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Nursing Care of Patients with Cardiac Dysrhythmias
Chapter 25 Nursing Care of Patients with Cardiac Dysrhythmias
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Cardiac Conduction System
Sinoatrial (SA) Node: bpm Across Both Atria AV Node Bundle of His Right and Left Bundle Branches Purkinje Fibers
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Cardiac Conduction System (cont’d)
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Cardiac Cycle One Heartbeat
Electrical Representation of Contraction, Relaxation of Atria/Ventricles
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Components of Cardiac Cycle
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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
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ECG Graph Paper
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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
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PR Interval
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QRS Complex
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QRS Interval
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T Wave
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U Wave
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ST Segment
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ST Segment Inverted or Depressed
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ST Segment Elevated
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Interpretation of Cardiac Rhythms
Five-Step Process 1. Regularity of Rhythm 2. Heart Rate 3. P Wave 4. P-R Interval 5. QRS Complex
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Normal Cardiac Waves Are Equal Distances Apart
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Counting R Waves in a 6-Second Strip
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Normal Sinus Rhythm
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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
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Dysrhythmias Rhythm Disturbances Impulse Formation Disturbed
Disturbance in Conduction
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Sinoatrial Node Dysrhythmias
Sinus Bradycardia Sinus Tachycardia
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Sinus Bradycardia
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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
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Sinus Tachycardia
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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
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Atrial Dysrhythmias Premature Atrial Contractions Atrial Flutter
Atrial Fibrillation
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Premature Atrial Contractions
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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
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Atrial Flutter
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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
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Atrial Fibrillation
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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
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Ventricular Dysrhythmias
Premature Ventricular Contraction Ventricular Tachycardia Ventricular Fibrillation
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Premature Ventricular Contractions (PVC)
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Bigeminal PVC
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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
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Ventricular Tachycardia
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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
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Ventricular Fibrillation
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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
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Asystole
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Asystole Rules 1. Rhythm: None 2. Heart Rate: None 3. P Waves: None
4. P-R Interval: None 5. QRS Interval: None
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Cardiac Pacemakers External and Temporary Internal and Permanent
Override Dysrhythmias Generate an Impulse Can Be Placed in Atria, Ventricle, or Both
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Dual-Chamber Pacemaker
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Pacemakers
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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
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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
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Placement of Defibrillator Paddles
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Synchronized Defibrillation
Allows R wave to be sensed for appropriately timed delivery. Used in dysrhythmias when R wave present unless pulseless rhythm.
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Automatic External Defibrillator
External device automatically analyzes rhythms, automatically delivers or prompts operator to deliver electrical shock if shockable rhythm (Vfib or VT) detected.
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Implantable Cardioverter Defibrillator
Automatically Delivers Electrical Shock When Lethal Rhythm Detected Cardioverts When VT Detected
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Cardioversion Atrial Fibrillation, Atrial Flutter, Supraventricular Tachycardias Unresponsive to Drugs Conscious Sedation Synchronize Mode 25-50 Joules
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Implanted Cardioverter Defibrillator
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Nursing Diagnoses for Dysrhythmias
Decreased Cardiac Output Ineffective Tissue Perfusion Activity Intolerance Anxiety Deficient Knowledge
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Nursing Care of Patients with Heart Failure
Chapter 26 Nursing Care of Patients with Heart Failure
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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
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Causes Coronary Artery Disease MI Cardiomyopathy Heart Valve Disorders
Hypertension
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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.
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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
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Left-sided Heart Failure (cont’d)
Hypertension Major Cause Blood Backs up from Left Ventricle Alveolar Edema Results p. 482 table 26.1
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Left-sided Heart Failure (cont’d)
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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
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Right-sided Heart Failure (cont’d)
Table 26.2 p. 481
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Pulmonary Edema Acute Heart Failure
Severe Fluid Congestion in the Alveoli Life-threatening Drowning In Own Secretions
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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
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Therapeutic Interventions
Immediate Treatment Reduce Workload of Left Ventricle Treat Underlying Cause Fowler’s Position Oxygen/Mechanical Ventilation
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Therapeutic Interventions (cont’d)
Morphine IV Diuretics Inotropic Agents IV Vasodilators IV Nesiritide (Natrecor) IV Table 26.5 p. 487
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Nursing Diagnoses Impaired Gas Exchange Decreased Cardiac Output
Acute Pain Anxiety Excess Fluid Volume
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Chronic Heart Failure Progressive
Signs aqnd Symptoms May Worsen over Time
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Signs And Symptoms Fatigue and Weakness Exertional Dyspnea Cough
Orthopnea Paroxysmal Nocturnal Dyspnea Cough Crackle and Wheezes Tachycardia Chest Pain Cheyne-Stokes Respiration
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Signs And Symptoms (cont’d)
Edema Nocturia Cyanosis Altered Mental Status Malnutrition
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Complications of Heart Failure
Liver and Spleen Enlarge Pleural Effusion Thrombosis and Emboli Cardiogenic Shock
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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
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Therapeutic Interventions
Activity Sodium Restriction Oxygen Therapy Drug Therapy ACE Inhibitors Duretics Inotropic Agents: Digitalis Beta Blockers
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