Chapter 22 Management of Patients With Arrhythmias and Conduction Problems - Tagged.pdf

Management of Patients With Arrhythmias and Conduction Problems nursing cardiology

1. Chapter 22
Management of Patients
with Arrhythmias and
Conduction Problems

2. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Arrhythmias #1
Disorders of formation or conduction (or both) of
electrical impulses within heart
Can cause disturbances of
oRate
oRhythm
oBoth rate and rhythm
Potentially can alter blood flow and cause
hemodynamic changes
Diagnosed by analysis of electrographic
waveform

3. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Arrhythmias #2
Atrial
oPremature atrial complex
oAtrial flutter
oAtrial fibrillation
Ventricular
oPremature ventricular complex
oVentricular tachycardia
oVentricular fibrillation
oVentricular asystole

4. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Normal Electrical Conduction
SA node (sinus node)
AV node
Conduction
Bundle of His
Right and left bundle branches
Purkinje fibers
Depolarization = stimulation = systole
Repolarization = relaxation = diastole

5. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Conduction Abnormalities
First-degree AV block
Second-degree AV block, type I (Wenckebach)
Second-degree AV block, type II
Third-degree AV block

6. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Relationship of ECG Complex,
Lead System, and Electrical Impulse

7. Copyright © 2022 Wolters Kluwer · All Rights Reserved
ECG Electrode Placement

8. Copyright © 2022 Wolters Kluwer · All Rights Reserved
The Electrocardiogram (ECG)
Electrode placement
oElectrode adhesion
Types of ECG
ECG interpretation
oP wave
oQRS complex
oT wave
oU wave
oPR interval
oST segment
oQT interval
oTP interval
oPP interval

9. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Analyzing the ECG Rhythm Strip
Normal sinus rhythm
Sinus node arrhythmias
oSinus bradycardia
oSinus tachycardia

10. Copyright © 2022 Wolters Kluwer · All Rights Reserved
ECG Graph and Commonly Measured
Components

11. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Normal Sinus Rhythm

12. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Sinus Bradycardia

13. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Sinus Tachycardia

14. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Sinus Arrhythmia

15. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #1
The nurse is preparing a male patient to have a 12-
lead ECG performed. When prepping the skin the
nurse notices that the patient has abundant chest
hair. What is the most appropriate nursing
intervention to improve adhesion of the ECG leads?
A.Use alcohol swabs to clean the skin before applying
the leads
B.Clip the chest hair with the patient’s permission
before applying the leads
C.Apply the leads to the arms and legs only
D.Reschedule the ECG

16. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #1
B. Clip the chest hair with the patient’s permission
before applying the leads
Rationale: Clipping the patient’s hair would provide
access to the skin to assist with adhesion. Alcohol
should not be used to prep the skin because it
increases the skin’s electrical impedance, thereby
hindering the detection of the cardiac electrical signal.
The ECG would not be performed correctly if the leads
were only placed on the extremities, and there is no
need to reschedule the ECG at this time

17. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Assessment of the Patient with an
Arrhythmia #1
Causes of arrhythmia, contributing factors, the
arrhythmia’s effect on the heart’s ability to pump
an adequate blood volume
Assess indicators of cardiac output and
oxygenation
Health history: previous occurrences of
decreased cardiac output, possible causes of the
arrhythmia
All medications (prescribed and over-the-
counter)
Psychosocial assessment: patient’s “perception”
of arrhythmia

18. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Assessment of the Patient with an
Arrhythmia #2
Physical assessment include
oSkin (pale and cool)
oSigns of fluid retention (JVD, lung auscultation)
oRate, rhythm of apical, peripheral pulses
oHeart sounds
oBlood pressure, pulse pressure

19. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collaborative Problems and Potential
Complications
Cardiac arrest
Heart failure
Thromboembolic event, especially with
atrial fibrillation

20. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Planning and Goals for the Patient with an
Arrhythmia
Goals
oEradicating or decreasing occurrence of
arrhythmia to maintain cardiac output
oMinimizing anxiety
oAcquiring knowledge about arrhythmia and
its treatment

21. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Nursing Interventions for the Patient with
an Arrhythmia
Monitor and manage the arrhythmia
Reduce anxiety
Promote home- and community-based care
Educate the patient about self-care
Continuing care

22. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Nursing Intervention: Monitor and
Manage the Arrhythmia
Assess vital signs on an ongoing basis
Assess for lightheadedness, dizziness, fainting
If hospitalized
oObtain 12-lead ECG
oContinuous monitoring
oMonitor rhythm strips periodically
Antiarrhythmic medications
o“6-minute walk test”

23. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Nursing Intervention: Minimize Anxiety
Stay with patient
Maintain safety and security
Discuss emotional response to arrhythmia
Help patient develop a system to identify factors
that contribute to episodes of the arrhythmia
Maximize the patient’s control

24. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Nursing Intervention: Promote Home and
Community-Based Care
Educate the patient
oTreatment options
oTherapeutic medication levels
oHow to take pulse before medication
administration
oHow to recognize symptoms of the arrhythmia
oMeasures to decrease recurrence
oPlan of action in case of an emergency
oCPR (family)

25. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Nursing Intervention: Continuing Care
Referral for home care
oHemodynamically unstable with signs of
decreased CO
oSignificant comorbidities
oSocioeconomic issues
oLimited self-management skills
oElectronic device recently implanted

26. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Evaluation of the Patient with an
Arrhythmia
Maintain cardiac output
oStable VS, no signs of arrhythmia
Experience reduced anxiety
oPositive attitude, confidence in ability to act if an
emergency occurs
Express understanding of arrhythmia and treatment

27. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #2
The nurse is assessing a patient admitted with a heart
block. When placed on a monitor, the patient’s
electrical rhythm displays as progressively longer PR
durations until there is a nonconducted P wave. Which
type of heart block does the nurse expect that this
patient has?
A.First-degree
B.Second-degree, type 1
C.Second-degree, type 2
D.Third-degree

28. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #2
B. Second-degree, type 1
Rationale: In second-degree, type 1 AV block, the PR
interval becomes longer with each succeeding ECG
complex until there is a P wave not followed by a QRS.
The changes in the PR interval are repeated between
each “dropped” QRS, creating a pattern in the
irregular PR interval measurements. In first-degree
heart block, the PR is constant but greater than 0.20
seconds. Second-degree AV block, type 2 has a
constant PR interval and the presence of more P
waves than QRS complexes. Third-degree AV block
presents with irregular PR intervals.

29. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Adjunctive Modalities and Management
Used when medications alone are ineffective against
arrhythmias
Pacemakers
Cardioversion
Defibrillation
Nurse responsible for assessment of the patient’s
understanding regarding the mechanical therapy

30. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Pacemakers
Electronic device that provides electrical stimuli to
heart muscle
Types
oPermanent
oTemporary
Pacemaker generator functions
oNASPE-BPEG code for pacemaker function

31. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Implanted Transvenous Pacemaker

32. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Complications of Pacemaker Use
Infection
Bleeding or hematoma formation
Dislocation of lead
Skeletal muscle or phrenic nerve stimulation
Cardiac tamponade
Pacemaker malfunction

33. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Cardioversion and Defibrillation
Treat tachyarrhythmias by delivering electrical
current that depolarizes critical mass of myocardial
cells
oWhen cells repolarize, sinus node is usually able
to recapture role as heart pacemaker
In cardioversion, current delivery is synchronized
with patient’s ECG
In defibrillation, current delivery is unsynchronized

34. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Paddle Placement for Defibrillation

35. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Safety Measures for Defibrillation
Ensure good contact between skin, pads, and paddles
oUse conductive medium, 20 to 25 pounds of pressure
Place paddles so they do not touch bedding or clothing and are
not near medication patches or oxygen flow
If cardioverting, turn synchronizer on
If defibrillating, turn synchronizer off
Do not charge device until ready to shock
Call “clear” three times; follow checks required for clear
oEnsure no one is in contact with patient, bed, or
equipment

36. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Implantable Cardioverter Defibrillator
(ICD) #1
Device that detects and terminates life-threatening
episodes of tachycardia and fibrillation
NASPE-BPEG code
Antitachycardia pacing

37. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Implantable Cardioverter Defibrillator
(ICD) #2

38. Copyright © 2022 Wolters Kluwer · All Rights Reserved
Nursing Management of the Patient with a
Permanent Electronic Device
ECG assessment
CXR
Nursing assessment
oCO and hemodynamic stability
oIncision site
oSigns of ineffective coping
oLevel of knowledge and education needs of
family and patient