Cardiovascular Therapeutic Management

Question 1

The ECG strip has a grid in the background.
Each little box is .04 sec.
Each large box is .20 sec - One box = 0.2 = normal PR interval
30 large boxes = 1 minute
1500 small boxes = 1 minute
Left to right is time - more beats on strip with HR faster
Sweep speed - speed up to see what going on in PR to spread it out; afib, PSVT, wolf-Parkinson’s
Up and down is the amplitude - lumps and bumps made by electrical current of heart; can change based on conditions; larger LV - bigger QRS

Answer 1

The basics

Question 2

Heart Rate Determination
Rhythm Determination
P Wave Evaluation
PR Interval Evaluation
QRS Complex Evaluation

Answer 2

5 step approproach

Question 3

Irregular rhythms: the number of QRS complexes in 6 seconds
Regular rhythms: 1500 method - Count the number of small boxes between two p waves or QRS waves then divide by 1500. 1500/20 small boxes = 75 bpm
Atrial rate:
Ventricular rate
The first thing to assess when evaluating a rhythm strip is the ventricular rate. Regardless of the dysrhythmia involved, the ventricular rate and blood pressure are key to whether the a patient can tolerate the dysrhythmia (i.e., maintain CO and mentation). Once the patient can no longer tolerate the dysrhythmia, often a ventricular rate greater than 200 or less than 30, emergency measures must be started to correct the condition. A detailed analysis of the underlying rhythm disturbance can proceed later, once the patient’s clinical condition has stabilized.
The three methods for calculating rate (Fig. 13.53A) are as follows:
1. Number of R-R intervals in 6 seconds times 10 (ECG paper is usually marked at the top in 3-second increments, making a 6-second interval easy to identify).
2. Number of large boxes between QRS complexes divided into 300
3. Number of small boxes between QRS complexes divided into 1500

Answer 3

Heart Rate Determination

Question 4

Regular or regularly irregular or regularly irregular
The term rhythm refers to the regularity with which the P waves or R waves occur. Calipers assist in determining rhythm. One point of the calipers is placed on the beginning of one R wave, and the other point is placed on the next R wave. Leaving the calipers “set” at this interval, each succeeding R-R interval is checked to be sure it is the same width as the first one measured.
In describing the rhythm, three terms are used. If the rhythm is regular, the R-R intervals are the same, within 10%. If the rhythm is regularly irregular, the R-R intervals are not the same, but some sort of pattern is involved, which could be grouping, rhythmic speeding up and slowing down, or any other consistent pattern. If the rhythm is irregularly irregular, the R-R intervals are not the same, and no pattern can be found.

Answer 4

Rhythm Determination

Question 5

Are there P waves?
Do all P waves look alike?
Is there a P wave for every QRS?
The P wave is analyzed by considering whether the P wave is present or absent. If present, is each P wave associated with a QRS complex? It is expected that one P wave will be in front of every QRS. Sometimes, two, three, or four P waves may be in front of every QRS complex. If this pattern is consistent, the P waves and QRS are still associated, although not on a 1:1 basis.

Answer 5

P Wave Evaluation

Question 6

Are all PR intervals the same?
The duration of the PR interval, which normally is 0.12 to 0.20 second (120 to 200 ms), is measured first. This is measured from the start of a visible P wave to the beginning of the next QRS complex (Fig. 13.55). All PR intervals on the strip are verified to be sure they have the same duration as the original interval.

Answer 6

PR Interval Evaluation

Question 7

Are there QRS complexes?
QRS complexes consistent: same shape and width
QRS interval:
Is there a QRS for every P wave?
The entire ECG strip must be evaluated to ascertain that the QRS complexes are consistently the same shape and width. The normal QRS complex duration is 0.06 to 0.10 second (60 to 110 ms). Any QRS longer than 0.10 second is considered abnormal. If more than one QRS shape is visible on the strip, each QRS complex must be measured. The QRS complex is measured from where it leaves the baseline to where it returns to the baseline

Answer 7

QRS Complex Evaluation

Question 8

No P wave - Hidden in QRS complex
Priority:
assess the patient: pulse or not
Pt is pulseless:
ACLS - initiate CPR and follow code
Pt is unstable but awake
Unstable sx: chest pain, SOB, pale because not perfusing not well and clamped down to compensate to get BP up, dizziness, syncope eventually
Synchronized cardioversion
Pt is stable
Feel butterfly/flutter
Elective synchronized cardioversion
Unresponsive and pulseless
Code and defibrillation
Medications
Stable: amiodarone (antiarrythmic), lidocaine (acts faster; old school - acts faster and wears off faster)
Pulseless: epinephrine - anything pulseless gets this drug

Answer 8

Vtach

Question 9

First third and fifth beat abnormal
First beat - P wave
Interval within normal limits
Followed by QRS and that is within normal limits and followed by T wave
Initiated in the ventricle - big, fat and ugly; not following highway of the conduction system - takes more time left to right
Some going backwards - positive and negative inflection - currents going towards and away positive lead
Bigemeny - every other beat; more symptomatic - every time have PVC - comes early - ventricle not have time to fill completely; contracting early, preload/amount of blood is less - affects CO - lower CO, lower BP and be symptomatic
After 4 beats = quadrigeminy
SX: lightheaded, dizzy
PR within normal limits, QRS and T after it; 1 P for 1 QRS for 1 T
Last beat comes early
Causes: drugs, caffeine, potassium, magnesium, ischemic heart/heart attack - LV not like be deprived O2 and when happens acts up throws early beats and then goes into vtach, hypoxemia - low O2 in blood - not getting O2 to heart - not from cardiac but more general cause - cannot tolerate weaning, acidosis, cardiomyopathy - LV big - lot muscle go through and competing electrical currents
Electrolyte replacement order: potassium, magnesium, phosphates

Answer 9

PVC - premature ventricular contractions

Question 10

Are P waves, are QRS, are T waves
Not 1 to 1 to 1 - now block
Too many P waves - go to blocks
All P waves look the same - atria contracting
Faster - atria
Blocks - determine communication - atria and ventricle - conduction sys between atria and ventricle
Regular QRS rhythm
Regular P rhythm
Divorced couple - not communicating
Complete heart block - regular - a and v regular - own rate; 3rd degree AV block
Each beating independently of each other
Need do: pacemaker - not last long; eventually goes to asystole - does not work with atropine - must do pacemaker

Answer 10

Complete heart block/3rd degree heart block

Question 11

No P waves
Atria quivering and collecting a clot at the bottom
Pt Not know when start; Just started feeling funny - do not shock to get back to NSR - throw clot
Have know when start - gen 2 hours; now admitted on anticoag (3-5 weeks) then elective cardioversion - on unit and witnessed then go to electroconversion if symptomatic
Asymptomatic - start with antiarrhythmics
Symptomatic and know when started - unscheduled elective cardioversion
Symptomatic and not know - slow rate and not convert
Really symptomatic may do transesophageal cardiogram and not know when started really look in atria to see if clot and convert if nothing
Try to get out rhythm - controlled with antiarrhythmic meds and meds to control rate so not go to rapid response because had it for rapid response

Answer 11

Afib

Question 12

Dissect if same PR interval - yes
1:1 ratio
Always Document with underlying rhythm
Looks exactly like NSR with long PR
Benign rhythm
Too long PR
PR >0.20 - 1 big box
a sinus based rhythm with a consistent, long PR interval
Do nothing with it
Let ride it out; benign

Answer 12

First degree atrioventricular (AV) block

Question 13

The PR gets longer with each beat until a QRS is dropped
Extra P waves
Not 1 to 1 to 1 ratio
Too many P waves - in either 2nd or 3rd degree block
Now dissect it - PR intervals not same
Each PRs = each gets longer until P wave with no QRS after it then start over
Generally see pattern
Too many P waves = AV block
Longer longer drop
Treatment: watch them
Dropping lot beats - less ventricular beats - more symptomatic - more aggressive - gen let it go
Stable for very long time - leave alone; watch; dropping lot - less ventricular beats - more sx and more aggressive
Can give type medication: but usually leave alone
Depends on Ventricular rate - not pacemaker immediately
Not make worse

Answer 13

Second degree type I AV block

Question 14

Mobitz
Ratio not 1:1:1
Too many P waves = AV blocks
PR interval is consistent that has P followed by an R
Always be a dropped ventricular beat
Looks like NSR with P hanging out
Bundle: 2 goes to LV and 1 to RV - once impulse to AV junction impulse stops so ventricle not contract
Various patterns
Treat: third degree waiting to happen; pacemaker
Temp in then permanent if needed
Normal CO with normal beats with QRS
The PR is the same for all complexes with a QRS. There is a p wave with no QRS after it.
Lot dropped beats; will be symptomatic

Answer 14

Second degree type II AV block

Question 15

The atria (p waves) have a higher rate than the ventricles (QRS). Both are regular but are independent of each other.
Not 1:1:1 ratio
Too many p waves
Not definite PR / no pattern - no consistent PR
P wave is regular rhythm
Ventricular rate slower - not as many QRS on strip
Regular beat - QRS and P waves regular - have Own rate
SA node beating on own rate; ventricle not on same condition so is own - own focus somewhere in ventricle - slower rate; own pacemaker site initially
Atria- SA node
Ventricle - usually below bundle of His
No atropine
Tx: Pacemaker ASAP

Answer 15

Third degree AV block

Question 16

An electronic device that is used to initiate the heartbeat with the intrinsic electrical system of the heart cannot generate a rater adequate to support cardiac output
For electrical probs; not coronary artery probs; fixes electrical component - point to where conduction and Purkinje level not work to where pacemaker not make it beat; pacemaker not guaranteed rhythm once get sick enough

Answer 16

Pacemakers

Question 17

Temporary Pacemaker: Used supportively or prophylactically, until the condition responsible for the rate or conduction disturbance resolves - typ transvenous - distal tip; can do it until drugs wear off - do until drugs wear off; done lot in night; typically transvenous with distal tip in RV - touching the septum - generating electrical pacing; can put in until drugs wear off or in night
Permanent Pacemaker: Used for persistent rate or conduction disturbance despite adequate interventions; device inserted under skin; wire in same spot
Defib them - pace them transdermal; another way to temporarily pace them; pretty brutal

Answer 17

For electrical probs; not coronary artery probs; fixes electrical component - point to where conduction and Purkinje level not work to where pacemaker not make it beat; pacemaker not guaranteed rhythm once get sick enough

Question 18

Delivers a pacing stimulus at a set (fixed) rate regardless of the occurrence of spontaneous myocardial depolarization; occurs in nonsensing modes
Getting x many microshocks to get set bpm
Not care about underlying rhythm
Ventricles

Answer 18

Fixed-Rate (Asynchronous)

Question 19

Pacemaker able to sense underlying rhythm; pts HR higher than set, not do anything; underlying HR lower, fill in gaps to set it up; not be regular; goes by milliseconds; how many milliseconds come by and what = to x beats/min; not determine QRS; says should be beat here and if beat, timer resets and if no beat, will beat
Delivers a pacing stimulus only when the heart’s intrinsic pacemaker fails to function at a predetermined rate; the pacing stimulus is either inhibited or triggered by the sensing of intrinsic activity
Atrial

Answer 19

Demand (Synchronous)

Question 20

Most now today
Means Lead in atria and ventricle - both pacing
Have Shock in atria and ventricle making each pump
Have AV synchrony optimizing CO
Delivers a pacing stimulus to the atrium and ventricle in physiologic sequence with sufficient atrioventricular delay to permit adequate ventricular filling

Answer 20

Atrioventricular Sequential (Dual-Chamber)

Question 21

The capacity of the pacemaker to sense the heart’s electrical activity
Pacemaker sensing or seeing underlying rhythm

Answer 21

Sensing

Question 22

When the pacemaker provides electrical stimulation to the myocardium
Is the pacemaker generating/delivering microshock/micro amp to myocardium

Answer 22

Firing

Question 23

The ability of the pacemaker to effectively stimulate the atria and/or ventricle to beat
Is that little microshock make chamber contract

Answer 23

Capture

Question 24

Electrical stimulus (mA) necessary to elicit a myocardial depolarization

Answer 24

Threshold

Question 25

Generates the electrical current that travels through the pacing leads and exits through an electrode that is in direct contact with the heart.
Lump under skin
Brains and batter
Replace pacemaker: replace generator - not pulling leads - huge time consuming and dangerous procedure - really long and in venous system tend to get scarred over - not just pulling them out
Can take hours to get rid of it
Subclavian to SVC
Generator replaced wires not unless infected

Answer 25

Pulse Generator

Question 26

Put in for slow rhythms
Know going to be short-term: going to place this and let ride out
Rate contributes to CO
Once rate up to normal rate/NSR rate - then pt comes less symptomatic
Dysrhythmias that are unresponsive to medication. Used until the condition responsible for conduction disturbance resolves.
Bradydysrhythmias
Tachydysrhythmias (Overdrive pacing)
Permanent pacemaker failure
Support of cardiac output after cardiac surgery

Answer 26

Temporary pacemaker indications

Question 27

Increase the ventricular rate and enhance cardiac output
Used in the treatment of symptomatic bradycardia or progressive heart block secondary to MI, medication overdose, or illegal drug toxicity.
HR too low - not perfusing end organs: sx: syncopal or dizzy - not have underlying: passed out or found unresponsive - not know about rhythm; pacemaker brings back to normal rhythm

Answer 27

Bradydysrhythmias

Question 28

For people with PSVTs
See for afib with rapid vent rate - compete with ectopic focus - too many little spots in atria initiating with impulse - compete with it until win race then takes over and slows it down

Answer 28

Tachydysrhythmias (Overdrive pacing)

Question 29

Batteries run out - syncopal and pacemaker placed years ago
Run out based on amount pacing
Temp until can replace it since fully reliant

Answer 29

Permanent pacemaker failure

Question 30

Usually wires coming out of substernal - wrapped with gauze so no microshocks
Conduction disturbances after valve surgery
Improve a transiently depressed, rate-dependent cardiac output.

Answer 30

Support of cardiac output after cardiac surgery

Question 31

A pacemaker system is a simple electrical circuit consisting of a pulse generator and a pacing lead (an insulated electrical wire) with one, two, or three electrodes
Pacing Leads & Routes

Answer 31

Temporary pacemakers

Question 32

Transcutaneous: Emergency pacing is achieved by depolarizing the heart through the chest by means of two large skin electrodes; same pads use in codes; go to pacemaker set-up
Transvenous: The pacing electrode is advanced through the femoral, intrajugular, or subclavian vein into the right atrium and/or right ventricle; use same veins as would for central line
Epicardial: Used after cardiac open heart surgery - Pacing electrodes are sewn to the epicardium during cardiac surgery; after open heart surgeries - wires poked into LV and wires on outside; when HR and rhythm stable - pull them out - attached to temp pacemaker box

Answer 32

Pacing Leads & Routes

Question 33

Temporary transvenous pacemakers are most commonly inserted in the internal jugular or femoral vein.
Jugular, subclavian, femoral vein used
Diff brands have diff look
Newer one
Gen: sheath introduced into vein - green in body and distal tip in heart
Screwed into it (like closed suctioning) & secured down - no way suture it because inside suture - distal tip not sutured in - in RV towards septum and in trebecula and in pits - gravity keeps there - moving around - stop touching heart
Keep sleeve sterile but if way out - will need a new product - May need stiff wire if cannot stay still
Chart where it is at the hub - fat lines: 50cm; thin: 10cm; imp measure where at at the hub
Dual chamber = 2 wires
Box = control rate and NA (right atrium node); can turn rate all the way down to look at underlying rhythm
Treated like central line: sterility; dressing over insertion site; catheter into central vein

Answer 33

Transvenous temporary pacemaker

Question 34

When have pacemaker - list everything out; Tell which chamber paced, sense, shocked; what will it do - inhibit the shock/not
Now sixth code for special functions

Answer 34

Five-letter pacemaker codes

Question 35

Rate control
Output
Right spot: CXR - if playing with it or manipulating with it can pull it
Sensitivity control

Answer 35

Pacemaker settings

Question 36

Number of impulses that can be delivered to the heart per minute.
Usually 60 and 80 beats/min
No magic number - somewher in NSR number - put generally at 80; some at 70 - depending on metabolic demand of elevated heart rate and keep it there; when looking at underlying rhythm turn off; temp pacemaker - chart capturing, settings are, sensing, and underlying rhythm to justify use

Answer 36

Rate control

Question 37

Regulates the amount of electrical current in mA that is delivered to the myocardium (atrial and/or rt. ventricle) to initiate depolarization
MA/current shocking them with - milliamps; may decrease capturing - determine if in right spot or if have scar tissue forming and need increase MA to get same response
People who have pacemakers longterm/short-term - scar tissue forms around distal tip and takes more electrical current to get response
Do have locks so not confuse with remote control

Answer 37

Output

Question 38

Ability to see underlying rhythm
See if sensitive enough for threshold - seeing underlying rhythm: seeing too much: counting P as QRS; or not counting QRS; counting tall wall if electrolyte imbalance with QRS
Regulates the ability of the pacemaker to detect the heart’s intrinsic electrical activity.
Measured in mV

Answer 38

Sensitivity control

Question 39

Lumps and bumps of ECG
Pacemaker fires electrical impulse - ECG reads electrical impulse in the heart
Since electrical impulse from a machine - usually a linear line before chamber pacing - normal rhythms not have straight up and down line because moving in time
Most pacemakers smaller but temporary big
The pacemaker firing is seen on the ECG tracing as “spikes” before the atria and/or ventricle. The size of the spike and whether you can see them at all is determined by the type of pacemaker.
The pacemaker fires directly into the myocardium
The cell-to-cell depolarization is slower resulting in paced beats are wide waveforms on the ECG

Answer 39

Pacemaker artifact

Question 40

It does not take advantage of the heart’s normal conduction system.
The electrical impulse must travel from cell to cell to depolarize the myocardium.

Answer 40

The pacemaker fires directly into the myocardium

Question 41

If the pacemaker spike/artifact precedes a p wave – it is an atrial paced pacemaker
If the pacemaker spike/artifact precedes a QRS complex – it is a ventricular paced pacemaker
If the pacemaker spike precedes the p-wave and the QRS complex – it is an AV paced pacemaker

Answer 41

Pacemaker spikes

Question 42

Only pacing the atria
Atria = P wave
Straight vertical line before P wave

Answer 42

If the pacemaker spike/artifact precedes a p wave – it is an atrial paced pacemaker

Question 43

Ventricular paced rhythm
Not going through normal conduction pathway
Normally be wider - takes more time because inefficient conduction compared to normal
Straight line before little wider QRS = ventricular

Answer 43

If the pacemaker spike/artifact precedes a QRS complex – it is a ventricular paced pacemaker

Question 44

2 lines = AV paced
Pacing both chambers
More and more of this - maintain AV synchrony

Answer 44

If the pacemaker spike precedes the p-wave and the QRS complex – it is an AV paced pacemaker

Question 45

Pacing in the ventricles. Sensing is off. Response to sensing off
A pacemaker that paces at a programmed rate regardless of the heart’s intrinsic activity
84 beats/min = asynchronous
AKA asynchronous pacing
Perfect normal rhythm; on time - come at exact same interval; does not care about underlying rhythm
Takes over regardless what doing
Do not need all this help for every patient
Have an underlying rhythm that is appropriate
This strip has a VOO pacemaker set to pace in 60 BPM.
What potential issues are seen with this mode of pacing?
With this pacing mode - fires at the set interval - concrete thinker - paces at set pace - if paces on absolute refractory period of T wave - send into vtach/vfib - so not used that often
R on T shock - putting into tach arrhythmia

Answer 45

VOO: - Common pacing modes

Question 46

Pacing in the ventricle. Sensing in the ventricle. The response will be to pace or inhibit if intrinsic activity is sensed.
Inherit rate fine at beginning
Looking at underlying rhythm
Pacer spike here and there = synchronous
Look to see if needed and makes it happen if necessary
With every paced beat the pacemaker starts a clock. If at the end of the set time limit, the pacemaker doesn’t see any intrinsic activity, it will pace. If it senses a beat, the clock is reset.
Pacemaker capable of sensing the heart’s intrinsic activity and withholding pacing when it’s unnecessary.
Synchronous Pacing
This strip has a VVI pacemaker set at a lower rate of 60 BPM.
Spike here and there
Why are there 3 different QRS morphologies?
First two normal - NSR
Yellow - paced
PVC
Any advantages over using an asynchronous mode?
Are not taking over for whole electrical sys; electrical sys can get lazy because machine doing it all; machine letting do as much as and can to help preserve own electrical conduit sys
Letting own rhythm come through; helping out before taking over
Rarely see R on T shock

Answer 46

VVI: - Common pacing modes

Question 47

Pacing in the atria & ventricle. Sensing in the atria & ventricle. The response: Intrinsic P-waves and QRS can inhibit pacing. Intrinsic P wave or atrial pace can trigger an AV delay
Dual chamber - AV pacing
Spike here and there
Synchronous with this too
Only stepping in with synchronous pacemaker - steps in when needed; should be P wave - shock in atria in AV pacemaker; should be QRS - happens = no shock, not happen = shock; sensing and only stepping in to help when needed
Synchronous Pacing
This strip has a VVI pacemaker set at a lower rate of 60 BPM and an AV delay of 0.20 sec
Why aren’t pacer spikes before every p wave and QRS?
With every paced beat the pacemaker starts a clock. If at the end of the set time limit, the pacemaker doesn’t see any intrinsic activity, it will pace. If it senses a beat, the clock is reset.
Any advantages of this mode?
This mode can adapt to what the heart is doing. The pacemaker will mimic normal conduction as closely as possible.

Answer 47

DDD: - Common pacing modes

Question 48

Assessment and prevention of pacemaker malfunction
Protection against microshock
Infection
Patient education

Answer 48

Nursing management - prevent complications: temporary pacemaker

Question 49

Monitor them even with temp pacemaker - distal tip not secured in; can move - cannot say rhythm fixed because of this machine
Continuous ECG monitoring - distal tip not secured in so can move
Secure pacing lead and bridging cable with tape
Secure pulse generator
Have replacement battery in room - needs be there; battery not there - go back to previous rhythm that needed pacing until get new battery; changing the battery - turns it off, so do it quickly so not without pacing long

Answer 49

Assessment and prevention of pacemaker malfunction

Question 50

Pacemaker delivering a shock and have wires - need to make sure cables not exposed - end cables are just wire - cover with gauze
Wear gloves when handling pacing wires
Secure all connections between the pulse generator, pacing cable, and leads
Insulate lead tips with nonconducting materials when not attached to generator (manufacturer’s cap, finger cot, plastic syringe)
Keep dressings and pacing equipment dry and intact just like central line
Ensure all electrical equipment is properly grounded
Use battery-operated shavers to mess with it

Answer 50

Protection against microshock

Question 51

Assess for purulent drainage, erythema, and edema, and the patient is observed for signs of systemic infection
Site care per protocol

Answer 51

Infection

Question 52

Give edu on why need it
IMP
Esp not need for long
Description of pacemaker therapy
Care of pacemaker system
Minimize handling of leads or cables
Notify nurse if dressing becomes wet or loose
Activity restrictions (minimize upper extremity movement with transvenous leads)
Keep extremity straight
Electrical safety precautions (no electric razors)
Sx to report (dizziness) - may not be pacing

Answer 52

Patient education

Question 53

Something wrong with pacemaker battery or where catheter or product
Prob where pacemaker (temp or permanent) not pacing; electrical current not enough to make response need to see, goes to asynchronous mode for some reason - seen on strips
Most pacemaker malfunctions can be categorized as abnormalities of pacing or of sensing.
Problems with pacing can involve failure of the pacemaker to deliver the pacing stimulus
A pacing stimulus that fails to depolarize the heart or an incorrect number of pacing stimuli per minute.

Answer 53

Pacemaker malfunctions

Question 54

Pacemaker doing its job - giving impulse when needed; have spike and no response
Not listening to pacemaker
The pacemaker fires (+ pacer spike) but fails to initiate a myocardial depolarization (no p and/or QRS follows it).
Causes
Troubleshooting
Need ventricular contraction for CO
Nothing behind/following it

Answer 54

Failure to capture

Question 55

Displacement of the pacing electrode
Transcutaneous - put new pads - sweaty
Transvenous - IJ, vena cava - pulling that lead; put it in, pill roller - may mess and roll it; may fiddle with it
Medications: antiarrhythmics - mess with ability of heart to respond to electrical impulse from pacemaker
An increase in threshold: the result of medications, metabolic disorders, electrolyte imbalances (K and Mg), fibrosis (scar tissue) or myocardial ischemia at the site of electrode placement (Distal tip - where tip where tissue dead - not beat; dead meat don’t beat)
Hard to pace them at bundle of HIs

Answer 55

Causes - Failure to capture

Question 56

Temp - increase mA until get capture
Permanent pacemaker - call product rep to reprogram it to get mA turned up so get a response - not contribute CO because need ventricular contraction
In many cases, increasing the output (mA) elicits capture.
Transvenous leads (PCP - puts it in, intervnentional cardiologist), repositioning the patient on his or her left side may improve lead contact and restore capture - not nursing scope of practice

Answer 56

Troubleshooting - Failure to capture

Question 57

Sensing is seeing
Not seeing what underlying rhythm is
Looks like asynchronous pacing - not care not needed; cannot tell type pacemaker
Problem with the threshold - threshold is too high - not seeing underlying rhythm and thinking not there - going to beat at the prescribed rate
Going to have Pacer spikes where not need be
In inappropriate spots
The pacemaker fails to sense (see) the p-waves and/or QRS complexes
Essentially makes the pacemaker asynchronous.
Cause
Troubleshooting

Answer 57

Undersensing

Question 58

Inadequate wave amplitude (height of the P or R wave)
Inappropriate (asynchronous) mode selection - confused patients may have flipped it
Lead displacement or fracture, loose cable connections, and pulse generator failure.

Answer 58

Cause - Undersensing

Question 59

Check the cable connections - is slip tip into there - not lot holding connection into box; easily pulled out - turning someone can pull it out and even pull out just little bit can affect its functioning
Change the lead of ECG
May have swuitched modes

Answer 59

Troubleshooting - Undersensing

Question 60

Concepts: Same settings, artificats, pacemaker malfunctions
Difference where inserted and is permanent
Permanent - Where get into resyncrnonization - end stage CHF - big LV and normal conduction sys cannot get it to contract
QRS wide enough and too long depolarize - put a 2nd lead - in mid RA (end venous return for coronary arteries into lateral edge) 2 impulses to make LV beat - make beat more efficient increasing CO - shortens QRS
Pacemaker therapy aims to simulate normal physiologic cardiac depolarization and conduction.
Resynchronization Therapy
Nursing management:

Answer 60

Permanent pacemakers

Question 61

Rate-responsive pacing, affecting responses to sensed atrial activity (DDD)
Various physiologic sensors (body motion or minute ventilation).
Pts who do not have a functional sinus node that cannot increase their heart rate

Answer 61

Pacemaker therapy aims to simulate normal physiologic cardiac depolarization and conduction.

Question 62

For patients with symptomatic heart failure, in SR with a cardiac output ≤ 35%, and a prolonged QRS
What are we synchronizing?
Can improve EF and CO
Why is this important?
Important for QoL - keep off transplant list longer - improving CO

Answer 62

Resynchronization Therapy

Question 63

Pacemaker generator stays in there; subdermal; not in hospital very long; most outpt
Monitor for complications
Pacemaker generator stays in there; subdermal; not in hospital very long; most outpt
Monitor for complications
Pacemaker malfunction: same as the Temporary Pacemakers
Postoperative complications
The process for identification of a permanent pacemaker
Documentation
CMS (Circulatory Motor Sensory) to extremity
Vital signs
Teaching performed

Answer 63

Nursing management:

Question 64

Perforate RV - muscle tiny; when placing it: putting a piece equipment with straw to steer it
Dissect the vein - not big muscle like the artery; easily
Incorrect technique - See pneumothorax
Risk for bleeding; big central vein - bleed quite a bit
Infection
Lead displacement - can give malfunctions
Until tip in lead in place with scar tissue - movable from pt moving

Answer 64

Postoperative complications

Question 65

Can do when goes in or CXR

Answer 65

The process for identification of a permanent pacemaker

Question 66

Say what type
Model number, make
Complications - s&s
Pacemaker settings
EKG interpretation
Insertion site assessment

Answer 66

Documentation

Question 67

Document mode in - usually DDD
Programmed mode of pacing
The lower rate setting - need know when need be concerned
All numbers in

Answer 67

Pacemaker settings

Question 68

Underlying rhythm - why have the pacemaker put in; need to know
% paced - imp to know; before every P or QRS get paced

Answer 68

EKG interpretation

Question 69

IMP
Thick and gooey drainage - pussy - not good; looks infected - doc must assess
Edges not approximated - not together and can see pacer lead/wire; pacemaker: Once get infected lead - must take it out; pocket/infected generator set - temp until infection gone - switch sites - see any part pacemaker = prob; call doc
Steristrips over incision site; hematoma - small breast implant - doc knows about it may just let reabsorb; new: issue = not go home until seen to make sure they know about - under = subclavian vein = venous return for arm and without return = issues: motorsensory issues - not as profound as arterial - edema because not as effective venous return; hematoma big enough presses on underlying structures; pt says hand keeps going numb and pins and needles on affected side - need to investigate - need do motor-sensory assessment: since venous pulses should be good; hematoma can be big enough to affect artery; check for pallor and ruddy on both sides; fingers sizes: sausage versus normal; new: must be seen; not express out of suture site; symptomatic: physician may schedule surgery to evacuate hematoma because slides on out
Infection - pacemaker
Will there be bruising?
Tiny bit
Should not be profound color change
Blunt dissect it to place
Should be little red around edges with granulation tissue
Should you see the pacemaker?
NEVER

Answer 69

Insertion site assessment

Question 70

HR imp - pacemaker higher than HR - see if failure to capture and what prob is

Answer 70

Vital signs

Question 71

Restrictions: lot more MRI compatible pacemakers - tell if is/not; next week or two - arm in sling to immobilze because moving around can displace lead

Answer 71

Teaching performed

Question 72

With permanent pacemakers; not with temporaries
Fancy pacemaker; pacemaker with ICD; usually is pacing
Usually try override pacing then shock; try save from shock
Tach arrhythmias
Congenital sudden cardiac death - want assurance
End stage congestive HF - boggy LV - so much muscle mass to move - at high risk
Takes more surface area because more Extra coil to generate higher joul - no longer micro shocks; much more electricity in defib shock
Upper 200s way too fast - time for ventricular fill not enough - barely ejecting anything - program says let run for x time then deliver shock then go to underlying/paced rhythm
Shocked even tho lower joul - feels like getting kicked in chest by a horse
Very nerve wracking
Some people see as beneficial and contribute QoL - not drop dead; anxiety producing - hurts so bad
An Implantable cardioverter-defibrillator (ICD) is used to treat tachydysrhythmias
It is a pacemaker with an integrated defibrillator coil
Identifies and terminates life-threatening ventricular dysrhythmias.
Nursing management
Pt edu

Answer 72

Implantable cardioverter-debrillator

Question 73

Implanted in EP lab - putting fancy func on it; usually end stage CHF or someone with sudden cardiac death in fam
High risk
Fancy device in them does not mean no longer monitoring rhythms - still on tele; monitoring rhythm to ensure pacemaker rhythm and if in lethal rhythm - get shocked
Do test in lab by putting in lethal to see how many joules to convert them; Anesthesia sedation - propofol
If the ICD system was implanted during open-heart surgery, postoperative nursing management is similar to that for any patient undergoing cardiac surgery.
If an endocardial lead system is implanted (PPM ICD), nursing management is less intense, and the hospital stay is shorter.
Assess for ventricular arrhythmias.

Answer 73

Nursing management

Question 74

Assess laboratory values, s/s ischemia, EF as a cause for arrhythmias
Assess the patient if an ICD shock is delivered
Can pass out
Not shocked into normal rhythm
Keep getting shocked or first time in 3 days - inform doc
Ensure pt fine
Assess rhythm before ICD shock
After look at the pt
And rhythm after shock
If ICD doesn’t shock, what should the nurse do?
250 and waiting - do same thing as without ICD - get code cart and defib
Go in and shock them
Pads on - below pacemaker

Answer 74

Assess for ventricular arrhythmias.

Question 75

Most edu before get it
Then reinforce before dismissed
Let know getting for this reason
Pathophysiology of the underlying disease process, including sudden cardiac death, ventricular dysrhythmias, and heart disease
Information regarding how the implantable cardioverter defibrillator is programmed to function
Feel fluttering in chest for certain amount time - sit down so when shocked not fall and face plant - SAH results
Actions to take if a shock occurs
Importance of continuing antidysrhythmic and heart failure medications
Not get stop these meds
Most want to because expensive and feel bad taking them
Have continue on them as soon as take them
May be taken off later on
Not immediately after implementation
Activity limitations related to driving and avoiding strong magnetic fields
Need know limitations of magnetic fields
Signs and symptoms of device failure
Same sx that brought in - device failing - need be seen
Decreased CO sx
Dizzy
Light headed
Faint
See sparkles when change positions
Follow-up schedule for remote monitoring and office visits
Product interrogated to see how functioning and tweak settings
Cardiopulmonary resuscitation training for all family members
Not a fix
Not all rhythms are shockable or respond to being shocked
Usually pacemaker with ICD; lot try override pace then shock

Answer 75

Pt edu

Question 76

Nothing concerning
Does have straight lines
Ventricular pacemaker/ventricular paced rhythm

Answer 76

A patient is on the unit post temporary pacemaker placement in the right IJ. The nurse completes a focused assessment. The right IJ dressing is dry and intact, covered with an occlussive dressing. CV assessment: Heart tones are S1, S2. Vital signs: BP is 118/75, HR 83, RR 16, SaO2 94% on RA. Identify this Rhythm.

Question 77

Assess the patient - assess what pacemaker doing - new pacemaker in
Look make sure not bleeding
Hematoma
ECG
Know symptomatic
Run VS to see CO low via BP
Investigate because way feeling
Not normal

Answer 77

After assessing the patient, the nurse asks if they need a boost in bed. The nurse helps the client reposition by pulling on the upper arm as the patient pushes with their legs. 10 minutes after the nurse leaves the room, the nurse returns with the patient’s medication. The patient is diaphoretic and is reporting feeling dizzy. What should the nurse do next?

Question 78

Causing prob because HR low
Somewhat symptomatic
Call Rapid Response if still awake
Prepare for emergency treatment
May need to cardiac cath lab for interventional radiologist to advance it back in
In IJ (yes in neck but then go down and into subclavian)
Treat pt - no P waves - try atropine
Bradyarrythmia algorithm where temporary pacemaker repositioned

Answer 78

What is the nurse’s priority action?

Question 79

Jerking on arms - displaced that lead - not take much early in the game

Answer 79

What happened?

Question 80

Line - Ventricular paced before QRS then tach arrhythmia then slow back down
Have an ICD
Have a pacemaker - went into arrhythmia and ICD shocked them out of it
This is a ventricular paced rhythm that goes into rapid polymorphic ventricular tachycardia, which is terminated by a single endocardial shock after appropriate detection

Answer 80

The nurse is caring for a patient in the cardiac step-down unit. They are reviewing the telemetry strips for their team of patients. While at the telemetry monitors, the nurse observes the following continuous rhythm strip of the patient with a pacemaker and ICD. What is happening in this strip?

Question 81

Assess the patient

Answer 81

What should the nurse do next (the priority)?

Question 82

Acute MI - fix it
Treating smae thing - diff approproach; physician preference; determine if graft in aorta; marfans syndrome
Now getting into blood flow; no longer talking about electricity; now with the plumber
Pacemaker is electricity
IABP (big sheath into artery) and impella is new; in IR - short term
Tandem Heart and ECMO - surgery and then CVICU - more long term
Impella in ventricle itself; facilitating getting blood out; no balloon pushing against it
IABP - counter pulsation; cannot place if incompetent aortic valve/something wrong with aorta/marfans syndrome - not going to happen; dissect aorta; coronary arteries at the cusp - right above aortic valve, coronary arteries come around; umph to perfuse coronary arteries not get with Impella; augment coronary artery perfusion
Mechanical circulatory support (MCS) devices

Answer 82

Short term mechanical circulatory support short-term

Question 83

Helping LV struggling
Have huge anterior MI
End-stage CHF
LV not working
Goals of MCS: To ↓ myocardial workload, maintain adequate perfusion to vital organs, reduce pulmonary congestion, IABP will augment coronary perfusion (Impella will not), provide circulatory support during procedures (decrease myocardial workload), and limit infarction size.

Answer 83

Mechanical circulatory support (MCS) devices

Question 84

If acute heart failure is reversible: to allow the myocardium time to recover. - big MI; heart recovers and ischemic rings come back when perfused - this gets over that hump
If the condition is irreversible, may be used as a bridge to heart transplantation for qualified candidates - huge anterior wall MI and not come fast enough; whole LV not performing and EF going to be single digits, talk more long-term devices and transplant
Not all transplant candidate - may use LVAD, BVADS, RVADS as bridge therapy
Destination therapy for patients who have no other surgical options - end of line; once heart no longer functioning with help, only option
Must have preload - do not let get dehydrated

Answer 84

Goals of MCS: To ↓ myocardial workload, maintain adequate perfusion to vital organs, reduce pulmonary congestion, IABP will augment coronary perfusion (Impella will not), provide circulatory support during procedures (decrease myocardial workload), and limit infarction size.

Question 85

Put in lot with cath lab
Most commonly used percutaneous circulatory assist device
Must be timed right; balloon deflated when aortic valve open so can eject
Indications for use
Complications
Nursing management

Answer 85

Intra-aortic balloon pump (IABP)

Question 86

Acute congestive heart failure exacerbation with hypotension
As prophylaxis or adjunct treatment in high-risk percutaneous coronary intervention
Myocardial infarction
Decreased left ventricular function
Mechanical complications causing cardiogenic shock (acute mitral regurgitation due to papillary muscle rupture or ventricular septal rupture)
Low cardiac output state after coronary artery bypass grafting surgery

Answer 86

Indications for use - Intra-aortic balloon pump (IABP)

Question 87

Bleeding
Gigantic sheath in femoral artery - are bendy
Calcified aortas
Can rupture balloon
Balloon rupture/leak
Thrombus formation on balloon
Aortic dissection
Balloon inflation result
Balloon occluding vital circulation (renal arteries, subclavian artery, mesenteric artery)
Catheter migrates
HIT
On heparin
Risk for developing heparin induced thrombocytopenia

Answer 87

Complications - Intra-aortic balloon pump (IABP)

Question 88

Maintain the timing of the IABP - ensure timed right
Assess for complications - bleeding, hematomas, frank bleeding, retroperitoneal bleeding when turning them
Assess peripheral circulation
Assess left radial pulse, level of consciousness, urinary output, and gastrointestinal symptoms is essential along with a daily chest radiograph/x-ray - see if working - adequate end organ perfusion - make sure organs getting perfused and urinary output picked up
Assess IABP counsel for helium leak - tiny tank - not last forever; seems like not working - not inflating - not shuttling helium because bottle is empty
Notify the physician of complications

Answer 88

Nursing management - Intra-aortic balloon pump (IABP)

Question 89

Distal tip in LV
A nonpulsatile axial flow pump that draws blood from the LV and ejects it proximally into the ascending aorta.
Inserted in the cardiac catheterization lab through the femoral artery
Complications
Nursing management: Care must be taken to prevent catheter dislodgement, which could lead to systemic desaturation or device malfunction.
Our job is to say something wrong; nothing we can do to troubleshoot it

Answer 89

Impella

Question 90

Related to the need for anticoagulation - heparin: HIT
Same bleeding comps: frank bleeding, retroperitoneal, hematomas
Transseptal puncture - In LV - stiffer of catheter - can move - keeps tapping septum; can rupture/puncture it
Thrombo- or air embolism - air in balloon keeping it
Hemolysis - any time pulling blood than in blood movement - affect shape of RBC - lyse/destroy it

Answer 90

Complications - Impella

Question 91

Cool and diaphoretic - CO not enough to perfuse the skin
Edema - look at hx
Left sided - crackles
Right sided - JVD, pitting edema
HR compensatory mechanism
RR high
No

Answer 91

A patient presents to the emergency department with acute exacerbation of CHF. Assessment: Neuro: pt is alert but lethargic. CV: S1, S2, S3. Skin is cool and diaphoretic. 3+ pitting edema in all dependent areas. + JVD. Pulm: Crackles throughout. Vital signs: Pulse: 120, Respiration: 22, Temperature: 98.8° F, Blood Pressure: 100/50, and SpO2% of 92% Sinus rhythm with a wide QRS
Is this assessment normal?

Question 92

Unstable
Lethargy - pretty much unstable
Rest complete the package
Cool and diaphoretic = unstable

Answer 92

Is this patient stable or unstable?

Question 93

Low CO from HF; LV not pumping
Not enough blood going out to sys to perfuse end organs - causing sx
Not know if need Impella or IABP - not enough info

Answer 93

What is causing the symptoms?

Question 94

Positive inotropes: dopamine and Doputamine - ailing LV - help contractility; in CO

Answer 94

What medication should the nurse prepare to administer?

Question 95

If no response to positive inotropes, IABP or Impella
Know chronic - go for Tandem heart or ECMO
With all interventions - start with minimally invasive - medications to see if helps; some do good with Doputamine infusion therapy but some need this

Answer 95

What should the nurse prepare for?

Question 96

Concerning low urine output
Obstruction of the renal arteries - blocks it when slips down
LV not responsive sometimes but most likely IABP slipped

Answer 96

The patient is sent to the cardiac catheterization lab and an IABP is inserted. The urine output is 60 ml over the last 3 hours. What can be causing the low urine output?

Question 97

HIT
Bleeding
Aorta dissection - 3 seconds to figure that out
Look at circulation - pulses in all extremities - slip too low - occlude iliac - not have distal perfusion
Big sheath in artery treat like art line - CMS to the affected limb - for bleeding

Answer 97

What complications should the nurse assess for?