1. Chapter 26 Management of Patients With Dysrhythmias and Conduction Problems

2. 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

3. 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

4. Relationship of ECG Complex, Lead System, and Electrical Impulse

5. 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

6. ECG Electrode Placement

7. ECG Graph and Commonly Measured Components

8. Heart Rate Determination

9. Normal Sinus Rhythm

10. Sinus Bradycardia

11. Sinus Tachycardia

12. Sinus Arrhythmia

13. 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.

14. 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.

15. 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

16. 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

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

18. Collaborative Problems and Potential Complications
Cardiac arrest
Heart failure
Thromboembolic event, especially with atrial fibrillation

19. 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

20. 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

21. 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”

22. 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

23. 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)

24. 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

25. 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

26. 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

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

28. Implanted Transvenous Pacemaker

29. Transcutaneous Pacemaker

30. 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

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

32. ICD (cont’d)

33. 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

34. 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

35. 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

36. 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

37. Paddle Placement for Defibrillation

38. 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

39. 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.

40. 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