Linda S. Williams / Paula D. Hopper Copyright © F.A. Davis Company Understanding Medical Surgical Nursing, 4th Edition Chapter 25 Nursing Care of Patients with Cardiac Dysrhythmias

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Cardiac Conduction System  Sinoatrial (SA) Node: 60 to 100 bpm  Across Both Atria  AV Node  Bundle of His  Right and Left Bundle Branches  Purkinje Fibers

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Cardiac Conduction System (cont’d)

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Cardiac Cycle  One Heartbeat  Electrical Representation of Contraction, Relaxation of Atria/Ventricles

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of Cardiac Cycle

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Electrocardiogram (ECG)  Shows Cardiac Electrical Activity  12-lead ECG = 12 Different Views  Waveforms Change Appearance in Different Leads  Continuous Monitoring Often in Lead II  Waveforms Upright in Lead II

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition ECG Graph Paper

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition ECG Graph Paper (cont’d)  Calibrated Grids for Measurement  Time Calibrated Horizontally  Heavy Lined Blocks of 25 (5 X 5)  Small Box 0.04 Seconds Wide  Five Small Squares 0.20 Seconds Wide

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Isoelectric Line  No Electrical Activity  Straight Line Produced  Waves Upright or Downward from Isoelectric Line

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle  P Wave  First Wave, Atrial Depolarization  P–R Interval  Beginning of P to Beginning of QRS  0.12 to 0.20 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition PR Interval

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle (cont’d)  QRS Complex  Three Waves: Q, R, S  After P Wave  Q Wave First Downward Deflection  R Wave First Upward Deflection  S Wave Second Negative Deflection if Q Wave or First Negative Deflection after R Wave

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle (cont’d)  QRS Complex  Ventricular Depolarization

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition QRS Complex

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle (cont’d)  QRS Interval  Beginning of QRS to End of QRS  Less than or Equal to 0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition QRS Interval

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle (cont’d)  T Wave  Ventricular Repolarization  Follows QRS Complex

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition T Wave

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle (cont’d)  QT Interval  Beginning of Q Wave to End of T Wave  Normal Ranges: 0.34 to 0.43  Varies Based on Gender, Heart Rate, Age  Prolonged or Shortened Can Lead to Ventricular Dysrhythmias

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle (cont’d)  U wave  Rare  Indicates Hypokalemia  After T Wave

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition U Wave

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Components of a Cardiac Cycle (cont’d)  ST Segment  End of QRS to Beginning of T Wave  Depressed with Ischemia  Elevated with Cardiac Injury

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition ST Segment

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition ST Segment Inverted or Depressed

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition ST Segment Elevated

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Interpretation of Cardiac Rhythms  Six-step Process 1. Regularity of Rhythm 2. Heart Rate 3. P Wave 4. P–R Interval 5. QRS Complex 6. QT Interval

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Normal Cardiac Waves Are Equal Distances Apart

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Counting R Waves in a 6-Second Strip

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Heart Rate

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Normal Sinus Rhythm

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Normal Sinus Rhythm Rules  Rhythm: Regular  Heart Rate: 60 to 100 bpm  P Wave: Rounded, Before each QRS  PR Interval: 0.12 to 0.20 Seconds  QRS Interval: < 0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Dysrhythmias  Rhythm Disturbances  Impulse Formation Disturbed  Disturbance in Conduction

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinoatrial Node Dysrhythmias  Sinus Bradycardia  Sinus Tachycardia

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinus Bradycardia

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinus Bradycardia Rules  Rhythm: Regular  Heart Rate: < 60 bpm  P Waves: Rounded, Before Each QRS  PR Interval: 0.12 to 0.20 Seconds  QRS Interval: < 0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinus Bradycardia (cont’d)  Signs and Symptoms  None or Fatigue, Fainting  Treatment  None if Asymptomatic  Oxygen, Atropine, Dopamine, Epinephrine, Pacemaker

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinus Tachycardia

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinus Tachycardia Rules  Rhythm: Regular  Heart Rate: 101 to 180 bpm  P Waves: Rounded, Before Each QRS  P–R Interval: 0.12 to 0.20 Seconds  QRS Interval: < 0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinus Tachycardia (cont’d)  Signs and Symptoms  None  Angina or Dyspnea  Elderly More Sensitive

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Sinus Tachycardia (cont’d)  Therapeutic Interventions  Treat Cause  Digoxin, Calcium Channel Blockers, Beta Blockers

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Dysrhythmias  Premature Atrial Contractions  Atrial Flutter  Atrial Fibrillation

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Atrial Contractions

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Atrial Contractions Rules  Rhythm: PAC Interrupts Rhythm  Heart Rate: Per Underlying Rhythm  P Waves: Early Beat, Abnormal Shape  P–R Interval: Usually Normal  QRS Interval: < 0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Atrial Contractions (cont’d)  Signs and Symptoms  None

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Atrial Contractions (cont’d)  Therapeutic Interventions  None  Treat Cause  Beta Blockers

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Flutter

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Flutter Rules  Rhythm: Atrial Rhythm Regular  Heart Rate: Varies  P Waves: F Waves, Sawtooth Pattern  P–R Interval: None Measurable  QRS Interval: < 0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Flutter (cont’d)  Signs and Symptoms  Ventricular Rate Normal  None  Rapid Ventricular Rate  Palpitations, Angina, Dyspnea

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Flutter (cont’d)  Therapeutic Interventions to Slow Heart Rate  Cardioversion  Calcium Channel  Beta Blockers  Digoxin

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Fibrillation

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Fibrillation Rules  Rhythm: Irregularly Irregular  Heart Rate: Atrial Rate Not Measurable, Ventricular Rate 100 Rapid Ventricular Response  P Waves: No Identifiable P Waves  P–R Interval: None Measurable  QRS Interval: < 0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Fibrillation (cont’d)  Signs and Symptoms  Palpitations  Faint Radial Pulse

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Fibrillation (cont’d)  Therapeutic Interventions  Synchronized Cardioversion  Medications  Digoxin  Beta Blockers  Calcium Channel Blockers  Amiodarone or Dronedarone  Warfarin (Coumadin)

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Atrial Fibrillation (cont’d)  Therapeutic Interventions (cont’d)  Ablation  Biatrial Pacing  Implantable Atrial Defibrillators  Surgical Maze Procedure

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Dysrhythmias  Premature Ventricular Contraction  Ventricular Tachycardia  Ventricular Fibrillation

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Ventricular Contractions (PVC)

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Bigeminal PVC

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Ventricular Contraction Rules  Rhythm: PVC Interrupts Rhythm  Heart Rate: Per Underlying Rhythm  P Waves: Absent in PVC  P–R Interval: None for PVC  QRS Interval: Pvcs >0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Ventricular Contractions (PVC) (cont’d)  Signs and Symptoms  Palpitations  Fatigue, Dizziness, Severe Dysrhythmias

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Premature Ventricular Contractions (PVC) (cont’d)  Therapeutic Interventions  None  Antidysrhythmics  Amiodarone (Cordarone, Pacerone)  Beta Blockers

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Tachycardia

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Tachycardia Rules  Rhythm: Usually Regular  Heart Rate: 150 to 250 Ventricular bpm  Slow VT <150 bpm  P Waves: Absent  P–R Interval: None  QRS Interval: >0.10 Seconds

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Tachycardia (cont’d)  Signs and Symptoms  Dyspnea  Palpitations  Light-headedness  Angina  Cardiac Arrest

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Tachycardia (cont’d)  Therapeutic Interventions  If Pulseless  CPR, Defibrillation, Vasopressors, Anti-arrhythmics  If Stable  Amiodarone  Consider Magnesium

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Fibrillation

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Fibrillation Rules  Rhythm: Chaotic, Extremely Irregular  Heart Rate: Not Measurable  P Waves: None  P–R Interval: None  QRS Interval: None

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Fibrillation (cont’d)  Signs and Symptoms  Unconscious  No Heart Sounds, Peripheral Pulses, BP  Respiratory Arrest  Cyanosis  Pupil Dilation

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Ventricular Fibrillation Therapeutic Interventions  ACLS Protocols  Immediate Defibrillation  CPR  Epinephrine, Vasopressin, Amiodarone, Magnesium  Endotracheal Intubation

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Asystole

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Asystole Rules  Rhythm: None  Heart Rate: None  P Waves: None  P–R Interval: None  QRS Interval: None

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Asystole (cont’d)  Therapeutic Interventions  CPR  ACLS Protocols  Endotracheal Intubation  Epinephrine  Vasopressin  Atropine

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Cardiac Pacemakers  External and Temporary  Internal and Permanent  Override Dysrhythmias  Generate an Impulse  Can Be Placed in Atria, Ventricle, or Both

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Dual-Chamber Pacemaker

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Pacemakers

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Cardiac Pacemaker Problems  Failure to Sense  Failure to Pace  Failure to Capture

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Nursing Care for Pacemakers  Monitor ECG  Rest Several Hours  Monitor Apical Pulse, Symptoms

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Patient Pacemaker Education  Incision Care  How to Take Radial Pulse  Symptoms to Report  Pacemaker ID Card  Things to Avoid

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Patient Pacemaker Education (cont’d)  Trigger Metal Detectors  Grounded Appliances Safe  Periodic Pacemaker Checks

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Defibrillation  Electrical Shock Delivered to Reset Lethal Ventricular Dysrhythmias  Pulseless Ventricular Tachycardia  Ventricular Fibrillation

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Defibrillation (cont’d)  Conductive Jelly or Saline Pads Used  Paddles Pressed Firmly Against Chest  Second Intercostal Space, Right of Sternum  Anterior Axillary Line, Fifth Intercostal Space  Announce “Clear”  Increasing Energy: 200, 300, 360 Joules

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Placement of Defibrillator Paddles

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Synchronized Cardioversion  Allows R Wave to be Sensed for Appropriately Timed Delivery  Used In Dysrhythmias when R Wave Present  Ventricular Tachycardia with Pulse  Atrial Fibrillation, Atrial Flutter, Supraventricular Tachycardia  Conscious Sedation  25 to 50 Joules

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Automatic External Defibrillator External device automatically analyzes rhythms, automatically delivers or prompts operator to deliver electrical shock if shockable rhythm (V-Fib or VT) detected

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Implantable Cardioverter fibrillator  Automatically Defibrillates when Lethal Rhythm Detected  Cardioverts when VT Detected

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Implanted Cardioverter Defibrillator (cont’d)

Copyright © F.A. Davis Company Linda S. Williams / Paula D. Hopper Understanding Medical Surgical Nursing, 4th Edition Nursing Diagnoses for Dysrhythmias  Decreased Cardiac Output  Ineffective Tissue Perfusion  Activity Intolerance  Anxiety  Deficient Knowledge