Cardiac Dysrhythmias Part II Exams with 100% correct verified Questions and Answers 2024/2, Exams of Nursing

Download Cardiac Dysrhythmias Part II Exams with 100% correct verified Questions and Answers 2024/2 and more Exams Nursing in PDF only on Docsity! Cardiac Dysrhythmias Part II Exams with 100% correct verified Questions and Answers 2024/2025 Describe treatment of dysrhythmias To 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)? Hypovolemia 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? Bradycardias Tachycardias Pulseless arrest **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 stable, measure QRS Tachycardia may be related to Patient being to "light" after anesthesia (if pupils pinpoint=not "light") Hypovolemic Hyperthermic Early hypoxia or hypercapnia **THE TREATMENT OF TACHYCARDIAS DEPENDS UPON THE PATIENT'S ABILITY TO TOLERATE THE DYSRHYTHMIA. FOR VT MUST KNOW IF PATIENT HAS A PULSE BECAUSE THE ALGORITHMS ARE DIFFERENT DEPENDING ON PULSE OR PULSELESS VT HEART RATES GREATER THAN 100/MIN ARE CONSIDERED TACHYCARDIC. HOWEVER, A DROP IN CARDIAC OUTPUT USUALLY DOES NOT OCCUR UNTIL THE RATE IS GREATER THAN 140 How do you treat unstable tachycardia? Perform immediate synchronized cardioversion (never put pads over pacer or ICD site) (there is a sync button on defibrillator that must be on for synchronized cardioversion; delivers shock on R wave) (use 50-100J biphasic or 100 Joules monophasic) Establish IV access and give sedation if patient is conscious and if there is time Consider expert consultation If patient becomes pulseless, move to comprehensive algorithm (defibrillate) **IF TACHYCARDIC AND UNSTABLE, IMMEDIATE CARDIOVERSION; IF CAN DELAY CARDIOVERSION THEY CHECK FOR A CLOT WITH A TEE DELAYED CARDIOVERSION- ANTICOAGULATION TIMES 3 WEEKS, THEN CARDIOVERSION, THEN ANTICOAGULATION TIMES 4 WEEKS MORE. EARLY CARDIOVERSION- BEGIN IV HEPARIN AT ONCE, THEN TEE TO EXCLUDE ATRIAL CLOT, THEN CARDIOVERSION WITHIN 24 HOURS, THEN ANTICOAGULATION TIMES 4 MORE WEEKS. What should you make sure when shocking a pt? Make sure you're shocking on R wave not during the refractory period Describe biphastic and monophastic shocking Biphasic-goes in two directions- hits heart and goes both ways in the conduction system Monophasic- one direction, requires higher number of Joules (can go all the way up to 200 Joules) What describes an unstable pt? THE PATIENT IS UNSTABLE IF HYPOTENSION, ACUTELY ALTERED MENTAL STATUS, SIGNS OF SHOCK, ISCHEMIC CHEST DISCOMFORT, ACUTE HEART FAILURE. IF THE HEART RATE IS GREATER THAN 150 IT IS VERY LIKELY THAT THE INSTABILITY IS CAUSED BY THE TACHYDYSRHYTHMIA AND NOT SOMETHING ELSE (FEVER, DEHYDRATION, STRESS, ANXIETY...) CAN BE UNSTABLE VENTRICULAR TACHCYCARDIA OR CAN BE SUPRAVENTRICULAR TACHYCARDIA MAY GO TO 200 JOULES FOR MONOPHASIC SYNCHRONIZED CARDIOVERSION How do you treat a stable tachycardic client? Narrow QRS that is regular IV access and 12 lead ECG Consider vagal maneuvers Give adenosine 6 mg rapid IV push. If no conversion, give 12 mg rapid IV push (expect period of asystole after adenosine) Consider expert consultation Control rate- diltiazem (calcium channel blocker), beta-blockers **NARROW-COMPLEX SVTS- JUNCTIONAL TACHYCARDIA, PAROXYSMAL SVT, ATRIAL TACHYCARDIA. ADENOSINE IS AN ANTI-DYSRHYTHMIC THAT SLOWS CONDUCTION THROUGH SA AND AV NODES; HALF LIFE IS 10 SECONDS; MIX IN NS AND PUSH DRUG IN 1-2 SECONDS PATIENT MAY EXPERIENCE DYSCOMFORT AND A FEELING OF WARMTH AND FLUSHING GIVE 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? OXYGEN SATURATION MONITOR, SUCTION DEVICE, IV LINE, INTUBATION EQUIPMENT. What is the treatment of dysrhythmias- pulseless arrest (VF/VT) confirm 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 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? MAY REPLACE 1 DOSE OF EPINHEPHRINE WITH 40 UNITS VASOPRESSIN (ADH AND A PRESSOR) What is Torsades De Pointes? TORSADES 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? NEVER 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 MONOPHASIC 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? Hands free How do you treat asystole/PEA (not shockable)? CPR 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? Describe the pacemaker system Pacing 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 Newer technology- leadless pacemaker that is implanted in the right ventricle ***THE PULSE GENERATOR IS BATTERY POWERED HEART MUSCLE IS "CAPTURED" AND STIMULATED TO CONTRACT MOST PACEMAKERS ARE DEMAND PACEMAKERS; SENSE INTRINSIC HR AND FIRE WHEN HEART'S RATE FALLS BELOW PRESET RATE PACEMAKERS CAN PACE THE ATRIUM AND ONE OR BOTH VENTRICLES THE CIRCUITRY OF THE PACEMAKER IS PROGRAMABLE OFTEN THE LEADLESS PACEMAKER IS FOR ATRIAL FIBRILLATION WITH AV BLOCK What are some things to know about temporary transcutaneous pacemakers? MUSCLE CONTRACTIONS CREATED BY THE PACEMAKER ARE UNCOMFORTABLE USE LOWEST VOLTAGE POSSIBLE TO ACHIEVE CAPTURE WITH MINIMUAL PATIENT DISCOMFORT MIGHT GIVE ANALGESIA OR SEDATION WITH TRANSCUTANEOUS PACEMAKER Describe epicardial wires Epicardial invasive temporary pacing- applied by using a transthoracic approach; the lead wires are loosely threaded on the epicardial surface of the heart after cardiac surgery **Often prophylactic after heart surgery What are some extra things to know about permanent pacemakers? CAN BE REPROGRAMMED IF NECESSARY BY NONINVASIVE TRANSMISSION FROM AN EXTERNAL PROGRAMMER TO THE IMPLANTED GENERATOR. PACEMAKERS ARE POWERED BY A LITHIUM BATTERY THAT HAS AN AVERAGE LIFE SPAN OF 10 YEARS, ARE NUCLEAR POWERED WITH A LIFE SPAN OF 20 YEARS OR LONGER, OR ARE DESIGNED TO BE RECHARGED EXTERNALLY. HAVE CELL PHONE APPLICATIONS NOW THAT CAN MONITOR PACEMAKER FUNCTION Practice exercises for deciphering pacemaker codes A VVIR pacemaker can sense in which chamber(s) of the heart? A VVIR PACEMAKER SENSES ELECTRICAL ACTIVITY ONLY IN THE VENTRICLE. Describe permanent pacemakers Pulse generator is internal and surgically implanted in a subcutaneous pocket under the clavicle, over pectoral muscle on patient's non-dominant side The leads are passed transvenously via the cephalic, subclavian, or jugular vein to the endocardium on the right side of the heart (RA and one or both ventricles) May be single chambered , or may be dual chambered (RA, RV, or RA and RV) It is programmed when inserted and can be reprogrammed if necessary Practice exercises for deciphering pacemaker codes What is the response of an AAI pacemaker to a sensed intrinsic electrical beat? WHEN AN AAI PACEMAKER SENSES AN INTRINSIC ELECTRICAL BEAT IN THE ATRIUM, IT INHIBITS THE GENERATOR FROM FIRING. THIS IS CALLED DEMAND (SYNCHRONOUS) (NON-COMPETITIVE); FUNCTIONS WHEN THE HEART RATE GOES BELOW A SET RATE; DEMAND PACEMAKER INHIBITS PACEMAKER FIRING WHEN THE HR IS OK AND TRIGGERS FIRING WHEN THE HR IS SLOW Practice exercises for deciphering pacemaker codes Can an AOO pacemaker sense in any chamber of the heart? AN 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? Temporary 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 When 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 Describe the modes of failure (failure to capture) Pacemaker 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? Antibiotics 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) Occurs 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? 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 Describe the patient education with an ICD Pathophysiology of underlying disease process Information regarding how the ICD functions Actions to take if a shock occurs Activity limitations related to driving and avoiding strong magnetic fields If hand held screening at airport is used avoid direct contact with ICD site Wear medic alert bracelet Same post implantation education as PPM Follow-up schedule with health care professional CPR training for family members Support groups- to facilitate a positive psychological adjustment to the ICD Avoid direct blows to ICD site If ICD fires contact HCP immediately If ICD fires and patient feels sick, contact emergency response system Caregivers should learn CPR **OK TO WALK THROUGH ANTI-THEFT DEVICES AT STORES BUT SHOULD NOT STAND CLOSE TO THEM FOR AN EXTENDED PERIOD OF TIME **DRIVING AVOIDED UNTIL CLEARED BY HCP. DECISION BASED ON PRESENCE OF DYSRHYTHMIAS, FREQUENCY OF ICD FIRINGS, OVERALL HEALTH AND STATE LAWS REGARDING DRIVERS WITH ICDS IF TWO OR MORE SHOCKS IN 24 HOURS CONTACT ERS EVEN IF FEEL FINE "SICK" MEANS CHEST PAIN/PRESSURE, SHORTNESS OF BREATH, DIZZY, CONFUSED, TACHYCARDIC... Describe radiofrequency ablations Uses electrical energy to burn (ablate) areas in the conduction system to treat tachydysrhythmias Electrophysiology study (mapping) will be completed to identify the source of the dysrhythmia Venous access Post procedure care is similar to post cardiac catheterization **CAN DO SVT, A FLUTTER, ATRIAL FIBRILLATION ABLATIONS CAN HAVE LONGER ANESTHESIA TIME WITH ATRIAL FIBRILLATION ABLATIONS AND SO HAVE TO INSTITUTE POST ANESTHESIA CARE ATRIAL FIBRILLATION ABLATIONS TYPICALLY STAY OVER NIGHT