1 Nursing Care of Patients with Cardiac DysrhythmiasChapter 25 Nursing Care of Patients with Cardiac Dysrhythmias
2 Cardiac Conduction SystemSinoatrial (SA) Node: bpm Across Both Atria AV Node Bundle of His Right and Left Bundle Branches Purkinje Fibers
3 Cardiac Conduction System (cont’d)
4 Cardiac Cycle One HeartbeatElectrical Representation of Contraction, Relaxation of Atria/Ventricles
5 Components of Cardiac Cycle
6 Electrocardiogram (ECG)Shows Cardiac Electrical Activity 12-Lead ECG = 12 Different Views Waveforms Change Appearance in Different Leads Continuous Monitoring Often in Lead II Waveforms Upright in Lead II
7 ECG Graph Paper
8 ECG Graph Paper (cont’d)Calibrated Grids for Measurement Time Calibrated Horizontally Heavy Lined Blocks of 25 (5 × 5) Small Box 0.04 Seconds Wide Five Small Squares 0.20 Seconds Wide
9 PR Interval
10 QRS Complex
11 QRS Interval
12 T Wave
13 U Wave
14 ST Segment
15 ST Segment Inverted or Depressed
16 ST Segment Elevated
17 Interpretation of Cardiac RhythmsFive-Step Process 1. Regularity of Rhythm 2. Heart Rate 3. P Wave 4. P-R Interval 5. QRS Complex
18 Normal Cardiac Waves Are Equal Distances Apart
19 Counting R Waves in a 6-Second Strip
20 Normal Sinus Rhythm
21 Normal Sinus Rhythm Rules1. Rhythm: Regular 2. Heart Rate: bpm 3. P Wave: Rounded, Before Each QRS 4. PR Interval: Seconds 5. QRS Interval: Seconds
22 Dysrhythmias Rhythm Disturbances Impulse Formation DisturbedDisturbance in Conduction
23 Sinoatrial Node DysrhythmiasSinus Bradycardia Sinus Tachycardia
24 Sinus Bradycardia
25 Sinus Bradycardia Rules1. Rhythm: Regular 2. Heart Rate: <60 bpm 3. P Waves: Rounded, Before Each QRS 4. PR Interval: Seconds 5. QRS Interval: Seconds
26 Sinus Tachycardia
27 Sinus Tachycardia Rules1. Rhythm: Regular 2. Heart Rate: bpm 3. P Waves: Rounded, Before Each QRS 4. P-R Interval: 0.12 To 0.20 Seconds 5. QRS Interval: 0.06 To 0.10 Seconds
28 Atrial Dysrhythmias Premature Atrial Contractions Atrial FlutterAtrial Fibrillation
29 Premature Atrial Contractions
30 Premature Atrial Contractions Rules1. Rhythm: PAC Interrupts Rhythm 2. Heart Rate: Per Underlying Rhythm 3. P Waves: Early Beat, Abnormal Shape 4. P-R Interval: Usually Normal 5. QRS Interval: Seconds
31 Atrial Flutter
32 Atrial Flutter Rules 1. Rhythm: Atrial Rhythm Regular2. Heart Rate: Varies 3. P Waves: Flutters , Sawtooth Pattern 4. P-R Interval: None Measurable 5. QRS Interval: Seconds
33 Atrial Fibrillation
34 Atrial Fibrillation Rules1. Rhythm: Irregularly Irregular 2. Heart Rate: Atrial Rate Not Measurable, Ventricular Rate <100 Controlled Response, >100 Rapid Ventricular Response 3. P Waves: No Identifiable P Waves 4. P-R Interval: None Measurable 5. QRS Interval: Seconds
35 Ventricular DysrhythmiasPremature Ventricular Contraction Ventricular Tachycardia Ventricular Fibrillation
36 Premature Ventricular Contractions (PVC)
37 Bigeminal PVC
38 Premature Ventricular Contraction Rules1. Rhythm: PVC Interrupts Rhythm 2. Heart Rate: Per Underlying Rhythm 3. P Waves: Absent in PVC 4. P-R Interval: None for PVC 5. QRS Interval: PVCs >0.11 Seconds
39 Ventricular Tachycardia
40 Ventricular Tachycardia Rules1. Rhythm: Usually Regular 2. Heart Rate: Ventricular bpm Slow VT <150 bpm 3. P Waves: Absent 4. P-R Interval: None 5. QRS Interval: >0.11 Seconds
41 Ventricular Fibrillation
42 Ventricular Fibrillation Rules1. Rhythm: Chaotic, Extremely Irregular 2. Heart Rate: Not Measurable 3. P Waves: None 4. P-R Interval: None 5. QRS Interval: None
43 Asystole
44 Asystole Rules 1. Rhythm: None 2. Heart Rate: None 3. P Waves: None4. P-R Interval: None 5. QRS Interval: None
45 Cardiac Pacemakers External and Temporary Internal and PermanentOverride Dysrhythmias Generate an Impulse Can Be Placed in Atria, Ventricle, or Both
46 Dual-Chamber Pacemaker
47 Pacemakers
48 Patient Pacemaker EducationIncision Care How to Take Radial Pulse Symptoms to Report Pacemaker ID Card Things to Avoid Trigger Metal Detectors Grounded Appliances Safe Periodic Pacemaker Checks
49 Defibrillation Electrical shock delivered to reset lethal ventricular dysrhythmias. Conductive Jelly or Saline Pads Used Paddles Pressed Firmly Against Chest Second Intercostal Space, Right of Sternum Anterior Axillary Line, Fifth Intercostal Space Announce “Clear” Increasing Energy: 200, 300, 360 Joules
50 Placement of Defibrillator Paddles
51 Synchronized DefibrillationAllows R wave to be sensed for appropriately timed delivery. Used in dysrhythmias when R wave present unless pulseless rhythm.
52 Automatic External DefibrillatorExternal device automatically analyzes rhythms, automatically delivers or prompts operator to deliver electrical shock if shockable rhythm (Vfib or VT) detected.
53 Implantable Cardioverter DefibrillatorAutomatically Delivers Electrical Shock When Lethal Rhythm Detected Cardioverts When VT Detected
54 Cardioversion Atrial Fibrillation, Atrial Flutter, Supraventricular Tachycardias Unresponsive to Drugs Conscious Sedation Synchronize Mode 25-50 Joules
55 Implanted Cardioverter Defibrillator
56 Nursing Diagnoses for DysrhythmiasDecreased Cardiac Output Ineffective Tissue Perfusion Activity Intolerance Anxiety Deficient Knowledge
57 Nursing Care of Patients with Heart FailureChapter 26 Nursing Care of Patients with Heart Failure
58 Heart Failure Syndrome occurs from progressive inability of heart to pump enough blood to meet body’s oxygen/nutrient needs. Older Term: Congestive Heart Failure
59 Causes Coronary Artery Disease MI Cardiomyopathy Heart Valve DisordersHypertension
60 Pathophysiology Each ventricle pumps equal amount of blood.If more than either ventricle can handle, heart not effective pump, Left ventricle typically weakens first. Failure of one leads to failure of other.
61 Left-sided Heart FailurePreload Degree of stretch in ventricles before systole Afterload Force generated by left ventricle to eject blood into aorta through aortic valve. Peripheral Vascular Resistance (PVR) Pressure Within Aorta/Arteries PVR Influences Afterload
62 Left-sided Heart Failure (cont’d)Hypertension Major Cause Blood Backs up from Left Ventricle Alveolar Edema Results p. 482 table 26.1
63 Left-sided Heart Failure (cont’d)
64 Right-sided Heart FailureLeft-sided Heart Failure Major Cause Must continually pump blood against increased fluid in pulmonary artery and lungs. Cor Pulmonale Right ventricle hypertrophies/fails due to increased pulmonary pressures. Backward Buildup of Blood in Systemic Blood Vessels Peripheral Edema Results
65 Right-sided Heart Failure (cont’d)Table 26.2 p. 481
66 Pulmonary Edema Acute Heart FailureSevere Fluid Congestion in the Alveoli Life-threatening Drowning In Own Secretions
67 Signs and Symptoms Classic: Pink, Frothy SputumRapid Respirations with Accessory Muscles Severe Dyspnea, Orthopnea Crackles, Wheezes Coughing Anxiety, Restlessness Pale Skin/Mucous Membranes Clammy, Cold Skin
68 Therapeutic InterventionsImmediate Treatment Reduce Workload of Left Ventricle Treat Underlying Cause Fowler’s Position Oxygen/Mechanical Ventilation
69 Therapeutic Interventions (cont’d)Morphine IV Diuretics Inotropic Agents IV Vasodilators IV Nesiritide (Natrecor) IV Table 26.5 p. 487
70 Nursing Diagnoses Impaired Gas Exchange Decreased Cardiac OutputAcute Pain Anxiety Excess Fluid Volume
71 Chronic Heart Failure ProgressiveSigns aqnd Symptoms May Worsen over Time
72 Signs And Symptoms Fatigue and Weakness Exertional Dyspnea CoughOrthopnea Paroxysmal Nocturnal Dyspnea Cough Crackle and Wheezes Tachycardia Chest Pain Cheyne-Stokes Respiration
73 Signs And Symptoms (cont’d)Edema Nocturia Cyanosis Altered Mental Status Malnutrition
74 Complications of Heart FailureLiver and Spleen Enlarge Pleural Effusion Thrombosis and Emboli Cardiogenic Shock
75 Therapeutic Intervention GoalsImprove Heart’s Pumping Ability and Decrease Heart’s Oxygen Demands Identify and Correct Underlying Cause Increase Strength of Heart’s Contraction Maintain Optimum Water and Sodium Balance Decrease Heart’s Workload
76 Therapeutic InterventionsActivity Sodium Restriction Oxygen Therapy Drug Therapy ACE Inhibitors Duretics Inotropic Agents: Digitalis Beta Blockers