Dysrhythmias

A. "This means the pacemaker fires in an asynchronous pattern."

A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review? A. "This means the pacemaker fires in an asynchronous pattern." B. "This means the pacemaker fires only when the heart rate is below a certain rate." C. "The pacemaker can automatically adjust to a client's increased activity level." D. "The pacemaker activity is triggered by heart muscle activity."

D. Assess the client and check lead placement.

A client in the telemetry unit is on a cardiac monitor. The monitor technician notices that there are no ECG complexes, and the alarm sounds. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.

D. Apply transcutaneous pacemaker pads.

A nurse is admitting a client who has complete heart block as demonstrated by ECG. The client's heart rate is 34/min and blood pressure is 83/48 mmHg. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? A. Transport the client to the cardiovascular laboratory. B. Prepare the client for insertion of a permanent pacemaker. C. Obtain a signed informed consent form for a pacemaker. D. Apply transcutaneous pacemaker pads.

A. Cool and clammy foot with capillary refill of 5 seconds C. Persistent hiccups

A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Cool and clammy foot with capillary refill of 5 seconds B. Observed pacing spike followed by a QRS complex C. Persistent hiccups D. Heart rate 84/min E. Blood pressure 104/62 mm Hg

A. Avoid large magnetic fields C. Take body temperature at the same time each day.

A nurse is completing discharge teaching with a client following placement of an ICD. Which of the following information should the nurse include? (Select all that apply.) A. Avoid large magnetic fields B. Caution family members that they can receive harmful unexpected shocks for the ICD C. Take body temperature at the same time each day. D. Wear tight clothing to hold the device in place E. Perform arm stretching exercises to strengthen the muscles surrounding the ICD

A. "I will notify the airport screeners about my pacemaker."

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? A. "I will notify the airport screeners about my pacemaker." B. "I will expect to have occasional hiccups." C."I will have to disconnect my garage door opener." D."I will take my pulse every 2 to 3 days."

1. Premature atrial complexes 2. Supraventricular tachycardia 3. Atrial fibrillation

Atrial Dysrhythmias · In patients with atrial dysrhythmias, the focus of the impulse generation shifts away from the sinus node to the atrial tissues. § The shift changes the axis (direction) of atrial depolarization, resulting in a P-wave shape that differs from normal P waves. · The most common atrial dysrhythmias are: 1. 2. 3. Ventricular Dysrhythmias · Ventricular dysrhythmias are potentially more life threatening than atrial dysrhythmias because the left ventricle pumps oxygenated blood throughout the body to perfuse organs and tissues. · The most common or life threatening ventricular dysrhythmias include: 1. Premature ventricular complexes 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Ventricular asystole

1. Premature ventricular complexes 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Ventricular asystole

Atrial Dysrhythmias · In patients with atrial dysrhythmias, the focus of the impulse generation shifts away from the sinus node to the atrial tissues. § The shift changes the axis (direction) of atrial depolarization, resulting in a P-wave shape that differs from normal P waves. · The most common atrial dysrhythmias are: 1. Premature atrial complexes 2. Supraventricular tachycardia 3. Atrial fibrillation Ventricular Dysrhythmias · Ventricular dysrhythmias are potentially more life threatening than atrial dysrhythmias because the left ventricle pumps oxygenated blood throughout the body to perfuse organs and tissues. · The most common or life threatening ventricular dysrhythmias include: 1. 2. 3. 4.

VF or pulseless VT only

Automated External Defibrillation · You need 5, maybe 6 people total: § 1. Team Leader (ICU nurse, shift leader, until DR arrives): tells you what to do § 2. Recorder: stand at door/corner with EMR/chart open. Chart what they were here for, what happened before code, what symptoms they had, etc. § 3. Defibrillator: responsible for making sure that every person around the bed/client is clear before defibrillating. § 4. RT: intubation, etc. § 5. 2 people for CPR, one on compressions, then they rotate · To use an AED, the patient must be on a dry, firm surface. · The rescuer places two large adhesive patch electrodes on the patient's chest in the same position as for the defibrillator electrodes. · The rescuer stops CPR and commands anyone present to move away and not touch the patient, so that the AED can detect the heart rhythm. · The rescuer presses the analyze button. After rhythm analysis, which may take up to 30 seconds, the machine advises either a shock or that shock is not needed. § Shocks are recommended for ______________ and _____________ only (NOT ASYSTOLE). The AED will recognize these rhythms, and will instruct to deliver a shock if VF or pulseless VT is present. · If shock is indicated, command to clear all contact with the patient and press the charge button. Once the AED is charged, press the shock button, and the shock is delivered. · The rescuer then resumes CPR until the AED instructs to stop CPR to analyze the rhythm

R wave

Cardioversion (Covered LAST SEMESTER) · Cardioversion: a synchronized (to QRS complex) countershock that is performed to restore normal condition in a patient with new-onset atrial fibrillation. § When the onset of atrial fibrillation is greater than 48 hours, the patient must take anticoagulants for 4-6 hours before the procedure to prevent clots from moving from the heart to the brain or lungs. § If the onset of atrial fibrillation is uncertain, a transesophageal echocardiogram (TEE) can be performed to assess for clot formation on the left atrium · There must be emergency medical equipment present during the procedure · transesophageal echocardiogram (TEE) should precede cardioversion to see if the patient has a clot that could be dislodged during cardioversion (CAUSES STROKE) · Lower Joules: 10, 15, or 12 joules ( compared to defibrillation with 150-200 joules) · Synchronized to deliver electrical current on the ______________. The defibrillator should be set in the synchronized mode, and a dot/line will appear over each QRS complex. This avoids discharging the shock on the T wave. · For safety, turn off oxygen and move it away from patient getting an ELECTRICAL CARDIOVERSION because a fire can result. Shout CLEAR before the delivery for safety

shorten diastolic time and coronary perfusion time (the amount of time available for blood to flow through the coronary arteries to the myocardium)

Common Dysrhythmias · Any disorder of the heartbeat is called a dysrhythmia. Many have no signs and symptoms, but often have serious consequences if not treated. · Bradydysrhythmias occur when the heart rate is less than 60 beats/min § Myocardial O2 demand is reduced from slow rate, which can be beneficial § Coronary perfusion time may be adequate because of a prolonged diastole, which is desirable § Coronary perfusion may decrease if the heart rate is too slow to provide adequate cardiac output and BP (very serious consequence) § Therefore, the patient may tolerate the bradydysrhythmia well if the BP is adequate. If BP is not adequate, symptomatic bradydysrhythmias may lead to myocardial ischemia or infarction, dysrhythmias, hypotension, and heart failure. · Tachydysrhythmias are heart rates greater than 100 beats/min, and are serious with coronary artery disease (CAD). Coronary artery blood flow occurs mostly during diastolic time and blood pressure in the root of the aorta. - Tachydysrhythmias are serious because: § They ___________________________ § They initially increase cardiac output and BP; but a continued rise in HR decreases ventricular filling time and stroke volume. Thus, CO and BP decrease, reducing coronary perfusion. § They increase the work of the heart, increasing myocardial O2 demand. - Patients with a tachydysrhythmia may have: 1. Palpitations 2. Chest discomfort 3. Restlessness 4. Anxiety 5. Pale/cool skin 6. Syncope. (passing out due to lack of blood flow to brain) - Tachydysrhythmias can lead to heart failure. Presenting symptoms of heart failure can include dyspnea, lung crackles, distended neck veins, fatigue, and weakness. · Symptoms of tachy/Bradydysrhythmias: chest discomfort/pressure/pain, restlessness, anxiety, nervousness, confusion, dizziness, syncope, palpitations, change in pulse, pulse deficit, dyspnea, tachypnea, pulmonary crackles, orthopnea, S3/4 heart sounds, JVD, weakness, fatigue, pale/cool skin, diaphoresis, N/V, decreased urine output, delayed capillary refill, hypotension. · Care of the patient with dysrhythmias: § Assess vitals every 4 hours and monitor for dysrhythmias (document pt response to dysrhythmias) § Encourage client to tell nurse when chest pain occurs § Assess chest pain § Assess peripheral circulation, pulse, cap refill, color/temp of extremities § Provide antidysrhythmic therapy as ordered, monitor/document response § Monitor lab values (cardiac enzymes, electrolyte levels) § Monitor patient's activity tolerance and rest/activity periods to avoid fatigue § Observe for respiratory difficulty (SOB, rapid RR, labored breathing) § Promote stress reduction § Offer spiritual support to the patient and family (contact clergy) as needed

doing things that stimulate the vagus nerve, like raising the arms above the head, applying pressure over carotid artery, applying pressure on eyes, bearing down or straining during BM, and stimulating a gag reflex when brushing teeth or putting objects in mouth

Common Dysrhythmias · Any disorder of the heartbeat is called a dysrhythmia. Many have no signs and symptoms, but often have serious consequences if not treated. · Dysrhythmias are classified in several ways. · As broad categories, dysrhythmias include premature complexes, Bradydysrhythmias (bradycardias), and tachydysrhythmias (tachycardias) · How to Prevent or Decrease Dysrhythmias (Chart 34-6) § For Patients At Risk For Vasovagal Attacks Causing Bradydysrhythmias · Avoid _________________________________ § For Patients With Premature Beats And Ectopic Rhythms: · Take prescribed meds and report adverse effects · Stop smoking, avoid caffeine and energy drinks, drink alcohol only in moderation · Learn ways to avoid getting too tired and manage stress § For Patients With Ischemic Heart Disease · If you have an angina attack, treat it promptly with rest and nitroglycerin as prescribed. This decreases chance of experiencing a dysrhythmia · If chest pain is not relieved after taking prescribed amount of nitroglycerin, seek medical attention promptly. Seek medical attention if pain becomes worse or you have other symptoms like sweating, nausea, weakness, and palpitations § For Patients At Risk For Potassium Imbalance · Know the symptoms of decreased potassium levels, such as muscle weakness and cardiac irregularity · Eat foods high in potassium, such as tomatoes, beans, prunes, avocados, bananas, strawberries, and lettuce · Take potassium supplements as prescribed

· Take prescribed meds and report adverse effects · Stop smoking, avoid caffeine and energy drinks, drink alcohol only in moderation · Learn ways to avoid getting too tired and manage stress

Common Dysrhythmias · Any disorder of the heartbeat is called a dysrhythmia. Many have no signs and symptoms, but often have serious consequences if not treated. · Dysrhythmias are classified in several ways. · As broad categories, dysrhythmias include premature complexes, Bradydysrhythmias (bradycardias), and tachydysrhythmias (tachycardias) · How to Prevent or Decrease Dysrhythmias (Chart 34-6) § For Patients At Risk For Vasovagal Attacks Causing Bradydysrhythmias · Avoid doing things that stimulate the vagus nerve, like raising the arms above the head, applying pressure over carotid artery, applying pressure on eyes, bearing down or straining during BM, and stimulating a gag reflex when brushing teeth or putting objects in mouth § For Patients With Premature Beats And Ectopic Rhythms: -____________________ -____________________ -____________________ § For Patients With Ischemic Heart Disease · If you have an angina attack, treat it promptly with rest and nitroglycerin as prescribed. This decreases chance of experiencing a dysrhythmia · If chest pain is not relieved after taking prescribed amount of nitroglycerin, seek medical attention promptly. Seek medical attention if pain becomes worse or you have other symptoms like sweating, nausea, weakness, and palpitations § For Patients At Risk For Potassium Imbalance · Know the symptoms of decreased potassium levels, such as muscle weakness and cardiac irregularity · Eat foods high in potassium, such as tomatoes, beans, prunes, avocados, bananas, strawberries, and lettuce · Take potassium supplements as prescribed

B. Stop suctioning the patient.

During routine suctioning of a client with a tracheostomy, the client becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.

The QRS is more than 5 blocks, it is prolonged, and longer than 0.20 - On the NRS strip, the normal QRS is 0.20 (5 blocks)

First Degree AV Block · First-Degree AV Block: _______________________ - · May be normal · Impulses from Atria Consistently Delayed at AV Node · May be Temporary -Can progress to more severe · PR Interval > 0.20 seconds · Everything Else Normal · Determine Underlying Cause · Normally Not Symptomatic · If the R is Far From the P, Then You Have a First-Degree!

Permanent Pacemaker

Pacemakers · Pacemaker: They electrically stimulate the heart when the natural pacemaker of the heart fails to maintain an acceptable rhythm. · When a pacing stimulus is delivered to the heart, a spike (pacemaker artifact) is seen on the monitor or ECG strip. The spike should be followed by a p wave or QRS complex. This is referred to as the capture, indicating the pacemaker has successful depolarized the chamber · ______________________: the SURGICAL insertion of a _________________ pacemaker is done to treat conduction disorders that are not temporary, such as complete heart block. They have an internal pacing unit that electrically stimulates the heart when the natural pacemaker of the heart fails to maintain an acceptable rhythm. § These are usually battery powered and last about 10 years. After battery is depleted, the generator must be replaced by a procedure with the patient under local anesthesia § Biventricular pacemakers can be used to coordinate contractions between the right and left ventricles. This is usually used in patients with moderate-severe heart failure to improve functional ability § The electrophysiologist implants the pulse generator in a subQ pocket in the right or left subclavicular area, which may create a visible bulge. § The leads are introduced transvenously via cephalic or subclavian vein to the endocardium on the right side of the heart. § After the procedure, the nurse should monitor ECG, check surgical site for bleeding, swelling, redness, tenderness, and infection. The patient should be afebrile with stable vital signs.

Temporary Pacing

Pacemakers · Pacemaker: They electrically stimulate the heart when the natural pacemaker of the heart fails to maintain an acceptable rhythm. · When a pacing stimulus is delivered to the heart, a spike (pacemaker artifact) is seen on the monitor or ECG strip. The spike should be followed by a p wave or QRS complex. This is referred to as the capture, indicating the pacemaker has successful depolarized the chamber · ____________________________ is a NONSURGICAL intervention that provides a timed electrical stimulus to the heart when either the impulse initiation or the conduction system of the heart is defective. The electrical stimulus then spreads throughout the heart to depolarize cells § This is used for patients with symptomatic bradydysrhythmias who do not respond to atropine or for patients with asystole. There are 2 types of temporary pacing § Transcutaneous pacing: the pacing energy is delivered transcutaneously through the thoracic musculature to the heart via 2 large external electrodes on the skin that are attached to an impulse generator. · the generator emits electrical pulses to provide ventricular depolarization when the patient's HR is slower than the rate set on the pacemaker · this is used as an emergency measure to provide demand ventricular pacing in very bradycardic or asystolic patient until intensive pacing can be used or the HR returns to normal · this method of pacing is painful because it requires a large amount of electricity and may require administration of pain/sedative meds · it is a temporary measure until a more permanent method of pacing can be used § Epicardial Pacing: pacemaker leads are attached directly to the heart during open heart surgery. Wires run externally through the chest incision and can be attached to an external impulse generator. It is usually used during and after open heart surgery § Endocardial (transvenous) Pacing: pacing wires are threaded through a large central vein (subclavian, jugular, cephalic) and lodged into the wall of the right ventricle (ventricular pacing), right atrium (atrial pacing), or both chambers (dual chamber pacing)

transmitter towers for radio, TV, and radar; garage door openers, burglar alarms, strong magnets, large stereo speakers, generators. Radio, TV, antennas, and other home appliances do not pose a hazard

Patient Teaching for Permanent Pacemakers (chart 34-3) · Follow instructions for permanent pacemaker skin care as prescribed. Report any fever, redness, swelling, soreness, or drainage from the incision site · Do not manipulate the pacemaker site · Keep medical ID card and bracelet at all times · Take pulse for 1 minute at the same time each day and record the rate in pacemaker diary. Take pulse any time you feel symptoms of pacemaker failure and report HR/symptoms to doctor · Know the rate the pacemaker is set at and basic functioning of the pacemaker. REPORT HEART RATE LOWER THAN SET RATE ON PACEMAKER (means pacemaker isn't working) · Do not apply pressure over the generator. Avoid tight clothing or belts · You can take showers or baths with generator · Inform all your doctors that you have a pacemaker because MRIs can damage it · Know indications of battery failure and report findings if they occur · Do not operate electrical appliances directly over the pacemaker site because it can cause malfunction · Keep handheld cellular phones 6 inches away from the generator, with the handset on the ear opposite the side of the generator. · Do not lean over electrical or gasoline engines/motors. Be sure they are properly grounded · Avoid ____________________________________________________ · Avoid sources of strong electromagnetic fields, like magnets and telecommunications transmitters, NO MRIs · Be aware that antitheft devices in stores may cause temporary pacemaker malfunction. If symptoms develop, move away from the device · Inform airport personnel of your pacemaker before passing through metal detectors and show medical ID card · Stay away from any arc welding equipment · Be aware that it is safe to operate a microwave oven unless it does not have any proper shielding or is defective · Report trouble breathing, dizziness, fainting, chest pain, weight gain, prolonged hiccupping. Check your pulse and call the doctor · If you feel symptoms when near any device move 5-10 feet away from it and check your pulse. They should return to normal · Keep doctors' appointments, followed prescribed diet, follow instructions on physical activity (such as no sudden, jerky movement for 8 weeks to allow pacemaker to settle in place) · If surgical incision is near the shoulders, AVOID LIFTING THE ARM OVER THE HEAD OR LIFTING MORE THAN 10LB FOR THE NEXT 4 WEEKS (it could dislodge pacemaker)

1. Stress 2. Fatigue 3. Anxiety 4. Inflammation 5. Infection 6. Caffeine 7. Nicotine 8. Alcohol 9. Meds 10.Illicit Drugs 11.MI 12.Electrolyte Imbalances 13.Atrial Stretch (atrial stretch can result from congestive heart failure, valvular disease, and pulmonary HTN with cor pulmonale) 14.Hypermetabolic States

Premature Atrial Complexes (PACs) · Premature Atrial Complex (PAC) occurs when atrial tissue becomes irritable. This ectopic focus fires an impulse before the next sinus impulse is due. The premature P wave may not always be clearly visible because it can be hidden in the receding T wave. § Examine the T wave closely for any change in shape and compare with other T waves. § A PAC is usually followed by a pause § All the Beats are Normal, except one comes early! § Causes of atrial irritability: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

they may lead to more serious atrial tachydysrhythmias and therefore may need treatment with Antidysrhythmics.

Premature Atrial Complexes (PACs) · Premature Atrial Complex (PAC) occurs when atrial tissue becomes irritable. This ectopic focus fires an impulse before the next sinus impulse is due. The premature P wave may not always be clearly visible because it can be hidden in the receding T wave. § Examine the T wave closely for any change in shape and compare with other T waves. § A PAC is usually followed by a pause § All the Beats are Normal, except one comes early! § Causes of atrial irritability: 1. Stress 2. Fatigue 3. Anxiety 4. Inflammation 5. Infection 6. Caffeine 7. Nicotine 8. Alcohol 9. Meds 10.Illicit Drugs 11.MI 12.Electrolyte Imbalances 13.Atrial Stretch (atrial stretch can result from congestive heart failure, valvular disease, and pulmonary HTN with cor pulmonale) 14.Hypermetabolic States · With premature atrial complexes, the patient usually has no symptoms except for possible heart palpitations. · No intervention is needed except to treat causes such as heart failure. · If PACs occur frequently, _____________________________________ · Teach the patient to manage stress and substances to avoid, such as caffeine and alcohol, that are known to increase atrial irritability.

1. If no underlying heart disease, PVCs are not usually treated with anything except removing/managing any contributing cause (caffeine, stress) 2. Potassium or magnesium is given for replacement therapy if hypokalemia or hypomagnesemia is the cause 3. If the # of PVCs in a 24-hr period is excessive, the patient may be placed on beta blockers 4. Symptomatic: RX Antidysrhythmics

Premature Ventricular Complexes (PVCs) · Premature Ventricular Complexes (PVCs) or premature ventricular contractions, result from increased irritability of ventricular cells and are seen as early ventricular complexes followed by a pause. · Patients may be asymptomatic or have palpitations/chest discomfort caused by increased stroke volume of the normal beat after the pause. § Peripheral pulses may be diminished or absent with the PVCs themselves because the decreased stroke volume may decrease peripheral perfusion · Because other dysrhythmias can cause widened QRS complexes, assess whether the premature complexes perfuse to the extremities. Palpate the carotid, brachial, or femoral arteries while observing monitor for widened complexes or auscultating apical heart sounds. § With acute MI, PVCs may be considered as a warning, possibly triggering life-threatening ventricular tachycardia or ventricular fibrillation · Treatment for Premature Ventricular Complexes (PVCs): 1. 2. 3. 4.

The PR Interval is .24, the next one is 0.28, the next one is .32, then it drops a beat altogether. § Mobitz I or Wenckebach · Longer, Longer, Drop Must Be The One & Only Wenckebach!

Second Degree AV Block Type I · Second Degree AV Block Type I: _______________________ - - - · Each Impulse Delayed a Little Longer Until an Impulse to the Ventricle is Dropped · Causes: CAD, MI, Rheumatic Fever, BBs, CCBs, Digoxin, Increased Vagal Stimulation · Normally Temporary · May Progress to More Serious · P Waves > QRS Complexes · S/S of Decreased CO · Asymptomatic: No Treatment

PR interval stays constant, but there's Extra P waves with no QRS complexes.

Second Degree AV Block Type II (Mobitz II) · Second Degree AV Block Type II (Mobitz II): ___________________________________ · Less Common · Occasional Impulses From SA node Fail to get to Ventricles · PR Consistent - Dropped QRS · Causes: MI, Aging, CAD · Ventricles Much Slower Than Atria · Lightheaded, Dizzy, Hypotension, Syncope, etc. · More QRSs Dropped = More Symptomatic · Treatment? · If some Ps don't get through(to ventricles), then you have a Mobitz II!

rapid stimulation of atrial tissue at a rate of 100-280 beats/min in adults.

Supraventricular Tachycardia (SVT) · Supraventricular Tachycardia (SVT) involves the _______________________________________________ § During SVT, P waves may not be visible, especially if there is a 1:1 conduction with rapid rates, because the P waves are embedded in the preceding T wave. § SVT may occur in health young people, especially women § SVT is usually caused by a re-entry mechanism in which one impulse circulates repeatedly throughout the atrial pathway, re-stimulating the atrial tissue at a rapid rate § Paroxysmal Supraventricular Tachycardia (PSVT) is used when the rhythm is intermittent. It is initiated suddenly by a premature complex such as PAC and terminated suddenly without intervention. § S/S of SVT depend on Duration & Rate of Ventricles

studied in the electrophysiology study (EPS) laboratory Study § The preferred treatment for recurrent SVT is radiofrequency catheter ablation

Supraventricular Tachycardia (SVT) · Supraventricular Tachycardia (SVT) involves the rapid stimulation of atrial tissue at a rate of 100-280 beats/min in adults. · In patients with nonsustained (or slower ventricular response), the patient may be asymptomatic except for occasional palpitations · IF SVT occurs in a healthy person and stops on its own, no intervention may be needed other than eliminating identified causes · In patients with Persistent or Recurrent SVT, the patient should be __________________________________________________ · Desired Patient Outcomes of Treatment for SVT: § Decrease VR § Convert to NSR § Treat Cause

nonsustained (or slower ventricular response)

Supraventricular Tachycardia (SVT) · Supraventricular Tachycardia (SVT) involves the rapid stimulation of atrial tissue at a rate of 100-280 beats/min in adults. · Symptoms of Sustained SVT: § palpitations § Chest pain § Weakness § Fatigue § SOB § Nervousness § Anxiety § Hypotension § Syncope § Cardiovascular deterioration may occur if the rate does not sustain adequate BP. In this case, SVT can result in angina, heart failure, and cardiogenic shock. · In patients with _____________ SVT , the patient may be asymptomatic except for occasional palpitations

C. "I'm glad I don't need to change my diet. Salads are my favorite food."

The primary health care provider prescribes warfarin (Coumadin) for a client with atrial fibrillation. Which statement made by the client indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider" C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

Complete Heart Block, nothing is communicating correctly.

Third Degree AV Block · Definition: _______________ · Atria Sending Impulses - Ventricles Never Hear Them · Sometime it looks like in SYNC BY CHANCE ONLY · Cause: Congenital Heart Problems, CAD, MI, Aging, Digoxin Toxicity, BBs, CCBs, Cardiac Surgery · Most Life-Threatening! High risk of cardiac arrest · Severe Fatigue, Dyspnea, CP, Lightheaded, Mental Status Changes, Loss of Consciousness, Hypotension, Pale, Diaphoretic · Permanent Pacemaker Needed · If Ps and Qs DON'T Agree, Then You Have a Third-Degree!

· Symptomatic · Treat the Same as Bradycardia · Correct Underlying Condition · Oxygen · Atropine · Epinephrine · Transcutaneous Pacing · Permanent Pacemaker

Treatments for Heart Blocks:

this occurs with repetitive firing of an irritable ventricle tissue (ventricular ectopic focus) at a rate of 140-180 bpm

Ventricular Tachycardia · Ventricular Tachycardia (VT) or V tach: _________________________ § VT may result from increased automaticity or a re-entry mechanism § VT may be: · intermittent VT: nonsustained VT · sustained VT: lasting longer than 15-30 seconds § The sinus node may continue discharging independently, depolarizing the atria but not the ventricles, although P waves are seldom seen in sustained VT

1. Ischemic Heart Disease 2. MI 3. Cardiomyopathy 4. Hypokalemia/hypomagnesemia 5. Valvular heart disease 6. HF 7. Drug Toxicity (steroids) 8. Hypotension 9. Illicit Drugs (cocaine, illicit inhalants)

Ventricular Tachycardia · Ventricular Tachycardia (VT) or V tach: this occurs with repetitive firing of an irritable ventricle tissue (ventricular ectopic focus) at a rate of 140-180 bpm § VT may result from increased automaticity or a re-entry mechanism § VT may be: · intermittent VT: nonsustained VT · sustained VT: lasting longer than 15-30 seconds § The sinus node may continue discharging independently, depolarizing the atria but not the ventricles, although P waves are seldom seen in sustained VT · Causes of Ventricular Tachycardia (VT) or V tach: 1. 2. 3. 4. 5. 6. 7. 8. 9. § SAMPLE EXAM QUESTION: Which of the following clients is at risk for V-Tach? Clients taking cocaine because it excites cardiac irritability.

VT is commonly the initial rhythm before deterioration into ventricular fibrillation as the terminal rhythm!!!!

Ventricular Tachycardia · Ventricular Tachycardia (VT) or V tach: this occurs with repetitive firing of an irritable ventricle tissue (ventricular ectopic focus) at a rate of 140-180 bpm · In patients who go into cardiac arrest, ____________________________________ · S/S of VT Depend on Ventricular Rate: § Slower the rate, the less severe the symptoms § Faster the rate, the more severe symptoms § VT can cause cardiac arrest

indicates that the SA node has fired; atrial depolarization; this is what forces blood to go down into the ventricles

· All cardiac cells have a basic function of automaticity, the ability to generate the electrical impulse spontaneously and repetitively. · Components of a Normal Electrocardiogram: § P-wave: __________________________________________________________ § PR Interval: measured from the beginning of the P wave to the end of the PR segment. It represents the time required for atrial depolarization, the impulse delay in the AV node, and the travel time to the Purkinje fibers · Normal PR Interval: 0.12-0.20 · Normally is no longer than 5 little boxes. · If it is longer than 5 little boxes, it indicates AV block § QRS Complex: represents ventricular depolarization § QRS Duration: represents the time required for depolarization of both ventricles. § ST Segment: an isoelectric line that represents early ventricular repolarization § T wave: follows the ST segment and represents ventricular repolarization · These can become taller, inverted, or flatten out due to myocardial ischemia, potassium or calcium imbalances, medications, or ANS effects. § U wave: when present, follows the T wave and may result from slow repolarization of ventricular purkinje fibers. It is always indicative of hypokalemia § QT-Interval: represents the total time required for ventricular depolarization and repolarization and is measured from the beginning of the QRS complex to the end of the T wave. · Shortens with a faster heart rate · Lengthens with longer heart rate rate · Can be prolonged by medications, electrolyte imbalances, or subarachnoid hemorrhage. · As the QT interval continues to prolong, it can lead to torsades de pointes, which leads to V-Fib · A client with a wide QRS and decreased HR can be stable. Check them for consciousness and get vitals .

measured from the beginning of the P wave to the end of the PR segment. It represents the time required for atrial depolarization, the impulse delay in the AV node, and the travel time to the Purkinje fibers Normal PR Interval: 0.12-0.20

· All cardiac cells have a basic function of automaticity, the ability to generate the electrical impulse spontaneously and repetitively. · Components of a Normal Electrocardiogram: § P-wave: indicates that the SA node has fired; atrial depolarization; this is what forces blood to go down into the ventricles § PR Interval: _________________________________________________________________ · Normal PR Interval: _________________ · Normally is no longer than 5 little boxes. · If it is longer than 5 little boxes, it indicates AV block § QRS Complex: represents ventricular depolarization § QRS Duration: represents the time required for depolarization of both ventricles. § ST Segment: an isoelectric line that represents early ventricular repolarization § T wave: follows the ST segment and represents ventricular repolarization · These can become taller, inverted, or flatten out due to myocardial ischemia, potassium or calcium imbalances, medications, or ANS effects. § U wave: when present, follows the T wave and may result from slow repolarization of ventricular purkinje fibers. It is always indicative of hypokalemia § QT-Interval: represents the total time required for ventricular depolarization and repolarization and is measured from the beginning of the QRS complex to the end of the T wave. · Shortens with a faster heart rate · Lengthens with longer heart rate rate · Can be prolonged by medications, electrolyte imbalances, or subarachnoid hemorrhage. · As the QT interval continues to prolong, it can lead to torsades de pointes, which leads to V-Fib · A client with a wide QRS and decreased HR can be stable. Check them for consciousness and get vitals .

an isoelectric line that represents early ventricular repolarization

· All cardiac cells have a basic function of automaticity, the ability to generate the electrical impulse spontaneously and repetitively. · Components of a Normal Electrocardiogram: § P-wave: indicates that the SA node has fired; atrial depolarization; this is what forces blood to go down into the ventricles § PR Interval: measured from the beginning of the P wave to the end of the PR segment. It represents the time required for atrial depolarization, the impulse delay in the AV node, and the travel time to the Purkinje fibers · Normal PR Interval: 0.12-0.20 · Normally is no longer than 5 little boxes. · If it is longer than 5 little boxes, it indicates AV block § QRS Complex: represents ventricular depolarization § QRS Duration: represents the time required for depolarization of both ventricles. § ST Segment: ______________________________________________ § T wave: follows the ST segment and represents ventricular repolarization · These can become taller, inverted, or flatten out due to myocardial ischemia, potassium or calcium imbalances, medications, or ANS effects. § U wave: when present, follows the T wave and may result from slow repolarization of ventricular purkinje fibers. It is always indicative of hypokalemia § QT-Interval: represents the total time required for ventricular depolarization and repolarization and is measured from the beginning of the QRS complex to the end of the T wave. · Shortens with a faster heart rate · Lengthens with longer heart rate rate · Can be prolonged by medications, electrolyte imbalances, or subarachnoid hemorrhage. · As the QT interval continues to prolong, it can lead to torsades de pointes, which leads to V-Fib · A client with a wide QRS and decreased HR can be stable. Check them for consciousness and get vitals .

follows the ST segment and represents ventricular repolarization

· All cardiac cells have a basic function of automaticity, the ability to generate the electrical impulse spontaneously and repetitively. · Components of a Normal Electrocardiogram: § P-wave: indicates that the SA node has fired; atrial depolarization; this is what forces blood to go down into the ventricles § PR Interval: measured from the beginning of the P wave to the end of the PR segment. It represents the time required for atrial depolarization, the impulse delay in the AV node, and the travel time to the Purkinje fibers · Normal PR Interval: 0.12-0.20 · Normally is no longer than 5 little boxes. · If it is longer than 5 little boxes, it indicates AV block § QRS Complex: represents ventricular depolarization § QRS Duration: represents the time required for depolarization of both ventricles. § ST Segment: an isoelectric line that represents early ventricular repolarization § T wave: __________________________________________________________ · These can become taller, inverted, or flatten out due to myocardial ischemia, potassium or calcium imbalances, medications, or ANS effects. § U wave: when present, follows the T wave and may result from slow repolarization of ventricular purkinje fibers. It is always indicative of hypokalemia § QT-Interval: represents the total time required for ventricular depolarization and repolarization and is measured from the beginning of the QRS complex to the end of the T wave. · Shortens with a faster heart rate · Lengthens with longer heart rate rate · Can be prolonged by medications, electrolyte imbalances, or subarachnoid hemorrhage. · As the QT interval continues to prolong, it can lead to torsades de pointes, which leads to V-Fib · A client with a wide QRS and decreased HR can be stable. Check them for consciousness and get vitals .

represents the total time required for ventricular depolarization and repolarization and is measured from the beginning of the QRS complex to the end of the T wave. · Shortens with a faster heart rate · Lengthens with longer heart rate rate · Can be prolonged by medications, electrolyte imbalances, or subarachnoid hemorrhage. · As the QT interval continues to prolong, it can lead to torsades de pointes, which leads to V-Fib · A client with a wide QRS and decreased HR can be stable. Check them for consciousness and get vitals .

· All cardiac cells have a basic function of automaticity, the ability to generate the electrical impulse spontaneously and repetitively. · Components of a Normal Electrocardiogram: § P-wave: indicates that the SA node has fired; atrial depolarization; this is what forces blood to go down into the ventricles § PR Interval: measured from the beginning of the P wave to the end of the PR segment. It represents the time required for atrial depolarization, the impulse delay in the AV node, and the travel time to the Purkinje fibers · Normal PR Interval: 0.12-0.20 · Normally is no longer than 5 little boxes. · If it is longer than 5 little boxes, it indicates AV block § QRS Complex: represents ventricular depolarization § QRS Duration: represents the time required for depolarization of both ventricles. § ST Segment: an isoelectric line that represents early ventricular repolarization § T wave: follows the ST segment and represents ventricular repolarization · These can become taller, inverted, or flatten out due to myocardial ischemia, potassium or calcium imbalances, medications, or ANS effects. § U wave: when present, follows the T wave and may result from slow repolarization of ventricular purkinje fibers. It is always indicative of hypokalemia § QT-Interval: _____________________________________________________ - - - -

EMBOLISM

· Atrial Fibrillation: the most common dysrhythmia. It is characterized by multiple rapid impulses from many atrial foci that depolarize the atria in a totally disorganized manner at a rate of 350-600 times per minute. Ventricular response is usually 120-200 · The biggest concern with Afib, is _________. · Clients with Afib are at a high risk for TIAs. This can progress to an embolic stroke · It can cause DVT or pulmonary embolisms. · Treatment: based on patient value and preference § Expected outcome: the patient should remain free of clot formation. § Antidysrhythmics · DILTIAZEM · Amiodarone § Beta Blockers § Rhythm Control Drugs: § Blood Thinner Patient Teaching

1. CAD 2. MI 3. Low Potassium or Magnesium 4. Hemorrhage 5. Drug Therapy 6. SVT 7. Shock 8. Surgery 9. Trauma

· Causes of Ventricular Fibrillation (VF): 1. 2. 3. 4. 5. 6. 7. 8. 9. · Signs and Symptoms of Ventricular Fibrillation (VF): § When VF begins, the patient becomes faint, immediately loses consciousness, and becomes pulseless and apneic. § There is no BP and heart sounds are absent. § Respiratory and metabolic acidosis develop § Seizures may occur § Within minutes, the pupils become fixed and dilated, and the skin becomes cold and mottled § Death results without prompt intervention.

0.04 to 0.10

· Normal Sinus Rhythm (NSR): the rhythm originating from the sinoatrial (SA) node (dominant pacemaker) that meets these ECG criteria: § Rate: Atrial and ventricular rates are 60-100 beats/min § Rhythm: Atrial and ventricular rhythms are regular § P waves: P wave is present, consistent configuration, with 1 P wave before each QRS complex § PR interval: 0.12 to 0.20 seconds and constant § QRS duration: ____________________ seconds and constant § PR interval, QRS interval, and QT interval are normal

Fixed Rate (asynchronous)

· Pacemaker Modes: § __________ Rate: pacemaker fires at a constant rate without regard for the hearts electrical activity

Demand rate (synchronous)

· Pacemaker Modes: § ___________ Rate: pacemaker detects the heart's electrical impulses and fires at a preset rate only if the heart's intrinsic rate is below a certain level. · Inhibited: pacemaker activity is inhibited and does not fire · Triggered: pacemaker activity is triggered/fires when intrinsic activity is sensed

contact sports or heavy lifting of more than 10lb

· Postprocedure Pacemaker Placement: § Document time/date of insertion, model, settings, rhythm strip, presence of adequate pulse, and blood pressure § Monitor HR and rhythm; compare to ECG rhythm and pacemaker settings § Obtain chest x-ray to assess lead placement and for pneumothorax, hemothorax, or pleural effusion § Minimize shoulder movement initial to allow leads to anchor § Monitor site for bleeding, hematoma, or infection § After pacemaker insertion, assess for hiccups, which can indicate that the generator is pacing the diaphragm § Following transcutaneous pacing, inspect the skin under the electrodes for thermal burns. § For permanent placement of pacemaker/ICD: provide clients with ID card including manufacturers name, model number, mode of function, rate parameters, and expected battery life. § Client Education: · For temporary pacemakers: used only in controlled facility with telemetry. If needed, a permanent pacemaker can be inserted for discharge home. · Cary ID card at all times · Prevent wire dislodgement (wear sling when out of bed, do not raise arm above shoulder for 1-2 weeks) · Take pulse daily at the same time for those with pacemakers or combination devices. Notify DR is heart rate is less than set rate · Report dizziness, fainting, weakness, fatigue, chest pain, hiccupping, palpitations, difficulty breathing, or weight gain · Follow activity restrictions as prescribed (no __________________________________ for the next 4 weeks) · Don't wear tight clothes around the pacemaker · Avoid direct blows/injury to generator site · Resume sexual activity as desired, avoiding positions that put stress on incision site · Complications: pericardial effusion, pericardial tamponade, diaphragmatic pacing (pain at diaphragm and muscle contractions over diaphragm synchronized with HR)

1. MI 2. CHF 3. COPD 4. Anemia 5. Hypokalemia 6. Hypomagnesemia 7. Meds (sympathomimetic agents) 8. Anesthesia 9. Stress 10.Nicotine 11.Caffeine 12.Alcohol 13.Infection 14.Surgery 15.Post-Menopause (often find that Caffeine causes palpitations and PVCs)

· Premature Ventricular Complexes (PVCs) or premature ventricular contractions, result from increased irritability of ventricular cells and are seen as early ventricular complexes followed by a pause. § When multiple PVCs are present, the QRS complexes may be: · unifocal or uniform: meaning that they are of the same shape - In the picture, bigeminy is unifocal (Unifocal trigeminy) · multifocal or multiform: meaning that they are of different shapes - In the picture, quadrigeminy is multifocal · Causes of Premature Ventricular Complexes (PVCs): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

age

· Premature Ventricular Complexes (PVCs) or premature ventricular contractions, result from increased irritability of ventricular cells and are seen as early ventricular complexes followed by a pause. § When multiple PVCs are present, the QRS complexes may be: · unifocal or uniform: meaning that they are of the same shape o In the picture, bigeminy is unifocal (Unifocal trigeminy) · multifocal or multiform: meaning that they are of different shapes o In the picture, quadrigeminy is multifocal § PVCs frequently occur in repetitive rhythms, such as bigeminy (two), trigeminy (3), and quadrigeminy (four). § 2 sequential PVCs are a pair or couplet § 3 or more successive PVCs are usually called nonsustained ventricular tachycardia (NSVT) · Premature ventricular contractions are common, and frequency increases with __________________.

early rhythm complexes (early beats) that occur when a cardiac cell or cell group (other than the sinoatrial (SA) node) becomes irritable and fires an impulse before the next sinus impulse is produced.

· Premature complexes are _____________________________________ § The abnormal focus is called an ectopic focus and may be generated by the atrial, junctional, or ventricular tissue. § After the premature complex, there is a pause before the next normal complex, creating an irregularity in the rhythm · Patients with premature complexes may be unaware of them or feel palpitations (or a "skipping" of the heart beat") § If the premature complex (especially ventricular ones) become more frequent, the patient may experience symptoms of decreased cardiac output. § Always check BP and Perfusion! They may not need treatment, but if signs of decreased perfusion are present, they may need interventions. · Can be a Precursor · Can be Isolated or Repetitive · Premature complexes can occur repetitively in a rhythmic fashion: § Bigeminy exists when normal complexes and premature complexes occur alternately in a repetitive two-beat pattern, with a pause occurring after each premature complex so complexes occur in pairs § Trigeminy is a repeated three beat pattern, occurring as two sequential normal complexes followed by a premature complex and a pause, with the same pattern repeating itself in triplets § Quadrigeminy is a repeated four-beat pattern, usually occurring as three sequential normal complexes followed with a premature complex and a pause, with the same pattern repeating itself in a four-beat pattern.

clean site; trim hair; NO shaving, rubbing, or alcohol on skin

· Preprocedure Pacemaker Placement: § Assess client knowledge of procedure, obtain signed informed consent § Prepare skin: ________________________ § Temporary Pacemaker: · Wires and a pacemaker box will be on the client's chest after the procedure · Don't touch the dials on the pacemaker box · Do not shower, the wires and box need to be kept dry § If transcutaneous pacing is needed, large ECG pacing pads will be placed on the chest/back. Alert clients need sedation/analgesia for transcutaneous pacing

ATROPINE, dopamine, epinephrine, pacemaker

· Signs and Symptoms of Sinus Bradycardia: § Possibly asymptomatic § Syncope, blackouts, fainting § Dizziness and weakness § Confusion § Hypotension § Diaphoresis § Shortness of breath § Chest pain · Nursing Interventions and Treatment for Sinus Bradycardia: § Meds/Treatment: ____________________________________ § If patient is stable, treatment is treating the underlying cause § If the patient has any symptoms and cause cannot be determined, the treatment is given atropine 0.5mg IV, increase intravascular volume IV fluids, and apply O2 § If beta blocker overdose is suspected, administer glucagon to attempt to increase HR and BP § If HR does not increase sufficiently, prepare for transcutaneous or transvenous pacing to increase the heart rate § If treatment of the underlying cause does not restore normal sinus rhythm, the patient will require permanent pacemaker implantation

1. carotid sinus massage 2. vomiting 3. suctioning 4. Valsalva maneuvers 5. ocular pressure 6. pain 7. hypoxia, hypoxemia, or ischemia 8. MI or diseases of the nodes 9. Lyme disease 10.Electrolyte disturbances 11.Neurologic disorders, like ICP 12.hypothyroidism 13.beta blockers, calcium channel blockers, and digoxin.

· Sinus Bradycardia: Excessive vagal (parasympathetic) stimulation to the heart causes a decreased heart rate § The heart rate is less than 60 beats/min § Normal P wave in lead II § P wave before each QRS § Sinus bradycardia increases coronary perfusion time, but it may decrease coronary perfusion pressure. Myocardial O2 demand is decreased § Well-conditioned athletes with bradycardia have a hypereffective heart in which the strong heart muscle provides an adequate stroke volume and a low heart rate to achieve a normal cardiac output. · Causes of Sinus Bradycardia: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

CALL DOCTOR IMMEDIATELY AND GET ECG. This is indicating that the chest pain is ischemic because of a lack of oxygen. The lack of oxygen is causing them to have chest pain.

· Sinus Tachycardia: Sympathetic nervous stimulation results in an increased rate of SA nose discharge which increases the heart rate -> Sinus rhythm with a rate of 100 to 150 beats/min · Assess for symptoms of Sinus Tachycardia (low cardiac output): § Fatigue, weakness, SOB, orthopnea, decreased O2 sat, increase pulse rate, decreased BP, restlessness, anxiety (low cerebral perfusion), decreased urine output (impaired renal perfusion), angina ,palpitations § s/s of hypovolemia: Increased pulse rate, decreased urinary output, decreased blood pressure, dry skin, and mucous membranes § ECG: T-wave inversion or ST segment elevation or depression § If the client complains of substernal chest pain with tachycardia.. __________________________________________________ · Nursing Interventions and Treatment for Sinus Tachycardia: § Decrease rate to normal by treating underlying cause § Tell patient to remain on bedrest if tachycardia is causing hypotension or weakness § Avoid substances that increase HR like caffeine, alcohol, nicotine § Develop a stress management strategy or refer to mental health professional

1. Hyperthyroidism 2. Hypovolemia or dehydration; hypovolemic shock 3. heart failure; myocardial infarction 4. anemia 5. exercise 6. use of stimulants, epinephrine, atropine, caffeine, alcohol, nicotine, cocaine, aminophylline, and thyroid medications 7. fever or infection 8. sympathetic response to fear or pain and anxiety may cause sinus tachycardia

· Sinus Tachycardia: Sympathetic nervous stimulation results in an increased rate of SA nose discharge which increases the heart rate § Sinus rhythm with a rate of 100 to 150 beats/min § Normal P wave § P wave before every QRS · Sinus tachycardia initially increases cardiac output and blood pressure. But continued increases in heart rate decrease coronary perfusion time, diastolic filling time, and coronary perfusion pressure while increasing myocardial O2 demand. · Causes of Sinus tachycardia: 1. 2. 3. 4. 5. 6. 7. 8.

variant of NSR that results from changes in intrathoracic pressure during breathing. The heart rate increases during inspiration and decreases during exhalation. It is frequently observed in healthy adults

· Sinus arrythmia is a _________________________________________ § All characteristics of NSR except for its irregularity. The PP and RR intervals vary, with the difference being between the shortest and longest intervals being greater than 0.12 second (3 small blocks) § Atrial and ventricular rhythms are irregular, with the shortest PP or RR interval varying at least 0.12 seconds from the longest PP or RR interval. § Sinus arrythmias are occasionally due to nonrespiratory causes like digoxin or morphine. These drugs enhance vagal tone and cause decreased heart rate and irregularity unrelated to the respiratory cycle.

Atropine, Epinephrine, Possibly Vasopressin

· Treatment and Nursing Interventions for Ventricular Asystole: · Cardiopulmonary Resuscitation (CPR, BLS)! In community setting, confirm unresponsiveness and CALL 911! When in the hospital setting, call the emergency response team! Use the CAB (compressions, airway, breathing) § Compressions: Check for carotid pulse for 5-10 seconds. If absent, start chest compressions of 100-120 compressions per minute and a compression depth of at least 2 inches (no more than 2.4in). Push hard and fast! Avoid leaning into the chest after each compression to allow for full chest wall recoil. § Airway: Maintain patent airway § Breathing: Ventilate with a mouth-to-mask device (ambu bag bask). Give rescue breaths at a rate of 10-20 breaths/min. If advanced airway is in place, one breath should be given every 6-8 seconds (8-10 breaths/min) § Ventilation to compression ratio should be 30 compressions to 2 breaths if advanced airway is not in place. Limit interruptions to compressions to less than 10 seconds. When possible, compressors should be rotated every 2 minutes. § Complications of CPR: · Rib fractures · Fracture of sternum · Costochondral separation · Lacerations of the liver and spleen · Pneumothorax · Hemothorax · Cardiac tamponade · Lung contusions · Fat emboli · As soon as help arrives, place a board under the patient who is not on a firm surface. When AED arrives, don't stop compressions while its being set up. § IMPORTANT: If the patient is in VF or pulseless VT (NOT VENTRICULAR ASYSTOLE), then DEFIBRILLATE! Defibrillation is an asynchronous countershock that depolarizes a critical mass of the myocardium simultaneously to stop the reentry circuit, allowing the sinus node to regain control of the heart. § After defibrillation, CPR is resumed § DO NOT DEFRIBRILLATE VENTRICULAR ASYSTOLE. The purpose of defibrillation is to disrupt a chaotic rhythm (in ventricular asystole, no electrical impulses are present to disrupt) · After the ACLS team initiates interventions, the role of the nurse is to provide info about the patients (summary of medical condition, events that occurred up until cardiac arrest, initial cardiac rhythm, answer questions, document, assist with compressions) · In hospital setting, consider allowing family to stay in the room during the code to promote closure with death of a loved one (when possible). · CPR & Meds: _____________________________________________ · Need to get some sort of rhythm back! Then go from there!

DO NOT DEFRIBRILLATE VENTRICULAR ASYSTOLE

· Treatment and Nursing Interventions for Ventricular Asystole: · Cardiopulmonary Resuscitation (CPR, BLS)! In community setting, confirm unresponsiveness and CALL 911! When in the hospital setting, call the emergency response team! Use the CAB (compressions, airway, breathing) § Compressions: Check for carotid pulse for 5-10 seconds. If absent, start chest compressions of 100-120 compressions per minute and a compression depth of at least 2 inches (no more than 2.4in). Push hard and fast! Avoid leaning into the chest after each compression to allow for full chest wall recoil. § Airway: Maintain patent airway § Breathing: Ventilate with a mouth-to-mask device (ambu bag bask). Give rescue breaths at a rate of 10-20 breaths/min. If advanced airway is in place, one breath should be given every 6-8 seconds (8-10 breaths/min) § Ventilation to compression ratio should be 30 compressions to 2 breaths if advanced airway is not in place. Limit interruptions to compressions to less than 10 seconds. When possible, compressors should be rotated every 2 minutes. § Complications of CPR: · Rib fractures · Fracture of sternum · Costochondral separation · Lacerations of the liver and spleen · Pneumothorax · Hemothorax · Cardiac tamponade · Lung contusions · Fat emboli · As soon as help arrives, place a board under the patient who is not on a firm surface. When AED arrives, don't stop compressions while its being set up. § IMPORTANT: If the patient is in VF or pulseless VT (NOT VENTRICULAR ASYSTOLE), then DEFIBRILLATE! Defibrillation is an asynchronous countershock that depolarizes a critical mass of the myocardium simultaneously to stop the reentry circuit, allowing the sinus node to regain control of the heart. § After defibrillation, CPR is resumed § DO NOT __________________________________. The purpose of defibrillation is to disrupt a chaotic rhythm (in ventricular asystole, no electrical impulses are present to disrupt) · After the ACLS team initiates interventions, the role of the nurse is to provide info about the patients (summary of medical condition, events that occurred up until cardiac arrest, initial cardiac rhythm, answer questions, document, assist with compressions) · In hospital setting, consider allowing family to stay in the room during the code to promote closure with death of a loved one (when possible). · CPR & Meds: Atropine, Epinephrine, Possibly Vasopressin · Need to get some sort of rhythm back! Then go from there!

Cardiopulmonary Resuscitation (CPR, BLS)!

· Treatment and Nursing Interventions for Ventricular Asystole: · __________________________! In community setting, confirm unresponsiveness and CALL 911! When in the hospital setting, call the emergency response team! Use the CAB (compressions, airway, breathing) § Compressions: Check for carotid pulse for 5-10 seconds. If absent, start chest compressions of 100-120 compressions per minute and a compression depth of at least 2 inches (no more than 2.4in). Push hard and fast! Avoid leaning into the chest after each compression to allow for full chest wall recoil. § Airway: Maintain patent airway § Breathing: Ventilate with a mouth-to-mask device (ambu bag bask). Give rescue breaths at a rate of 10-20 breaths/min. If advanced airway is in place, one breath should be given every 6-8 seconds (8-10 breaths/min) § Ventilation to compression ratio should be 30 compressions to 2 breaths if advanced airway is not in place. Limit interruptions to compressions to less than 10 seconds. When possible, compressors should be rotated every 2 minutes. § Complications of CPR: · Rib fractures · Fracture of sternum · Costochondral separation · Lacerations of the liver and spleen · Pneumothorax · Hemothorax · Cardiac tamponade · Lung contusions · Fat emboli · As soon as help arrives, place a board under the patient who is not on a firm surface. When AED arrives, don't stop compressions while its being set up. § IMPORTANT: If the patient is in VF or pulseless VT (NOT VENTRICULAR ASYSTOLE), then DEFIBRILLATE! Defibrillation is an asynchronous countershock that depolarizes a critical mass of the myocardium simultaneously to stop the reentry circuit, allowing the sinus node to regain control of the heart. § After defibrillation, CPR is resumed § DO NOT DEFRIBRILLATE VENTRICULAR ASYSTOLE. The purpose of defibrillation is to disrupt a chaotic rhythm (in ventricular asystole, no electrical impulses are present to disrupt) · After the ACLS team initiates interventions, the role of the nurse is to provide info about the patients (summary of medical condition, events that occurred up until cardiac arrest, initial cardiac rhythm, answer questions, document, assist with compressions) · In hospital setting, consider allowing family to stay in the room during the code to promote closure with death of a loved one (when possible). · CPR & Meds: Atropine, Epinephrine, Possibly Vasopressin · Need to get some sort of rhythm back! Then go from there!

SOTALOL, AMIODARONE,

· Treatment and Nursing Interventions for Ventricular Fibrillation (VF): § Emergency care for ventricular fibrillation is critical for survival! START CPR! § Goal: Convert to NSR NOW! § Priority is to defibrillate the patient immediately according to ACLS protocol! Get an AED if in the community! § If a defibrillator is not available, high quality CPR must be initiated and continued until the defibrillator arrives. § Example exam question: · IF THE PATIENT IS IN V-FIB and pulseless.. · do you give CPR? YES! · Do we give the patient Amiodarone? YES · Do we give early defibrillation? YES · Do we get a crash cart to the bedside? YES § Medications: ______________, _____________ Procainamide, Lidocaine, Propranolol, Verapamil, Mag Sulfate · The goal of Sotalol is to keep the HR at 60-100 · Amiodarone decreases ventricular irritability. Its often given in a code blue event. With VFib, you give 300mg · Drug therapy is used when dysrhythmias are sustained and/or life threatening. · The Vaughn-Williams classification is commonly used to categorize drugs according to their effects on the action potential of cardiac cells (Classes I through IV). · Magnesium Sulfate is an electrolyte administered to treat refractory VT or VF because the patient may be hypomagnesemic, with increased ventricular irritability. It can also be used to treat torsades de pointes

YES! YES! YES! YES!

· Treatment and Nursing Interventions for Ventricular Fibrillation (VF): § Emergency care for ventricular fibrillation is critical for survival! START CPR! § Goal: Convert to NSR NOW! § Priority is to defibrillate the patient immediately according to ACLS protocol! Get an AED if in the community! § If a defibrillator is not available, high quality CPR must be initiated and continued until the defibrillator arrives. § Example exam question: · IF THE PATIENT IS IN V-FIB and pulseless.. · do you give CPR? _________ · Do we give the patient Amiodarone? _________ · Do we give early defibrillation? _________ · Do we get a crash cart to the bedside? _________ § Medications: Procainamide, Lidocaine, Propranolol, SOTALOL, AMIODARONE, Verapamil, Mag Sulfate · The goal of Sotalol is to keep the HR at 60-100 · Amiodarone decreases ventricular irritability. Its often given in a code blue event. With VFib, you give 300mg · Drug therapy is used when dysrhythmias are sustained and/or life threatening. · The Vaughn-Williams classification is commonly used to categorize drugs according to their effects on the action potential of cardiac cells (Classes I through IV). · Magnesium Sulfate is an electrolyte administered to treat refractory VT or VF because the patient may be hypomagnesemic, with increased ventricular irritability. It can also be used to treat torsades de pointes

Defibrillation & CPR · Nursing actions FOR NCLEX PURPOSES: · 1. CPR · 2. then DEFIBRILLATION

· Treatment and Nursing Interventions for Ventricular Tachycardia: § Assess patient's circulation, airway, breathing, LOC, and O2 level. (ABCs) § For the stable patient with sustained VT, administer O2 and confirm the rhythm via 12-lead ECG. Amiodarone, lidocaine, or magnesium sulfate may be given § Medications: AMIODARONE, Lidocaine, BBs, CCBs, Magnesium Sulfate (Torsades) · AMIODARONE IS THE DRUG FOR VENTRICULAR IRRITABILITY § For patients with Stable VT: Elective Cardioversion · If the patient has been taking digoxin, the drug is withheld for up to 48 hours before elective cardioversion. Digoxin increases ventricular irritability and puts the patient at risk for VF after countershock. § Unstable VT w/Pulse: Assess blood pressure and perfusion. They need Synchronized Cardioversion at Bedside and Amiodarone. If blood pressure keeps falling, they can become unstable. § If Unstable and Pulseless: _______________________________ § Patients who persist with episodes of stable VT (Recurrent): EP Study w/Radiofrequency Catheter Ablation

Assess blood pressure and perfusion. They need Synchronized Cardioversion at Bedside and Amiodarone. If blood pressure keeps falling, they can become unstable

· Treatment and Nursing Interventions for Ventricular Tachycardia: § Assess patient's circulation, airway, breathing, LOC, and O2 level. (ABCs) § For the stable patient with sustained VT, administer O2 and confirm the rhythm via 12-lead ECG. Amiodarone, lidocaine, or magnesium sulfate may be given § Medications: AMIODARONE, Lidocaine, BBs, CCBs, Magnesium Sulfate (Torsades) · AMIODARONE IS THE DRUG FOR VENTRICULAR IRRITABILITY § For patients with Stable VT: Elective Cardioversion · If the patient has been taking digoxin, the drug is withheld for up to 48 hours before elective cardioversion. Digoxin increases ventricular irritability and puts the patient at risk for VF after countershock. § Unstable VT w/Pulse: ____________________________________________. § If Unstable and Pulseless: Defibrillation & CPR · Nursing actions FOR NCLEX PURPOSES: · 1. CPR · 2. then DEFIBRILLATION § Patients who persist with episodes of stable VT (Recurrent): EP Study w/Radiofrequency Catheter Ablation

Elective Cardioversion · If the patient has been taking digoxin, the drug is withheld for up to 48 hours before elective cardioversion. Digoxin increases ventricular irritability and puts the patient at risk for VF after countershock.

· Treatment and Nursing Interventions for Ventricular Tachycardia: § Assess patient's circulation, airway, breathing, LOC, and O2 level. (ABCs) § For the stable patient with sustained VT, administer O2 and confirm the rhythm via 12-lead ECG. Amiodarone, lidocaine, or magnesium sulfate may be given § Medications: AMIODARONE, Lidocaine, BBs, CCBs, Magnesium Sulfate (Torsades) · AMIODARONE IS THE DRUG FOR VENTRICULAR IRRITABILITY § For patients with Stable VT: ___________________________________ § Unstable VT w/Pulse: Assess blood pressure and perfusion. They need Synchronized Cardioversion at Bedside and Amiodarone. If blood pressure keeps falling, they can become unstable. § If Unstable and Pulseless: Defibrillation & CPR · Nursing actions FOR NCLEX PURPOSES: · 1. CPR · 2. then DEFIBRILLATION § Patients who persist with episodes of stable VT (Recurrent): EP Study w/Radiofrequency Catheter Ablation

AMIODARONE

· Treatment and Nursing Interventions for Ventricular Tachycardia: § Assess patient's circulation, airway, breathing, LOC, and O2 level. (ABCs) § For the stable patient with sustained VT, administer O2 and confirm the rhythm via 12-lead ECG. Amiodarone, lidocaine, or magnesium sulfate may be given § Medications: _________________, Lidocaine, BBs, CCBs, Magnesium Sulfate (Torsades) · ___________________ IS THE DRUG FOR VENTRICULAR IRRITABILITY § For patients with Stable VT: Elective Cardioversion · If the patient has been taking digoxin, the drug is withheld for up to 48 hours before elective cardioversion. Digoxin increases ventricular irritability and puts the patient at risk for VF after countershock. § Unstable VT w/Pulse: Assess blood pressure and perfusion. They need Synchronized Cardioversion at Bedside and Amiodarone. If blood pressure keeps falling, they can become unstable. § If Unstable and Pulseless: Defibrillation & CPR · Nursing actions FOR NCLEX PURPOSES: · 1. CPR · 2. then DEFIBRILLATION § Patients who persist with episodes of stable VT (Recurrent): EP Study w/Radiofrequency Catheter Ablation

defibrillator and resuscitative equipment available at all times during procedure

· Treatments for Supraventricular Tachycardia (SVT): · Assess HR and BP. They could be stable. If they have an MAP of 65 or greater, they are stable and asymptomatic. There's no treatment needed if it stops on its own and they're stable. However, eventually it would cause symptoms if it doesn't resolve. -2 Treatments: Vagal maneuvers and Medication (ADENOSINE) · Vagal Maneuvers: these induce vagal stimulation of the cardiac conduction system, specifically the SA and AV nodes. It is not as commonly used today, but it may be attempted to treat SVT § Methods include: Carotid Sinus Massage and Valsalva maneuvers § Carotid Sinus Massage: the PHYSICIAN massages over one carotid artery for a few seconds, observing for a change in cardiac rhythm. This induces vagal stimulation, slowing AV/SA node conduction · To prepare patient for this procedure, tell them to turn the head slightly away from one side to be massaged and observe the cardiac monitor for change in rhythm. · MUST have a __________________________________________________ · An ECG strip is recorded before, during, and after the procedure · After procedure, assess vitals and LOC · Complications: bradydysrhythmias, asystole, ventricular fibrillation, and cerebral damage (Because of these risks, carotid massage is not commonly performed) § Valsalva Maneuver: instruct patient to bear down like having a BM, cough hard · Assess HR, rhythm, and BP. Observe cardiac monitor and record ECG strip before, during, and after procedure

ADENOSINE 1st dose is 6mg RAPID IV PUSH at the closest IV port to the client. This is always FOLLOWED BY A RAPID NORMAL SALINE FLUSH.

· Treatments for Supraventricular Tachycardia (SVT): · Assess HR and BP. They could be stable. If they have an MAP of 65 or greater, they are stable and asymptomatic. There's no treatment needed if it stops on its own and they're stable. However, eventually it would cause symptoms if it doesn't resolve. -Treatments: Vagal maneuvers, Medication, Synchronized Cardioversion, and possible radio frequency catheter ablation. · Medication Therapy is prescribed for some patients to convert SVT to NSR: § _____________: used to terminate the acute episode and given rapidly (over several seconds) followed by a saline bolus. It basically stops the heart to allow the cardiac cells to line up correctly, so that when the node fires, the heart returns to a normal beat. · How to Administer: _____________________________ · Side effects: significant bradycardia with pauses, nausea, vomiting · MUST have emergency equipment available. § Beta Blockers (BBs) and Calcium Channel Blockers (CCBs) are AV nodal blocking agents that may be used to treat SVT · If symptoms of poor perfusion are severe/persistent, the patient may require Synchronized Cardioversion to immediately terminate the SVT · For long-term treatment, patients are referred to an electrophysiologist for EPS studies and radiofrequency catheter ablation.

1 MI 2 HF 3 Severe Hyperkalemia 4 Acidosis

· Ventricular Asystole (ventricular standstill): the complete absence of any ventricular rhythm. § There are no electrical impulses in the ventricles and therefore NO ventricular depolarization, no QRS complex, no contraction, no cardiac output, and no perfusion to the rest of the body. § No Ventricular Rhythm (QRS)-No Pulse, Respirations, BP, Cardiac Output, Perfusion! · Signs and Symptoms of Ventricular Asystole: § No pulse, no RR, no BP § Full cardiac arrest. The entire conduction system is electrically silent, with no P waves on ECG. · Cardiac Arrest Even Though SA Node Still Firing! In some cases, the SA node may continue to fire and depolarize the atria with only P waves seen on ECG. But the impulses don't conduct to the ventricles, and QRS complexes remain absent. § When cardiac arrest occurs, CO stops. The patient loses consciousness, and without prompt treatment, it is fatal. · Causes of Ventricular Asystole: 1. 2. 3. 4.

the result of electrical chaos in the ventricles and is life threatening!

· Ventricular Fibrillation (VF) or V fib: ___________________________ § Impulses from many irritable foci fire in a totally disorganized manner so ventricular contraction cannot occur § The ventricles merely quiver, consuming tremendous amount of O2 § There is no cardiac output, no pulse, no respirations and therefore no cerebral, myocardial, or systemic perfusion. This rhythm is rapidly fatal if not successfully ended within 3-5 minutes!