1. CARDIAC DYSRHYTHMIAS

2. PYRAMID POINTS Six-second strip method to determine heart rate
Recognizing rhythms and the appropriate treatment measures
Normal sinus rhythm
Premature ventricular contractions
Atrial fibrillation
Ventricular tachycardia
Ventricular fibrillation
Cardioversion and defibrillation procedures
Client teaching for pacemakers

3. SIX-SECOND STRIP METHOD TO DETERMINE HEART RATE
Can be used to determine heart rate for both regular and irregular rhythms
To determine atrial rate, count the number of P-P intervals in 6 seconds and multiply by 10 to obtain a full-minute rate
To determine ventricular rate, count the number of R-R intervals in 6 seconds and multiply by 10 to obtain a full-minute rate
For accuracy, timing should begin on the P wave or the QRS complex and end exactly at 30 large blocks later

4. SIX-SECOND STRIP METHOD TO DETERMINE HEART RATE
From Paul, S. & Hebra, J. (1998). The nurse’s guide to cardiac rhythm interpretation. Philadelphia: W.B. Saunders

5. NORMAL SINUS RHYTHM DESCRIPTION Rhythm originates from the SA node
Atrial and ventricular rhythms are regular
Atrial and ventricular rates are 60 to 100 beats per minute

6. NORMAL SINUS RHYTHM
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

7. SINUS BRADYCARDIA DESCRIPTION
Atrial and ventricular rates are below 60 beats per minute
Treatment may be necessary if the client is symptomatic
Note that a low heart rate may be normal for some individuals

8. SINUS BRADYCARDIA
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

9. SINUS BRADYCARDIA IMPLEMENTATION
Attempt to determine cause and if a medication is suspected as causing the bradycardia, hold the medication and notify the physician
Administer oxygen as prescribed
Administer atropine sulfate as prescribed to increase the heart rate to 60 beats per minute

10. SINUS BRADYCARDIA IMPLEMENTATION
Be prepared to apply a noninvasive pacemaker initially as prescribed, if the atropine sulfate does not increase the heart rate sufficiently
Avoid additional doses of atropine sulfate because they will induce tachycardia
Monitor for hypotension and administer IV fluids as prescribed
Depending on the cause of the bradycardia, the client may need a permanent pacemaker

11. SINUS TACHYCARDIA DESCRIPTION
Atrial and ventricular rates are 100 to 180 beats per minute
IMPLEMENTATION
Identify the cause of the tachycardia
Decrease the heart rate to normal by treating the cause

12. SINUS TACHYCARDIA
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

13. ATRIAL FIBRILLATION DESCRIPTION
Multiple rapid impulses from many foci depolarize in the atria in a totally disorganized manner at a rate of 350 to 600 times per minute
The atria quiver, which can lead to the formation of thrombi
P wave is absent

14. ATRIAL FIBRILLATION
From Paul, S. & Hebra, J. (1998). The nurse’s guide to cardiac rhythm interpretation. Philadelphia: W.B. Saunders.

15. ATRIAL FIBRILLATION IMPLEMENTATION Administer oxygen
Administer anticoagulants as prescribed because of the risk of emboli
Administer cardiac medications as prescribed to control the ventricular rhythm and assist in the maintenance of cardiac output
Prepare the client for cardioversion as prescribed
Instruct the client in the use of medications as prescribed to control the dysrhythmia

16. PREMATURE VENTRICULAR CONTRACTIONS (PVCs)
DESCRIPTION
Early ventricular complexes result from increased irritability of the ventricles
PVCs frequently occur in repetitive rhythms such as bigeminy, trigeminy, and quadrigeminy
The QRS complexes may be unifocal or multifocal

17. PREMATURE VENTRICULAR CONTRACTIONS (PVCs)
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

18. PREMATURE VENTRICULAR CONTRACTIONS (PVCs)
IMPLEMENTATION
Notify the physician if PVCs are noted
Identify the cause and treat based on the cause
Evaluate electrolytes, particularly the potassium level, since hypokalemia can cause PVCs
Administer oxygen as prescribed

19. PREMATURE VENTRICULAR CONTRACTIONS (PVCs)
IMPLEMENTATION
Administer lidocaine as prescribed
Notify the physician if the client complains of chest pain, if PVCs increase in frequency, are multifocal, occur on the T wave (R on T), or occur in runs of ventricular tachycardia

20. VENTRICULAR TACHYCARDIA (VT)
DESCRIPTION
Occurs when there is a repetitive firing of an irritable ventricular ectopic focus at a rate of 140 to 250 beats per minute or more
May present as a paroxysm of three self-limiting beats or more, or may be a sustained rhythm
Can cause cardiac arrest

21. VENTRICULAR TACHYCARDIA (VT)
From Paul, S. & Hebra, J. (1998). The nurse’s guide to cardiac rhythm interpretation. Philadelphia: W.B. Saunders.

22. VENTRICULAR TACHYCARDIA (VT)
STABLE CLIENT WITH SUSTAINED VT
Administer oxygen as prescribed
Administer antidysrhythmics as prescribed

23. VENTRICULAR TACHYCARDIA (VT)
UNSTABLE CLIENT WITH VT
Administer oxygen and antidysrhythmic therapy as prescribed
Prepare for synchronized cardioversion if unstable
Attempt cough cardiopulmonary resuscitation (CPR) by asking the client to cough hard every 1 to 3 seconds
PULSELESS CLIENT
Defibrillation and cardiopulmonary resuscitation (CPR)

24. VENTRICULAR FIBRILLATION (VF)
DESCRIPTION
Impulses from many irritable foci fire in a totally disorganized manner
Chaotic rapid rhythm in which the ventricles quiver
Rapidly fatal if not successfully terminated within 3 to 5 minutes
Client lacks a pulse, blood pressure, respirations, and heart sounds

25. VENTRICULAR FIBRILLATION (VF)
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

26. VENTRICULAR FIBRILLATION (VF)
IMPLEMENTATION
Defibrillate immediately, up to three times consecutively at 200, 300, and 360 joules
Initiate CPR
Administer oxygen as prescribed
Administer epinephrine (Adrenalin) and antidysrhythmic therapy with lidocaine as prescribed
Prepare to administer additional prescribed antidysrhythmics

27. VAGAL MANEUVERS DESCRIPTION
Induce vagal stimulation of the cardiac conduction system
Used to terminate supraventricular tachydysrhythmias

28. CAROTID SINUS MASSAGE
The physician instructs the client to turn the head away from the side to be massaged
The physician massages over the carotid artery for 6 to 8 seconds until there is a change in cardiac rhythm
Observe the cardiac monitor for a change in rhythm
Record an ECG rhythm strip before, during, and after the procedure
Have a defibrillator and resuscitative equipment available
Monitor VS, cardiac rhythm, and level of consciousness (LOC) following the procedure

29. VALSALVA MANEUVERS
The physician instructs the client to bear down or induces a gag reflex in the client, both of which stimulate a vagal reflex
Monitor the heart rate, rhythm, and BP
Observe the cardiac monitor for a change in rhythm; record an ECG rhythm strip before, during, and after the procedure
Provide an emesis basin if the gag reflex is stimulated, and initiate precautions to prevent aspiration
Have a defibrillator and resuscitative equipment available

30. CARDIOVERSION DESCRIPTION
Synchronized countershock to convert an undesirable rhythm to a stable rhythm
An elective procedure performed by the physician
A lower amount of energy is used than with defibrillation
Defibrillator is synchronized to the client’s R wave to avoid discharging the shock during the vulnerable period (T wave)
If the defibrillator were not synchronized, it would discharge on the T wave and cause VF

31. CARDIOVERSION PREPROCEDURE Obtain consent
Administer sedation as prescribed
Hold digoxin (Lanoxin) 48 hours preprocedure as prescribed to prevent postcardioversion ventricular irritability

32. CARDIOVERSION DURING THE PROCEDURE
Ensure that the skin is clean and dry in the area where the electrode paddles will be placed
Stop the oxygen during the procedure to avoid the hazard of fire
Be sure that no one is touching the bed or the client when delivering the countershock

33. CARDIOVERSION POSTPROCEDURE Maintain airway patency
Administer oxygen as prescribed
Assess VS
Assess LOC
Monitor cardiac rhythm
Monitor for indications of successful response, such as conversion to sinus rhythm, strong peripheral pulses, and an adequate BP

34. DEFIBRILLATION DESCRIPTION
An asynchronous countershock used to terminate pulseless VT or VF
Three rapid, consecutive shocks are delivered with the first at an energy of 200 joules
If unsuccessful, the shock is repeated at 200 to 300 joules
The third and subsequent shock will be at 360 joules

35. DEFIBRILLATION DURING THE PROCEDURE
Stop the oxygen to avoid the hazard of fire
Be sure that no one is touching the bed or the client when delivering the countershock

36. DEFIBRILLATION USE OF PADDLE ELECTRODES Apply conductive pads
One paddle is placed at the third intercostal space to the right of the sternum; the other is placed at the fifth intercostal space on the left midaxillary line
Apply firm pressure with the paddles
Be sure that no one is touching the bed or the client when delivering the countershock

37. ANATOMICAL POSITION OF THE HEART
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

38. PADDLE PLACEMENT
From Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.

39. AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
Used by laypersons and emergency medical technicians for prehospital cardiac arrest
Place the client on a firm dry surface
Stop CPR
Ensure that no one is touching the client to avoid motion artifact during rhythm analysis
Place the electrode paddles in the correct position on the client’s chest
Press the analyzer button to identify the rhythm, which may take 30 seconds; the machine will advise whether a shock is necessary

40. AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
Shocks are recommended for pulseless VF only
If shock is recommended, the shock is initially delivered at an energy of 200 joules
If unsuccessful, the shock is repeated at 200 to 300 joules
The third and subsequent shock will be at 360 joules
If unsuccessful, CPR is continued for 1 minute, and then another series of 3 shocks are delivered each at 360 joules of energy

41. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)
DESCRIPTION
Monitors cardiac rhythm and detects and terminates episodes of VT and VF
It senses VT or VF and delivers 25 to 30 joules up to four times if necessary
Used in clients with episodes of spontaneous sustained VT or VF unrelated to a myocardial infarction or in clients whose medication therapy has been unsuccessful in controlling life-threatening dysrhythmias
Electrodes are placed in the right atrium and ventricle and apical pericardium; the generator is implanted in the abdomen

42. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)
From Lewis SM, Heitkemper M, Dirksen S: Medical-Surgical Nursing: Assessment and Management of Clinical Problems (5th ed), St. Louis, 2000, Mosby.

43. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)
CLIENT EDUCATION
Basic functioning of the ICD
How to perform cough CPR
How to take the pulse; the pulse is taken daily and a diary of pulse rates is maintained
Wear loose-fitting clothing
Avoid contact sports and strenuous activities

44. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)
CLIENT EDUCATION
Report any fever, redness, swelling, or drainage from the insertion site
Report symptoms of fainting, nausea, weakness, blackouts, and rapid pulse rates to the physician
During shock discharge, the client may feel faint or short of breath
To sit or lie down if they feel a shock and to notify the physician

45. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)
CLIENT EDUCATION
How to access emergency medical system
Encourage the family to learn CPR
Maintain a diary of any shocks that are delivered including the date, preceding activity, the number of shocks, and if the shocks were successful

46. IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)
CLIENT EDUCATION
Avoid electromagnetic fields directly over the ICD because they can inactivate the device
Move away from the magnetic field immediately if beeping tones are heard, and notify the physician
Keep a pacemaker ID in the wallet and obtain and wear a Medic Alert bracelet
Inform all health care providers that an ICD is inserted

47. PACEMAKERS DESCRIPTION
A temporary or permanent device that provides electrical stimulation and maintains the heart rate when the client’s intrinsic pacemaker fails to provide a perfusing rhythm

48. PACEMAKERS
SETTINGS
Synchronous or demand pacemaker: Senses the client’s rhythm and paces only if the client’s intrinsic rate falls below the set pacemaker rate
Asynchronous or fixed rate: Paces at a preset rate regardless of the client’s intrinsic rhythm
Overdrive pacing: To suppress the underlying rhythm in tachydysrhythmias so that the sinus node will regain control of the heart

49. PACEMAKERS
SPIKES
When a pacing stimulus is delivered to the heart, a spike (straight vertical line) is seen on the monitor or ECG strip
The spike should be followed by a P wave indicating atrial depolarization, or a QRS complex indicating ventricular depolarization; this pattern is referred to as “capture,” indicating that the pacemaker successfully depolarized, or captured, the chamber

50. PACEMAKERS
SPIKES
If the electrode is in the ventricle, the spike is in front of the QRS complex; if the electrode is in the atrium, the spike is before the P wave
If the electrode is in both the atrium and ventricle, the spike is before both the P wave and QRS complex

51. PACEMAKER SPIKES
From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

52. TEMPORARY PACEMAKERS NONINVASIVE TEMPORARY PACING (NTP)
Used as an emergency measure or when a client is being transported and the risk of bradydysrhythmia exists
A large electrode patch is placed on the chest and back

53. TEMPORARY PACEMAKERS NONINVASIVE TEMPORARY PACING (NTP)
Wash the skin with soap and water prior to applying electrodes
Do not shave the hair or apply alcohol or tinctures to the skin
Place the posterior electrode between the spine and left scapula behind the heart, avoiding placement over bone
Place the anterior electrode between V2 and V5 position over the heart

54. TEMPORARY PACEMAKERS NONINVASIVE TEMPORARY PACING (NTP)
Do not place the anterior electrode over female breast tissue; rather, displace breast tissue and place under the breast
Do not take the pulse or BP on the left side because the results will not be accurate due to the muscle twitching and electrical current
Assure that electrodes are in good contact with the skin
If loss of “capture” occurs, assess the skin contact of the electrodes and increase the current until “capture” is regained

55. TEMPORARY PACEMAKERS TRANSVENOUS INVASIVE TEMPORARY PACING
Pacing lead wire is placed through antecubital, femoral, jugular, or subclavian vein into the right atrium for atrial pacing, or through the right ventricle, and positioned in contact with the endocardium
Monitor cardiac rhythm continuously
Monitor vital signs
Monitor pacemaker insertion site
Restrict client movement to prevent lead wire displacement

56. TRANSVENOUS INVASIVE TEMPORARY PACING
From Thelan LA et al (1998) Critical care nursing (3rd ed). St. Louis: Mosby.

57. TEMPORARY PACEMAKERS EPICARDIAL INVASIVE TEMPORARY PACING
Applied using a transthoracic approach
The lead wires are loosely threaded on the epicardial surface of the heart after cardiac surgery

58. EPICARDIAL INVASIVE TEMPORARY PACING
From Black, J. Hawks, J., and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders

59. TEMPORARY PACEMAKERS REDUCING THE RISK OF MICROSHOCK
Use only inspected and approved equipment
Insulate the exposed portion of wires with plastic or rubber material (fingers of rubber gloves) when wires are not attached to the pulse generator, and cover with nonconductive tape
Ground all electrical equipment using a three-pronged plug
Wear gloves when handling exposed wires
Keep dressings dry

60. PERMANENT PACEMAKERS
Pulse generator is internal and surgically implanted in a subcutaneous pocket under the clavicle or abdominal wall
The leads are passed transvenously via the cephalic or subclavian vein to the endocardium on the right side of the heart
May be single-chambered, in which the lead wire is placed in the chamber to be paced, or dual-chambered, with lead wires placed in the atrium and right ventricle

61. PERMANENT PACEMAKERS
It is programmed when inserted and can be reprogrammed if necessary by noninvasive transmission from an external programmer to the implanted generator
Pacemakers are powered by either a lithium battery that has an average life span of 10 years, nuclear-powered with a life span of 20 years or longer, or are designed to be recharged externally

62. PACEMAKERS: CLIENT EDUCATION
About the pacemaker including the programmed rate
The signs of battery failure and when to notify the physician
Report any fever, redness, swelling, or drainage from the insertion site
Report signs of dizziness, weakness or fatigue, swelling of the ankles or legs, chest pain, or shortness of breath

63. PACEMAKERS: CLIENT EDUCATION
Keep a pacemaker identification card in the wallet and obtain and wear a Medic Alert bracelet
How to take the pulse, to take the pulse daily, and maintain a diary of pulse rates
Wear loose-fitting clothing
Avoid contact sports
Inform all health care providers that a pacemaker is inserted
Inform airport security about the pacemaker because the pacemaker may set off the security detector

64. PACEMAKERS: CLIENT EDUCATION
Most electrical appliances can be used without any interference with the functioning of the pacemaker; however, advise the client not to operate electrical appliances directly over the pacemaker site
Avoid transmitter towers and antitheft devices in stores
If any unusual feelings occur when near any electrical devices to move 5 to 10 feet away and to check the pulse
The importance of follow-up with the physician