Download Cardiac Dysrhythmias Part 2 Questions With Complete Solutions and more Exams Nursing in PDF only on Docsity! Cardiac Dysrhythmias Part 2 Questions With Complete Solutions Describe treatment of dysrhythmias - correct answerTo determine if treatment is necessary, assess the patient. Then ask the following questions: Is he or she experiencing signs and symptoms of decreased cardiac output? Is the dysrhythmia potentially life threatening? If the answer to either of these questions is yes, the patient will need to treatment for the dysrhythmia. ***WE WILL DISCUSS TREATMENTS OF DYSRHYTHMIAS BASED UPON CURRENT ACLS TREATMENT ALGORITHMS CLINICAL MANIFESTATIONS OF DECREASED CARDIAC OUTPUT INCLUDE CHEST PAIN, DYSPNEA, DECREASED LEVEL OF CONSCIOUSNESS, HYPOTENSION, HEART FAILURE IF PATIENT IS NOT SHOWING SIGNS OF DECREASED CO THEN SEARCH FOR CONTRIBUTING CAUSES AND SEEK EXPERT CONSULTATION POTENTIALLY LIFE THREATENING DYSRHYTHMIAS: SECOND DEGREE AV BLOCK TYPE II, COMPLETE HEART BLOCK, VENTRICULAR TACHYCARDIA, VENTRICULAR FIBRILLATION What are the Hs and Ts (potential causes of rhythm issues)? - correct answerHypovolemia Hydrogen ions (acidosis) Hyper/hypokalemia Hypoxia Hypothermia Hypervagal Hypoglycemia Malignant Hyperthermia Tension pneumothorax Tamponade (cardiac) Toxins Thrombosis (cardiac) Thrombosis/embolus (pulmonary) Trauma QT prolongation Pulmonary hypertension What categories can dysrhythmias be divided into for determining treatment? - correct answerBradycardias Tachycardias Pulseless arrest Cardiac Dysrhythmias Part 2 Questions With Complete Solutions **AS A GENERAL RULE, IF A DYSRHYTHMIA IS CAUSING A DROP IN CARDIAC OUTPUT AND IT IS TOO FAST, YOU SLOW IT DOWN; IF IT IS TOO SLOW, YOU SPEED IT UP. IF ECTOPICS ARE PRESENT, YOU SUPPRESS THEM BY DECREASING THE IRRITABILITY. IF CARDIAC ARREST IS PRESENT, YOU GENERATE A MORE VIABLE RHYTHM. What are the steps for treatment of dysrhythmias in general? - correct answerIdentify and treat underlying cause (might need to treat emergently if the patient has manifestations of decreased cardiac output) Maintain airway Give O2 IV access 12 Lead ECG (but should not delay treatment) How do you treat bradycardia dysrhythmias? - correct answerIf a patient is experiencing altered mental status, chest pain, dyspnea, lightheadedness, hypotension, or ventricular ectopy, treatment should be instituted: Give O2; give fluids (to normalize BP) Atropine 0.5 mg IV (drug of choice) (maximum dose 3 mg) (while awaiting pacemaker) Transcutaneous pacing (if available) Prepare for transvenous pacing Dopamine (2-10 mcg/kg/min), or Epinephrine (0.05-0.1 mcg/kg/min) (if a transcutaneous pacemaker is unavailable and patient not responsive to atropine) **THE TREATMENT OF BRADYCARDIAS DEPENDS UPON THE PATIENT'S ABILITY TO TOLERATE THE DYSRHYTHMIA. CAN ALSO USE TRANSVENOUS TEMPORARY PACEMAKING Vasoactive drips=work on the blood vessels- can get necrotic fingers and toes (dopamine and epinephrine) LOOK WHAT ALPHA 1 AND BETA 1 RECEPTORS DO Sustained v tach is greater than 30 seconds HEART RATES LESS THAN 60/MIN ARE CONSIDERED BRADYCARDIC. DYSRHYTHMIAS THAT MAY HAVE VENTRICULAR RATES BELOW 60/MIN INCLUDE SINUS BRADYCARDIA, JUNCTIONAL RHYTHM, A-V BLOCKS, AND IDIOVENTRICULAR RHYTHM WITH A PULSE. DOPAMINE 2 TO 10 MCG/KG/ MINUTE (ALPHA ONE BETA ONE) EPINEPHRINE 0.05 TO 0.1 MCG/KG/MIN (ALPHA ONE BETA ONE BETA TWO) Cardiac Dysrhythmias Part 2 Questions With Complete Solutions DRONEDARONE (MULTAQ) IS A DRUG LIKE AMIODARONE THAT DOES NOT CONTAIN IODINE SOTOLOL 100 MG (1.5 MG/KG) OVER 5 MINUTES; AVOID IF PROLONGED QT INTERVAL Describe how you treat a stable tachycardic pt with a wide QRS that is regular (probably v tach with a pulse) - correct answerIf VT or uncertain rhythm, give amiodarone 150 mg IV over 10 minutes. Repeat as needed if VT recurs Also give calcium chloride 1 gram IV Alternative to amiodarone is lidocaine 1-1.5 mg/kg IV every 3-5 minutes for total of 3 doses Prepare for synchronized cardioversion (bc they have a pulse) Consider expert consultation **Lidocaine can cause confusion in older people How do you treat a stable tachycardic pt with a wide QRS that is irregular? - correct answerPotentially Torsades de Pointes Give magnesium 2 grams IV over 5 minutes (may need a repeat dose) Consider expert consultation Describe Torsades de Pointes - correct answerGIVE MAGNESIUM. POLYMORPHIC VT. QRS COMPLEXES GRADUALLY CHANGE BACK AND FORTH FROM ONE SHAPE SIZE, AND DIRECTION TO ANOTHER OVER A SERIES OF BEATS. TORSADES DE POINTES IS FRENCH FOR TWISTING OF THE POINTS OFTEN TREATE WITH MAGNESIUM OR POTASSIUM What should you have at the beside for VT/VF pulseless? - correct answerOXYGEN SATURATION MONITOR, SUCTION DEVICE, IV LINE, INTUBATION EQUIPMENT. What is the treatment of dysrhythmias- pulseless arrest (VF/VT) - correct answerconfirm EKG If shockable; Give 1 shock (biphasic 120 to 200 joules) (monophasic 360 joules) Resume CPR immediately Give 2 minutes of CPR Obtain IV/IO access Check rhythm & if shockable , give 1 shock (continue CPR while defibrillator is charging) When IV is ready, give vasopressor during CPR before or after the shock Epinephrine 1 mg IV- repeat every 3 to 5 minutes Consider advanced airway and capnography Cardiac Dysrhythmias Part 2 Questions With Complete Solutions Consider antiarrhythmics- amiodarone (dose 300 mg), lidocaine (1-1.5 mg/kg IV every 3-5 minutes for three doses), magnesium sulfate (2 gms IV) (for torsades de pointes which is polymorphic VT) **ALWAYS DO CPR WHILE AWAITING DEFIBRILLATOR What can you replace 1 dose of epi with? - correct answerMAY REPLACE 1 DOSE OF EPINHEPHRINE WITH 40 UNITS VASOPRESSIN (ADH AND A PRESSOR) What is Torsades De Pointes? - correct answerTORSADES DE POINTES IS POLYMORPHIC VT (TORSADES DE POINTES CAN BE AN INTERMEDIARY DYSRHYTHMIA BETWEEN VT AND VF What are some things to know about paddle placement? - correct answerNEVER PUT PADS/PADDLES OVER ICD OR PACEMAKER SAY ALL CLEAR RIGHT OF STERNUIM BELOW CLAVICLE; OTHER PADDLE LEFT OF APEX SELECT ENERGY LEVEL ON DEFIBRILLATOR PERSON DELIVERS SHOCK; CAN HAVE AUTOMATIC EXTERNAL DEFIBRILLATOR (AED) CONDUCTIVE PADS (GEL PADS) SHOULD BE USED FOR DEFIBRILLATION MAKE SURE OXYGEN IS NOT BLOWING ACROSS CHEST Describe biphastic and monophastic defibrillators - correct answerMONOPHASIC DELIVERS IMPULSE IN ONE DIRECTION; BIPHASIC DELIVERS IMPULSE IN TWO DIRECTIONS; BIPHASIC CAN LEAD TO SUCCESSFUL SHOCK AT LOWER ENERGY WITH FEWER POST SHOCK ECG ABNORMALITIES DEFIBRILLATION IS MOST EFFECTIVE WHEN MYOCARDIAL CELLS ARE NOT ANOXIC AND ACIDOTIC SO DO IT QUICK. SHOCK DEPOLARIZES AND THE AFTER REPOLARIZATION HOPEFULLY SA NODE TAKES OVER What are multifunctional pads for defibrillation? - correct answerHands free How do you treat asystole/PEA (not shockable)? - correct answerCPR When IV is ready, give vasopressor epinephrine 1 mg IV- repeat every 3 to 5 minutes Consider calcium chloride if hyperkalemia is present May replace 1 dose of epi with vasopressin 40 units IV What is overdrive pacing? - correct answerOVERDRIVE PACING IS PACING THE ATRIUM AT A RATE OF 200-500/MINUTE TO ATTEMPT TO TERMINATE ATRIAL TACHYCARDIA (ATRIAL FLUTTER WITH RAPID VENTRICULAR RESPONSE IS AN EXAMPLE) Cardiac Dysrhythmias Part 2 Questions With Complete Solutions Describe temporary pacemakers - correct answerNoninvasive temporary pacing (transcutaneous)- used as an emergency measure or when a client is being transported and the risk of bradydysrhythmia exists Transvenous invasive temporary pacing- pacing lead wire is placed through antecubital, femoral, jugular, or subclavian vein into the right atrium for atrial pacing, or through the right ventricle, and positioned in contact with the endocardium Epicardial pacemakers **POWER SOURCE IS OUTSIDE THE BODY Describe pacemakers - correct answerA temporary or permanent device that provides electrical stimulation and maintains the heart rate when the client's intrinsic pacemaker fails to provide a perfusing rhythm **Ch 10 ECG book What are some indications for a pacemaker? - correct answerBradydysrhythmias Drug toxicities Electrolyte imbalances MI, cardiomyopathy 2nd or 3rd degree AV block SA node dysfunction Tachydysrhythmias "Overdrive" pacing can decrease the rate of a rapid rhythm "Antitachycardia pacing involves the delivery of a stimulus to the ventricle to end tachydysrhythmias What are the indications for temporary pacemakers? - correct answerCan be used in emergency situations Maintenance of HR and rhythm during surgery, post-operative recovery, cardiac catheterization Temporarily until PPM is implanted Prophylactically after open heart surgery Acute anterior MI with 2nd or 3rd degree heart blocks Symptomatic bradycardia During EP (electrophysiology) studies to evaluate patient with brady or tachy dysrhythmias Describe the pacemaker system - correct answerPacing Pulse Generator- generates an electrical current Pacing Lead System- current travels through the pacing leads(wires) and exits through an electrode that is in direct contact with the heart Cardiac Dysrhythmias Part 2 Questions With Complete Solutions Describe modes of failure (failure to pace) - correct answerOccurs when the pacemaker should deliver a pacing impulse but does not **ON ECG TRACING, FAILURE TO PACE IS CHARACTERIZED BY A PROLONGED INTERVAL BETWEEN 2 BEATS THAT EXCEEDS THE TIMING INTERVAL FOR THE LOW RATE LIMIT. Practice exercises for deciphering pacemaker codes What does the "R" stand for in the code DDDR? - correct answerAN R IN THE 4TH LETTER POSITION INDICATES THAT THE PACEMAKER HAS A RATE RESPONSIVE CAPABILITY. Practice exercises for deciphering pacemaker codes Can an AOO pacemaker sense in any chamber of the heart? - correct answerAN AOO PACEMAKER IS A FIXED RATE PACEMAKER; IT CANNOT SENSE ANY INTRINSIC ELECTRICAL ACTIVITY. FIXED RATE (ASYNCHRONOUS) (COMPETITIVE); BECAUSE IT WOULD COMPETE WITH THE INSTRINSIC RHYTHM BECAUSE IT CAN'T SENSE IT What is the nursing managment for a temporary pacemaker? - correct answerTemporary pacing lead and bridging cable must be secured to body Take special care while handling the external components of the pacing system to avoid conducting stray electrical current from other equipment (wear rubber gloves & insulate the terminal pins of the pacing wires when they are not in use) Immobilize extremity where temporary pacemaker access is (transvenous) to prevent dislodgement; if femoral vein then the patient is on bedrest Assess site for infection, bleeding, drainage, swelling Monitor HR and rhythm; if pacemaker is set at 60, acceptable range of HR is 55-65 CXR after insertion to assess for pneumothorax Describe pacemaker spikes - correct answerWhen a pacing stimulus is delivered to the heart, a spike (straight vertical line) is seen on the monitor or ECG strip If the electrode is in the ventricle, the spike is in front of the QRS complex If the electrode is in the atrium, the spike is before the P wave If the electrode is in both the atrium and the ventricle, the spike is before both the P wave and QRS complex **The spike should be followed by a P wave indicating atrial depolarization, or a QRS complex indicating ventricular depolarization; this pattern is referred to as "capture", indicating that the pacemaker successfully depolarized, or captured, the chamber Cardiac Dysrhythmias Part 2 Questions With Complete Solutions Describe the modes of failure (failure to capture) - correct answerPacemaker initiates an impulse, but the stimulus is not strong enough to produce depolarization **A PACING SPIKE MAY BE PRESENT, BUT P WAVES OR QRS COMPLEXES OR BOTH ARE ABSENT. CAUSED BY PACER LEAD DAMAGE, BATTERY FAILURE, DISLODGEMENT OF ELECTRODES, ELECTRICAL CHARGE SET TOO LOW, FIBROSIS OF ELECTRODE TIP; FAILURE TO CAPTURE CAN RESULT IN BRADYCARDIA OR ASYSTOLE What is the nursing management of PPM? - correct answerAntibiotics prior to and after insertion Assess site of insertion (assess for bleeding, signs of infection) Immobilize extremity for at least 24 hours No movement above shoulder or posteriorly for about 4 weeks Cannot get incision wet until healed (4 to 7 days) CXR to determine lead placement and assess for pneumothorax IV access on the side the pacemaker is to be implanted Typically discharged the day after a PPM is implanted **HR ACCEPTABLE RANGE 55-65 IF SET AT 60 INTERROGATION OF THE PACEMAKER PRIOR TO DISCHARGE Describe modes of failure (failure to sense) - correct answerOccurs when the pacemaker fires randomly at any point during the cardiac cycle instead of at the indicated or appropriate time **THE PACEMAKER FAILS TO DETECT PREVIOUS ELECTRICAL ACTIVITY, AND THE PACEMAKER FIRES INAPPROPRIATELY. THE ECG TRACING SHOWS RANDOM PACEMAKER SPIKES APPEARING THROUGHOUT THE ECG TRACING. CAN CAUSE VT. CAUSED BY FIROSIS AROUND TIP OF PACING LEAD, BATTERY FAILURE, SENSING SET TOO HIGH, DISLODGEMENT OF ELECTRODE What are some complications of pacemakers? - correct answerDislodgement and migration of endocardial leads Wire breakage Infection and hematoma formation at insertion site Interference with pacemaker function by exposure to electromagnetic fields (MRI equipment, metal detectors at airports, store security systems) Perforation of myocardium or RV by pacing lead Battery failure Pneumothorax What is some patient education for pacemakers? - correct answerCheck pulse daily, report increase/decrease Cardiac Dysrhythmias Part 2 Questions With Complete Solutions Carry ID card Request hand scanning at security check points Should not hold hand held device over PPM site Avoid electromagnetic fields Periodic generator checks Teach to report increased body temperature or arm pain Avoid direct blows to pacemaker site Consider pacemaker support group ***ELECTRICAL EQUIPMENT AROUND THE PATIENT SHOULD BE PROPERLY GROUNDED PPM- DOCUMENT MODEL, DATE AND TIME OF INSERTION, LOCATION OF PULSE GENERATOR, STIMULATION THRESHOLD, PACER RATE NEED TO HAVE PACER FUNCTION CHECKED REGULARLY (OFFICE, TELEPHONE, CELL PHONE APPLICATIONS TO MONITOR) Describe an implantable cardioverter defibrillator (ICD) - correct answerAn electrical device used in the treatment of tachydysrhythmias Capable of identifying and terminating life-threatening ventricular dysrhythmias What are ICD use for? - correct answerFor patients who have: Survived SCD Have spontaneous sustained VT Have syncope with inducible VT or VF during EPS Are at high risk for future life threatening dysrhythmias (cardiomyopathy) **USE OF ICDS HAS DECREASED MORTALITY IN THESE PATIENTS Describe the ICD system - correct answerLead system placed via subclavian vein transvenously to endocardium Sensing electrodes to recognize the dysrhythmia (recognizes VT, VF, set to recognize certain rate) Defibrillation electrodes or patches that are in contact with the heart and can deliver a shock These electrodes are connected to a generator that is surgically implanted (battery powered pulse generator placed subcutaneously over pectoral muscle on patient's non- dominant side) **EVERY ICD IS ALSO A PACEMAKER BUT NOT EVERY PACEMAKER IS AN ICD CAN PROVIDE OVERDRIVE PACING FOR SVT AND SOMETIMES VT THERE IS NOW A SUBCUTANEOUS ICD (S-ICD); PULSE GENERATOR UNDER SKIN TO THE LEFT SIDE OF THE CHEST; ELECTRODE PLACED UNDER SKIN ABOVE STERNUM; NO PACING ABILITY; JUST SHOCK IF VT OR VF DELIVERS 25 JOULES AND CAN DELIVER THE SHOCK MULTIPLE TIMES