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NURS3313 Adult Health > Chapter 22 Management of Patients w/Arrhythmias & Conduction Problems > Flashcards

Chapter 22 Management of Patients w/Arrhythmias & Conduction Problems Flashcards

1
Q

Arrhythmias

A

Disorders of the formation or conduction (or both) of the electrical impulse w/in the heart

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2
Q

How are arrhythmias named?

A

They are named according to the site of origin of the electrical impulse & mechanism of formation or conduction involved

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3
Q

Where do electrical impulses normally originate in the heart?

A

The sinoatrial (SA) node
-Near the vena cava in the RT atrium

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4
Q

Function of the SA node

A

Serves as the pacemaker of the heart
-Electrical impulse stimulates and paces the cardiac muscle

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5
Q

What is the normal SA node electrical impulse rate?

A

The normal rate is between 60-100 bpm

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6
Q

Conduction

A

Process where the electrical impulse travels from the SA node to the atrioventricular (AV) node

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7
Q

Function of the AV Node

A

Slow down the electrical impulse
-Allows the atria to contract & fill the ventricles w/blood

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8
Q

Atrial Kick

A

When the atria contract & the ventricles fill w/blood

Accounts for ~1/3 of the volume ejected during ventricular contraction

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9
Q

After the electrical impulse has traveled to the SA node, where does it go next?

A

It travels quickly to the Bundle of His on the RT, the RT & left bundle branches, & then the Purkinje fibers (located in ventricular muscle)

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10
Q

Depolarization

A

The electrical stimulus

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11
Q

Systole

A

Mechanical contraction of the heart

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12
Q

Repolarization

A

Electrical relaxation of the heart

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13
Q

Diastole

A

Mechanical relaxation of the heart

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14
Q

SNS Influence on the Heart

A

Positive chronotropy

Positive dromotropy

Positive inotropy

Peripheral blood vessel constriction-> increased BP

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15
Q

Positive Chronotropy

A

Increased HR

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16
Q

Positive Dromotropy

A

Increased AV Conduction

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17
Q

Positive Inotropy

A

Increased force of myocardial contraction

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18
Q

PSNS Influence of the Heart

A

Negative chronotropy

Negative dromotropy

Negative Inotropy

Dilation of peripheral blood vessels-> Decreased BP

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19
Q

Does SNS stimulation increase or decrease the incidence of arrhythmias?

A

It increases the incidence of arrhythmias

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20
Q

Examples of SNS Stimulation

A

Exercise, anxiety, admin of catecholamines (dopamine)

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21
Q

Examples of PSNS Stimulation

A

Beta-adrenergic meds, relaxation, anti-anxiety meds

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22
Q

Electrocardiogram (ECG)

A

A record of a test that graphically measures the electrical activity of the heart, including each phase of the cardiac cycle

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23
Q

Nursing Considerations for Obtaining an ECG

A

Gently abrading the skin with a clean dry gauze pad or sandpaper edge of the electrode

Wash area w/soap & H2O prior to adhesion

Clip excessive hair

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24
Q

Artifact

A

Distorted, irrelevant, and extraneous ECG waveforms

(Can be caused by poor electrode adhesion)

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25
Q

What are electrodes and cables used for?

A

They are used to detect electrical activity of the heart

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26
Q

Hardwire Monitoring

A

A cardiac monitor at the patient’s bedside for continuous reading

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27
Q

12-Lead ECG

A

An ECG machine placed at the patient’s side for an immediate recording

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28
Q

What are leads?

A

Imaginary lines formed between two electrodes
- Provide a “snapshot” of electrical activity in the heart

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29
Q

Where is the white lead placed?

A

“White on right”

Placed on RT shoulder

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30
Q

Where is the black lead placed?

A

Placed on LT shoulder

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31
Q

Where is the green lead placed?

A

“White clouds over green pastures”

Placed on RT leg

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32
Q

Where is the red lead placed?

A

“Smoke over fires”

Placed on LT leg

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33
Q

Where is the brown lead placed?

A

“Chocolate is close to a nurse’s heart”

Placed over Precordium

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34
Q

How often do we need to change lead locations?

A

Change it every 24 hrs (gel conductivity can decrease)

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35
Q

Telemetry

A

A small box that the patient carries and that continuously transmits the ECG information by radiowaves to a central monitor located elsewhere

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36
Q

Intermittent Monitoring

A

A very small device inserted under the skin or worn externally on a wrist band can perform ECG monitoring on demand whenever a patient is symptomatic

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37
Q

Continuous ECG Monitoring

A

A small, lightweight tape recorder-like machine that the patient wears for a prescribed period of time and that continuously records the ECG, which is later viewed and analyzed with a scanner

(Can include Holter monitor)

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38
Q

Positive Deflection

A

When an ECG waveform move towards the top of the paper

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39
Q

Negative Deflection

A

When an ECG waveform moves towards the bottom of the paper

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40
Q

P Wave

A

Represents the electrical impulse starting in the SA node and spreading through the atria
-Atrial depolarization

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41
Q

P-Wave Duration

A

0.11 secs or less normally (2.5 mm or less in height)

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42
Q

QRS Complex

A

Represents ventricular depolarization

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43
Q

QRS complex duration

A

Not all QRS complexes have the three waveforms
-Q wave: Normally less than 0.04 secs & less than 25% of the R-wave amplitude

QRS Duration: Normally less than 0.12 secs in duration

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44
Q

T Wave

A

Ventricular Repolarization (AKA resting phase)

Follows the QRS complex & usually follows the same direction

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45
Q

U Wave

A

Represents repolarization of the Purkinje fibers
-Sometimes appears in patients w/hypokalemia, HTN, or heart disease
-Follows the T-wave
-Usually smaller than the P-wave

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46
Q

PR Interval

A

AV Node Conduction
-Represents the time needed for sinus node stimulation, atrial depolarization, & conduction via AV node before ventricular depolarization

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47
Q

How do you measure the PR interval?

A

Measure from the beginning of the P-wave to the beginning of the QRS complex
-The spot where the isolectric line begins to change direction

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48
Q

Normal PR Interval Duration

A

Ranges from 0.12-0.20 secs in duration

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49
Q

ST Segment

A

Represents early ventricular repolarization

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50
Q

How do you measure the ST segment?

A

Lasts from the end of the QRS complex to the beginning of the T-wave

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51
Q

QT Interval

A

Represents the total time for ventricular depolarization & repolarization

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52
Q

How do you measure the QT interval?

A

Measure from the beginning of the QRS complex to the end of the T-wave

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53
Q

Normal QT Interval Duration

A

Ranges between 0.32-0.40 secs in duration, if HR is between 65-95 bpm

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54
Q

Deadly Consequence of QT Interval Prolongation

A

Torsades de Pointes

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55
Q

How do you measure the TP interval?

A

Measure from the end of the T-wave to the beginning of the next P-wave

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56
Q

PP Interval

A

Used to determine atrial rate & rhythm

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57
Q

How do you measure the PP interval?

A

Measure from the beginning of one p-wave to the next p-wave

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58
Q

RR Interval

A

Used to determine ventricular rate & rhythm

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59
Q

How do you measure the RR interval?

A

Measure from one QRS complex to the next QRS complex

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60
Q

ECG Time Measurements

A

Time measurements are recorded in hundredths, with a trailing zero if necessary
- 1 small box = 0.04 second
- 5 small boxes = 1 large box = 0.20 second
- 5 large boxes = 1 second
- 30 large boxes = 6 seconds

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61
Q

Steps of Rhythm Strip Interpretation

A

1) ) Rhythm: (Regular/Irreg)

2) HR: Fast or slow?

3) Locate the P wave: Is there a P wave for every QRS?

4) Determine the PR interval (Norm: 0.12-0.20 secs)

5) Identify the QRS (Normal <0.12 secs)

6) Identify the ST segment: Is it at baseline?

7) Identify the T wave: Upright? Peaked or flattened?

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62
Q

Step 1: Is the Rhythm Regular or Irregular?

A

Plot out the R-R intervals

Plot out the P-P intervals

For irreg determine if (essentially reg w/some irregularity or irregularly irregular)
- If the beat is the same, then it is regular

63
Q

Step 2: Measure the HR

A

Count the number of R waves in a 6 second strip and multiply by 10

Is it fast or slow?

Normal is 60-100

Example:
7 R waves in a 6 second strip, the heart rate is 70
(7x10=70)

64
Q

Step 3a Locate the P Wave: Is there a P wave for every QRS?

A

Normal: Similar in size, shape, appearance - may be assumed to originate from SA node

Different shapes: Diff foci (different places of origin)

65
Q

Measuring HR: 300 Method

A

Count the # of big boxes between each R waves

Divide 300 by that number.

66
Q

Measuring HR: 1500 Method

A

Count the # of small boxes between each P wave OR QRS complex

Divide 1500 by that number

66
Q

Sequence Method

A

Find a P or R that peaks on the heavy red line

Assign the following numbers to the next heavy red line: 300, 150, 100, 75, 60 , & 50

Rate will be where the next P or R falls

67
Q

Step 3b: Examine the P to QRS ratio

A

Every P-wave should be followed by a QRS complex

Every QRS complex should be preceded by a P-wave

68
Q

Step 4: Determine PR Interval

A

Normal 0.12-0.20 seconds

Longer: 1st degree AV blocks, PR >0.20 (this will not be tested on)

Varied: 2nd and 3rd degree AV blocks (this will not be tested on)

69
Q

Step 5: Examine the QRS complex

A

Size & shape should be similar

Width should be <0.12 secs

-Wider: Likely ventricular in origin

-Narrower: SA or AV node in origin

QT interval measurement should also be examined: Is it getting longer?
- 1/2 of the patient’s R-R interval (usually 0.32-0.40 in a SR)

70
Q

Steps 6 & 7: Examine ST segment & T waves

A

Look for ST elevation

71
Q

Step 8: Interpret the Rhythm

A

Look for signs of hemodynamic compromise:

-Cool, clammy, diaphoretic, dizzy

-Decreased LOC

-Decreased BP

Remember: Check the patient first!

Always, always, always treat the patient, not the monitor!

72
Q

Sinus rhythms originate in the…

A

…SA node

73
Q

(Normal) Sinus Rhythm

A

Rate: 60-100 bpm (atrial & ventricular)

Rhythm: regular

P waves: uniform and upright

P to QRS Ratio: one for each QRS

PR Interval: 0.12-0.20 secs

QRS Complex: < 0.12 secs

74
Q

Sinus Bradycardia

A

Rate: < 60 bpm (ventricular & atrial)

Rhythm: regular

P-waves: uniform and upright

P to QRS Ratio: one for each QRS

PR Interval: 0.12-0.20 secs

QRS Complex: < 0.12 secs

75
Q

Sinus Tachycardia

A

Rate: 100 bpm (ventricular & atrial) (usually less than 120)

Rhythm: regular

P-waves: uniform and upright

P to QRS Ratio: one for each QRS

PR Interval: 0.12-0.20 secs

QRS Complex: < 0.12 secs

76
Q

What occurs in atrial rhythms?

A

Atria takes over as the pacemaker (P waves all look different)

77
Q

Signs & Symptoms of Sinus Tachycardia

A

Dizziness
Palpitations
SOB
Nausea
Lightheadedness
Chest pain
Syncope

78
Q

Management of Sinus Tach

A

Correct causes:
- Give fluids, blood products, pain medications, reduce anxiety, remove meds/stimulants

If patient is hemodynamically unstable:
Vagal maneuvers:
- Carotid massage
- Gagging
Valsalva maneuver
- Coughing
- Face in ice water
- Straw/bubbles

Adenocard (Adenosine)
FAST IVP!!
Dose: 6mg, 12mg, 12mg
- MAX DOSE: 30 mg

Synchronized cardioversion

79
Q

Defibrillation vs. Cardioversion

A
80
Q

Prepping for Cardioversion: Oh, Say It Isn’t So

A

Signed Consent BEFORE!!

O2 Monitoring
Suction
IV Access
Intubation supplies
Sedation & analgesics
- Propofol

81
Q

Premature Atrial Contraction (PAC)

A

An electrical impulse begins in the atria, but not in the SA node (it’s an ectopic beat)

-Impulse is faster than SA node-> causes early beat that leads to early contraction

82
Q

PACs Causes

A

Atrial dilation

Substances: Caffeine, nicotine, alcohol

Ischemia/infarction

Anxiety

Electrolytes: Low K

Hypermetabloic States (Pregnancy)

83
Q

Nursing Considerations for PAC

A

PACs are common in healthy individuals, and usually don’t require treatment

However, frequent and/or symptomatic PACs may indicate a worsening condition, and could lead to more serious dysrhythmias

84
Q

Signs & Symptoms of PACs

A

The patient may say, “My heart skipped a beat.”

A pulse deficit (a difference between the apical and radial pulse rate) may exist

85
Q

Atrial Fibrillation (A-Fib) Characteristics

A

Rate: Atrial 350-600 bpm; ventricular- variable

Rhythm: irregularly irregular

P waves: no P-waves; fibrillatory waves

P to QRS Ratio: no identifiable P-waves

PR Interval: unable to measure

QRS Complex: usually narrow

86
Q

Dangers of A-Fib

A

Loss of atrial kick decreases CO (20-30%)

Increased risk of emboli due to pooled, clotted blood in the atria

Risk for stroke & PE

87
Q

Atrial Flutter (A-Flutter) Characteristics

A

Rate: Atrial 250-350; ventricular- variable

Rhythm: usually regular

P waves: sawtooth pattern

P to QRS Ratio: typically 3:1 or 4:1

PR Interval: unable to determine

QRS Complex: usually narrow

88
Q

Signs & Symptoms of A-Fib

A

May be asymptomatic

May experience palpitations and clinical manifestations of heart failure
shortness of breath

Hypotension
dyspnea on exertion
fatigue

89
Q

Treatment of A-Fib

A

Anticoagulation

Rate Control

Calcium channel blockers: Diltiazem, etc.

Beta blockers: Metoprolol, etc.

Conversion-
ANTICOAGULATE/TEE

Medications
Amiodarone, flecainide

Electrical
Surgical Procedures
LAAO- (WATCHMAN) Reduces the risk of LAA blood clots from entering the bloodstream- stroke
Maze procedure- small transmural incisions are made in the atria resulting in scar formation

Ablation therapy

90
Q

A-fib/flutter Causes

A

Impairment to cardiac system

-HTN

-CHF

-Valve disease

-Atrial dilation

-Hypertrophy

-Surgery

Age

Diabetes

Obesity

OSA

Alcohol abuse

Smoking

Genetics

91
Q

Nursing Considerations for A-fib/flutter

A

Examine causes

-Sustained vs non-sustained

-Cardiac conds vs lifestyle modification

Procedures:

-Cardioversion/TEE (ECHO): Check for blood clots (if clots are present, not a candidate)

-Fast-> A fib ablation

-Slow-> nodal ablation & pacemaker

92
Q

Signs & Symptoms of Aflutter

A

Tend to be more symptomatic than A-fib

Chest pain
SOB
Low BP

93
Q

Med Management of A-fib/flutter

A

Rate management for goal HR <80 bpm

-Class II antiarrhythmic beta-blockers and Class IV antiarrhythmic calcium channel blockers (like metoprolol and diltiazem)

Rhythm management

-Class III and IC antiarrhythmics (like Amiodarone, Dofetilide, Sotolol, Flecainide)

Clot prevention

-Anticoagulants and Antiplatelets (like Pradaxa, Eliquis, Aspirin, Warfarin)

->Warfarin is based on INR goal of 2-3 and needs lots of education*Based on risk score

94
Q

What occurs in ventricular rhythms?

A

Ventricles become the pacemaker

95
Q

Premature Junctional Complex

A

Rate: depends on underlying rhythm

Rhythm: irregular due to early P waves, creating a PP interval that is shorter than others. Sometimes followed by a longer-than-normal PP interval, but one that is less that twice the normal PP interval (noncompensatory pause)

P waves: May be absent, may follow the QRS, or may occur before the QRS

P to QRS Ratio: 1:1

PR Interval: less than 0.12

QRS Complex: usually normal, but may be abnormal or absent (blocked)

96
Q

PJC Causes

A

Digitalis Toxicity
HF
CAD

97
Q

Junctional Rhythm

A

Rate: Ventricular 40-60 bpm, Atrial 40-60 bpm is P waves are discernible
Rhythm: regular
P waves: May be absent, after the QRS, or before the QRS, may be inverted
P to QRS Ratio: 1:1 or 0:1
PR Interval: If the P is in front of the QRS, the PR is less than 0.12 seconds
QRS Complex: Usually normal, may be abnormal

98
Q

Junctional Rhythm Causes

A
99
Q

Signs & Symptoms of Junctional rhythm

A

Symptoms of reduced cardiac output
Lightheadndness
Palpitations
Activity intolerance
Chest heaviness
Neck tightness or pounding
Shortness of breath
Weakness

100
Q

Junctional Rhythm Management

A

Treatment: if symptomatic-same as for sinus bradycardia
Atropine
Emergency pacing

101
Q

Junctional Tachycardia

A

Rate: Ventricular 70-120 bpm, Atrial 70-120 bpm is

P waves are discernible

Rhythm: regular

P waves: May be absent, after the QRS, or before the QRS, may be inverted

P to QRS Ratio: 1:1 or 0:1

PR Interval: If the P is in front of the QRS, the PR is less than 0.12 seconds

QRS Complex: Usually normal, may be abnormal

102
Q

Junctional Tachy Causes

A
103
Q

Signs & Symptoms of Junctional Tachy

A

Will depend on precipitating cause

Symptoms of digoxin toxicity may be present

104
Q

Management of Junctional Tachy

A

Eliminate or treat the underling cause

105
Q

Atrioventricular Nodal Reentry Tachycardia (AVNRT)

A

AKA Paroxysmal Atrial Tachycardia (PAT), Paroxysmal supraventricular tachycardia (PSVT)

Rate: Atrial 150-250 bpm, ventricular 120-200 bpm

Rhythm: Regular, sudden onset and termination

P waves: Difficult to discern

P to QRS Ratio: 1:1, 2:1

PR Interval: If the P is in front of the QRS, the PR is less than 0.12 seconds

QRS Complex: Usually normal, may be abnormal

106
Q

PAT Causes

A

Caffeine
Nicotine
Hypoxemia
Stress
Not associated w/ underlying structural heart disease

107
Q

Signs & Symptoms of PAT

A

Decreased cardiac output can cause
- Restlessness
- Chest pain
- SOB
- Pallor
- Hypotension
- Loss of consciousness

108
Q

Management of PAT

A

Stable
- Vagal maneuvers
- Adenosine: 6mg/12mg/12mg IV, rapid push
- IV calcium channel blocker, IV beta-blocker, or IV digoxin
-Consider synchronized cardioversion

Unstable: Immediate synchronized cardioversion

Long-Term
Ablation Therapy

109
Q

Premature Ventricular Contraction (PVC)

A

“Wide & Bizzare”

Rhythm: Irregular

P waves: Depends on timing of the PVC, may or may not be visible

P to QRS Ratio: 0:1, 1:1

PR Interval: If P is in front of QRS, PR interval is less that 0.12

QRS wide ( > or = 0.12 sec) and bizarre

T-wave usually opposite QRS direction

Interrupts regularity of underlying rhythm

110
Q

PVCs Causes

A

Substances: Caffeine, nicotine, alcohol

Ischemia/infarction

Digitalis Toxicity

Increased workload to the heart (HF)

Electrolytes: Low K & Mg, Acidosis

111
Q

Are PVCs more urgent when it is unifocal or multifocal?

A

Multifocal are more urgent

112
Q

Treatment

A

Usually doesn’t need treatment, solely monitoring

Correct the underlying cause

113
Q

Ventricular Tachycardia (V-Tach)

A

Usually regular - may be slightly irregular

Typically 150-250 bpm may be faster or slower

No P-waves

QRS wide & bizarre (a lot of PVCs that do not stop)

114
Q

V-Tach Causes

A

Same as PVCs, but worsened conditions

Large areas of ischemia w/ MI

Very low EF

Critically low K/Mg

115
Q

Ventricular Fibrillation (V-fib)

A

CALL FOR HELP IMMEDIATELY!!!!!

D-FIB!!
- If you cannot defib, immediately start CPR

Severe electrical chaos in the ventricles

Multiple foci fire in erratic and disorganized manner

No ventricular contraction

No perfusion to vital organs

116
Q

Signs & Symptoms of Vtach

A

May or may not have a pulse
- Check carotid or femoral pulse
- If in a code, check femoral

Hypotension

117
Q

Treatment

A

Treatment:
Underlying cause must be identified and corrected
Long term management may include placement of an ICD

IF STABLE:
12 lead EKG
Adenosine 6 mg rapid IV push, if regular and monomorphic

Antiarrhythmic bolus followed by maintenance infusion

Amiodarone 150 mg over 10 minutes, then 1 mcg/min. for 1st 6 hours followed by 0.5 mcg/min for 18 hours, then oral Amiodarone

Lidocaine most common alternative antiarrhythmic

Procainamide 20 to 50 mg/min until suppressed followed by maintenance of
-1 mg/min for 1st 6 hours

Sotalol (Betapace) 100 mg over 5 minutes (avoid with prolonged QT interval)

IF UNSTABLE:
Immediate synchronized cardioversion if available for monomorphic VT
If not available, use treatments below until cardioverter arrives.

118
Q

Polymorphic V-Tach or Torsades de Pointes

A

Usually associated with prolonged QT interval

Many antiarrhythmics ineffective.

Common Treatments:
Magnesium Sulfate, IV – first line therapy

Isoproterenol
Mexiletine
Atrial pacing (shortens QT interval)

Antiarrhythmics can be considered but often ineffective and sometimes harmful

119
Q

Complications of V-fib

A

If untreated, can lead to death

120
Q

V-Fib Causes

A

Cardiac damage

-Ischemia/CAD/MI

-Cardiomyopathy

-Valve disease

-Untreated V Tach

ELECTRIC SHOCK

Acid-base and electrolyte imbalances

Medication side effects/toxicity

121
Q

Treatments for
V-fib

A

No pulse/No respirations→→Call for help

Early and immediate defibrillation

Do not delay defibrillation!

High quality CPR

Medical management
- Epinephrine, 1 mg IV push q 3-5 minutes
- Amiodarone, 300 mg initial bolus, followed by 150 mg
- Lidocaine is appropriate substitute for amiodarone

Post-resuscitation Management: Amiodarone or Lidocaine drip

Identify reversible/underlying causes

122
Q

Super Ventricular Tachycardia (SVT)

A

Any HR > 150

Synchronized cardioversion (symptomatic/ unstable cases)

Adenosine per ACLS guidelines

123
Q

Asystole (Ventricular Standstill)

A

“Flatline”

No electrical activity

124
Q

Asystole (T/F) You can defibrillate this rhythm

A

False, there is no rhythm to regulate (can only treat via medication/CPR until a rhythm is regained)

125
Q

Asystole Causes

A

Attempted Defib of Vtach or VFib

Decompensation of prolonged VFib

Hs & Ts

126
Q

H’s & T’s of Asysteole

A

H’s
- Hypovolemia
- Hypoxia
- H+ (acidosis)
- Hypo/Hyperkalemia
- Hypothermia

T’s
-Tension pneumothorax
- Tamponade, Cardiac
- Toxins
- Thrombosis (coronary)
- Thrombosis (pulmonary

127
Q

Treatment for Asystole

A

Immediate action: activate emergency system protocols

High quality CPR

Medical management
- Epinephrine, 1 mg IV push q 3-5 minutes
- Amiodarone, 300 mg initial bolus, followed by 150 mg

Underlying cause must be corrected- think H’s and T’s.

Very poor prognosis

Prevention is critical!

128
Q

Pulseless Electrical Activity (PEA)

A

Rate: varies

Rhythm: varies

P waves: varies

P to QRS Ratio: varies

PR Interval: varies

QRS Complex: varies

129
Q

Which cardiac rhythms can be defibrillated?

A

V-tach & V-fib

130
Q

Causes of Bradycardia

A

Lower metabolic needs (sleeping, athletic heart)

Vagal stim (vomiting, straining)

Med side-effects (beta blockers, ca+blockers)

Nodal dysfunc/sick sinus syndrome

Coronary artery disease, HF, MI

131
Q

Long QT Syndrome

A

Delay in repolarization of the heart after the initial depolarization and ventricular contraction.

QRS to T = 0.36-0.44, greater than 0.5 is cause for immediate concern

132
Q

Causes of Long QT Syndrome

A

Hereditary

Common cause of cardiac arrest in young people

Genetic testing available

Certain medications
- Zofran

133
Q

Bundle Branch Blocks

A

First division of the ventricle conduction after the bundle of His.

A delay or blockage of electrical impulses, resulting in the heart pumping blood less efficiently.

Cause differs based on which bundle branch is affected

LBBB – MI, HTN, myocarditis, cardiomyopathy

RBBB – PE, MI, congenital heart defects, pulmonary HTN, myocarditis

Signs/symptoms:
Usually asymptomatic
Dizziness, syncope

Treatment is usually not needed if asymptomatic

134
Q

1st Degree AV Block

A

Prolonged PR interval
greater than 0.20 seconds

Constant PR interval for each beat

Usually asymptomatic and only needs monitoring

If symptomatic, treat with atropine

135
Q

2nd Degree AV Block: Mobitz Type I (Wenckebach)

A

Steady lengthening of the PR interval

QRS complex is dropped or blocked

PP interval regular

RR interval irregular

QRS normal
Self-limiting; rarely progresses

May decrease cardiac output

Usually asymptomatic and only needs monitoring

If symptomatic, treat with atropine

136
Q

2nd Degree AV Block: Mobitz Type II

A

PR interval is fixed

PP interval is regular

Occasional P wave not followed by QRS

Typically unstable and needs treatment

Treatment:
Atropine
if ineffective then pacemaker

137
Q

3rd Degree AV Block: Complete

A

THE WORST AV BLOCK!!

Atria and ventricles beat independently of each other

P waves not associated with QRS complex

Causes:
Extensive MI, acidosis, hypoxia, hyperkalemia, dig tox., post-cardiac surgery

Treatment:
Eliminate cause
Atropine can be given but ineffective

Transcutaneous, transvenous, or implanted permanent pacemaker

138
Q

Pacemaker Terms

A

Rate
Pacing rate-in bpm
Usually a ‘backup rate”

Mode
demand or fixed

Sensitivity: millivolts (mV)
Minimum myocardial voltage required to be detected
Lower number = more sensitive

Output: milliamperes (mA)
Current that produces a pulse

Capture
Pacing rate-in bpm
Usually a ‘backup rate”

Pacing or capture threshold
Minimum amount of current (mA) required to initiate depolarization of the paced chamber

Spike
Line that represents pacing on EKG

139
Q

Failure to Pace

A

Fails to initiate an electrical stimulus when it should fire

The alarm clock isn’t working

140
Q

Failure to Capture

A

When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted

The alarm clock is going off, but sleeping through it

141
Q

Failure to Sense

A

When the pacemaker does NOT sense the patient’s own cardiac rhythm & initiates an electrical impulse

You wake up before the alarm clock and after you began getting ready, the alarm goes off

142
Q

Pacemaker Surveillance

A
143
Q

Implantable Cardioverter-Defibrillator

A
144
Q

Patient Education for Pacemaker

A

1st 2 weeks:
- Immobilize arm
- No heavy lifting
- No immersion in water (bath, swim)
- No driving

Forever: Check pulse
Report any shortness of breath or dizziness
Carry ID card

Keep pacemaker 6” away from:
- Cell phones
- E-cigarettes
- Headphones

Avoid medical procedures including:
- Electrocautery
- MRI
- Radiation therapy
- Microwave diathermy
- Lithotripsy
TENS
Avoid contact sports
Household appliances are okay!
Avoid metal detectors,
body scanners are okay!

145
Q

Bradycardia Treatments

A

Meds like atropine (per MD order) & epinephrine (per ACLS guidelines)

Pacemaker (symptomatic/too slow)

146
Q

PAC & PVC Treatment

A

Treat underlying causes

-Replace electrolytes

-Reduce stress/anxiety

-Dietary changes

Asymptomatic: No treatment

Symptomatic: Amino & beta blockers

147
Q

Defibrillation

A

Electrical current delivered through the chest wall and heart to depolarize myocardial cells

148
Q

What are the 2 types of defibrillation?

A

AED & Manual

149
Q

Purpose of Defibrillation

A

Goal is to allow primary pacemaker to resume control

150
Q

Defibrillator Steps

A

1) Self-adhesive pads are applied to the patient’s chest

-Remove hair PRN

2) Protect the patient from burns

3) Defibrillator charged and “All clear”

4) Shock is delivered

5) Begin CPR

5a) If normal rhythm resumes: Assess pulse

5b) If no pulse…CPR resumes

151
Q

Is defibrillation used for atrial dysrhythmias or ventricular dysrhythmias?

A

Defibrillation is used for ventricular dysrhythmias
-Cardioversion is used for atrial dysrhythmias

152
Q

General Nursing Interventions for Dysrhythmias

A

Continue to monitor HR & CO

Position pt as safely as indicated

Perform & interpret physical assessment

Prepare & admin meds as ordered

Apply O2 as needed

Page primary provider to update & obtain new orders

Reduce pt anxiety

Monitor for side effects of meds

Educate pt about potential treatments & associated risks

153
Q

Emergent Nursing Interventions for Dysrhythmias

A

Position pt safely for CPR

Begin CPR/call code if indicated

Apply O2 PRN

Call for help from charge nurse or MET/MRT/RRT

Page primary provider as quickly as possible

Call for stat EKG if needed

Prepare for IV infusions or pushes

Bring code cart and/or defibrillator to the doorway

NURS3313 Adult Health (27 decks)

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