Chapter 26 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 and rhythm Potentially can alter blood flow and cause hemodynamic changes Diagnosed by analysis of electrographic waveform

Normal Electrical Conduction SA node (sinus node) AV node Conduction Bundle of His Right and left bundle branches Purkinje fibers Depolarization = stimulation = systole Repolarization = relaxation = diastole

Relationship of ECG Complex, Lead System, and Electrical Impulse

The Electrocardiogram (ECG) P wave QRS complex T wave U wave PR interval ST segment QT interval TP interval PP interval Electrode placement Electrode adhesion Types of ECG ECG Interpretation

ECG Electrode Placement

ECG Graph and Commonly Measured Components

Heart Rate Determination

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Sinus Arrhythmia

Question The nurse is preparing a male patient to have a 12-lead ECG performed. When prepping the skin the nurse notices that the patient has abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads? Use alcohol swabs to cleans the skin before applying the leads. Clip the chest hair with the patient’s permission before applying the leads. Apply the leads to the arms and legs only. Reschedule the ECG.

Answer Clip the chest hair with the patient’s permission before applying the leads. Rationale: Alcohol should not be used to prep the skin because it increases the skin’s electrical impedance, thereby hindering the detection of the cardiac electrical signal. Clipping the hair would provide access to the skin to assist with adhesion. The ECG would not be performed correctly if the leads were only placed on the extremities, and there is no need to reschedule the ECG at this time.

Nursing Process: Care of the Patient with a Dysrhythmia—Assessment Causes of dysrhythmia, contributing factors Assess indicators of cardiac output and oxygenation Health history: include presence of coexisting conditions, indications of previous occurrence All medications (prescribed and OTC) Psychosocial assessment: patient’s “perception” of dysrhythmia

Nursing Process: Care of the Patient with a Dysrhythmia—Assessment (cont’d) Physical assessment include Skin (pale and cool) Signs of fluid retention (JVD, lung auscultation) Signs of decreased CO (altered LOC) Rate, rhythm of apical, peripheral pulses Heart sounds Blood pressure, pulse pressure

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

Collaborative Problems and 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 and its treatment

Nursing Process: Care of the Patient With a Dysrhythmia—Nursing Interventions Monitor and manage the dysrhythmia Minimize anxiety Promote home- and community-based cared Educate the patient Continuing care

Nursing Intervention: Monitor and Manage the Dysrhythmia Assess vital signs on an ongoing basis Assess for lightheadedness, dizziness, fainting If hospitalized Obtain 12-lead ECG Continuous monitoring Monitor rhythm strips periodically Antiarrhythmic medications “6-minute walk test”

Nursing Intervention: Minimize Anxiety Stay with patient Maintain safety and security Discuss emotional response to dysrhythmia Help patient develop a system to identify factors that contribute to episodes of the dysrhythmia Maximize the patient’s control

Nursing Intervention: Promote Home and Community-Based Cared Educate the patient Treatment options Therapeutic medication levels How to take pulse before medication administration How to recognize symptoms of the dysrhythmia Measures to decrease recurrence Plan of action in case of an emergency CPR (family)

Nursing Intervention: Continuing Care Referral for home care Hemodynamically unstable with signs of decreased CO Significant comorbidities Socioeconomic issues Limited self-management skills Electronic device recently implanted

Nursing Process: Care of the Patient With a Dysrhythmia—Evaluation Maintain cardiac output Stable VS, no signs of dysrhythmia Experience decreased anxiety Positive attitude, confidence in ability to act if an emergency occurs Express understanding of dysrhythmia and treatment

Adjunctive Modalities and Management Used when medications alone are ineffective against dysrhythmia Pacemakers Cardioversion Defibrillation Nurse responsible for assessment of the patient’s understanding regarding the mechanical therapy

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

Implanted Transvenous Pacemaker

Transcutaneous Pacemaker

Complications of Pacemaker Use Infection Bleeding or hematoma formation Dislocation of lead Skeletal muscle or phrenic nerve stimulation Cardiac tamponade (pressure on the heart when fluid builds up between muscle and sac) Pacemaker malfunction

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

ICD (cont’d)

Nursing Management (After Permanent Electronic Device Insertion) ECG assessment CXR Nursing assessment CO and hemodynamic stability Incision site Signs of ineffective coping Level of knowledge and education needs of family and patient

Cardioversion and Defibrillation Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial cells 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 Ensure good contact between skin, pads, and paddles Use conductive medium, 20 to 25 pounds of pressure Place paddles so they do not touch bedding or clothing and 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 Ensure no one is in contact with patient, bed, or equipment

Paddle Placement for Defibrillation

What must a patient with an automatic ICD do? Question What must a patient with an automatic ICD do? 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

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

Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias Electrophysiologic studies Ablation Cardiac conduction surgery Maze procedure ("Maze" refers to the series of incisions arranged in a maze-like pattern in the atria) Catheter ablation therapy