Chapter 31 _ Concepts of Care for Patients with Dysrhythmias _ Med Surg

Sinus Arrhythmia

1.Heart Rate: ___60-100_________ 2.Rhythm: Irregular 3.P wave: Rounded, before each QRS 4.PR Interval: Normal 5.QRS Complex: Normal

Normal Sinus Rhythm

1.Heart Rate: ___60-100_________ 2.Rhythm: Regular 3.P wave: Rounded, before each QRS 4.PR Interval: Normal 5.QRS Complex: Normal

Sinus Bradycardia

1.Heart Rate: ___less than 60_________ 2.Rhythm: Regular 3.P wave: Rounded, before each QRS 4.PR Interval: Normal 5.QRS Complex: Normal •Causes •Heart attack •Brain injury •Medications: _beta blockers, calcium channel blockers, narcotics__________________ •Athletes •Signs and Symptoms •May have none •sweating •syncope •Dizzy / confused sob •Treatment •None if asymptomatic •Oxygen •Atropine - given to raise heartrate •Pacemaker

Atrial Fibrillation (a-fib)

1.Heart Rate: ____120-200________ 2.Rhythm: Irregularly irregular 3.P wave: No identifiable P waves 4.PR Interval: None measurable QRS Complex: Normal •Most Common Dysrhythmia •Causes •Chaotic electrical impulses •Aging •Hypertension •Diabetes •Heart Failure •Signs and Symptoms •Palpitations •Dyspnea Hypotension •Intermittent or Chronic •Patients at Risk For: •Blood Clots: PE, Stroke •Treatment •Medications •Anticoagulants •Calcium Channel Blockers, •Cardioversion •Ablation

Atrial Flutter (a-flutter)

1.Heart Rate: ____varies ______ 2.Rhythm: Regular 3.P wave: Hallmark SAWTOOTH pattern - can have 2-4 sawtooth P waves for every QRS 4.PR Interval: None measurable 5.QRS Complex: Normal •Causes •Organized electrical impulses •Valve disease •Heart disease •Signs and Symptoms •Same as a-fib, but less severe •Palpitations •Dyspnea Hypotension •Patients at Risk For: •Blood Clots: PE, Stroke •Treatment •Medications •Anticoagulants •Calcium Channel Blockers, •Cardioversion •Ablation

Analysis of Strips - Steps

1.Determine the heart rate 2.Determine the heart rhythm •Is it regular or irregular? (use your calipers...) 3.Analyze the P waves •Is there a P wave? •Is it consistent? •Is there 1 P wave for every QRS? 4.Measure the PR interval 5.Measure the QRS Duration 6.Examine the ST Segment 7.Assess the T wave 8.Measure the QT interval

Asystole

1.Heart Rate: None 2.Rhythm: None 3.P wave: None 4.PR Interval: None 5.QRS Complex: None •Causes •Death •Massive MI or PE •Hyper/hypokalemia •Severe acidosis •Prolonged hypoxemia •Drug overdose (cocaine) •Hypothermia •Signs and Symptoms •Unresponsiveness •Pulseless Apneic •Treatment •Immediate initiation of CPR •ACLS protocols •Intubation •Medications- Epinephrine •DO NOT SHOCK

Ventricular Fibrillation (V-fib)

1.Heart Rate: Not measurable 2.Rhythm: extremely irregular 3.P wave: None 4.PR Interval: None measurable 5.QRS Complex: None measurable •Rapidly fatal if not successfully ended within 3-5 minutes •Causes •Acute MI •Cardiac procedures •Electrocution •Severe Electrolyte Imbalances •Severe acidosis •Signs and Symptoms •Unresponsiveness •Pulseless Apneic •Treatment •Immediate initiation of CPR •ACLS protocols •Defibrillation •Medications

Premature Ventricular Contraction (PVC)

1.Heart Rate: Varies depending on number of PVCs 2.Rhythm: PVCs interrupt rhythm 3.P wave: Hidden in PVC 4.PR Interval: None measurable 5.QRS Complex: Wide and distorted •This is a "with" rhythm •Ex) Normal Sinus with PVCs •Causes •Stimulants •MI, heart failure, CAD •Electrolyte Imbalances •Age •Signs and Symptoms •Palpitations •Can have severe symptoms with runs or V-tach •Different Types: •Unifocal •Multifocal •Bigeminy •Trigeminy •Couplet •3+ PVCs = "a run" or VTach •Treatment •Medications •Electrolyte Replacement

Ventricular Tachycardia (V-tach)

1.Heart Rate: ___140-180___________ 2.Rhythm: Regular or Irregular 3.P wave: Not usually visible 4.PR Interval: None measurable QRS Complex: Wide and distorted •Causes •Heart Disease; Cardiomyopathy •MI, Heart Failure •Hypokalemia •Drug Toxicity •Signs and Symptoms •Dyspnea •Palpitations •Light-headedness •Angina •If progresses to V-fib: cardiac arrest •Types •Monomorphic •Polymorphic •Treatment •If stable: •Medications •Unstable •Cardioversion •Pulseless: •CPR •Defibrillation •Vasopressors

Supraventricular Tachycardia

1.Heart Rate: ___200-280_________ 2.Rhythm: Regular 3.P wave: Often buried in the preceding T wave 4.PR Interval: Difficult to measure 5.QRS Complex: Normal •Causes •Strong emotions •Caffeine •Alcohol •Medications: •Asthma meds •Herbal supplements •Signs and Symptoms •Stable •Shortness of breath/Tachypnea •Palpitations •Dizziness •Unstable •Ongoing chest pain •Loss of consciousness Numbness of body parts •Treatment •Stable •Vagal maneuvers - baredown •Medications (Adenosine) •Unstable •Cardioversion

Sinus Tachycardia

1.Heart Rate: __greater thn 100 but less thn 160__________ 2.Rhythm: Regular 3.P wave: Rounded, before each QRS 4.PR Interval: Normal 5.QRS Complex: Normal •Causes •Strong emotions •Cardiac conditions-mi, hyperthyroidism, CHF • •Medications: epinephrine, caffine, nicotine, psudofedrin, robutussin •Signs and Symptoms •May have none •Dizziness •Dyspnea Hypotension •Treatment •None if temporary •Treat underlying cause •Digoxin •Calcium Channel Blockers •Beta Blockers

•Which actions are essential nursing care for a client immediately after elective cardioversion? Select all that apply. • A.Administer oxygen B.Assess vital signs and level of consciousness C.Provide sips of water or ice chips D.Monitor for dysrhythmias E.Maintain an open airway F.Document the results of the cardioversion

A.Administer oxygen B.Assess vital signs and level of consciousness D.Monitor for dysrhythmias E.Maintain an open airway F.Document the results of the cardioversion

•Which waveform does the nurse recognize as atrial depolarization when a client is placed on a cardiac monitor? • A.P wave B.PR segment C.QRS complex D.T wave

A.P wave

•Which dysrhythmia does the nurse consider life threatening because it causes the ventricles to quiver and results in the absence of cardiac output for a client? • A.Asystole B.Ventricular tachycardia C.Atrial fibrillation Ventricular fibrillation

Ventricular fibrillation

Dysrhythmias

•Any disorder of the heartbeat is called a dysrhythmia • •Rhythm disturbance • •Electrical Impulse formation disturbed •Impulse may arise from atria, AV node, or ventricles • •Disturbance in Conduction Impulse is initiated by the SA node, but becomes blocked with the conduction system along the way

Pulseless Electrical Activity

•Common during code situations •Organized rhythm, but NO PULSE due to electromechanical dissociation •Treat as asystole

Intro to Dysrhythmias

•Definition: A disorder of the heartbeat involving a disturbance in cardiac rhythm; irregular heartbeat •Too slow, too fast, or irregular •Some are life-threatening and many are not Diseases and Conditions can affect the conduction system of the heart •Heart disease •Heart injury •Electrolyte Imbalances •Changes in oxygenation or hydration •Drug Toxicity

ECG Graph Paper

•Horizontal Axis: •1 tiny square = ___0.04________ seconds •1 large square = ___.2 ________seconds •5 large squares = ___1________ second •30 large squares = __6_________ seconds •Vertical Axis: •Measures voltage •Amplitude of ECG waves

Components of the Cardiac Cycle

•P Wave •First wave •Atrial Depolarization •Normal: __0.6-0.12_____ seconds •Normal: 1 P wave for every QRS complex •P-R Interval •Beginning of P wave to the beginning of the QRS •Normal: _0.12-0.20______ seconds •QRS Complex •Follows the P wave •Ventricular Depolarization •3 Waves: •Q wave - 1st negative deflection •R wave - 1st positive deflection •S wave - 2nd negative deflection if Q wave present or first negative deflection after R wave •Normal: __0.04-0.12________ seconds or 1-3 small boxes •If >0.12 sec = Bundle Branch Block •ST Segment •End of QRS to beginning of T wave •In identifying mi or eschimia •Normal: ___0.12______ seconds • •T wave •Ventricular Repolarization so ventricle relaxing •Usually Upright •Normal: __0.16______seconds • •QT Interval •Beginning of QRS to end of T wave •Abnormal myocardial problem •Prolonged antrythmic medications could be the cause sometimes haloldol •Normal: __<0.4_______ seconds • •If you see a u wave indicative of a pot imbalance usually hypokalemia

Electrocardiogram (ECG/EKG)

•Shows cardiac electrical activity •10 actual leads •Waveforms change appearance in different leads •Continuous monitoring often in Lead II •Waveforms are upright in Lead II

Pacemakers

•Used to correct a slow or irregular heartbeat •Cardiac Pacemakers OVERRIDE dysrhythmias •External and temporary •Internal and permanent •Generate an impulse •Can be placed in atria, ventricle, or both •Pacer spikes •Education •Type and Settings •Report pulse lower than pacemaker setting •Report incision complications •Avoid electromagnetic fields

Defibrillation

•Used to correct lethal ventricular dysrhythmia •Electrical shock resets the lethal dysrhythmia •Conductive jelly or saline pads are used •Paddles/pads pressed firmly against the chest •Announce "CLEAR" before shock •Increasing energy: 200, 300, 360 joules

Synchronized Cardioversion

•Used to correct unstable a-fib or a-flutter, stable or unstable SVT, or stable V-tach(when medications have failed to convert the rhythm) • •Low energy shock delivered on the R wave (of the QRS) • •Conscious sedation

Automatic External Defibrillators (AEDs)

•Used to treat shockable rhythms "in the field" •External device automatically analyzes rhythms, prompts user, and delivers shock if shockable rhythm is detected • •Hands free defibrillation • •Common in airports, malls, restaurants

Automatic Implantable Cardioverter Defibrillator (AICD)

•Used to treat shockable rhythms in patients at high risk for life-threatening dysrhythmias •Automatically delivers electrical shock if lethal rhythm detected •Cardioverts when V-tach is detected •Education •Significant "kick" •Avoid strong magnetic fields •Know how to contact EMS after shock •Family members