chapter 27 management of patients with dysrhythmias and conduction problems

Copyright © 2008 Lippincott Williams & Wilkins.

Chapter 27Management of Patients With

Dysrhythmias and Conduction Problems

Chapter 27Management of Patients With

Dysrhythmias and Conduction Problems


Dysrhythmias (See Chart 27-1)Dysrhythmias (See Chart 27-1)

• Dysrhythmias: disorders of the formation or conduction (or both) of the electrical impulses in the heart

• These disorders can cause disturbances of:

– Rate

– Rhythm

– Both rate and rhythm

• Potentially can alter blood flow & cause hemodynamic changes

• Diagnosed by analysis of ECG waveform


Relationship of ECG Complex, Lead System, and Electrical ImpulseRelationship of ECG Complex, Lead System, and Electrical Impulse


ECG Electrode PlacementECG Electrode Placement


ECG Graph and Commonly Measured ComponentsECG Graph and Commonly Measured Components


Heart Rate DeterminationHeart Rate Determination


Normal Sinus Rhythm Normal Sinus Rhythm


Sinus BradycardiaSinus Bradycardia


Sinus TachycardiaSinus Tachycardia


Sinus ArrhythmiaSinus Arrhythmia


Premature Atrial ComplexesPremature Atrial Complexes


Atrial FlutterAtrial Flutter


Atrial FibrillationAtrial Fibrillation


Multifocal PVCs-QuadrigeminyMultifocal PVCs-Quadrigeminy


Ventricular TachycardiaVentricular Tachycardia


Ventricular FibrillationVentricular Fibrillation


AsystoleAsystole


First-Degree AV BlockFirst-Degree AV Block


Second-Degree AV Block, Type 1Second-Degree AV Block, Type 1


Second-Degree AV Block, Type 2Second-Degree AV Block, Type 2


Third-Degree AV BlockThird-Degree AV Block


Nursing Process: The Care of the Patient with a Dysrhythmia: AssessmentNursing Process: The Care of the Patient with a Dysrhythmia: Assessment

• Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness.

• Physical assessment includes:

– Rate and rhythm of apical and peripheral pulses

– Assess heart sounds

– Blood pressure and pulse pressure

– Signs of fluid retention

• Health history: include presence of coexisting conditions and indications of previous occurrence

• Medications


Nursing Process: The Care of the Patient with a Dysrhythmia: DiagnosisNursing Process: The Care of the Patient with a Dysrhythmia: Diagnosis

• Decreased cardiac output

• Anxiety

• Deficient knowledge


Collaborative Problems/Potential ComplicationsCollaborative Problems/Potential Complications

• Cardiac arrest

• Heart failure

• Thromboembolic event, especially with atrial fibrillation


Nursing Process: The Care of the Patient with a Dysrhythmia: PlanningNursing Process: The Care of the Patient with a Dysrhythmia: Planning

• Goals may include eradicating or decreasing the occurrence of the dysrhythmia to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia and its treatment.


Decreased Cardiac OutputDecreased Cardiac Output

• Monitoring

– ECG monitoring

– Assessment of signs and symptoms

• Administration of medications and assessment of medication effects

• Adjunct therapy: cardioversion, defibrillation, pacemakers


Other InterventionsOther Interventions

• Anxiety

– Use a calm, reassuring manner.

– Measures to maximize patient control to make episodes less threatening

– Communication and teaching

• Teaching self-care

– Include family in teaching


PacemakersPacemakers

• An electronic device that provides electrical stimuli to the heart muscle

• Types:

– Permanent

– Temporary

• NASPE-BPEG code for pacemaker function


Implanted Transvenous PacemakerImplanted Transvenous Pacemaker


Transcutaneous PacemakerTranscutaneous Pacemaker


ECG On-Demand PacingECG On-Demand Pacing


Complications of Pacemaker UseComplications of Pacemaker Use

• Infection

• Bleeding or hematoma formation

• Dislocation of the lead

• Skeletal muscle or phrenic nerve stimulation

• Cardiac tamponade

• Pacemaker malfunctionSee Table 27-2


Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Assessment

Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Assessment• Device function; ECG

• Cardiac output and hemodynamic stability

• Incision site

• Coping

• Patient and family knowledge


Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Diagnosis

Nursing Process: The Care of the Patient with an Implanted Cardiac Device: Diagnosis• Risk for infection

• Risk for ineffective coping

• Knowledge deficiency


Nursing Process: The Care of the Patient with an Implanted Cardiac Device- Planning

Nursing Process: The Care of the Patient with an Implanted Cardiac Device- Planning• Goals include absence of infection, adherence to self-care

program, effective coping, and maintenance of device function.


InterventionsInterventions

• Risk for ineffective coping

– Support of patient and family coping

– Setting of realistic goals

– Allow patient to talk, share feeling and experiences

– Support groups or referral

– Stress reduction techniques

• Knowledge deficiency

– Patient and family teachingSee Chart 27-3


Cardioversion and DefibrillationCardioversion and Defibrillation

• Treat tachydysrhythmias by delivering an electrical current that depolarizes a critical mass of myocardial ceils. When cells repolarize, the sinus node is usually able to recapture its role as heart pacemaker.

• In cardioversion, the current delivery is synchronized with the patient’s ECG.

• In defibrillation, the current delivery is unsynchronized.


Safety Measures Safety Measures

• Ensure good contact between skin and pads or paddles. Use a conductive medium and 20-25 pounds of pressure.

• Place paddles so that they do not touch bedding or clothing and are not near medication patches or oxygen flow.

• If cardioverting, turn the synchronizer on.

• If defibrillating, turn the synchronizer off.

• Do not charge the device until ready to shock.

• Call “clear” three times; follow checks required for clear and ensure that no one is in contact with the patient, bed, or equipment.


Paddle Placement for DefibrillationPaddle Placement for Defibrillation


Implantable Cardioverter Defibrillator (ICD)Implantable Cardioverter Defibrillator (ICD)

• A device that detects and terminates life-threatening episodes of tachycardia or fibrillation

• NASPE-BPEG code

• Antitachycardia pacing


ICDICD


Invasive Methods to Diagnose and Treat Recurrent DysrhythmiasInvasive Methods to Diagnose and Treat Recurrent Dysrhythmias

• Electrophysiologic studies

• Cardiac conduction surgery

– Maze procedure

– Catheter ablation therapy

chapter 27 management of patients with dysrhythmias and conduction problems

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