CHAPTER 36 Care of Patients with Dysrhythmias

Chapter

36

Care of Patients with Dysrhythmias

CAsE sTudy: THE PATiEnT wiTH BRAdyCARdiA

A patient in a critical care unit on telemetry develops the following rhythm: normal P waves at a regular rate of 88 beats per minute. There is a separate ventricular regular rate of 55 with a normal QRS complex.

1. What can be determined about the relationship of the P wave and the QRS complexes? Answer: An AV block exists because the atria and ventricles are independent of each other. 2. Based on this ECG, what assessment findings might be identified with this dysrhythmia? Answer: Confusion, light-headedness, seizures; hypotension related to decreased cardiac output 3. What would make a difference in the physical findings? Answer: Ventricular rate, location of block, and cardiac output 4. What type of heart block has been identified? Answer: Third-degree heart block 5. What interventions are necessary for this patient? Answer: Oxygen and pacemaker 6. Differentiate between invasive and noninvasive temporary pacing. Describe the two types of invasive temporary pacing. Answer: Both types are hooked up to an external generator. External/noninvasive is the use of large electrode patches in an emergency situation for profound bradycardia or asystole. It is temporary until patient converts or invasive measures are used. Invasive pacing uses lead wires. Two types of invasive pacing are transvenous and epicardial. Transvenous is pacing wires percutaneously placed through a vein to the right ventricle. Epicardial pacing is done after cardiac surgery and is accomplished by wires on the epicardial surface of the heart.

Copyright 2010, 2006, 2002, 1999, 1995, 1991 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 CHAPTER 36 Care of Patients with Dysrhythmias 7. Identify the three complications that can occur with noninvasive pacemaker therapy. Answer: Cutaneous and muscle stimulation, skin irritation, and diaphoresis; loss of capture; inappropriate pacing 8. Briefly describe what the synchronous, or demand, mode means regarding pacemaker therapy. Answer: Demand mode means that a cardiac pacemaker is set so that it produces an electrical impulse to trigger a contraction only if the patients own intrinsic rhythm is less than a targeted range. If the patients heart is capable of producing and conducting its own impulses, the demand pacemaker does not initiate an impulse. 9. Would the patient have a temporary or permanent pacemaker? Answer: Permanent pacemaker 10. What would be included in a teaching plan for a patient with a pacemaker? Answer: ROM exercises, follow-up appointment with the physician, teach how to take pulse, what signs and symptoms to report, medications, pacemaker battery follow-up, medical alert bracelet, indications of battery failure, diet, physical activity, do not operate electrical appliances directly over the pacemaker, inform the dentist regarding pacemaker. Teaching includes information that the use of microwave ovens is safe, avoid MRI scanners, and travel without restrictions. (See Chart 36-7 for more information.)

Copyright 2010, 2006, 2002, 1999, 1995, 1991 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CHAPTER 36 Care of Patients with Dysrhythmias

CAsE sTudy: THE PATiEnT wiTH A dysRHyTHmiA

A 78-year-old woman is admitted to a telemetry unit directly from her physicians office for evaluation and management of congestive heart failure. She has a history of systemic hypertension and chronic moderate mitral regurgitation. Her medication orders include furosemide (Lasix) 80 mg orally four times a day, digoxin 0.125 mg orally daily, and diltiazem (Cardizem) 60 mg orally three times a day. The initial assessment of the patient reveals a pulse rate that is rapid and very irregular. The patient is restless, her skin is pale and cool, she states she is dizzy when she stands up, and she is slightly short of breath and anxious. Her blood pressure is 106/88. Her ECG monitor pattern shows uncontrolled atrial fibrillation, with a rate ranging from 150 to 170 beats/min. Her oxygen saturation level is 90%.

1. Given the assessment findings, what should the nurse do first? Answer: Begin oxygen, ensure (or establish) IV access, administer antidysrhythmic medications as ordered 2. What additional physical assessment techniques would the nurse perform? Answer: Heart and lung sounds, character and rhythm, check for JVD, check for edema, temperature 3. Because the length of time the patient has been in atrial fibrillation is unknown, what potential complication may occur if cardioversion is attempted? Answer: Dilation and blood stagnation in the atria can lead to thrombus formation, which increases the risk of stroke or other embolic events. 4. What should be done before elective cardioversion is attempted? Answer: Anticoagulant therapy before elective cardioversion to prevent a thromboembolic event, transesophageal echocardiogram (TEE) to assess for any atrial clots 5. Later that evening, the patient calls the nurse because she feels like something terrible is going to happen. She reports chest pain, has increased shortness of breath, and has coughed up blood-tinged sputum. What should the nurse suspect? What is the first thing the nurse should do, and what further assessments should be performed at this time? Answer: A pulmonary embolism is possible. Give supplemental oxygen. The physician should be notified immediately and the patient further assessed for changes in mentation, speech, and sensory and motor function. Take vital signs, assess strength and quality of pulses, urine output, back pain, and check for reports of GI disturbances.

Copyright 2010, 2006, 2002, 1999, 1995, 1991 by Saunders, an imprint of Elsevier Inc. All rights reserved.