: Unidentified T wave: Indiscernible QT interval: Unmeasurable QT interval: Unmeasurable Other: None 11  Nursing Control the rate and convert rhythm Interventions If cardioversion is indicated, administer sedative and resuscitation equipment at the bedside. Evaluate for bradycardia because cardioversion reduces heart rate Monitor symptoms of decreased cardiac output (syncope, dizziness, chest pain) and heart failure (dyspnea and peripheral edema) Drug therapy (anticoagulants, beta-adrenergic blockers, calcium channel blockers) 4. Junctional Arrhythmias – if the SA node fails to function properly, the specialized junctional pacemaker cells in the AV junction take over as the heart’s pacemaker and have an inherent firing rate of 40 to 60 beats/min. JUNCTIONAL ESCAPE RHYTHM JUNCTIONAL TACHYCARDIA Parameter Rhythm: Regular Rhythm: Regular Rate: 40 to 60 beats/min Rate: 100 to 200 beats/min P wave: Inverted, or absent P wave: Inverted or hidden PR interval: Shortened PR interval: Shortened or unmeasurable QRS complex: Normal QRS complex: 0.08 sec T wave: Normal T wave: Normal QT interval: Normal QT interval: Normal Other: None Other: None *Three or more PJCs occur in a row 12 Nursing Identify and correct underlying causes Interventions Monitor cardiac rhythm, Monitor digoxin and electrolyte level Give atropine and keep emergency equipment ready Watch for signs of decreased cardiac output such as hypotension, syncope, blurred vision, change in mental status and weak peripheral pulses o Use of Vagal maneuvers and drugs such as adenosine o May administer potassium supplement o Pacemaker 5. Ventricular Arrhythmias - a more serious arrhythmia that begins in the lower chambers of the heart. PREMATURE VENTRICULAR CONTRACTIONS ASYSTOLE ( VENTRICULAR STANDSTILL) Parameter: Rhythm: Irregular Rhythm: Atrial - indiscernible Rate: Varies Rate: Atrial - indiscernible P wave: Absent, but present with other QRS complexes P wave: May be present PR interval: Unmeasurable except in underlying rhythm PR interval: Unmeasurable QRS complex: Early with bizarre and wide configuration QRS complex: Absent, occurs during stimulus T wave: Normal; opposite direction T wave: Absent QT interval: Usually unmeasurable QT interval: unmeasurable Other: Underlying rhythm sinus tachycardia Other: nearly flat line Note: Asystole must be confirmed in more than one ECG lead. 13  Nursing If infrequent and asymptomatic, treatment is not Cardiopulmonary resuscitation (CPR) Interventions required Oxygen therapy Monitor if with underlying heart diseases IV or intraosseous epinephrine, vasopressin and If cardiac in origin, may give drugs that suppress atropine ventricular irritability such as procainamide, Treat reversible cause such as hypovolemia, amiodarone or lidocaine cardiac tamponade, and tension pneumothorax Educate family how to contact Emergency response team and how to perform CPR ‘ VENTRICULAR TACHYCARDIA TORSADES DE PONTES VENTRICULAR FIBRILLATION (V-TACH) (V-FIB) Parameter: Rhythm: Atrial- unmeasurable, Rhythm: Paroxysmal, starting and Rhythm: Chaotic, no recognizable ventricular – regular or slightly irregular stopping suddenly pattern Rate: Atrial- Unmeasurable, Rate: Atrial- unmeasurable, Rate: Indiscernible ventricular - regular 100 to 250 ventricular - regular 150 to 250 P wave: Absent beats/min beats/min PR interval: Unmeasurable P wave: absent P wave: absent QRS complex: Indiscernible PR interval: unmeasurable PR interval: Unmeasurable T wave: Indiscernible QRS complex: greater than 0.12 QRS complex: wide with changing Other: Waveform is a wavy line seconds, wide and bizarre amplitude T wave: Opposite direction of QRS T wave: Opposite direction of QRS Note: It is the most common cause of complex complex sudden cardiac death in people outside QT interval: Unmeasurable QT interval: Unmeasurable the health care facility Other: Variations include ventricular Other known as twisting about the 14  flutter and torsades de pointes points Nursing Continuous ECG monitoring, ensure patent venous access Start defibrillation and CPR Interventions Monitor the level of consciousness, respiration rate, and pulse rate Drug of choice: Epinephrine and May require a defibrillator and CPR, or synchronized cardioversion vasopressin, amiodarone, lidocaine, Teach the family about the nature of the disease and how to call magnesium sulfate emergency medical care and perform CPR when at home Educate family on how to call Administer magnesium sulfate emergency medical care perform Electric cardioversion CPR and use an automated external defibrillator when at home 6. Atrioventricular Heart Blocks – This refers to an interruption or delay in the conduction of electrical impulses between the atria and the ventricles. The block can occur at the AV node, bundle of His, or the bundle branches. First-degree atrioventricular block Type I second-degree atrioventricular block Parameter: Rhythm: Regular Rhythm: Atrial-Regular; ventricular - irregular Rate: Normal Rate: Normal P wave: Normal P wave: Normal PR interval: Prolonged PR interval: Progressively prolonged QRS complex: Normal QRS complex: Normal T wave: Normal, may be prolonged T wave: Normal QT interval: Normal QT interval: Normal Other: None Other: Wenckebach pattern of grouped beats 15 Nursing Identify and correct underlying causes Interventions Check patient’s medication regimen Monitor signs of myocardial ischemia Monitor cardiac rhythm Asymptomatic – treatment rarely required Patent venous line For slow HR, to give atropine Pacemaker if indicated Type II second-degree atrioventricular block Third-degree atrioventricular block Parameter: Rhythm: Atrial-Regular; ventricular - irregular Rhythm: -Regular Rate: normal Rate: Atrial- 60 to 100 beats/minute; ventricular – 40 to 60 P wave: Normal beats/minute PR interval: Normal or prolonged P wave: Normal QRS complex: Normal or widened PR interval: Variable T wave: Normal QRS complex: normal; or widened QT interval: Normal T wave: Normal Other: None QT interval: appears normal Other: None 16 Nursing Maintain ECG monitoring Interventions Patent venous line Complete bed rest Oxygen therapy Teach family about the use of pacemaker Drug of choice dopamine, epinephrine or atropine to increase cardiac output Pacemaker Note: Use atropine cautiously for it could worsen the ischemia during MI and may induce ventricular tachycardia or fibrillation. 7. Pulseless Electrical Activity (PEA) There are electrical impulses throughout the heart but the heart is not responding to that impulse, meaning the heart is not beating. These patients present the same as asystole and given time without intervention will progress to asystole 8. Serum Electrolytes Imbalances- shows distinctive rhythm changes on the ECGs. Ions such as potassium and calcium play a major role in the heart’s electrical activity. 17  HYPERKALEMIA HYPOKALEMIA Parameter: Rhythm: Regular Rhythm: Regular Rate: Normal Rate: Normal P wave: Normal P wave: Normal; may become peak PR interval: Normal or prolonged PR interval: May be prolonged QRS complex: Widened QRS complex: Normal or widened, prolonged (severe) T wave: Tall, peaked-classic T wave: Tall, peaked-classic QT interval: Shortened QT interval: Indiscernible Other: Intraventricular conduction disturbances ST segment: Depressed Other: Amplitude of U wave is increased and fusing with the T wave Nursing Identify and correct underlying cause Identify and correct the underlying cause Interventions Maintain continuous ECG monitoring Maintain continuous ECG monitoring Patent venous line Patent venous line Start drug therapy (calcium gluconate, insulin and Monitor potassium level glucose, and sodium bicarbonate), sodium Encourage adequate intake of foods and fluids rich polystyrene sulfonate (cation exchange resins in potassium Dialysis for patients with renal failure Give potassium supplement Monitor potassium level Adequate hydration before, during and after the administration of the chemotherapy Complete bed rest Oxygen therapy Teach the family about the use of pacemaker Drug of choice dopamine, epinephrine or atropine to increase cardiac output Pacemaker 18  Hypercalcemia Hypocalcemia Parameter: Rhythm: Regular Rhythm: Regular Rate: Normal, bradycardia may occur Rate: Normal P wave: Normal P wave: Normal PR interval: May be prolonged PR interval: Normal QRS complex: Normal, but may be prolonged QRS complex: Normal T wave: normal, but may be depressed T wave: normal, but maybe flat or inverted QT interval: Shortened QT interval: Prolonged ST segment: Shortened ST segment: Prolonged Other: None Other: None Nursing Identify and correct the underlying cause Identify and correct the underlying cause Interventions Monitor patient for cardiac arrhythmias Monitor patient for cardiac arrhythmias Prepare to give oral phosphate to patients with Monitor serum calcium level, start oral calcium normal renal function replacement Large volumes of normal saline administration Prepare to give emergency IV calcium gluconate in Dialysis severe hypocalcemia 19 Medications Usage Usage Adenosine Effective in treating reentry Amiodarone Wide- and narrow-complex tachycardia, tachycardias that involve the AV node polymorphic VT, shock-refractory VF or pulseless VT, SVT, PSVT Atropine Treats symptom-producing bradycardia Beta-blockers MI, unstable angina, PSVT, A-fib, A-flutter, HTN and heart blocks Digoxin Used to treat heart failure, paroxysmal Diltiazem A-fib, A-flutter, PSVT refractory to adenosine with narrow supraventricular tachycardia, atrial (Calcium channel QRS complex and adequate BP fibrillation, and atrial flutter blockers) Epinephrine To restore cardiac rhythm and to treat Dopamine Symptomatic bradycardia and hypotension, symptom-producing bradycardia cardiogenic shock Lidocaine VF or pulseless VT, stable VT, Isoproterenol Symptomatic bradycardia, refractory torsade de wide-complex, tachycardia of uncertain pointes unresponsive to magnesium, bradycardia in heart origin, wide-complex PSVT. transplant patients, beta blocker poisoning. Procainamide Recurrent VT or VF, PSVT refractory to Vasopressin Vasodilatory (septic) shock, an alternative to adenosine epinephrine in shock-refractory VF and pulseless VT. and vagal stimulation, rapid A-fib, maintenance after conversion C. Adjunctive Modalities and Management 1. Cardioversion - A cardioversion procedure helps to correct arrhythmias. It is a procedure that utilizes an electrical current to bring your heart rhythm back to normal. It is usually used to treat atrial fibrillation and atrial flutter. 2. Pacemaker – a nonpharmacologic treatment used for arrhythmias using an artificial device that electrically stimulates the myocardium to depolarize, initiating mechanical contractions a. Permanent pacemaker b. Temporary pacemaker i. Transvenous ii. Transcutaneous iii. Epicardia 20  Pacemaker malfunction can lead to arrhythmias, hypotension, syncope and other signs and symptoms of decreased cardiac output. Common problems includes failure to capture, failure to pace, undersensing, and oversensing 3. Defibrillators a. Manual Defibrillator The voltage and timing for the electrical shock are manually determined after a healthcare provider assesses the heart rhythm. The majority of these units may be found in hospitals and on select ambulances. b. Automated external A type of defibrillator designed for use by untrained persons. It can analyse cardiac rhythms. As a defibrillator (AED) result, determining whether or not a rhythm is shockable does not necessitate the use of a qualified health expert. c. Cardioverter-Defibrillators known as implantable cardioverter-defibrillator (ICD) It is a pacemaker-like implant. According to the device's programming, they continuously monitor the patient's heart rhythm and automatically administer shocks for life-threatening arrhythmias. It is a device programmed to deliver an unsynchronized shock right away. References: Burns, S. (2014). AACN Essentials of Critical Care Nursing. New York: McGraw Hill Education. Perrin, K., & MacLeod, C. (2018). Understanding the Essentials of Critical Care Nursing. New York: Pearson Education Inc. 21