Cardiac Rhythms and Interventions***

Cardiac Tamponade Treatment

"Immediate pericardiocentesis. If recurrent, refer to cardiothoracic surgeon."

Premature Ventricular Contractions PVCs

*Wide QRS* - may be unifocal or multifocal - will have compensatory pause - irreg rhythm PVCs may be bigeminy, trigeminy, or quadrigeminy - "run of" PVCS - 3+ PVCs = Ventricular Tachycardia

A nursing student is aware that which of the following is the treatment for unstable atrial flutter? 1) Adenosine (Adenocard) 6 mg rapid IVP. 2) Cardioversion with adjacent Heparin therapy 3) Defibrillation STAT followed by CPR. 4) Altemose 3 mg IVP over 1-2 seconds.

2) Cardioversion with adjacent Heparin therapy Cardioversion is used if the patient is unstable. Anticoagulants are used if the arrhythmia has stuck around for 48 hr +. Adenosine may be used with a narrow QRS and regular RR interval.

A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention? A) Defibrillation B) ECG monitoring C) Implantation of a cardioverter defibrillator D) Angioplasty

A) Defibrillation Any type of VT in a patient who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will resolve the problem. An ICD and angioplasty do not address the dysrhythmia.

Sinus Bradycardia Treatment

Atropine Transcutaneous pacing Infusion of dopamine or epinephrine

A patient with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology of this disease process, the nurse would expect the patient to exhibit what heart rhythm?A.Ventricular fibrillation (VF) B. Ventricular tachycardia (VT) C. Atrial fibrillation D. Sinus bradycardia

C. Atrial fibrillation In patients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation.

Asystole Treatment

CPR

Ventricular Fibrillation Treatment DING DING - SLIDE 36 SLIDE 44

Defibrillation "Defib for Vfib" •Used for ventricular fibrillation and pulseless Ventricular Tachycardia (VT) 1) Ventricular Tachycardia/Ventricular Fibrillation can be treated with an Implantable Cardioverter Defibrillator (ICD)

Ventricular Tachycardia without pulse DING DING - SLIDE 36 SLIDE 44

Defibrillation •Used for ventricular fibrillation and pulseless Ventricular Tachycardia (VT) 1) Ventricular Tachycardia/Ventricular Fibrillation can be treated with an Implantable Cardioverter Defibrillator (ICD)

You are the nurse working on the telemetry unit and you have finally gotten to sit down to work on some charting. Suddenly the heart monitors at the station start beeping. Patient in room 18 is showing this rhythm on the monitor. The medical team advances together into the room and finds them unconscious. What is priority action by the nurse? A) Prepare to administer adenosine to the patient B) Begin chest compressions C) Prepare for defibrillation D) Check for a pulse

D) Check for a pulse A pulse would be assessed for first. Then the patient will be defibrillated and chest compressions will begin immediately.

Super Ventricular Tachycardia (SVT) Treatment DING DING - SLIDE 19 SLIDE 18 SLIDE 17

Vagal Response Bolus of adenosine MD can do carotid massage to initiate vagal response •If unable to terminate an SVT, a bolus of adenosine IV given to slow conduction in AV node (Allows visualization of P waves or to convert the rhythm- May give larger dose)

Atrial Flutter Treatment SLIDE 17 SLIDE 31

Vagal response Cardioversion •For dysrhythmias (Atrial flutter, atrial fibrillation) lasting longer than 48 hours. -AFib and AFlutter can be treated with vagal response

Atrial Fibrillation (A-Fib) Treatment SLIDE 17 SLIDE 31 SLIDE 44

Vagal response Cardioversion ICD -AFib and AFlutter can be treated with vagal response •For dysrhythmias (Atrial flutter, atrial fibrillation) lasting longer than 48 hours. Hard to treat Atrial Fibrillation (Refractory) can be treated with an Implantable Cardioverter Defibrillator (ICD)

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1. It can develop into ventricular fibrillation at any time. 2. It is almost impossible to convert to a normal rhythm. 3. It is uncomfortable for the client, giving a sense of impending doom. 4. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

1. It can develop into ventricular fibrillation at any time. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.

A group of nursing students are discussing atrial flutter. These students recognize that which of the following are seen with atrial flutter? Select all that apply: 1) Ventricular rate of 220-300 bpm. 2) Regular rhythm 3) Saw-tooth pattern 4) Measurable PR interval 5) Long QRS interval

2) Regular rhythm 3) Saw-tooth pattern The ATRIAL rate is 220-300 bpm. Ventricular is about 75-150. The rhythm is regular, with the P wave appearing as little flutter or a "saw tooth pattern". The PR interval is not measurable r/t this saw-tooth P wave. The QRS is normal.

(S) The nurse is caring for a client who is pulseless and experiencing ventricular tachycardia dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. 1. Prepare for cardioversion. 2. Prepare to administer epinephrine. 3. Prepare to administer digoxin (Lanoxin). 4. Provide cardiopulmonary resuscitation (CPR). 5. Prepare to administer amiodarone (Cordarone).

2. Prepare to administer epinephrine. 4. Provide cardiopulmonary resuscitation (CPR). 5. Prepare to administer amiodarone (Cordarone). Pulseless ventricular tachycardia is treated the same way as ventricular fibrillation with measures that include defibrillation, CPR and medication therapy, with agents such as vasopressin, epinephrine, amiodarone, lidocaine, and magnesium sulfate.

The patient has atrial fibrillation with a rapid ventricular response. What electrical treatment option does the nurse prepare the patient for? 1. Defibrillation 2. Synchronized cardioversion 3. Automatic external defibrillator (AED) 4. Implantable cardioverter-defibrillator (ICD)

2. Synchronized cardioversion Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death, have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.

A 26-year-old client with atrial fibrillation that has not responded to medication therapy has arrived at the hospital for an elective cardioversion. Which of the following patient statements most concerns the nurse? 1) "I can't wait to stop taking this Coumadin. I've been on this crap for weeks now." 2) "I'm starving. I haven't eaten anything in 3 hours." 3) "I feel really short of breath, can I lie down?" 4) "I haven't taken my Digoxin since 9 o'clock last night. Is that okay?"

3) "I feel really short of breath, can I lie down?" Patients with atrial fibrillation are at incredibly high risk for clots, even with anticoagulation therapy. Shortness of breath could indicate a PE, and this should be immediately investigated by the nurse. The patient should be NPO for at least 4 hr. prior to the procedure related to anesthesia use, but this is not as urgent of a concern. The patient should also withhold Digoxin therapy for 48 hours to ensure that, once cardioverted, NSR returns.

Which of the following does the nursing student realize is the treatment for a stable patient presenting with QRS intervals above 0.12 seconds with a regular rhythm and a rate of 100-250 bpm? 1) Atropine 2) Defibrillation 3) Amiodarone 4) Adenosine

3) Amiodarone This is describing ventricular tachycardia (QRS is a giveaway), and the treatment for a stable patient is Amiodarone or cardioversion. If the patient didn't have a pulse, we'd go ahead and defibrillate.

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1. Sensation of palpitations 2. Causative factors, such as caffeine 3. Precipitating factors, such as infection 4. Blood pressure and oxygen saturation

4. Blood pressure and oxygen saturation Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.

A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of atropine. What guidelines will the nurse follow when administering atropine? A) Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. B) Administer atropine as a continuous infusion until symptoms resolve. C) Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D) Administer atropine 1.0 mg sublingually.

A) Administer atropine 0.5 mg as an IV bolus every 3 to 5 minutes to a maximum of 3.0 mg. Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed options are inappropriate.

The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation (VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards, the nurse should anticipate the administration of what medication? A) Epinephrine 1 mg IV push B) Lidocaine 100 mg IV push C) Amiodarone 300 mg IV push D) Sodium bicarbonate 1 amp IV push

A) Epinephrine 1 mg IV push Epinephrine should be administered as soon as possible after the first unsuccessful defibrillation and then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and lidocaine are given if ventricular dysrhythmia persists.

A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A) Decrease SA node conduction B) Control ventricular heart rate C) Improve oxygenation D) Maintain anticoagulation

B) Control ventricular heart rate Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and then Coumadin.

The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to atropine. What might be the treatment of choice for this patient? A) Implanted pacemaker B) Transcutaneous pacemaker C) ICD D) Asynchronous defibrillator

B) Transcutaneous pacemaker If a patient suddenly develops a bradycardia, is symptomatic but has a pulse, and is unresponsive to atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide relief.

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

a. Assess airway, breathing, and level of consciousness. Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

What is the transesophageal echocardiogram (TEE) used for? (Select all that apply.) a. Detect thrombi before a cardioversion b. Check for cardiac arrhythmias c. Visualize vegetation on the heart valves d. Measure effectiveness of diuretic therapy e. Visualize abscesses on the heart valves

a. Detect thrombi before a cardioversion c. Visualize vegetation on the heart valves e. Visualize abscesses on the heart valves The TEE is used to check for thrombi before cardioversion, and to visualize vegetation and abscesses on the valves of the heart.

A 38-year-old female is brought to the Emergency Department with complaints of her "heart beating out of her chest". She is diaphoretic, tachypneic and her BP is 70/40. The cardiac monitor shows supraventricular tachycardia. Valsalva maneuvers and three doses of Adenosine have not been successful. The nurse should immediately: a.) prepare the patient for synchronized cardioversion. b.) give Epinephrine 1 mg IV and repeat in 3 minutes. c.) give Adenosine 6 mg IV per protocol. d.) perform unilateral carotid massage.

a.) prepare the patient for synchronized cardioversion.

You, the nurse, note the following rhythm on the EKG monitor for a patient named billy. What is the first thing the nurse should do? a) Check for a pulse b) Tell Billy to try to poop c) Prepare to defibrillate Billy d) Prepare to administer Amiodarone

b) Tell Billy to try to poop With SVT (Supraventricular tachycardia), the first thing to do would be to instruct the pt. to perform the Valsalva maneuver by bearing down.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.

b. Initiate cardiopulmonary resuscitation (CPR). The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength c. Ask the client what medications he or she takes .d. Administer 1 mg of atropine.

c. Ask the client what medications he or she takes This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first.

The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? a) Administer atropine 0.5 mg b) Administer epinephrine c) Defibrillate with 360 joules d) Begin cardiopulmonary resuscitation (CPR)

d) Begin cardiopulmonary resuscitation (CPR) We cannot defibrillate asystole.

A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below:How should the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

d. Sinus rhythm with premature ventricular contractions (PVCs) Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

Cardioversion DING DING - SLIDE 33

•Before cardioversion is performed, a Transesophageal Echocardiogram (T.E.E.) is used to evaluate for possible atrial thrombi (clots)

Tachycardia Treatment DING DING - SLIDE 19

•Synchronized cardioversion is treatment of choice for persistent tachycardia with hemodynamic instability