Pearson Vol 3 Chapter 12: Perfusion

Transcutaneous Pacing (TCP) monitoring

1. Assist healthcare provider performing the following actions as needed. -Connect electrocardiogram (ECG) cable to input connection on pacing generator. -Turn switch selector to MONITOR ON. ECG waveform will appear. -Set alarm, press ALARM ON. Ensure alarm parameters are set 20 beats higher and lower than patient's desired rate. -Record waveform by pressing START/STOP button. -Apply pacing pads as marked, first removing posterior pad covering, then placing posterior (back) pad left of spine between the scapulas. Place anterior "front" pad to left side of lower sternum. -Press firmly on and around pacing electrodes. Rationale: This ensures good skin contact. -Attach pacing cable to pace connector on defibrillator/monitor. -Select PACER button and green light will appear. -Set pacing rate to 60 to 80 beats/min. -Assess cardiac rhythm on oscilloscope and observe the QRS for sensing marker. -Set milliamperes (mA) threshold initially at 0. Rationale: This prevents pacemaker discharge while setting adjustment. -Activate pacing by depressing START/STOP button. -Increase mA slowly, increasing it until capture appears. 2. Assess pulse and blood pressure. Record ECG strip and document pacing parameters, significant events during the procedure, and patient's response to the procedure. 3. Monitor for perfusion. Continually assess patient's need for sedation. Rationale:Pacing causes discomfort. 4. Assist healthcare provider performing the following actions as needed: -Set dial at prescribed pacing rate (atrial and/or ventricular). -Set energy output (mA) on pulse generator to prescribed level (set for both atrial and ventricular pacing). Rationale: Energy output setting ensures that pacemaker stimulates the patient's myocardium. -Return plastic cover to protect generator dial settings and hang generator from pole at patient's bedside. -Monitor pacemaker function for sensing (light indicates patient's QRS complexes), capture (pacemaker spike is followed by QRS complex), and pacemaker rate. 5. Monitor patient's heart rhythm, vital signs, and other responses to pacing, including femoral pulsation palpable with captured beats. Rationale: These demonstrate effectiveness of pacemaker support. 6. Evaluate electrode insertion/exit sites and apply dressing according to facility protocol. 7. When the procedure is complete, perform hand hygiene and leave patient safe and comfortable. 8. Complete documentation using forms, checklists, or electronic dropdown lists supplemented by nurse's notes or additional comments as appropriate including ECG strip and significant events during the procedure, pacemaker settings, sterile dressing applied, and patient's response to the procedure.

Epicardial Pacing monitoring

1. Assist healthcare provider performing the following actions as needed: -Locate epicardial pacing wires on patient's chest wall. -Securely connect pacing wires to external generator. Rationale: This promotes pacemaker impulse reception from and transmission to the myocardium. -Connect cable to pulse generator (positive to positive, negative to negative). Rationale: Pacing stimulus goes from pulse generator to the negative terminal and back to pulse generator by the positive terminal. -Remove protective cover to dial settings. -Select pacing mode (e.g., atrial, ventricular, atrioventricular (AV) synchronous, or demand). 2. Return bed to lowest position. 3. Record ECG strip and document pacing parameters, significant events during the procedure, and patient's response to the procedure. 4. Assist healthcare provider performing the following actions as needed: -Set dial at prescribed pacing rate (atrial and/or ventricular). -Set energy output (mA) on pulse generator to prescribed level (set for both atrial and ventricular pacing). Rationale: Energy output setting ensures that pacemaker stimulates the patient's myocardium. -Return plastic cover to protect generator dial settings and hang generator from pole at patient's bedside. -Monitor pacemaker function for sensing (light indicates patient's QRS complexes), capture (pacemaker spike is followed by QRS complex), and pacemaker rate. 5. Monitor patient's heart rhythm, vital signs, and other responses to pacing, including femoral pulsation palpable with captured beats. Rationale: These demonstrate effectiveness of pacemaker support. 6. Evaluate electrode insertion/exit sites and apply dressing according to facility protocol. 7. When the procedure is complete, perform hand hygiene and leave patient safe and comfortable. 8. Complete documentation using forms, checklists, or electronic dropdown lists supplemented by nurse's notes or additional comments as appropriate including ECG strip and significant events during the procedure, pacemaker settings, sterile dressing applied, and patient's response to the procedure.

pacemaker insertion procedure

1. Introduce self to patient and verify the patient's identity using two identifiers. Explain to the patient that the healthcare provider is going to insert a pacemaker, why it is necessary, and how the patient can participate. Discuss how the results will be used in planning further care or treatments. 2. hand hygiene 3. Provide patient privacy. Provide comfort and safety 4. Prepare the patient. -Raise bed to appropriate height for procedure. -Place the patient in a supine position with head flat or slightly lower than body. -If either the subclavian or external jugular vein is to be used, place a towel roll under the patient's shoulders to provide better exposure of the insertion site. 5. Assist healthcare provider as needed. -Healthcare provider dons mask, sterile gown, and gloves. -Insertion site is cleansed with sterile antiseptic solution. -Drape area with sterile towels. -Break single-dose vial of lidocaine and hold for healthcare provider's withdrawal. -Healthcare provider withdraws lidocaine, using filtered needle, then changes to 25-gauge needle and injects skin. -Insertion is accomplished (transvenous method via cutdown or percutaneously). Catheter electrode wires are positioned, and skin sutures are applied. 6. Continuously monitor the ECG and patient status during the insertion. 7. Don gloves to prevent microshock to patient. 8. Assist in the connection of the pacing electrode to the appropriate outlet terminal (unipolar to negative and bipolar to both the positive and negative terminals). 9. Healthcare provider turns on power switch on external pacemaker and sets the rate. The milliamperes (mA) are set by determining threshold. To do this, the ECG is observed while the healthcare provider slowly increases the number of milliamperes from its lowest setting to a point where a QRS complex is captured and preceded by a pacing spike. 10. Healthcare provider sets sensitivity mode (usually 1.5 mV). 11. Secure all connections. The plastic cover is put back over pacemaker controls if required. 12. The external pacemaker and exposed wires are placed in a rubber glove to ensure insulation against electric shock to patient. 13. Sterile dressings are applied to insertion site and taped securely. 14. Lower bed to lowest height. 15. Chest x-ray is obtained following insertion to validate lead placement if pacemaker not inserted using fluoroscopy. 16. Obtain 12-lead ECG.

Arterial Blood Pressure: Monitoring

1. Level and calibrate (zero out) the system. -Calibrate system at beginning of each shift. Rationale: Monitor readings are altered by changes in atmospheric pressure. -Position patient with head of bed flat or at up to a 45-degree elevation. -Using a carpenter's level, align stopcock above transducer level with patient's left atrium (phlebostatic axis) and mark patient's chest for future readings. Rationale: Readings will be inaccurately high or low if stopcock above transducer is not level with patient's phlebostatic axis. -To zero ("calibrate") the system, turn stopcock near transducer off to patient. Remove cap from stopcock, opening it to air. -Depress ZERO button on monitor, release button, and note monitor reading is zero. Rationale: Zero reading indicates monitor is calibrated to atmospheric pressure. -Replace cap or place new sterile cap on stopcock. -Turn stopcock so transducer is open to patient. 2. Observe waveform at eye level for the sharp systolic upstroke, peak, dicrotic notch, and end diastole 3. Fast flush the continuous flush system and quickly release. A sharp upstroke followed by a horizontal line, then a brisk downstroke descending below, then returning to baseline indicates that the system requires no adjustment 4. Ensure pressure bag is maintained at 300 mmHg. 5. Leave cannulated extremity uncovered for easy observation. Assess site at every shift for signs of infection. 6. Assess circulation, motion, and sensation of extremity distal to cannulation site every 2 hr initially, then every 8 hr. 7. Immobilize extremity if necessary. 8. Change flush solution and tubing every 96 hr (according to facility policy). 9. Change dressing weekly or if it becomes wet, loose, or soiled. Rationale: Loose or soiled dressings increase risk of infection at site.

maintaining temporary pacemaker

1. Observe for failure of the pacemaker to sense. -Observe the monitor for presence of pacemaker artifact (spikes); artifact before QRS complex in ventricular paced or preceding the P waves and QRS waves in atrioventricular (AV) sequential pacing -Check connections -Check sensitivity dial 2. Observe for failure to pace. -Check that external generator is ON. -Check battery . -Check lead connector sites. -Check pace-sense indicator. (Absence of or slight deflection of the pace-sense indicator reveals battery failure.) 3. Observe for failure to capture. -Observe for pacing artifact not followed by QRS complex This indicates a failure of the stimulus to trigger a ventricular response. -Check the setting of the milliamperes (mA), or output dial, to determine if setting should be increased. The myocardial threshold may be altered as a result of disease or drugs. -Check all connector sites 4. Observe that sutures are intact. 5. Assess insertion site for bleeding, hematoma formation, or infection. 6. Obtain chest x-ray postinsertion. 7. Monitor patient's response to therapy.

the allen test procedure

1. Perform the modified Allen test to determine distal peripheral perfusion. This procedure assesses blood supply to the patient's hand to determine that the radial and ulnar arteries are functioning before an arterial line is inserted. -Compress both arteries at patient's wrist for about 1 minute. -Instruct patient to clench and unclench fist several times. This causes blanching in the hand and palm. -With patient's hand in open, relaxed position, release pressure on ulnar artery. -Observe how quickly (7 seconds) the palm color flushes. If color returns quickly, good collateral blood supply to the hand exists. If normal color does not return, there would be insufficient collateral circulation to the hand should radial artery occlusion occur. 2. Repeat procedure with release of the radial artery. 3. Report to healthcare provider if collateral blood flow is insufficient. A Doppler flow study may be used to help determine collateral blood flow. 4. When the procedure is complete, perform hand hygiene and leave patient safe and comfortable. 5. Complete documentation using forms, checklists, or electronic dropdown lists supplemented by nurse's notes or additional comments as appropriate.

arterial line insertion

1. Prepare the arterial line set-up. -Add heparin to normal saline solution and label bag with additive and date (commonly 2 units of heparin/mL fluid). Follow hospital protocols. -Connect IV tubing to solution bag. -Remove all air from flush solution bag. -Insert flush infusion bag into pressure bag and hang bag on IV pole. -Prepare and assemble pressurized monitoring system (transducer, continuous flush device, and stopcocks) following manufacturer's instructions. -Level stopcock above transducer to patient's phlebostatic axis -Inflate pressure bag to 300 mmHg using hand pump on bag. 2. Don gloves and PPE and prepare to assist the healthcare provider as needed -Skin is prepped briskly with 2% chlorhexidine for 3 seconds. -Lidocaine vial is cleansed with alcohol wipe. -Healthcare provider dons sterile gloves. -Sterile drape is placed over arterial insertion site. -Healthcare provider aspirates lidocaine with 18-gauge needle, changes needle, and injects patient's skin with 25-gauge needle. Rationale: This size is used for local anesthesia. -Percutaneous insertion is made at arterial insertion site, and arterial catheter is inserted. -Healthcare provider advances catheter in artery. -Arterial catheter is sutured in place with 000 silk suture secured with transparent dressing 3. Assist healthcare provider performing as needed the following actions: -Observe for pulsating bright-red blood spurting retrograde into catheter. Rationale: This evidence ensures arterial catheter position. -Attach catheter to primed pressure-monitoring system tubing. Make sure all connections are secure. -Press fast flush valve to clear system. -Observe oscilloscope for arterial waveform. -Apply sterile transparent dressing (with date and initials) to site after catheter is sutured into place.

interpreting ECG

1. assess ECG grid 2. Determine heart rate by calculating ventricular rate; normal is 60-100 beats/min. -Count the number of R waves in a 6-second period (30 large blocks) and multiply this by 10 to obtain the heart rate. -For true accuracy, count patient's apical heart rate for 1 full minute. 3. Determine the regularity of ventricular rhythm (R waves should be equally spaced.) 4. Determine the P-wave rate (atrial depolarizations). -There should be one P wave in front of each QRS complex. -Note if there are more P waves or fewer P waves than QRS complexes. 5. Determine the regularity of the P waves; are they all equally spaced? 6. Measure the PR interval (beginning of the P wave to the beginning of the QRS complex); represents conduction time through the electrical tissue to the ventricles (from the SA node, through the AV node, bundle of His, bundle branches, and Purkinje fibers); normal is 0.12-0.20 second. 7. Measure the QRS duration from beginning of the Q wave, if present, to end of the S wave; normal is less than 0.12 second 8. Interpret the patient's cardiac rhythm and place ECG rhythm sample strip in patient's chart, according to hospital policy. -Normal sinus rhythm; regular configuration, uniform P wave precedes each QRS Atrial rate: 60-100 PR interval: 0.12-0.2 second QRS width: less than (<) 0.12 second Ventricular rate: 60-100

The preferred IV catheter size is

18 or 20 gauge

It is recommended that transfusions of RBCs be started at

5 mL/min for the first 15 minutes of the transfusion to check for a reaction from the patient to the blood. The nurse should stay with the patient during this time to note adverse reactions, such as chilling, nausea, vomiting, dyspnea, headache, vital changes, skin rash, flank pain, or tachycardia. Rationale: The earlier a transfusion reaction occurs, the more severe it tends to be. Promptly identifying such reactions helps to minimize the consequences.

pacemaker

A pacemaker is a small electronic device that can be implanted just under the skin in the chest if permanent, or it can be worn outside the body if it is temporary. The pacemaker sends electrical signals through one or two wires that connect it to the heart to regulate rate, rhythm, or electrical conduction pathways to sustain necessary heartbeats.

transvenous pacemaker

A transvenous pacemaker has the pacing wire inserted into the jugular vein and advanced to the inner wall of the right ventricle. Temporary Cardiac Pacing Transvenous single-chamber (ventricular) pacing is most commonly used as an emergency measure to support ventricular contraction and cardiac output.

waveform variations of arterial blood pressure monitoring

A, Arterial line-normal waveform; B, arterial line-flattened waveform. Flattened arterial waveform indicates damping. Damping results from obstruction in arterial line or imbalance of transducer.

epicardial pacemaker

An epicardial pacemaker has the pacing wire placed on the epicardium, or outer layer of the heart muscle, during cardiac surgery. Temporary Cardiac Pacing Epicardial pacing electrodes provide either single-chamber atrial pacing, single-chamber ventricular pacing, or dual-chamber pacing, known as A-V sequential pacing, which is used to simulate normal pump function (atrial followed by ventricular stimulation/contraction).

dysrhythmia

Any disturbance in the rate or rhythm of the heartbeat means "a disturbance in cardiac rhythm," classified according to their site of origin: sinus, atrial, junctional, ventricular, and atrioventricular (AV) nodal tissue.

arterial blood sample

Arterial blood is needed to monitor arterial blood gases (ABGs) and provides valuable data about respiratory and metabolic function in maintaining acid-base balance and oxygenation status in the body.

A client is prescribed 3-lead telemetry to monitor atrial fibrillation. Which lead approach should the nurse use to obtain the best assessment of this client's atrial functioning? -Lead I -Lead II -Lead III -Lead aVL

Atrial activity is best detected in Lead II. Atrial arrhythmic activity is poorly identified in Lead I. Left inferior wall function is best detected in Lead III. Lead aVL records activity between the center of the heart and left arm.

how to determine heart rate on ECG grid (calculations)

Determine heart rate by calculating ventricular rate; normal is 60-100 beats/min. Count the number of R waves in a 6-second period (30 large blocks) and multiply this by 10 to obtain the heart rate. For true accuracy, count patient's apical heart rate for 1 full minute.

ECG grid

Each small square represents 0.04 second (horizontal measurement). Each large block (5 small squares) represents 0.20 second. 15 large blocks represent 3 seconds.

Patient Teaching Wearing Antiembolism Stockings at Home

Ensure the patient or caregiver knows how to apply antiembolism stockings. Reinforce the importance and the rationales for no wrinkles and no rolling down of the stockings. Reinforce the importance of removing the stockings daily and inspecting the skin on the legs. Include instructions about: Laundering the stockings (air dry because putting them in a dryer can affect their elasticity.) Needing two pairs of stockings to allow one pair to be worn while the other is being laundered. Replacing the stockings when they lose their elasticity. Reinforce knowledge about slipperiness of stockings if worn without slippers or shoes. If the patient is ambulatory, emphasize the need for footwear to prevent falling.

squarewave test for arterial blood pressure monitoring

Fast flush the continuous flush system and quickly release. A sharp upstroke followed by a horizontal line, then a brisk downstroke descending below, then returning to baseline indicates that the system requires no adjustment Fast flush the continuous flush system and quickly release. A sharp upstroke, followed by a horizontal line, then a brisk downstroke descending below and then returning to baseline indicates the system requires no adjustment (squarewave test).

V1

Fourth intercostal space, right sternal border. Records activity between the center of the heart and the fourth intercostal space; P wave is shown best here.

telemetry monitor, patient teaching

Introduce self to patient and verify the patient's identity using two identifiers. Explain that you are going to connect a telemetry monitor to the patient, why it is necessary, and how the patient can participate. Discuss how the results will be used in planning further care or treatments. Explain that radio waves transmit the heart's electrical activity to a central monitoring station. This system allows the patient to move around while the heart is constantly being monitored. Explain that the telemetry range is limited; therefore, patient cannot wander out of the range, which is usually the nursing unit. If patient goes off the unit, the nurse must be notified. Instruct the patient to notify the nurse if the electrode falls off.

Multifocal Premature Ventricular Contraction (PVCs)

Irregular rhythm P waves: none with premature beat, impulse originates in ventricle Atrial rate: undetermined PR interval: none with premature beat QRS width: greater than 0.12 second for premature beat Ventricular rate: varies Note: Each PVC has different configuration as foci are from different areas of heart. PVCs may be the result of imbalance between oxygen demand versus supply, thereby making the myocardium irritable. etiology Heart disease (myocardial infarction [MI]) Hypoxia Acidosis Electrolyte imbalances Myocardial ischemia Drug toxicity (especially digitalis) initial treatment Oxygen Potassium or magnesium if electrolytes dictate Lidocaine bolus-1-1.5 mg/kg; may repeat doses of 0.5-0.75 mg/kg every 5-10 min up to 3 mg/kg Refractory to lidocaine: amiodarone or procainamide Continuous lidocaine, amiodarone, or procainamide drip may be started following a bolus of the same medication Correct underlying cause

Ventricular Fibrillation

Irregular, totally chaotic rhythm Atrial rate: cannot differentiate PR interval: none QRS width: fibrillating waves only Ventricular rate: cannot differentiate Note: Ineffective quivering of ventricles with no audible heartbeat, pulse, or respiration Etiology Myocardial ischemia, acute MI Coronary artery disease Cardiomyopathy Acid-base imbalance Severe hypothermia Electrolyte imbalance Initial Treatment Immediately defibrillate, shock CPR-100 chest compressions/minute-no cycles Ventricular fibrillation continues-give a vasopressor (epinephrine 1 mg IV push), repeat 3-5 min Defibrillate again and continue CPR Second-line drugs may be used, such as amiodarone (300 mg IV), lidocaine

Atrial Fibrillation

Irregularly irregular rhythm Disorganized atrial activity: greater than 350 beats/min P waves: none identifiable PR interval: not measured QRS: variable QRS complex: irregular Etiology Heart failure Rheumatoid heart disease Coronary heart disease Hypertension Hyperthyroidism Initial Treatment Cardioversion Diltiazem Beta-blocker: carvedilol (Coreg) or metoprolol (Toprol XL) Digoxin Quinidine Procainamide Amiodarone or dronedarone ibutilide Anticoagulant to reduce risk of clot formation and stroke, if atrial fibrillation duration new in onset but older than 48 hr

Recommend Bed Rest for DVT?

Prolonged immobilization has been associated with DVT in critically ill patients. However, the value and safety of mobilizing patients with acute DVT has been a concern, largely because of the potential for venous thromboembolism (dislodging of the clot into the bloodstream) and life-threatening pulmonary embolism (PE). A number of studies have shown that patients with acute DVT who use compression stockings and begin ambulating early after initiation of anticoagulant therapy experience several benefits from this approach. Benefits include reduced pain level, more rapid reduction in edema, increased strength maintenance, and improved flexibility. Early ambulation in these patients, with careful monitoring for any evidence of PE, resulted in no increase in incidence of PE. Conversely, bed rest and immobilization did not result in any reduction in incidence of PE. Therefore, the current recommendation of the American College of Chest Physicians is ambulation with compression as tolerated, after starting anticoagulation, in patients with acute DVT.

Third-Degree Heart Block

Regular atrial and ventricular rhythm Atrial rate: greater than ventricular rate PR interval: varies QRS width: less than 0.12 second if pacemaker cell in junction; greater than 0.12 second if cell in ventricle Ventricular rate: 40-60 beats/min if pacemaker is from bundle of His; <40 beats/min if from Purkinje fibers in ventricle Note: Electrical impulse originates in SA node but is blocked in either the AV node, the bundle of His, or the Purkinje fibers. There is no correlation between the atrial rate and the ventricular rate. Etiology Digitalis toxicity Myocardial infarction, inferior or anterior wall Organic heart disease Initial Treatment Atropine bolus Transcutaneous pacing Dopamine or epinephrine Prepare for pacemaker insertion

Atrial Flutter

Regular or irregular rhythm (depending on block) Atrial rate: >250 beats/min P wave: usually sawtooth pattern; PR interval cannot be calculated PR interval: regular Ventricular rate can be irregular QRS complex: 0.6-0.10 second Etiology Sympathetic nervous system stimulation (i.e., anxiety), caffeine, and alcohol intake Thyrotoxins Coronary heart disease, MI, pulmonary embolism Initial Treatment Cardioversion-if symptomatic Diltiazem Calcium channel blocker (Cardizem) or beta-blocking agents to slow ventricular response Followed by ibutilide, quinidine, procainamide

Ventricular Tachycardia

Regular rhythm Atrial rate: cannot differentiate PR interval: none QRS width: greater than 0.12 second Ventricular rate: 130-250 beats/min Note: Ventricular tachycardia is a result of myocardial irritability and is life threatening. Etiology Acute MI Coronary artery disease, cardiomyopathy Electrolyte imbalance Drug intoxication (digitalis) Initial Treatment Lidocaine 1.5 mg/kg bolus; may repeat in 3-5 min to maximum dose of 3 mg/kg Amiodarone 300 mg IV/IO can be followed by 150 mg IV/IO Cardioversion if cardiac output is compromised Pulseless ventricular tachycardia-follow treatment for ventricular fibrillation (epinephrine)

Sinus Bradycardia

Regular rhythm: less than (<) 60 beats/min P waves: normal Atrial rate: <60 beats/min PR interval: 0.20 second QRS complex width: 0.08 second usually normal Note: A slow heart rate can be physiologically normal for some patients. etiology Drugs Hypoxia Altered metabolic states (hypothyroidism) Cardiac diseases Athleticism initial treatment Maintain patent airway; assist breathing as needed Oxygen IV Atropine 0.5-1 mg bolus IV if patient has signs of poor perfusion May repeat to a total dose of 3 mg Then, epinephrine (2-10 mg/min) or dopamine (2-10 mg/kg/min) infusion while awaiting pacemaker Transcutaneous pacing for symptomatic bradycardia

Sinus Tachycardia

Regular rhythm: more than (>) 100 beats/min P waves: normal Atrial rate: >100 beats/min PR interval: 0.12-2.0 second QRS complex width: 0.06-0.08 second usually normal Note: A moderately faster heart rate can be a physiological normal variant. etiology Underlying causes such as anxiety, fever, shock, drugs, exercise, electrolyte disturbances Initial Treatment Immediately initiate cardioversion if unstable Treatment dependent on elimination of cause Decreasing anxiety Pain relief Antipyretics O2 Medications (e.g., sedatives, tranquilizers, antianxiety) Calcium channel blockers and beta-blockers

The nurse assigns the UAP to complete morning care for a client with a sequential compression device. What information should the nurse instruct the UAP to report to the nurse? -Presence of pulses in the client's feet -Condition of the skin under the devices -Amount of time the devices were turned off -Sensation and movement of the client's feet

Since the UAP will be removing the devices for bathing, it is appropriate for the UAP to report the condition of the skin under the devices. The UAP is not responsible for assessing pulses in the feet of a client with sequential compression devices. This is the nurse's responsibility to assess. Although the devices should not be off for an extended period of time, it is not essential for the UAP to report the length of time the devices were turned off for bathing. Sensorimotor function assessment is a responsibility of the nurse. It is beyond the scope of practice for the UAP to assess for sensation and movement of the client's feet.

Temporary pacemakers

Temporary pacemakers have two parts, the pulse generator and the electrode. The pulse generator is external to the body. A, Epicardial ventricular pacemaker; B, Transvenous ventricular pacemaker. used for short-term external pacing of the heart for dysrhythmias such as bradycardia and tachycardia, postoperative cardiac surgery, or if the permanent pacemaker stops. Patients stay in the healthcare facility until the temporary pacemaker is not needed or the decision is made to insert a permanent pacemaker.

The Allen test

The Allen test is used before doing an arterial puncture of the radial artery. It is done to demonstrate adequate collateral blood flow through the ulnar artery due to the potential of thrombus formation after the radial artery puncture that would obstruct blood flow to the hand.

The nurse notes the following when analyzing a client's cardiac rhythm strip: atrial rate 60; ventricular rate 42; QRS width 0.10 seconds. Which diagnostic test should the nurse anticipate to determine the best treatment for this client's rhythm? -Digoxin level -T3 and T4 levels -Arterial blood gases -Serum electrolyte levels

The client is demonstrating third degree heart block. One reason for this rhythm is digoxin toxicity. Thyroid hormone imbalance is not a reason for this rhythm. Arterial blood gases will not help determine the reason for this rhythm. An electrolyte imbalance is not a reason for this rhythm.

The nurse visits the home of a client with a newly inserted permanent pacemaker. Which observation indicates that the client would benefit from additional teaching about the device? -Medical alert bracelet on the right wrist -Telephone transmission device installed -Pacemaker information card in the wallet -Cell phone in shirt pocket over the pacemaker

The client should be informed of electromagnetic interference restrictions, which include not placing a cell phone over the generator. It is wise for the client to wear a medical alert band/bracelet at all times. Many clients use telephone transmission of the generator's pulse rate to determine status of pacemaker function. Special equipment is used to transmit information concerning function of the pacemaker over the telephone to a receiving system in a pacemaker clinic. The client should carry a pacemaker information ID card in the wallet.

A new graduate is using an automated external defibrillator (AED) for a client who was discovered without a pulse. For which reason should the charge nurse intervene? -Resuming CPR after discharging the AED -Loudly stating "Clear" before discharging the AED -Stopping compressions for the AED to analyze the client's rhythm -Placing electrode pads below the right clavicle and above the left nipple

The electrode pads should be located below the right clavicle and below the left nipple. After the AED delivers a shock, CPR should be resumed. The graduate should loudly state "clear" before discharging the AED. The AED will automatically prompt to reanalyze the client in 2-3 min. Chest compressions should be stopped during the analysis.

Pneumatic Compression Device

This device has an air compressor that fills an inflatable sleeve for a period of time, usually positioned over a leg, then allows the air to drain out of the sleeve. The inflating and deflating cycle repeats, applying pressure every time the sleeve is inflated. This treatment, called compression therapy, helps prevent blood clots in deep veins of the legs.

equipment needed for blood transfusion

Unit of whole blood (for packed RBCs, or other blood components, see Skill 12.1) Blood administration set IV pump (follow facility policy for device and method of controlling flow rate if IV pump not available; see Skill 5.7) 250 mL normal saline for infusion Venipuncture start kit containing an 18- to 20-gauge needle or catheter (if one is not already in place) or, if the blood is to be administered quickly, a larger catheter Alcohol swabs Tape Clean gloves

The nurse evaluates the ability of the UAP to complete a 12-lead electrocardiogram for a client. Which lead placement should the nurse correct before the measurement is recorded? -Green lead placed on the client's left leg -White lead placed on the client's right wrist -V2 placed at the fourth intercostal space, left sternal border -V6 placed at the fifth intercostal space, left midclavicular line

V4, not V6, should be placed at the fifth intercostal space, left midclavicular line. It is correct to place the green lead on the client's left leg. It is correct to place the white lead on the client's right wrist. It is correct to place the V2 at the fourth intercostal space, left sternal border.

pacemaker insertion preparation

Validate that signed informed consent has been obtained for pacemaker insertion. Review healthcare provider's orders and patient's nursing plan of care. Perform a baseline assessment, including vital signs, sensorium, and heart rhythm. Provide sedation as ordered. Diazepam or midazolam is frequently used. Conscious sedation may be used. Connect patient to a continuous electrocardiogram (ECG) monitor. Have all equipment and supplies gathered.

A client receiving a unit of packed red blood cells begins to vomit 15 minutes into the transfusion. What should the nurse do first? -Call for help. -Stop the transfusion. -Provide an emesis basin. -Increase infusing normal saline.

Vomiting is an indication of a transfusion reaction. The first thing to do is to stop the transfusion. After the transfusion is stopped and the intravenous tubing changed to infuse normal saline, the nurse should call for help. Although the client is uncomfortable and vomiting, an emesis basin in not a priority. The transfusion needs to be stopped and the client's hemodynamic status needs to be supported first. The saline infusion should continue, not be increased; however, new tubing is required.

A new graduate reports that a client's arterial blood pressure monitor reading is 20 mmHg higher than the measurement from the previous shift. What should the nurse assess first to determine the reason for the change in measurement? -Calibration process -Pressure bag setting -Arterial site dressing -Angle of the head of the bed

When leveling and calibrating the monitoring system, the first action is to adjust the head of the bed to be between flat to up to a 45-degree angle. Then the calibration process is completed. Readings will be inaccurately high or low if the stopcock above the transducer is not level with the client's phlebostatic axis, which is done when calibrating the monitor. However, calibration is done after the head of the bed is adjusted. The pressure bag setting has no impact on the monitor reading. The arterial site dressing has no impact on the monitor reading.

sinus dysrhythmia

a change in rate or rhythm

Preventing venous stasis

an important intervention to reduce the risk of complications following surgery, trauma, or major medical problems. use of antiembolism stockings and sequential compression devices

pacemaker insertion equipment

emergency cart with defibrillator External pacemaker pulse generator Pacing catheter electrodes ECG monitor Patient cable Rubber glove Sterile antiseptic solution Sterile gloves, gown, and mask Sterile towels Lidocaine, 1-2% Alcohol wipes Syringe Needles Suture with attached needle Sterile 4 × 4 gauze pads Tape Venous cutdown tray Gloves

results of infusing blood component: fresh frozen plasma

given to build up clotting factors, albumin, and immune-globulins

results of infusing blood component: RBC's

given to build up red blood cell count for improved oxygenation and treatment of anemia.

results of infusing blood component: platelets

given to improve coagulation and prevent bleeding

12-lead electrocardiogram (ECG) recording

made from electrical activity in the heart muscle. The electrical activity is shown as deflections representing changes in the voltage and polarity magnitude over time and the electrical conduction pathway. The deflections are named the P wave, QRS complex, and T wave (sometimes a U wave, too).

he only IV solution that is appropriate to use when administering blood is

normal Saline

junctional dysrhythmia

occurs when there is a problem associated with the AV node as indicated by a change in the PR interval

normal ABG values

pH 7.35-7.45 PCO2 35-45 mmHg HCO3- 22-28 mEq

Compression stockings purpose

prescribed as a means of preventing deep venous thrombosis (DVT)-blood clots in the legs. Clots from DVT may travel to the lungs, producing a potentially fatal condition called pulmonary embolism (PE).

concepts related to perfusion: intracranial regulation

relationship to perfusion: Blood flow volume to brain can change intracranial pressure (ICP). nursing implications: Monitor vital signs, pupils, sensorium, and assess for motor or sensory neuro deficits

concepts related to perfusion: fluids and electrolytes

relationship to perfusion: Excess extracellular fluid volume causes lung congestion and impaired gas exchange. Nursing implications: Monitor fluid intake and output, vital signs, and oxygen saturation Implement oxygen therapy as ordered Administer medications as ordered

concepts related to perfusion: cognition

relationship to perfusion: Thought processing or mental status is affected if blood volume is decreased. nursing implications: Monitor oxygen saturation, vital signs, and orientation status Rule out physical reasons cognition may change

concepts related to perfusion: comfort

relationship to perfusion: Tissues not adequately oxygenated manifest pain. nursing implications: Monitor pain and for signs of local and systemic hypoxia Implement oxygen therapy as ordered Monitor oxygen saturations and vital signs

concepts related to perfusion: tissue integrity

relationship to perfusion: Wound healing delayed without adequate perfusion to tissue. nursing implications: Oxygen is needed for cell metabolism; hyperbaric oxygen therapy can be effective

atrial dysrhythmia

results from a disturbance with the sinoatrial (SA) node or atria indicated by an abnormality in the P-wave configuration.

ventricular dysrhythmia

results from a problem with the ventricle and is indicated by an abnormality in the configuration of the QRS complex the most life threatening because it compromises cardiac output

tissue perfusion

the movement of solutes such as oxygen, nutrients, and electrolytes in the blood through the vascular system to capillary networks

expected outcome for Arterial Line Care: Arterial blood pressure monitoring system functions reliably and accurately. unexpected outcome? interventions?

unexpected outcome Arterial waveform loses definition and digital pressures drop interventions -Reverse response with atropine administration. -Use low-compliance (rigid), short (less than [<] 90-120 cm [< 3-4 ft]) monitor tubing. -Check for thrombus formation by aspirating blood through stopcock and then flushing system. -Be sure to fast-flush arterial line thoroughly after arterial blood samples are obtained or system is zeroed. -Make sure all stopcocks are closed to air. -Maintain 300 mmHg of pressure in pressure bag. -Ensure secure fit of all stopcocks and connections. Avoid adding stopcocks and line extensions. -Change position of extremity in which catheter is placed. unexpected outcome Direct blood pressure readings vary significantly interventions -Flick tubing system to remove tiny air bubbles escaping the flush solution. -Recheck transducer and patient position to ensure accurate data. -Recalibrate transducer. -Flush system after sampling and zeroing. -Keep flush bag adequately filled and cleared of air. -Maintain bag external pressure at 300 mmHg. -Check that connections are tightly secured. unexpected outcome Patient has decreased urinary output or develops signs of radial artery occlusion. interventions -Suspect balloon migration. -Maintain head-of-bed elevation at less than 45 degrees to prevent kinking and migration of catheter. -Immobilize cannulated extremity to prevent catheter migration.

expected outcome for Electrical Conduction in the Heart: Peripheral perfusion distal to arterial catheter placement site remains adequate. unexpected outcome? interventions?

unexpected outcome Cannulated extremity develops diminished distal perfusion. interventions -Check periphery for changes in color, temperature, motion, and sensation resulting from possible thrombus occlusion or circulatory "steal." -Notify healthcare provider immediately. -Prepare for catheter removal.

expected outcome for Electrical Conduction in the Heart: Abnormal ECG findings interpreted accurately. unexpected outcome? interventions?

unexpected outcome ECG pattern is abnormal. interventions -If patient is asymptomatic, recheck lead placement and ensure cables are attached properly. -Check if pattern is a life-threatening arrhythmia (for ventricular tachycardia, call rapid response team; for ventricular fibrillation, call code). -Increasing PVCs-notify rapid response team. Notify healthcare provider immediately. unexpected outcome Asystole displays on monitor. interventions -Check patient's LOC, pulse, and electrodes, wires, and cable connection. -If the patient has an arterial line, check for an arterial waveform in the absence of an ECG waveform.

expected outcome for Electrical Conduction in the Heart: Monitor waveforms are distinct and readable. unexpected outcome? interventions?

unexpected outcome Electrocardiogram (ECG) is not clearly displayed on monitor. interventions -Ensure that electrodes are applied in correct position and are securely attached. -Observe for electrical interference resulting in a 60-cycle interference on oscilloscope. -Observe for excessive patient activity resulting in artifact display on oscilloscope. unexpected outcome Electrical interference appears on monitor. interventions -Check all other electric equipment in the immediate environment. -Check for proper grounding of monitor. -Change electrodes and cable; poor conduction may cause 60-cycle interference. -Check that monitor is calibrated. unexpected outcome Telemetry signal not picked up at base station. interventions -Check that patient hasn't wandered to an area where transmission is not available. -Check that transmitter battery is functioning. -Check that transmitter is ON. -Change wires. -Usual cause is a dry electrode. Replace electrodes.

expected outcome for Electrical Conduction in the Heart: ECG leads applied appropriately and without difficulty unexpected outcome? interventions?

unexpected outcome Electrodes do not adhere to skin, and interference appears on oscilloscope. interventions -Change placement of electrodes to another area. Clip hair if needed to improve skin contact. -Reclean skin thoroughly using skin prep or alcohol and allow to air dry.

expected outcome for maintaining blood volume: Pressure dressing is applied, and bleeding is controlled. unexpected outcome? interventions?

unexpected outcome Even with direct pressure and application of pressure dressing, bleeding continues. intervention -Reinforce pressure dressing. -Maintain IV infusion. -Notify healthcare provider, and be prepared to send patient to surgery for wound closure. -Monitor closely for signs of shock (level of consciousness [LOC], vital signs, oliguria or anuria, tachycardia, narrow pulse pressure, hypotension). -Apply pressure directly or proximal to wound. -Place tourniquets proximal to site of hemorrhage to control bleeding if all other actions are unsuccessful.

expected outcome for Antiembolism Devices: Compression stockings remain wrinkle free and pressure is evenly distributed. unexpected outcome? interventions?

unexpected outcome Graduated compression stockings are loose and do not provide support. interventions -Remeasure legs and compare to chart to determine correct size. -Hosiery may be old with no elasticity and should be discarded; ensure line drying rather than with electric dryer. -Need to order different knit design and elastomeric yarn denier that will increase pressure.

expected outcome for Arterial Line Care: Arterial cannulation is accomplished without complication. unexpected outcome? interventions?

unexpected outcome Hematoma or bleeding occurs at arterial insertion site. intervention -Apply direct pressure over artery while you check for leaks in the system. -Check all stopcocks: check if catheter is inserted in artery as it should be. -Keep cannulated extremity exposed for observation. -Remove catheter if oozing continues. unexpected outcome Signs of infection or inflammation appear at insertion site. intervention -Use sterile transparent dressings exclusively. -Always use aseptic technique with dressing changes; change dressing weekly. -Cap open port on stopcock to maintain asepsis. -Do not apply ointment to insertion site. -Change tubing, flush solution, and transducer every 96 hr or with catheter change using sterile technique. -Flush open port after obtaining blood specimens. -Prepare for catheter removal if infection is suspected.

expected outcome for Electrical Conduction in the Heart: Pacemaker is inserted without complications. unexpected outcome? interventions?

unexpected outcome Inflammation occurs at insertion site. interventions -Provide daily care using strict aseptic technique. -Keep dressing dry at all times. -Monitor vital signs. -Instruct patient to limit movement of extremities.

expected outcome for Electrical Conduction in the Heart:Patient is prepared psychologically and physically for insertion of the pacemaker. unexpected outcome? interventions?

unexpected outcome Patient does not understand function of pacemaker. interventions -If frightened, reassure the patient that a pacemaker is not dangerous. -If patient does not understand pacemaker or procedure, use illustrated learning aids. -Allow time for questions and further explanations. -Orient your teaching to the patient's intellectual and interest level.

expected outcome for Electrical Conduction in the Heart: Patient's cardiac rate is maintained through use of a pacemaker. unexpected outcome? interventions?

unexpected outcome Temporary pacing is ineffective. interventions -Check for battery depletion and change if necessary (9-volt batteries). -Record rhythm strip and correlate to patient's signs and symptoms. -Monitor vital signs, mental status. -Check sensitivity setting. (If too high, P or T wave may be sensed; if too low, fixed-rate pacing occurs.) -Check milliampere setting (may be too high). -Check pace indicator for movement. -Check rate setting. -Check all connections. -Check catheter insertion site for swelling, hematoma. unexpected outcome Failure to capture is suspected. interventions -Check patient's heart rate. If heart rate is less than the rate set on the generator, and if pace indicator shows firing, suspect failure to capture. -Check all connections. -Anticipate that pacer wires are dislodged. -Check battery. -Change position of extremity. -Turn patient on left side; catheter may float back to epicardial wall. -Increase amperage (mA) after checking threshold. -Obtain chest x-ray and 12-lead ECG. -Anticipate change of batteries, electrode terminals, or generator. unexpected outcome Battery depletion occurs. interventions -Have atropine and isoproterenol available. -Anticipate possible CPR. -Turn on power switch, and observe pace indicator. If there is little or no movement, replace battery immediately. -Record clock hours of battery usage. (Record should be taped to back of generator.) -Determine rate fluctuations. -Label each pacemaker with the date battery is inserted. -Store extra batteries in refrigerator and put new battery in pacemaker before use. -Disconnect catheter from pacemaker before replacing battery. Contact with battery terminal may be dangerous to the patient.

expected outcome for maintaining blood volume:Transfusion reaction does not occur. unexpected outcome? interventions?

unexpected outcome Transfusion reaction occurs. interventions -Stop blood administration and with new IV tubing, begin infusion of normal saline to keep vein open. -Check transfusion reaction form for appropriate nursing intervention. -Complete all relevant nursing actions. unexpected outcome Blood does not flow through tubing. interventions -Check patient's IV site and gauge of catheter (at least 18 or 20 gauge). -Gently agitate blood bag to mix blood cells with the anticoagulant. -Raise blood bag higher on IV pole. Squeeze flexible tubing to promote blood flow. -Adjust clamp on tubing. As the blood passes over the filter, more blood microaggregates clog the filter and slow drip rate. -Replace tubing. -Utilize an infusion pump, especially if administering blood through a small catheter. unexpected outcome Potential circulatory overload occurs. interventions -Monitor symptoms: sudden dyspnea, tachypnea, tachycardia, chest discomfort, distended neck veins, moist crackles and rales, restlessness, sudden increase in blood pressure. -Stop transfusion and place patient in Fowler position. -Start oxygen at 2 L/min per nasal cannula.

expected outcome for Antiembolism Devices: Peripheral pulses are present during use of sequential stockings and elastic hosiery. unexpected outcome? interventions?

unexpected outcome While compression device is being used, patient complains of numbness or tingling in leg. interventions -Remove devices immediately. -Suggest use of foot pulse device as alternate. -Complete neurovascular assessment. -Notify healthcare provider of assessment findings.

expected outcome for Arterial Line Care: Arterial blood samples are obtained. unexpected outcome? interventions?

unexpected outcomes Arterial blood sample is unobtainable. interventions -Suspect arterial spasm; allow spasm of artery to stop, then attempt to aspirate blood with gentle pressure using a 6-mL syringe rather than Vacutainer. -Reposition patient's arm, making sure there is no pressure at catheter insertion site. -Check that catheter is in artery (note waveform on oscilloscope), flush catheter, then attempt to obtain sample.