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Atrial fibrillation By: Emma Fleck.

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1 Atrial fibrillation By: Emma Fleck

2 Objectives ♥ What is A-Fib? ♥ Types ♥ Risk factors ♥ Signs/symptoms ♥ Tests ♥ Treatment/medications ♥ Patient scenario ♥ Review questions

3 A-fib
♥Is a dysrhythmia characterized by a disorganized, rapid, and irregular atrial rhythm resulting in an irregular ventricular rhythm ♥It’s a heart condition in which the upper chambers of the heart (the atria) beat too rapidly and cause the lower chambers of the heart (ventricles) to pump the blood abnormally and ineffectively throughout the body. (Julia Heisler,2009) Book The Patient with Atrial Fibrillation Julia Heisler Indik, MD, PhD, Joseph S. Alpert, MD Sarver Heart Center, College of Medicine, University of Arizona, Tucson.

4 Causes ♥ Acute MI ♥ Left atrial stretch ♥ Heart failure
♥ Temporary after open-heart surgery ♥ Long-standing hypertension ♥ Digoxin toxicity ♥ Alcohol intake, chronic or acute ♥ Stress, pain, anxiety ♥ Idiopathic (Osborn, Wraa & Watson, 2009)

5 prevalence “A-Fib is the most common cardiac arrhythmia, currently affecting more than 2 million people in the USA” “Expected to affect 12 million by 2050” (Jensen, 2013)

6 Risk Factors ♥Mitral valve disease Previous MI ♥Heart failure Diabetes ♥Rheumatic heart disease arteriosclerotic heart disease ♥hyperthyroidism acute and chronic obstructive lung disease (Richards, 2012) ♥ Age White ♥Male Family history ♥Cardiomyopathy Hypertension ♥Smoking pulmonary embolism. ♥Caffeine Alcohol Approximately 1 in 10 people over the age of 80 has atrial fibrillation, and for those over the age of 40, the lifetime risk of developing it is one in four Richards, G. (2012). An overview of atrial fibrillation. Nursing Standard, 26(52),

7 Signs and symptoms ♥ Exercise intolerance ♥ Weakness ♥ Shortness of breath ♥ Altered mental state ♥ May not have any symptoms ♥ Irregular pulse ♥ Lower than normal BP ♥ Angina ♥ Syncope ♥ Dizziness (Richards, 2012) Richards, G. (2012). An overview of atrial fibrillation. Nursing Standard, 26(52),

8 Types ♥ paroxysmal AF – usually self-terminating within 48 hours ♥ persistent AF – defined as an episode that lasts more than 7 days and requires termination by cardioversion ♥ chronic AF the heart is always in A-fib. Usually not responsive to cardioversion (Lee,2012) Atrial fibrillation in the elderly – Not a benign condition Geraldine A. Lee, Phd, RGN, NFESCa, b, , (Arrhythmia Research Nurse), Dion Stub, MBBS, FRACPa, b (Cardiologist), Han Ling, MBBS, FRACPa (Cardiologist)

9 Diagnosis /Tests 12-lead EKG where there is an absence of P waves ,loss of atrial kick, and a completely irregular rhythm will confirm the diagnosis. (Lee,2012) echocardiography- due to structural heart disease, size, function Stress test- sizze, function, blood flow CAD

10 Catheter ablation isolates
Treatments ♥ Rate Control. ♥ Anticoagulation. ♥ Cardioversion. /watch?v=rSusgpskmzk ♥Ablation ♥ Maze Procedure- /watch?v=FHiV31Xee5M Catheter ablation is then performed to destroy, through tiny burns, the electrically chaotic tissue in the heart. During EPS and catheter ablation, thin wires (or catheters) are introduced to the heart through veins in the leg and neck. Radiofrequency energy is sent through the catheters to the parts of the heart where the irregular electrical impulses are located. Ablation essentially creates scars in the heart that stabilize any electrical short circuits. Catheter ablation isolates cardiac tissue most commonly through the application of radio frequency energy, which heats the endocardium adjacent to the catheter tip thereby creating an area of scar that is no longer able to conduct electrical impulses. Catheter ablation can be done using different strategies, such as targeting areas of electrical activity at the junction of the pulmonary vein and left atrium Richards, G. (2012). An overview of atrial fibrillation. Nursing Standard, 26(52),

11 Medications For rhythm control, many patients will require antiarrhythmic drug therapy to maintain sinus rhythm. Antiarrhythmic drugs include the Rythmol or flecainide, Betapace, dofetilide, or amiodarone. Medications to achieve rate control include: digoxin, beta-blockers, and calcium channel blockers It should be noted that, for rate control patients, digoxin therapy slows resting but not exercise heart rate, and this agent does not prevent recurrent episodes of atrial fibrillation, although betablocker administration can accomplish this goal. Digoxin also should be used cautiously in the elderly and in patients with chronic kidney disease (Julia Heisler, 2009) of antiarrhythmic medication is dependent on whether there is any other heart disease such as significant hypertrophy, systolic heart failure, or coronary artery disease Julia Heisler

12 The presence of atrial fibrillation increases the patient’s risk for developing arterial embolism and stroke, depending on the presence of other clinical conditions, such as hypertension and diabetes. Most patients with atrial fibrillation should receive antithrombotic therapy with warfarin. Even patients in whom rhythm control is established should continue on warfarin because silent episodes of atrial fibrillation may still be occurring, (Julia Heisler, 2009) Anticoagulation for example, at night during sleep

13 Pacemaker implantation with AV node ablation
can be considered. Ablation of the AV node does not restore sinus rhythm, but controls the consequence of atrial fibrillation, Pacemakers stimulate the heart to speed up when it beats too slowly or reset the rate when the heart beats too fast. They can also substitute for the natural pacemaker of the heart (AV or SA node). (Julia Heisler, 2009) Monitor for signs/symptoms of infections. Know type of pacer and settings Monitor telemetry for sensing and capture. Assess and treat pain. Educate patient Keep site dry until healed. Avoid using operative side arm until healed. Monitor Pulse Avoid MRIs. Must be interrogated. Can use microwave. Carry pacemaker card. Julia Heisler

14 prognosis ♥ Those with A-Fib are 5 x more likely to have a stroke than someone without atrial fibrillation. You also have a risk of eventual heart failure due to the weakening of the heart muscle. ♥ Many patients do well for years and even decades. Therefore, the prognosis for the individual patient is variable. excellent rate control with beta blockers, calcium blockers and digoxin, along with anticoagulation and control of other cardiovascular risk factors, can stabilize patients with atrial fibrillation for years. ♥ Not acutely life threatening ,Reduced quality of life, stroke, heart failure, long term mortality increase (Julia Heisler, 2009) The Patient with Atrial Fibrillation Julia Heisler Indik, MD, PhD, Joseph S. Alpert, MD Sarver Heart Center, College of Medicine, University of Arizona, Tucson

15 Patient Scenario Male, age 83, white
Arrived to ER vomiting with abdominal pain, hypertensive Patient drinks occasionally, was a smoker for 40 years, PMI- A-fib, COPD, hypercholesterolemia, HTN, kidney stone, pacemaker Vitals (on my shift) , HR 70, BP 128/59 O2SAT 95, RR 18, pain 4 CA 8.0, HCT L 39.3, Hgb L 12.7 PT 19.4 H INR 1.67 RBC 4.33L Hgb 12.7L HCT 39.3L platelet 127L Medications- pantoprazole bisoprolol, enoxaparin levothyroxine terazosin (hypertension) tiotropium bromide (anticholinergic), valsartan

16 Nursing diagnosis Risk for decreased cardiac output r/t dysrhythmia Risk for bleeding r/t treatment-related side effects Fall risk r/t treatment-related side effects Risk of electrolyte imbalance

17 Question 1 A common arrhythmia found in some older clients is chronic atrial fibrillation. Based on the nurse's knowledge of the disease pathology, which of the following prescriptions should the nurse expect to be ordered? Aspirin (acetylsalicylic acid) Warfarin sodium (Coumadin) Simvastatin (Zocor) Vinorelbine tartrate (Navelbine)

18 Question 2 Which EKG shows A-Fib? A. B. C.

19 Reduce the ventricular rate to below 100 beats per minute
Question 3 In caring for a patient with atrial fib, which of the following goals would be a priority? Reduce the ventricular rate to below 100 beats per minute Identify and treat the underlying cause Control the heart rate and maintain cardiac output Increase the heart rate

20 Question 4 A. The presence of occasional coupled beats
When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: A. The presence of occasional coupled beats B. Long pauses in an otherwise regular rhythm C. A continuous and totally unpredictable irregularity D. Slow but strong and regular beats

21 References Jensen, P. N., Thacker, E. L., Dublin, S., Psaty, B. M., & Heckbert, S. R. (2013). Racial Differences in the Incidence of and Risk Factors for Atrial Fibrillation in Older Adults: The Cardiovascular Health Study. Journal Of The American Geriatrics Society, 61(2), doi: Julia Heisler, I., & Joseph S., A. (n.d). Review: The Patient with Atrial Fibrillation. The American Journal Of Medicine, doi: /j.amjmed Lee, G. A., Stub, D., & Ling, H. (2012). Atrial fibrillation in the elderly – Not a benign condition. International Emergency Nursing, 20(4), doi: Osborn, K. S., Wraa, C. E., & Watson, A. B. (2009). Medical-surgical nursing, preparation for practice. (Vol. 1). Prentice Hall. Richards, G. (2012). An overview of atrial fibrillation. Nursing Standard, 26(52), XReviewQuestionsSP2010Set%25202.pdf+&hl=en&gl=us&pid=bl&srcid=ADGEESj7hvGLAcw 8aLUV5VFarwSV0CwVjtamuCK-mQfiNP- Bi9Le5WHupUHwr6wpiaqVVMo6Z5V6Lni7CUQUFGhPCsoZGF0k0niRoN92E5aTReWCtEvNGe VuecY4KlaBi5dTuNy9ALHy&sig=AHIEtbRFvb-czS6sA-A6IjK1wPzZinfIVg ml

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