Chapter 27 Management of Patients With Dysrhythmias and Conduction Problems

Dysrhythmias Disorders of formation or conduction (or both) of electrical impulses within heart Can cause disturbances of Rate Rhythm Both rate, rhythm Potentially can alter blood flow, cause hemodynamic changes Diagnosed by analysis of electrographic waveform

Relationship of ECG Complex, Lead System, and Electrical Impulse

ECG Electrode Placement

ECG Graph and Commonly Measured Components

Heart Rate Determination

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Sinus Arrhythmia

Question Tell whether the following statement is true or false: The PR interval on an ECG strip that reflects normal sinus rhythm is between 0.12 and 0.20 seconds.

Answer True. Rationale: The PR interval on an ECG strip that reflects normal sinus rhythm is between 0.12 and 0.20 seconds.

Premature Atrial Complexes

Atrial Flutter

Atrial Fibrillation

Multifocal PVCs-Quadrigeminy

Ventricular Tachycardia

Ventricular Fibrillation

Asystole

First Degree AV Block

Second Degree AV Block, Type I

Second Degree AV Block, Type II

Third Degree AV Block

Question Tell whether the following statement is true or false: A “saw tooth” P wave is seen on an ECG strip with atrial fibrillation.

Answer False. Rationale: A “saw tooth” P wave is seen on an ECG strip with atrial flutter, not atrial fibrillation.

Nursing Process: Care of the Patient with a Dysrhythmia - Assessment Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness Physical assessment include Rate, rhythm of apical, peripheral pulses Heart sounds Blood pressure, pulse pressure Signs of fluid retention

Nursing Process: Care of the Patient with a Dysrhythmia – Assessment (cont’d) Health history: include presence of coexisting conditions, indications of previous occurrence Medications

Nursing Process: Care of the Patient with a Dysrhythmia - Diagnoses Decrease cardiac output Anxiety Deficient knowledge

Collaborative Problems/Potential Complications Cardiac arrest Heart failure Thromboembolic event, especially with atrial fibrillation

Nursing Process: Care of the Patient with a Dysrhythmia - Planning Goals Eradicating or decreasing occurrence of dysrhythmia to maintain cardiac output Minimizing anxiety Acquiring knowledge about dysrhythmia, its treatment

Decreased Cardiac Output Monitoring ECG monitoring Assessment of signs, symptoms Administration of medications, assessment of medication effects Adjunct therapy: cardioversion, defibrillation, pacemakers

Other Interventions Anxiety Use calm, reassuring manner Measures to maximize patient control to make episodes less threatening Communication, teaching Teaching self-care Include family in teaching

Pacemakers Electronic device that provides electrical stimuli to heart muscle Types Permanent Temporary NASPE-BPEG code for pacemaker function

Implanted Transvenous Pacemaker

Transcutaneous Pacemaker

ECG-On Demand Pacing

Complications of Pacemaker Use Infection Bleeding or hematoma formation Dislocation of lead Skeletal muscle or phrenic nerve stimulation Cardiac tamponade Pacemaker malfunction

Nursing Process: Care of the Patient with an Implanted Cardiac Device - Assessment Device function: ECG Cardiac output, hemodynamic stability Incision site Coping Patient, family knowledge

Nursing Process: Care of the Patient with an Implanted Cardiac Device - Diagnoses Risk for infection Risk for ineffective coping Knowledge deficient

Nursing Process: Care of the Patient with an Implanted Cardiac Device - Planning Goals Absence of infection Adherence to self-care program Effective coping Maintenance of device function

Interventions Risk for ineffective coping Support of patient, family coping Setting of realistic goals Allow patient to talk, share feelings, experiences Support groups or referral Stress-reduction techniques Knowledge deficient Patient, family teaching

Cardioversion and Defibrillation Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial ceils When cells repolarize, sinus node usually able to recapture role as heart pacemaker In cardioversion, current delivery synchronized with patient’s ECG In defibrillation, current delivery is unsynchronized

Safety Measures Assure good contact between skin, pads or paddles Use conductive medium, 20 to 25 pounds of pressure Place paddles so they do not touch bedding or clothing, are not near medication patches or oxygen flow If cardioverting, turn synchronizer on If defibrillating, turn synchronizer off

Safety Measures (cont’d) Do not charge device until ready to shock Call “clear” three times; follow checks required for clear Assure no one is in contact with patient, bed, or equipment

Paddle Placement for Defibrillation

Implantable Cardioverter Defibrillator (ICD) Device that detects, terminates life-threatening episodes of tachycardia or fibrillation NASPE-BPEG code Antitachycardia pacing

ICD

Question What must a patient with an automatic implantable cardioverter defibrillator (ICD) do? Can continue to go through metal-detection devices at the airport Call for assistance when blood pressure increases Document events that trigger a shock sensation Be compliant with all of the above-listed interventions

Answer C. Document events that trigger a shock sensation Rationale: The patient with an automatic implantable cardioverter defibrillator (ICD) must document events that trigger a shock sensation. The patient must avoid magnetic fields such as metal-detection devices at the airport and call for emergency assistance when feeling dizzy.

Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias Electrophysiologic studies Cardiac conduction surgery Maze procedure Catheter ablation therapy