Relias Dysrhythmia Basics Test Chapter 34 Dysrhythmias

Key Features Sustained Tachydysrhythmias, Brady dysrhythmias Chart 34-1 page 672 - *chest discomfort, pressure, pain (may radiate) *restlessness, anxiety, nervousness, confusion *dizziness, syncope *palpitations (tachydysrhythmias) *change in pulse strength, rate, rhythm *pulse deficit *SOB, dyspnea *tachypnea *crackles *orthopnea *S3/S4 *weakness, fatigue *cool, pale skin, diaphoresis *N/V *decreased UO *delayed cap refill *hypotension Care of the Patient with Dysrhythmias Chart 34-2 page 672 - *Assess vital signs at least every 4 hours and as needed. *Monitor patient for cardiac dysrhythmias. *Evaluate and document the patient's response to dysrhythmias. *Encourage the patient to notify the nurse when chest pain occurs. *Assess chest pain (OLDCARTS/PQRST) *Assess peripheral circulation (peripheral pulses, edema, capillary refill, color, and temperature) Nursing Safety Priority Action Alert page 673 Tachycardia - Assess for fatigue, wekaness, SOB, orthopnea, decreased SpO2, increased pulse rate and decreased BP; also assess for restlessness/anxiety (decreased cerebral perfusion) and decreased UO (impaired renal perfusion) Assess for anginal pain, palpitations EKG may show T wave inversion or ST elevation/depression (myocardial ischemia) Nursing Safety Priority Action Alert page 675 Permanent Pacemaker Teaching - *keep cellphones at least 6 inches away fromt he generator, and use ear opposite the side of the generator *avoid sources of strong electromagnetic fields (magnets, telecommunications transmitters) as these could change pacemaker settings *MRI is usually contraindicated *carry a pacemaker ID card and wear a Medic-Alert bracelet Common Examples of Drug Therapy Chart 34-4 page 677 Drug Class I: Na Channel Blockers - Sub-classes A (disopyramide), B (lidocaine, mexiletine, tocainide), C (felcanide, propafenone) Block sodium channels; slow or prolong conduction Common Examples of Drug Therapy Chart 34-4 page 677 Drug Class II: Beta Blockers - Only 4 are approved for treating dysrhythmias: propanolol acebutolol, esmolol, sotalol Reduce calcium entry; decrease conduction velocity Reduce rate through SNS activity Common Examples of Drug Therapy Chart 34-4 page 677 Drug Class III: Potassium Channel Blockers - Prolong repolarization Block potassium channels: prolong rest period sotalol, amiodarone, dronedarone, ibutilide, dofetilide Common Examples of Drug Therapy Chart 34-4 page 677 Drug Class IV: Calcium Channel Blockers - Block calcium entry; decrease contractility Slow AV conduction; reduce rate verapamil, diltiazem Common Examples of Drug Therapy Chart 34-4 page 677 Class: OTHER - Digoxin (a-fib, a-flutter), atropine (bradycardia), adenosine (SVT) Nursing Safety Priority Drug Alert page 678 Adenosine - Side effects include significant bradycardia with pauses (even period of asystole), N/V Have emergency equipment readily available Nursing Safety Priority Action Alert page 680 A-fib and clotting - At risk for PE due to blood pooling from ineffective atrial contraction; monitor for SOB, CP and/or hypotension and initiate RRT and HCP Also at risk for embolic stroke; monitor for S&S of stroke If valvular disease is also present, at risk for VTE; monitor for LE pain, swelling. Anticipate doppler u/s and anticoagulation. Nursing Safety Priority Drug Alert page 680 Anti-coagulation - Teach patients to report bruising, bleeding nose or gums, or other signs of bleeding to HCP immediately Nursing Safety Priority Critical Rescue page 681 Cardioversion - For safety before cardioversion, turn oxygen off and away from patient to prevent fire; shout CLEAR before shock delivery Considerations for Older Adults page 682 Patient Centered Care-Dysrhythmias - Older adults at increased risk for dysrhythmias (SA node has fewer pacemaker cells) May require pacemaker Most common dysrhythmias: PVCs and a-fib Dysrthymias are more serious in older adults as they are r/t underlying heart disease in which blood flow to major organs is already decreased (also due to aging) Nursing Focus on the Older Adult, Dysrhythmias Chart 34-5 page 682 - *evaluate immediately for life-threatening dysrhythmia or hemodynamic deterioration *assess for angina, hypotension, HF, and decreased renal/cerebral perfusion *assess for hypoxia, drug toxicity, electrolyte imbalance, HF, and MI *assess patient's level of understanding, hearing, learning style, and ability to understand/recall/read instructions *teach the patient trade and generic names of drugs and their purpose, dosage, side effects, instructions *provide clear written instructions *provide a written dosage schedule *assess for side effects/adverse reactions *teach patient how to take their pulse and to repsort changes to their HCP and where to get BP checked *teach the importance of keeping follow up appointments *include family members when possible *teach to avoid ETOH, nicotine, caffeinated beverages, and to follow prescribed diet Patient and Family Education: How to Prevent/Decrease Dysrhythmias Chart 34-6 page 682 Risk for Vasovagal Attacks/Bradycardia - Avoid doing things that stimulate the vagus nerve: *raising arms overhead *applying pressure to carotids or eyes *bearing down/straining during a BM *stimulating the gag reflex when brushing teeth Patient and Family Education: How to Prevent/Decrease Dysrhythmias Chart 34-6 page 682 Premature Beats/Ectopic Rhythms - *takes meds as prescribed and report adverse effects *stop smoking, avoid caffeine and energy drinks *ETOH in moderation *learn ways to manage stress and avoid fatigue Patient and Family Education: How to Prevent/Decrease Dysrhythmias Chart 34-6 page 682 Ischemic Heart Disease - *treat angina attacks promptly with NTG and rest to decrease possibility of dysrhythmia *Seek medical help if CP does not resolve after NTG or if it becomes more severe and/or you experience associated symptoms Patient and Family Education: How to Prevent/Decrease Dysrhythmias Chart 34-6 page 682 Potassium Imbalance - *know the symptoms of hypokalemia (muscle weakness, cardiac irregularity) *eat foods high in potassium (tomatoes, beans, prunes, avocados, bananas, strawberries, lettuce) *take potassium supplements as prescribed Nursing Safety Action Alert page 684 PVCs - Because other dysrhythmias can cause widened QRS complexes, assess whether premature complexes perfuse to the extremities Palpate the carotid, brachial, or femoral arteries while obseriving the monitor for widened complexes or aucultating apical HS. With acute MIs, these may be considered as a warning, possibly triggering v-tach or v-fib. Nursing Safety Priority Critical Rescue page 684 V-tach (VT) - In some patients, v-tach causes cardiac arrest. Assess circulation, airway, breating, LOC, and SpO2. For the stable patient with sustained VT, give oxygen and confirm rhythm with EKG. Amiodarone, lidocaine, or mag can be given Nursing Safety Priority page 686 Critical Rescue Defibrillation/VT VF - Early defibrillation is critical to resolve PULSELESS ventricular dysrhythmias in order to increase chances of survival; DO NOT DELAY! Do not defibrillate asystole! 1. Command all present to CLEAR before delivering shock 2. Deliver shock and immediately resume CPR for 5 cycles (2 minutes) 3. Reassess rhythm every 2 minutes 4. Charge defibrillator to deliver an additional shock at the same energy level previously used 5. During CPR, administer ACLS meds and interactions Dysrhythmias to know by sight for NCLEX Mark K - NSR V-tach V-fib Asystole Terminology: QRS Mark K - ventricular Terminology: P Mark K - atrial Terminology: "chaotic" Mark K - fibrillation Terminology: "bizarre" Mark K - tachycardia Lethal dysrhythmias: no cardiac output Mark K - Asystole V-fib NOTE: you have 8 minutes or LESS to correct V-tach Mark K - Life-threatening dysrhythmia with SOME cardiac output; can convert to v-fib at any time Treatment for ventricular dysrhythmias (PVCs, V-tach) Mark K - AMIODARONE (lidocaine is cheap and has long shelf life so rural EMS still uses it) Supraventricular dysrhythmias (atrial dysrhythmias): ABCDs' of treating atrial dysrhythmias Mark K - A: Adenosine: push in 8 seconds and use a big vein (fast IVP "slam" unlike the usual IVP "if you don't know, go slow" rule); be prepared for asystole for 30 seconds, but don't worry! They'll come out of it. B: Beta blockers (-lol) negative inotrope/chronotrope/dromotrope C: CCBs negative inotrope/chronotrope/dromotrope D: Digoxin (digitalis) Treatment for V-fib - Defibrillate, CPR Treatment for asystole - First epinephrine, then atropine (first and last letters of "asystole" in reverse order), CPR Cardiac Action Potential Cycle: Phase 0 - Influx of sodium Depolarization of atria (P wave) Cardiac Action Potential Cycle: Phase 1 - Outflow of potassium PR interval Cardiac Action Potential Cycle: Phase 2 - Influx of calcium (necessary for contraction strength) Ventricular depolarizatin (QRS complex) Cardiac Action Potential Cycle: Phase 3 - Potassium exchange Start of ventricular repolarization (ST segment, T wave) Cardiac Action Potential Cycle: Phase 4 - Influx of chloride Ventricular repolarization is complete (end of T wave, start of next P wave)