Life-threatening Dysrhythmias
When does a patient need a pacemaker?
-A pacemaker may be a good choice if your heart rate is very slow and you have symptoms like dizziness or fainting.
What is torsades de pointes?
-A type of VT where the QRS varies in size, shape, and amplitude. -Patient has episodes of palpitations, dizziness, and syncope. -Sudden cardiac death can occur with the first episode.
What is atrial flutter?
-Abnormal electrical circuit in the upper chambers of the heart (atria) makes the atria beat quickly or flutter instead of fully squeezing. -This Flutter is not able to move enough blood through the heart/body effectively. -The rhythm is more organized than with AFIB and forms a SAWTOOTH like F wave. -Type I has an atrial rate of 240-320 bpm. -Type II has an atrial rate of 350+ EKG READING: -Rapid and regular rhythm. -Sawtooth appearance. -Atrial impulses are usually evenly conducted between the QRS complexes. (2:1, 4:1, 6:1) -T wave is normally hidden in F-wave. MANIFESTATIONS: -Palpitations or a fluttering sensation in the chest or throat. -Decreased LOC, hypotension, decreased urinary output & cool clammy skin
When would you use adenosine?
-Adenosine and digoxin are both used to treat supraventricular tachycardia
Nursing Interventions
-Assess the patient for decreased CO, LOC, tachycardia, tachypnea, hypotension, low O2 sats, diaphoresis, low urine output, pallor or cyanosis, & diminished peripheral pulses. -Monitor ECG. Document any changes from baseline. -During acute dysrhythmia, assess vitals, ECG, and oxygen every 5-15 minutes. -Assess the patient for underlying causes of dysrhythmias (hypovolemia, hypoxia, anemia, vagal stimulation, or meds). -Assess the patient's serum electrolytes (K, Calcium magnesium). Also, assess digitalis & antidysrhythmic levels. -Be prepared to administer antidysrhythmic medications as needed. -If indicated, instruct the patient to perform the Valsalva maneuver (bear down as if straining or coughing) for SVT or VT without angina. -Prepare to assist the patient with cardioversion.
What is synchronized cardioversion?
-Delivers direct electrical current synchronized with the patient's heart rhythm. -Synchronized shock with the QRS complex prevents VF by avoiding current delivery during the vulnerable period of repolarization. -Usually done as an elective procedure. -Treats SVT, atrial fibrillation, atrial flutter, or hemodynamically stable VTs. -Patients with atrial fibrillation are at high risk for thromboembolism following cardioversion because of pooling blood in the atria. Anticoagulants are given for several weeks prior to the procedure. NURSING: -Administer sedatives because the procedure is painful. -Monitor the patient for signs of embolism. -Obtain any lab tests -Obtain and document ECG strips before, during & after -Set up the equipment -Monitor the patient's response.
What is ventricular tachycardia?
-It is a tachycardia, or fast heart rhythm, that originates in one of the ventricles of the heart. -An area within the ventricle generates an impulse in a regular fashion and at a very fast rate. -Allowed to continue, VT can turn into Vfib. -Sustained VT is a medical emergency requiring immediate intervention. INTERVENTIONS: -Check for a pulse. -If no pulse, start CPR immediately with defibrillation. TREATMENT: -Cardioversion -Surgical ablation (removes tissue to restore rhythm) -ICD insertion -CPR if no pulse -Sodium channel blockers: Procainamide, lidocaine -Class III drugs potassium channel blockers CAUSES: -Myocardial ischemia or infarction (most common) -Cardiac structural disorders. -Anorexia nervosa, metabolic disorders, or drug toxicity. EKG READING: -Abnormally wide QRS complex. -HR is Fast >100 and regular. -P-waves are typically absent.
Patient teaching for dysrhythmias
-It is important to take medications how they are prescribed. -Encourage patient to reduce or eliminate caffeine intake. -Participate in smoking cessation program and reduction or elimination of alcohol if appropriate. -Engage in regular exercise. -Contact PCP for evaluation if symptoms such as dizziness, fainting, frequent palpitations, SOB, unexplained falls, or chest pain. -Avoid cardiac stimulant drugs (decongestants) with SVT because they can trigger an episode. -Educate about Valsalva maneuver and that it is contraindicated when chest pain accompanies dysrhythmias.
What is atrial fibrillation?
-Multiple areas within the atrial muscle tissue fire impulses at random and at a very fast rate. -Some of these impulses make it through the AV node and depolarize the ventricles normally. EKG READING: -p waves are either absent or form small non-uniform fibrillation waves (chaotic atrial activity). -QRS complexes are normal. -Irregular HR & irregular rhythm. MANIFESTATIONS: -hypotension, SOB, fatigue, angina, distended neck veins. -Increased risk for CLOT FORMATION & STROKES. TREATMENT: -Synchronized cardioversion -MEDS: beta-blockers (metroprolol), diltiazem (CCBs), digoxin -CHRONIC afib may require long-term anticoagulant therapy (Coumadin)
Amiodarone
-Potassium channel blocker. -Use this before lidocaine. -Blocks potassium channels, prolonging repolarization and the refractory period. -Primarily for VT and Vfib but may also be used for SVT SIGNS OF TOXICITY: -pulmonary fibrosis (dyspnea, cough, hepatic dysfunction, LFTs changes, jaundice) -Vision changes (photosensitivity)
Lidocaine
-Sodium channel blocker -Used for VT and SVT. SIGNS OF TOXICITY: -Changes in neuro status (agitation, confusion, dizziness, nervousness).
Procainamide
-Sodium channel blocker. -Used for VTs and SVTs. -Decreases the amount of sodium in the cell to prolong the action potential. SIGNS OF TOXICITY: -signs of HF -Conduction delays or signs of dysrhythmias -Skin rash -Myalgias or arthralgias -Flu-like symptoms.
What medications are used for ventricular dysrhythmias?
-Sodium channel blockers Class IA (quinidine, procainamide, dysopyramide) Class IB (lidocaine, mexiletine, phenytoin). Lidocaine is the most common one used. -Potassium channel blockers Amiodarone, sotalol, ibutilide, dofetilide.
What is a valsalva maneuver?
-The Valsalva maneuver is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while expelling air out as if blowing up a balloon. -It increases vagal tone, slows conduction through the (AV) node, and prolongs the AV nodal refractory period, leading to a reduction in heart rate and reversion of supraventricular tachycardia.
What medications are used to treat SVTs?
-Used for Afib & Atrial flutter -Beta-blockers: metroprolol, propranolol, esmolol -Calcium Channel Blockers: Diltiazem, verapamil -Digoxin & adenosine
The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.
1. Document this as normal sinus rhythm.
The client has chronic atrial fibrillation. Which discharge teaching should the nursediscuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.
1. Instruct the client to use a soft-bristle toothbrush. The patient is at risk for bleeding because they are on a long-term anticoagulant therapy.
The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health-care provider to orderfor this client? 1. Lidocaine. 2. Atropine. 3. Digoxin. 4. Adenosine.
1. Lidocaine is the drug of choice for ventricular dysrhythmias.
The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.
1. Start cardiopulmonary resuscitation. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.
The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.
2. Administer atropine, an antidysrhythmic. It will decrease vagal stimulation and increase the heart rate.
Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.
2. Decreased cardiac output.
The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.
3. Assess the client's apical pulse and blood pressure. Determine if the client is in cardiac arrest and if they are then treat as v fib. If heart is beating, the nurse would then administer lidocaine.
The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation.
3. Call a STAT code and activate team arrival and code care being brought.
The client is exhibiting sinus bradycardia, is complaining of syncope and weakness,and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.
3. Patient is symptomatic, prepare for pacemaker
The telemetry nurse is unable to read the telemetry monitor at the nurse's station.Which intervention should the telemetry nurse implement first? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.
3. easiest intervention should be first, if client doesn't respond then should could have another nurse go check
The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.
4. Determine if the client is having pain. There is no set treatment for sinus tachycardia. It is important to find out what is causing tachycardia first.
Which intervention should the nurse implement when defibrillating a client who isin ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client.
4. Shout "all clear" prior to defibrillating the client.
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
Answer(s): 1, 2, 3 The ATRIAL rate is 220-300 bpm. Ventricular is about 75-150. The rhythm is regular, with the P wave appearing as a little flutter or a "sawtooth pattern". The PR interval is not measurable r/t this saw-tooth P wave. The QRS is normal.
A group of nursing students are studying AV blocks and ask their instructor, "what causes a first-degree block?" The nursing instructor responds that which of the following can cause a first-degree block: Select all that apply 1) Diarrhea 2) Chronic constipation 3) Diltiazem 4) Digoxin 5) Metoprolol
Answer(s): 2, 3, 4, 5 Diarrhea will not stimulate a vagal response, but vomiting can. Chronic constipation will cause a consistent vagal response. Digoxin, beta blockers, and calcium channel blockers can all contribute to first degree blocks. Relate this to bradycardia.
A nurse on a CVT unit views the monitor and sees the patient in room 452 has just begun having occasional PVCs. Which action should the nurse take first? 1) Check on the patient 2) Check last magnesium and potassium levels 3) Document the occurrence and watch for further PVCs 4) Contact the physician
Answer: 1) Although electrolytes are likely the culprit, the nurse first needs to first assess the patient. Then, the nurse should look in the patient's chart and evaluate or request an order for electrolyte levels. This may eventually need to be documented, but the nurse can be held liable for neglect if he/she does not assess the patient first. The physician may or may not need to be contacted.
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.
Answer: 2) Cardioversion is used if the patient is unstable. Anticoagulants are used if the arrhythmia has stuck around for 48 hr +.
A nurse working on a CVT unit receives report from day shift. After receiving report, which patient should the nurse see first? 1) A 23-year-old professional tennis player with a HR of 47 bpm. 2) A 69-year-old male with atrial fibrillation who has new onset confusion. 3) A 72-year-old female with atrial flutter who reports feeling unusually tired today and yesterday. 4) A 33-year-old female with sinus tachycardia who is asking for her at-home Metoprolol.
Answer: 2) Patients with a-fib are at risk for pulmonary and systemic emboli, and new onset of confusion may indicate a stroke in this patient. Patients with atrial flutter may feel more tired some days than others.
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?"
Answer: 3 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
Answer: 3) This is describing ventricular tachycardia (QRS is a giveaway), and the treatment for a stable patient is Amiodarone or cardioversion. If the patient were unstable, we'd go ahead and defibrillate.
The nurse is preparing to administer adenosine to the patient with the following rhythm which is symptomatic. What should the nurse plan on having in the patient room? a) Physician b) Crash cart c) IV pump d) EKG monitor e) Lidocaine
Answer: A, B, and D. Adenosine is administered as a very quick IV push. The physician must be present in the room and the crash cart must be on hand. An ekg monitor should be in the room to monitor the effectiveness of the medication.
The nurse is providing discharge teaching to the client who has just received a pacemaker. Which of the following should the nurse include in the plan of care? SATA: A) Use your cell phone on the opposite side of your pacemaker B) You should avoid using a microwave from now on C) For the next week, it would be best to limit activity on the side with your new pacemaker D) You will need to inform airport security about your pacemaker before you fly anywhere E) It would be a good idea to check your pulse daily
Answer: A, C, D, and E. A cellphone should not be used near the pacemaker and it's best to keep the phone about half a foot away from the pacemaker. It is not necessary for the client to avoid using a microwave or other electrical devices. However, magnets should be kept away from the device. In order to prevent disruption of the leads after implantation (the most common complication), patients are often taught to limit activity on the affected side for awhile after implantation. Pulses are a good indicator of whether the pacemaker is supplying the body with enough cardiac output.
The patient who has recently been experiencing runs of ventricular tachycardia suddenly loses consciousness. The patient is defibrillated, and the rate returns as the following. What should the nurse do first?A) Begin compressions B) Shock the client again immediately C) Prepare for intubation D) Administer adenosine
Answer: A. Following defibrillation, CPR is immediately initiated if a perfusable rhythm is not initiated. The client may need to be shocked again, but chest compressions must begin first.
Which of the following signs and symptoms indicate pacemaker failure? a) excessive thirst b) prolonged hiccups c) flushing of the skin d) increased urine output
Answer: B - prolonged hiccups indicate pacemaker failure. Other signs and symptoms of pacemaker failure are dysrhythmias, dizziness, faintness, chest pain, shortness of breath, increase or decrease in apical rate.
A patient with cardiomyopathy has been given an ICD. Which of the following medications would the nurse expect to see in the MAR for this patient? A) Warfarin B) Cardizem C) Nitroglycerin D) Digoxin
Answer: B. Antiarrhythmic medications are prescribed with the use of an ICD in order to prevent the tachycardic (or other deadly arrhythmia) from occurring in the first place. This makes sure that the ICD is used only when absolutely necessary.
The nurse has just administered adenosine via IV push and sees the following rhythm on the monitor. What is the nurse's priority intervention? a) Apply conductive gel and defibrillate the patient b) Document the findings and continue to monitor c) Administer another mg of the medication d) Begin chest compressions
Answer: B. This finding would be expected upon administration of adenosine. The rhythm should then begin again in some other rhythm, hopefully, a normal sinus rhythm. It would be important to document the exact time of this change and continue to monitor the change back to NSR. If this change does not occur, or if another rhythm is produced, appropriate action would then be taken based on the result.
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 Amiodorone
Answer: B. 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 sees the following rhythm on the monitor. Which of the following lab values does the nurse identify as being most likely to have caused this dysrhythmia? a) K 3.0 b) Ca 10.5 c) Hgb 9 d) Magnesium 2.1
Answer: C. Anemia can contribute to sinus tachycardia.
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. The 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
Answer: D. A pulse would be assessed for first. Then the patient will be defibrillated and chest compressions will begin immediately.
What is third degree heart block?
Complete heart block -The atria and ventricles are paced independently and there is no relationship between the P waves and QRS complex ECG READING: -QRS is wide -Atrial rate is 60-100, rhythm is regular. -Ventricular rate is <60, rhythm is regular. -There is no relationship between p waves and QRS complexes. TREATMENT: -Immediate pacemaker therapy
What is second degree AV block Type I?
Mobitz Type I or Wenckebach; -Progressively prolonged PR interval; -Usually asymptomatic; -A repeating pattern of increasing AV conduction delays until an impulse fails to conduct to the ventricles. ECG READING: -PR Intervals progressively lengthen until a QRS is dropped. -Atrial rhythm is regular. -Ventricular rhythm is irregular. TREATMENT: -Monitoring and observations because it rarely turns into something worse. -Atropine often works great
What is second degree AV block type II?
Mobitz type II -Intermittent failure of the AV node to conduct an impulse to the ventricles without preceding delays in conduction. -The bundle of His and/or lower regions of the conduction system are blocked. -High rate of mortality ECG READING: -PR intervals remain constant -P waves are not always followed by a QRS complex. -Atrial rhythm is regular. -Ventricular rhythm is irregular. TREATMENT: -Atropine can be tried but is often not successful. -pacemaker therapy is required.
The nurse should understand that which of the following treatments for Second Degree Type II AV Block would be appropriate?(Select all that apply) a.) Temporary pacemaker insertion b.) Close monitoring without intervention c.) Atropine to increase heart rate if symptomatic d.) Coronary stent placement to improve blood flow to myocardium e.) An implantable defibrillator surgically implanted
Rationale: a,c, and d are correct. Temporary pacing may be needed and atropine will temporarily improve heart rate cardiac output until the pacemaker can be inserted.
What is first degree AV block?
The impulse conduction through the AV node is slowed but it still makes it to the ventricles. -Generally poses no threat. -Has no symptoms. TREATMENT: -There is no treatment. ECG READING: -All characteristics of a NSR. -Rate and rhythm are normal. -The only sign is that the PR interval is >.20 (5 small boxes) CAUSES -vomiting, constipation (stimulates vagal response) -Injury or infarct to the AV node. -Drugs such as digoxin, beta blocker (metroprolol), or CCBs (diltiazem).
The nurse would expect which of the following to be the first choice to treat a stable patient with ventricular tachycardia? a.) Amiodarone b.) Procainamide c.) Synchronized cardioversion d.) Atropine
a.) Amiodarone
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.
A patient is to have synchronized cardioversion for treatment of atrial flutter. He has received Heparin 500 units subcutaneously. Which of the following interventions should now be performed? a.) Assist the MD in intubating the patient to stabilize airway. b.) Sedate the patient with Versed 2 mg IV push per protocol. c.) Set the defibrillator in asynchronous mode and charge to 300 joules. d.) Steadily increase the voltage until the beats are captured.
b.) is correct since cardioversion is very painful, the patient should be sedated prior to the procedure.
When a patient has long-term atrial fibrillation, the nurse would expect to include which drug in the plan of care to minimize the greatest risk that is commonly associated with atrial fibrillation? a.) Beta blockers b.) Digitalis c.) Anticoagulants d.) Antiarrhythmics
c.) Anticoagulants
Prior to discharge from the Emergency Department, the nurse prints a rhythm strip on a patient and notices that the P wave cannot be detected and the QRS complex is 0.24 seconds. This is a change in the patient's condition. What is the best action for the nurse to take?a.) Measure the PR interval. b.) Prepare the patient for discharge. c.) Notify the physician of this abnormal strip. d.) Continue to monitor for abnormalities.
c.) is correct because notifying the physician of the abnormal rhythm would be the most appropriate response. The patient has experienced a rhythm change and requires further treatment.
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)
A 21-year-old female is seen in the Emergency Department for vomiting and diarrhea for 3 days. Her BP is 94/64 and her EKG rhythm shows that she is sinus tachycardia. The best action for the nurse to take initially is to: a.) request pain medication for the patient. b.) cardiovert the patient immediately. c.) give Adenosine 6 mg IV push. d.) start IV and bolus normal saline per protocol.
d.) start IV and bolus normal saline per protocol. The patient is most likely dehydrated from the vomiting and diarrhea.