1. Nursing Care of Patients with Cardiac Dysrhythmias
Chapter 25
Nursing Care of Patients with Cardiac Dysrhythmias

2. Cardiac Conduction System
Sinoatrial (SA) Node: bpm
Across Both Atria
AV Node
Bundle of His
Right and Left Bundle Branches
Purkinje Fibers

3. Cardiac Conduction System (cont’d)

4. Cardiac Cycle One Heartbeat
Electrical Representation of Contraction, Relaxation of Atria/Ventricles

5. Components of Cardiac Cycle

6. 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

7. ECG Graph Paper

8. ECG Graph Paper (cont’d)
Calibrated Grids for Measurement
Time Calibrated Horizontally
Heavy Lined Blocks of 25 (5 × 5)
Small Box 0.04 Seconds Wide
Five Small Squares 0.20 Seconds Wide

9. PR Interval

10. QRS Complex

11. QRS Interval

12. T Wave

13. U Wave

14. ST Segment

15. ST Segment Inverted or Depressed

16. ST Segment Elevated

17. Interpretation of Cardiac Rhythms
Five-Step Process
1. Regularity of Rhythm
2. Heart Rate
3. P Wave
4. P-R Interval
5. QRS Complex

18. Normal Cardiac Waves Are Equal Distances Apart

19. Counting R Waves in a 6-Second Strip

20. Normal Sinus Rhythm

21. Normal Sinus Rhythm Rules
1. Rhythm: Regular
2. Heart Rate: bpm
3. P Wave: Rounded, Before Each QRS
4. PR Interval: Seconds
5. QRS Interval: Seconds

22. Dysrhythmias Rhythm Disturbances Impulse Formation Disturbed
Disturbance in Conduction

23. Sinoatrial Node Dysrhythmias
Sinus Bradycardia
Sinus Tachycardia

24. Sinus Bradycardia

25. Sinus Bradycardia Rules
1. Rhythm: Regular
2. Heart Rate: <60 bpm
3. P Waves: Rounded, Before Each QRS
4. PR Interval: Seconds
5. QRS Interval: Seconds

26. Sinus Tachycardia

27. Sinus Tachycardia Rules
1. Rhythm: Regular
2. Heart Rate: bpm
3. P Waves: Rounded, Before Each QRS
4. P-R Interval: 0.12 To 0.20 Seconds
5. QRS Interval: 0.06 To 0.10 Seconds

28. Atrial Dysrhythmias Premature Atrial Contractions Atrial Flutter
Atrial Fibrillation

29. Premature Atrial Contractions

30. Premature Atrial Contractions Rules
1. Rhythm: PAC Interrupts Rhythm
2. Heart Rate: Per Underlying Rhythm
3. P Waves: Early Beat, Abnormal Shape
4. P-R Interval: Usually Normal
5. QRS Interval: Seconds

31. Atrial Flutter

32. Atrial Flutter Rules 1. Rhythm: Atrial Rhythm Regular
2. Heart Rate: Varies
3. P Waves: Flutters , Sawtooth Pattern
4. P-R Interval: None Measurable
5. QRS Interval: Seconds

33. Atrial Fibrillation

34. Atrial Fibrillation Rules
1. Rhythm: Irregularly Irregular
2. Heart Rate: Atrial Rate Not Measurable, Ventricular Rate <100 Controlled Response, >100 Rapid Ventricular Response
3. P Waves: No Identifiable P Waves
4. P-R Interval: None Measurable
5. QRS Interval: Seconds

35. Ventricular Dysrhythmias
Premature Ventricular Contraction
Ventricular Tachycardia
Ventricular Fibrillation

36. Premature Ventricular Contractions (PVC)

37. Bigeminal PVC

38. Premature Ventricular Contraction Rules
1. Rhythm: PVC Interrupts Rhythm
2. Heart Rate: Per Underlying Rhythm
3. P Waves: Absent in PVC
4. P-R Interval: None for PVC
5. QRS Interval: PVCs >0.11 Seconds

39. Ventricular Tachycardia

40. Ventricular Tachycardia Rules
1. Rhythm: Usually Regular
2. Heart Rate: Ventricular bpm
Slow VT <150 bpm
3. P Waves: Absent
4. P-R Interval: None
5. QRS Interval: >0.11 Seconds

41. Ventricular Fibrillation

42. Ventricular Fibrillation Rules
1. Rhythm: Chaotic, Extremely Irregular
2. Heart Rate: Not Measurable
3. P Waves: None
4. P-R Interval: None
5. QRS Interval: None

43. Asystole

44. Asystole Rules 1. Rhythm: None 2. Heart Rate: None 3. P Waves: None
4. P-R Interval: None
5. QRS Interval: None

45. Cardiac Pacemakers External and Temporary Internal and Permanent
Override Dysrhythmias
Generate an Impulse
Can Be Placed in Atria, Ventricle, or Both

46. Dual-Chamber Pacemaker

47. Pacemakers

48. Patient Pacemaker Education
Incision Care
How to Take Radial Pulse
Symptoms to Report
Pacemaker ID Card
Things to Avoid
Trigger Metal Detectors
Grounded Appliances Safe
Periodic Pacemaker Checks

49. Defibrillation
Electrical shock delivered to reset lethal ventricular dysrhythmias.
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

50. Placement of Defibrillator Paddles

51. Synchronized Defibrillation
Allows R wave to be sensed for appropriately timed delivery.
Used in dysrhythmias when R wave present unless pulseless rhythm.

52. Automatic External Defibrillator
External device automatically analyzes rhythms, automatically delivers or prompts operator to deliver electrical shock if shockable rhythm (Vfib or VT) detected.

53. Implantable Cardioverter Defibrillator
Automatically Delivers Electrical Shock When Lethal Rhythm Detected
Cardioverts When VT Detected

54. Cardioversion
Atrial Fibrillation, Atrial Flutter, Supraventricular Tachycardias Unresponsive to Drugs
Conscious Sedation
Synchronize Mode
25-50 Joules

55. Implanted Cardioverter Defibrillator

56. Nursing Diagnoses for Dysrhythmias
Decreased Cardiac Output
Ineffective Tissue Perfusion
Activity Intolerance
Anxiety
Deficient Knowledge

57. Nursing Care of Patients with Heart Failure
Chapter 26
Nursing Care of Patients with Heart Failure

58. Heart Failure
Syndrome occurs from progressive inability of heart to pump enough blood to meet body’s oxygen/nutrient needs.
Older Term: Congestive Heart Failure

59. Causes Coronary Artery Disease MI Cardiomyopathy Heart Valve Disorders
Hypertension

60. Pathophysiology Each ventricle pumps equal amount of blood.
If more than either ventricle can handle, heart not effective pump,
Left ventricle typically weakens first.
Failure of one leads to failure of other.

61. Left-sided Heart Failure
Preload
Degree of stretch in ventricles before systole
Afterload
Force generated by left ventricle to eject blood into aorta through aortic valve.
Peripheral Vascular Resistance (PVR)
Pressure Within Aorta/Arteries
PVR Influences Afterload

62. Left-sided Heart Failure (cont’d)
Hypertension Major Cause
Blood Backs up from Left Ventricle
Alveolar Edema Results
p. 482 table 26.1

63. Left-sided Heart Failure (cont’d)

64. Right-sided Heart Failure
Left-sided Heart Failure Major Cause
Must continually pump blood against increased fluid in pulmonary artery and lungs.
Cor Pulmonale
Right ventricle hypertrophies/fails due to increased pulmonary pressures.
Backward Buildup of Blood in Systemic Blood Vessels
Peripheral Edema Results

65. Right-sided Heart Failure (cont’d)
Table 26.2 p. 481

66. Pulmonary Edema Acute Heart Failure
Severe Fluid Congestion in the Alveoli
Life-threatening
Drowning In Own Secretions

67. Signs and Symptoms Classic: Pink, Frothy Sputum
Rapid Respirations with Accessory Muscles
Severe Dyspnea, Orthopnea
Crackles, Wheezes
Coughing
Anxiety, Restlessness
Pale Skin/Mucous Membranes
Clammy, Cold Skin

68. Therapeutic Interventions
Immediate Treatment
Reduce Workload of Left Ventricle
Treat Underlying Cause
Fowler’s Position
Oxygen/Mechanical Ventilation

69. Therapeutic Interventions (cont’d)
Morphine IV
Diuretics
Inotropic Agents IV
Vasodilators IV
Nesiritide (Natrecor) IV
Table 26.5 p. 487

70. Nursing Diagnoses Impaired Gas Exchange Decreased Cardiac Output
Acute Pain
Anxiety
Excess Fluid Volume

71. Chronic Heart Failure Progressive
Signs aqnd Symptoms May Worsen over Time

72. Signs And Symptoms Fatigue and Weakness Exertional Dyspnea Cough
Orthopnea
Paroxysmal Nocturnal Dyspnea
Cough
Crackle and Wheezes
Tachycardia
Chest Pain
Cheyne-Stokes Respiration

73. Signs And Symptoms (cont’d)
Edema
Nocturia
Cyanosis
Altered Mental Status
Malnutrition

74. Complications of Heart Failure
Liver and Spleen Enlarge
Pleural Effusion
Thrombosis and Emboli
Cardiogenic Shock

75. Therapeutic Intervention Goals
Improve Heart’s Pumping Ability and Decrease Heart’s Oxygen Demands
Identify and Correct Underlying Cause
Increase Strength of Heart’s Contraction
Maintain Optimum Water and Sodium Balance
Decrease Heart’s Workload

76. Therapeutic Interventions
Activity
Sodium Restriction
Oxygen Therapy
Drug Therapy
ACE Inhibitors
Duretics
Inotropic Agents: Digitalis
Beta Blockers