1. Chapter 27 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, rhythm
Potentially can alter blood flow, cause hemodynamic changes
Diagnosed by analysis of electrographic waveform

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

4. ECG Electrode Placement

5. ECG Graph and Commonly Measured Components

6. Heart Rate Determination

7. Normal Sinus Rhythm

8. Sinus Bradycardia

9. Sinus Tachycardia

10. Sinus Arrhythmia

11. Question Tell whether the following statement is true or false:
The PR interval on an ECG strip that reflects normal sinus rhythm is between 0.12 and 0.20 seconds.

12. Answer
True.
Rationale: The PR interval on an ECG strip that reflects normal sinus rhythm is between 0.12 and 0.20 seconds.

13. Premature Atrial Complexes

14. Atrial Flutter

15. Atrial Fibrillation

16. Multifocal PVCs-Quadrigeminy

17. Ventricular Tachycardia

18. Ventricular Fibrillation

19. Asystole

20. First Degree AV Block

21. Second Degree AV Block, Type I

22. Second Degree AV Block, Type II

23. Third Degree AV Block

24. Question Tell whether the following statement is true or false:
A “saw tooth” P wave is seen on an ECG strip with atrial fibrillation.

25. Answer
False.
Rationale: A “saw tooth” P wave is seen on an ECG strip with atrial flutter, not atrial fibrillation.

26. Nursing Process: Care of the Patient with a Dysrhythmia - Assessment
Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness
Physical assessment include
Rate, rhythm of apical, peripheral pulses
Heart sounds
Blood pressure, pulse pressure
Signs of fluid retention

27. Nursing Process: Care of the Patient with a Dysrhythmia – Assessment (cont’d)
Health history: include presence of coexisting conditions, indications of previous occurrence
Medications

28. Nursing Process: Care of the Patient with a Dysrhythmia - Diagnoses
Decrease cardiac output
Anxiety
Deficient knowledge

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

30. 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, its treatment

31. Decreased Cardiac Output
Monitoring
ECG monitoring
Assessment of signs, symptoms
Administration of medications, assessment of medication effects
Adjunct therapy: cardioversion, defibrillation, pacemakers

32. Other Interventions Anxiety Use calm, reassuring manner
Measures to maximize patient control to make episodes less threatening
Communication, teaching
Teaching self-care
Include family in teaching

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

34. Implanted Transvenous Pacemaker

35. Transcutaneous Pacemaker

36. ECG-On Demand Pacing

37. Complications of Pacemaker Use
Infection
Bleeding or hematoma formation
Dislocation of lead
Skeletal muscle or phrenic nerve stimulation
Cardiac tamponade
Pacemaker malfunction

38. Nursing Process: Care of the Patient with an Implanted Cardiac Device - Assessment
Device function: ECG
Cardiac output, hemodynamic stability
Incision site
Coping
Patient, family knowledge

39. Nursing Process: Care of the Patient with an Implanted Cardiac Device - Diagnoses
Risk for infection
Risk for ineffective coping
Knowledge deficient

40. Nursing Process: Care of the Patient with an Implanted Cardiac Device - Planning
Goals
Absence of infection
Adherence to self-care program
Effective coping
Maintenance of device function

41. Interventions Risk for ineffective coping
Support of patient, family coping
Setting of realistic goals
Allow patient to talk, share feelings, experiences
Support groups or referral
Stress-reduction techniques
Knowledge deficient
Patient, family teaching

42. Cardioversion and Defibrillation
Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial ceils
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

43. Safety Measures Assure good contact between skin, pads or paddles
Use conductive medium, 20 to 25 pounds of pressure
Place paddles so they do not touch bedding or clothing, are not near medication patches or oxygen flow
If cardioverting, turn synchronizer on
If defibrillating, turn synchronizer off

44. Safety Measures (cont’d)
Do not charge device until ready to shock
Call “clear” three times; follow checks required for clear
Assure no one is in contact with patient, bed, or equipment

45. Paddle Placement for Defibrillation

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

47. ICD

48. Question
What must a patient with an automatic implantable cardioverter defibrillator (ICD) do?
Can 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

49. Answer C. Document events that trigger a shock sensation
Rationale: The patient with an automatic implantable cardioverter defibrillator (ICD) must document events that trigger a shock sensation. The patient must avoid magnetic fields such as metal-detection devices at the airport and call for emergency assistance when feeling dizzy.

50. Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias
Electrophysiologic studies
Cardiac conduction surgery
Maze procedure
Catheter ablation therapy