Ch. 26 Management of Patients With Dysrhythmias and Conduction Problems

What are dysrhythmias?

Disorders of formation or conduction (or both) of electrical impulses within heart

Can cause disturbances of

Rate

Rhythm

Both rate and rhythm

Potentially can alter blood flow and cause hemodynamic changes

Diagnosed by analysis of electrographic waveform

What is the normal electrical conduction system?

SA node (sinoatrial node): 60-100 bpm

AV node (atrioventricular node):

Conduction: transmission of electrical impulses from one cell to another

Bundle of His

Right and left bundle branches

Purkinje fibers

Depolarization = stimulation = systole

Repolarization = relaxation = diastole

How does the sympathetic system affect the heart rate?

Sympathetic (adrenergic): Increases

increases heart rate (positive chronotrophy)

Increases conduction through the AV node (Positive dromotropy)

Increases force of myocardial contraction (positive inotrophy)

Constricts peripheral blood vessels = increase BP

How does the parasympathetic system affect the heart rate?

Parasympathetic: Reduces

Reduces heart rate (negative chronotrophy)

Reduces AV conduction (negative dromotropy)

Reduces the force of myocardial contraction

Dilation of arteries = lowers BP

What is the electrocardiogram? (ECG)

Electrode placement

Electrode adhesion: gently abrade the skin, reduces impedance

Types of ECG: electrophysiology (EP) study: electrodes placed inside the heart, open heart surgery: temporary pacemaker wires sutured to the epicardium and brought out the chest wall

Lead: electrodes create an imaginary line, reference point

ECG Interpretation

Impedance: resistance to electrical signal conduction and detection of electrical current

Artifact: distorted, irrelevant & extraneous ECG waveform

What is the p wave?

P wave: impulse starting in the SA node and spreading through the atria (atrial depolarization), 0.11 seconds or < in duration

What is the QRS complex?

QRS complex: ventricular depolarization, < than 0.12 secs

What is the T wave?

T wave: ventricular repolarization/cells regain a negative charge/resting state

What is the U wave?

U wave: rare: repolarization of the Purkinje fibers, hypokalemia, hypertension or heart disease

What is the PR interval?

PR interval: beginning of the P wave to the beginning of the QRS complex: time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization. 0.12-0.20 seconds duration

What is the ST wave?

ST segment: early ventricular repolarization, lasts from the end of the QRS complex to the beginning of the T wave: isoelectric, is it above or below the isoelectric line?

What is the QT segment?

QT interval: total time for ventricular depolarization and repolarization, beginning of the QRS to the end of the T wave, 0.32-0.40 seconds duration. If the QT becomes prolonged, risk for ventricular dysrhythmia called torsades de pointes

What is the TP interval?

TP interval: end of the T wave to the beginning of the next P wave

What is the PP interval?

PP interval: measured from the beginning of one P wave to the beginning of the next P wave, used to determine atrial rate and rhythm

What is the RR interval?

RR interval: one QRS complex to the next, used to determine ventricular rate

How to determine heart rate with a strip?

A 1-minute strip contains 300 large boxes and 1500 small boxes, count the number of small boxes within an RR interval and divide 1500 by that number

10 small boxes between RR interval is 1500/10=150 bpm

25 small boxes between RR interval is 1500/25=60 bpm

How to determine if a wave is irregular?

Rhythm irregular: count the number of RR intervals in 6 seconds and multiply that number by 10, top of the ECG paper is marked in 3-second intervals, 15 large boxes horizontally

Find a R wave that peaks on a heavy black line (start line), heavy lines, count 300, 150, 100, 75, 60, 50

How to analyze an ECG strip?

1. Determine the ventricular rate

2. Determine the ventricular rhythm

3. Determine the QRS duration

4. Is the QRS duration consistent throughout the strip

5. Identify QRS shape

6. Identify P waves: is there a P in front of every QRS?

7. Identify P wave shape, is it consistent?

8. Determine the atrial rate

9. Determine the atrial rhythm

10. Determine the PR interval

11. Are the PR intervals consistent, irregular but with a pattern or just irregular?

12. How many P waves for every QRS complex

What is normal sinus rhythm?

Ventricular and atrial rate: 60-100 bpm

Ventricular and atrial rhythm: Regular

QRS shape and duration: Usually normal, but may be regularly abnormal

P wave: normal and consistent shape; always in front of the QRS

PR interval: consistent interval between 0.12 and 0.20 secs

P:QRS ratio 1:1

What is sinus bradycardia?

Sinus Bradycardia: SA node creates an impulse at a slower than normal rate

Ventricular and atrial rate: less than 60 bpm

Ventricular and atrial rhythm: regular

QRS shape and duration: usually normal, but may be regularly abnormal

P wave: normal and consistent shape, always in front of QRS

PR interval: consistent interval between 0.12 and 0.20 seconds

P:QRS ratio: 1:1

What are the causes of sinus bradycardia?

Causes: lower metabolic needs (sleep, athlete, hypothyroidism, vagal stimulation (vomiting, suctioning), medications (calcium channel blockers, amiodarone, beta-blockers), idiopathic sinus node dysfunction, increased intracranial pressure, CAD especially MI of the inferior wall

What is the TX and the symptomatic of sinus bradycardia?

TX: no symptoms, observe

Symptomatic: hemodynamically compromised=sob, alterations of mental status, angina, hypotension, ST-segment changes, PVCs

Treatment=increasing the HR, 0.5 mg of atropine IV every 3-5 minutes (total dose 3 mg), possible pacing

What is sinus tachycardia?

Ventricular and atrial rate: > than 100 bpm, usually < 120 bpm

Ventricular and atrial rhythm: regular

QRS shape and duration: usually normal, but may be regularly abnormal

P wave: normal and consistent shape; always in front of the QRS

PR interval: consistent interval between 0.12-0.20 seconds

P:QRS ratio: 1:1

What are the causes of sinus tachycardia?

Causes: does not start or end suddenly. As the HR increases, the diastolic filling time decreases=reduced CO=syncope and low blood pressure. May develop acute pulmonary edema

What is the TX and stability of sinus bradycardia?

TX: severity of symptoms and directed at the cause.

Hemodynamically unstable: synchronized cardioversion

Stable: vagal maneuvers, adenosine (wide QRS and uniform shape and ventricular rhythm regular)

Narrow QRS: beta-blockers, calcium channel blockers

What is sinus arrhythmia?

Ventricular and atrial rate: 60-100 bpm

Ventricular and atrial rhythm: irregular

QRS shape and duration: usually normal

P wave: Normal and consistent shape; always in front of the QRS

PR interval: consistent interval between 0.12 and 0.20 secs

P:QRS ratio: 1:1

Sinus node creates an impulse at an irregular rhythm

Rate usually increases with inspiration and decreases with expiration

Heart disease and valvular disease (rare)

What is the premature atrial complex?

Ventricular and atrial rate: depends on the underlying rhythm

Ventricular and atrial rhythm: irregular due to early P waves

QRS shape and duration: the QRS that follows the early P wave is usually normal

P wave: an early and different P wave may be seen or may be hidden in the T wave, other P waves in the strip are consistent

PR interval: the early P wave has a shorter than normal PR interval, but still between 0.12-0.20 secs

P:QRS ratio: usually 1:1

What should be avoided for premature atrial complex? and what is the treatment?

Very common

Single ECG complex that occurs earlier than normal

Caffeine, alcohol, nicotine, stretched atrial myocardium (hypovolemia), anxiety, hypokalemia, hypermetabolic states (pregnancy), atrial ischemia, injury, or infarction

Often seen with sinus tachycardia

Treatment: infrequent=no treatment

frequent > than 6/min, worsening disease state or onset of a more serious dysrhythmia (atrial fibrillation), treat the underlying cause

What is the atrial flutter?

Ventricular and atrial rate: atrial rate ranges between 250-400 bpm: ventricular rate usually ranges between 75-150 bpm

Ventricular and atrial rhythm: the atrial rhythm is regular; the ventricular rhythm is usually regular but may be irregular because of a change in the AV conduction

QRS shape and duration: usually normal

P wave: saw toothed shape; these waves are referred to as F waves

PR interval: multiple F waves may make it difficult to determine the PR interval

P:QRS ratio: 2:1, 3:1 or 4:1

What are some treatments for irregularities in heart?

Vagal maneuvers or adenosine (causes sympathetic block and slowing of conduction in the AV node, rapidly administered IV, followed by 20 cc saline flush, elevation of the arm

Does not terminate within 2 minutes, another larger dose of adenosine may be given

s/s: chest pain, sob, low BP

Electrical cardioversion

If rhythm has lasted longer than 48 hours, TEE shows no clot, anticoagulation may be indicated before cardioversion or ablation

Antithrombotic therapy same as atrial fibrillation

What is atrial fibrillation?

Ventricular and atrial rate: atrial rate is 300-600 bpm, ventricular rate is usually 120-200 bpm in untreated AF

Ventricular and atrial rhythm: highly irregular

QRS shape and duration: usually normal

P wave: no discernible P waves; irregular undulating waves, vary in amplitude and shape, fibrillatory or f waves

PR interval: cannot be measured

P:QRS ratio: Many:1

What is atrial fibrillation? what is the coordination? what are some risk factors?

Uncoordinated atrial electrical activation=rapid, disorganized, and uncoordinated twitching of atrial musculature. Ventricular rate depends on the ability of the AV node to conduct the atrial impulses

Acute, chronic, paroxysmal (occurs suddenly), persistent, and permanent

Most common sustained dysrhythmia, over 2 million people in the US, exact cause unknown

Risk factors: increasing age, male gender, higher BMI, systolic blood pressure > 160 mm Hg, hypertension, PR interval > 160 milliseconds, clinically significant heart murmur (grade 3 or higher), heart failure

What is the medical management of atrial fibrillation?

Medical management

history and physical exam: identify pattern of a-fibrillation, associated symptoms, underlying condition

12-lead ECG: ventricular hypertrophy, pre-excitation from accessory pathways, intraventricular conduction defects, history of MI

ECHO: assess cardiac chamber size, thickness, and function, identify potential causes, ie. Cardiomyopathy, valvular dysfunction, presence of a thrombus

Blood tests: thyroid, renal, hepatic function when the ventricular rate is difficult to control

What is some ways to assess for atrial fibrillation? chest xray? exercise test? holter monitor? EP study

Patients undergoing cardiac surgery with pacing wires attached, ECG assists in diagnosing a-fib and differentiating it from other common dysrhythmias.

Chest xray: evaluate pulmonary vasculature

Exercise test: assess rate control and myocardial ischemia

Holter monitor

EP study

What is some treatment for heart dysrhythmias?

Depends on the cause, pattern and duration, ventricular response rate, patient's symptoms, age and comorbidities

Rhythm control (conversion to sinus rhythm) vs rate control

Some studies: controlling rate (<80 bpm) equivalent to controlling rhythm in terms of quality of life, hospitalizations for heart failure and incidence of stroke

Some convert on their own

Electrocardioversion necessary if hemodynamically unstable

What are some medications and cardioversions?

Warfarin for 4 weeks after cardioversion

Before cardioversion perhaps: Amiodarone, flecainide, ibutilide, propafenone, sotalol to enhance cardioversion

ECG monitoring for 4 hours after procedure

Wolff-Parkinson-White (WPW) syndrome: QRS wide, ventricular rhythm very fast and irregular, atrial fibrillation with an accessory pathway should be suspected (congenital tissue between the atria, His bundle, AV note, Purkinje fibers or ventricular myocardium.

Beta-blockers: control the rate

The nurse is preparing a male patient to have a 12-lead ECG performed. When prepping the skin the nurse notices that the patient has abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads?

Use alcohol swabs to cleans the skin before applying the leads.

Clip the chest hair with the patient's permission before applying the leads.

Apply the leads to the arms and legs only.

Reschedule the ECG.

Clip the chest hair with the patient's permission before applying the leads.

Rationale: Alcohol should not be used to prep the skin because it increases the skin's electrical impedance, thereby hindering the detection of the cardiac electrical signal. Clipping the hair would provide access to the skin to assist with adhesion. The ECG would not be performed correctly if the leads were only placed on the extremities, and there is no need to reschedule the ECG at this time.

What is the junctional rhythm?

Ventricular and atrial rate: Ventricular rate 40-60 bpm; atrial rate also 40-60 bpm if P waves are seen

Ventricular and atrial rhythm: Regular

QRS shape and duration: Usually normal

P wave: May be absent, after the QRS complex, or before the QRS, may be inverted, especially in Lead II

PR interval: If the P wave is in front of the QRS, the PR interval is less than 0.12 secs

P:QRS ratio: 1:1 or 0:1

If s/s reduced CO, treatment same as Bradycardia, pacing may be needed

What is nonparoxysmal junctional tachycardia?

Caused by enhanced automaticity in the junctional area, looks like junctional, but faster, rate of 70-120 bpm

No detrimental hemodynamic effect

May indicate serious underlying condition

Digitalis toxicity

Myocardial ischemia

Cardioversion not effective because NJT caused by automaticity

What is Atrioventricular Nodal Reentry Tachycardia?

Ventricular and atrial rate: Atrial rate usually 150-250 bpm; ventricular rate usually 120-200 bpm

Ventricular and atrial rhythm: regular; sudden onset and termination of the tachycardia

QRS shape and duration: usually normal

P wave: usually very difficult to discern

PR interval: if the P wave is in front of the QRS, the PR interval is less than 0.12 secs

P:QRS ratio: 1:1, 2:1

What is Atrioventricular Nodal Reentry Tachycardia definition? goals? catheter ablation? vagal maneuvers?

When an impulse is conducted to an area in the AV node that causes the impulse to be rerouted back into the same area over and over again at a very fast rate

Usually benign, aim of therapy is to break the reentry of the impulse

Goal is to alleviate symptoms and improve quality of life

Catheter ablation: eliminate the area that permits the rerouting of the impulse that causes the tachycardia

Vagal maneuvers: carotid sinus massage, gagging, breath-holding, immersing the face in ice water

Adenosine, calcium channel blockers, cardioversion

What is Ventricular Dysrhythmias/Premature Ventricular Complex/PVC?

Ventricular and atrial rate: depends on the underlying rhythm (sinus rhythm)

Ventricular and atrial rhythm: irregular due to early QRS creating one RR interval that is shorter than the others. The PP interval may be regular, indicating that the PVC did not depolarize the sinus node

QRS shape and duration: duration is 0.12 seconds or longer; shape is bizarre and abnormal

P wave: visibility of the P wave depends on the timing of the PVC

PR interval: if the P wave is in front of the QRS, the PR interval is less than 0.12 secs

P:QRS ratio: 0:1, 1:1

What is ventricular tachycardia?

3 or more PVCs in a row, occurring at a rate >100 bpm.

Patients with larger MIs and lower ejection fractions are at higher risk of lethal VT

VT is an emergency, patient is usually unresponsive and pulseless

What is ventricular tachycardia definition?

Ventricular and atrial rate: Ventricular rate is 100-200 bpm; atrial rate depends on the underlying rhythm

Ventricular and atrial rhythm: usually regular; atrial rhythm may also be regular

QRS shape and duration: duration is 0.12 secs or more; bizarre, abnormal shape

P wave: very difficult to detect, so the atrial rate and rhythm may be undeterminable

PR interval: very irregular, if P waves are apparent

P:QRS ratio: difficult to determine, but if P waves are present, there are usually more QRS complexes

What is ventricular fibrillation?

Ventricular rate: greater than 300 bpm

Ventricular rhythm: extremely irregular, without a specific pattern

QRS shape and duration: irregular, undulating waves without recognizable QRS complexes

Medical management: no heart beat, no pulse, no respirations, cardiac arrest and death if not corrected

Early defibrillation is critical to survival

CPR until defibrillator is available

What is ventricular fibrillation after the initial defibrillation?

After the initial defibrillation, 5 cycles of CPR/rhythm check and defibrillation

Epinephrine every 3-5 minutes

Vasopressin, amiodarone, lidocaine, ?magnesium

Refractory v-fib=amiodarone

Current guidelines=inducing mild hypothermia in comatose adults who experience cardiac arrest. 32-34 degrees, started as soon as possible after circulation is restored for 12-14 hours

What is the most common dysrhytmia? most common cause?

Most common dysrhythmia in patients with cardiac arrest

Rapid, disorganized ventricular rhythm

Ineffective quivering of the ventricles

No atrial activity

Most common cause of v-fib is CAD and resulting acute MI

Untreated or unsuccessfully treated VT, cardiomyopathy, valvular heard disease, several proarrhythmic medications, acid-base and electrolyte abnormalities, electrical shock

What is the Idioventricular Rhythm/ventricular escape rhythm?

Ventricular rate: between 20-40 bpm; if the rate exceeds 40 bpm=accelerated Idioventricular rhythm

Ventricular rhythm: regular

QRS shape and duration: bizarre, abnormal shape; duration is 0.12 secs

Patient will lose consciousness, s/s of reduced CO

Tx same as for asystole and pulseless electrical activity (PEA)

Epinephrine, atropine, vasopressor, transcutaneous pacing

What is the first degree AV block?

Ventricular and atrial rate: depends on the underlying rhythm

Ventricular and atrial rhythm: depends on the underlying rhythm

QRS shape and duration: usually normal

P wave: in front of the QRS complex; shows sinus rhythm, regular shape

PR interval: Greater than 0.20 secs; PR interval measurement is constant

P:QRS ratio: 1:1

What is the 2nd degree AV block, type I, Wenekebach?

Repeating pattern in which all but one of a series of atrial impulses are conducted through the AV node into the ventricles

Ventricular and atrial rate: depends on the underlying rhythm, ventricular rate lower than the atrial rate

Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying NSR

QRS shape and duration: usually normal

P wave: in front of the QRS complex

PR interval: The PR interval becomes longer with each succeeding ECG complex until there is a P wave not followed by a QRS.

P:QRS ratio: 3:2, 4:3, 5:4, and so forth

What is the Second Degree AV Block, Type II?

Ventricular and atrial rate: depends on the underlying rhythm, ventricular rate is lower than the atrial rate

Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm. RR interval is usually regular but may be irregular

QRS shape and duration: usually abnormal

P wave: in front of the QRS complex

PR interval: the PR interval is constant for those P waves just before the QRS complexes

P:QRS ratio: 2:1, 3:1, 4:1, 5:1 and so on

What is the third degree heart block?

3rd Degree HB/Nobody is talking to each other/This is medical emergency=temporary pacing

No atrial impulse is conducted through the AV node into the ventricles

Two impulses stimulate the heart; one stimulates the ventricles and one stimulates the atria

Ventricular and atrial rate: depends on the escape rhythm and underlying atrial rhythm

Ventricular and atrial rhythm: the PP interval is regular and the RR interval is regular, but the PP interval is not equal to the RR interval

QRS shape and duration: depends on the escape rhythm; with junctional rhythm, QRS shape and duration are normal

P wave: depends on the underlying rhythm

PR interval very irregular

P:QRS ratio: more P waves than QRS complexes

How to assess and care for someone with dysrythmia?

Causes of dysrhythmia, contributing factors

Assess indicators of cardiac output and oxygenation

Health history: include presence of coexisting conditions, indications of previous occurrence

All medications (prescribed and OTC)

Psychosocial assessment: patient's "perception" of dysrhythmia

What is the physical assessment of someone with a dysryhtmia?

Physical assessment include

Skin (pale and cool)

Signs of fluid retention (JVD, lung auscultation)

Signs of decreased CO (altered LOC)

Rate, rhythm of apical, peripheral pulses

Heart sounds

Blood pressure, pulse pressure

How to diagnose someone with dysrhythmia?

Decrease cardiac output

Anxiety r/t fear of the unknown

Deficient knowledge about the dysrhythmia and its treatment

What are some Collaborative Problems and Potential Complications with dysrhythmias?

Cardiac arrest

Heart failure

Thromboembolic event, especially with atrial fibrillation

What are the Goals of caring a patient with dysrhythmias?

Goals

Eradicating or decreasing occurrence of dysrhythmia to maintain cardiac output

Minimizing anxiety

Acquiring knowledge about dysrhythmia and its treatment

What are some nursing interventions with someone with a dysrhythmia?

Monitor and manage the dysrhythmia

Minimize anxiety

Promote home- and community-based cared

Educate the patient

Continuing care

What are some Nursing Intervention: Monitor and Manage the Dysrhythmia?

Assess vital signs on an ongoing basis

Assess for lightheadedness, dizziness, fainting

If hospitalized

Obtain 12-lead ECG

Continuous monitoring

Monitor rhythm strips periodically

Antiarrhythmic medications

"6-minute walk test" nurse observes to identify patient's ventricular rate in response to exercise

How to minimize anxiety in patients ?

Stay with patient

Maintain safety and security

Discuss emotional response to dysrhythmia

Help patient develop a system to identify factors that contribute to episodes of the dysrhythmia

Maximize the patient's control

How to promote home and community based care?

Educate the patient

Treatment options

Therapeutic medication levels

How to take pulse before medication administration

How to recognize symptoms of the dysrhythmia

Measures to decrease recurrence

Plan of action in case of an emergency

CPR (family)

What is the referral for home care?

Referral for home care

Hemodynamically unstable with signs of decreased CO

Significant comorbidities

Socioeconomic issues

Limited self-management skills

Electronic device recently implanted

How to evaluate a patient for dysrhythmias?

Maintain cardiac output

Stable VS, no signs of dysrhythmia

Experience decreased anxiety

Positive attitude, confidence in ability to act if an emergency occurs

Express understanding of dysrhythmia and treatment

The nurse is assessing a patient admitted with a heart block. When placed on a monitor, the patient's electrical rhythm displays as progressively longer PR durations until there is a nonconducted P wave. Which type of heart block does the nurse expect that this patient has?

First degree

Second degree, type I

Second degree, type II

Third degree

Second degree, type I

Rationale: In first-degree heart block, the PR is constant but greater than 0.20 seconds. Second-degree AV block, type II has a constant PR interval and the presence of more P waves than QRS complexes. Third-degree AV block presents with irregular PR intervals.

What are some adjunctive modalities and management?

Used when medications alone are ineffective against dysrhythmia

Pacemakers

Cardioversion

Defibrillation

Nurse responsible for assessment of the patient's understanding regarding the mechanical therapy

What are pacemakers?

Electronic device that provides electrical stimuli to heart muscle

Types

Permanent: implanted into chest during surgery

Temporary: used to support until permanent one implanted

What is pacemaker language?

NASPE-BPEG code for pacemaker function: page 719

1st letter: chamber or chambers to be paced, A, V or D (dual)

2nd letter: chamber/s being sensed by pacemaker generator A,V,D,O(off)

3rd letter: type of response: I(inhibited), T (triggered), D (dual), O (none)

4h letter: generator's ability to vary the heart rate, O (no rate responsiveness), or R (rate modulation)

5th letter: 1multisite pacing capability with the letters A, V, D, and O

Example: D,V,I= both the atrium and the ventricle have a pacing electrode in place, the pacemaker is sensing the activity of the ventricles only and the pacemaker's stimulating effect is inhibited by ventricular activity

What are complications of pacemaker use?`

Infection: local infection at the entry site of the leads (temporary), or at the subcutaneous site for permanent generator placement. Prophylactic antibiotics

Pneumothorax: use of safe sheaths helps/hemothorax from puncture of the subclavian vein or internal mammary artery

Bleeding or hematoma formation

Dislocation/movement of the lead placed transvenously (perforation of the myocardium)

Skeletal muscle or phrenic nerve stimulation: (hiccupping)

Cardiac tamponade

Pacemaker malfunction

Pacemaker syndrome: Hemodynamic instability caused by the ventricular pacing and the loss of AV synchrony

What is Implantable Cardioverter Defibrillator (ICD)?

Device that detects and terminates life-threatening episodes of tachycardia and fibrillation

Patients who have survived life-threatening episodes of tachycardia or fibrillation

People with CAD 40 days post acute MI with moderate to severe L ventricular dysfunction, nonischemic dilated cardiomyopathy, symptomatic, recurrent, medication refractory atrial fibrillation

NASPE-BPEG code: page

Antitachycardia pacing

What is Nursing Management (After Permanent Electronic Device Insertion) ?

ECG assessment

CXR

Nursing assessment

CO and hemodynamic stability

Incision site

Signs of ineffective coping

Level of knowledge and education needs of family and patient

What is Cardioversion and Defibrillation?

Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial cells

When cells repolarize, sinus node usually able to recapture role as heart pacemaker

In cardioversion, current delivery synchronized with patient's ECG

In defibrillation, current delivery is unsynchronized

What are some safety measures? defib?

Ensure good contact between skin, pads, and paddles

Use conductive medium, 20 to 25 pounds of pressure

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

If cardioverting, turn synchronizer on

If defibrillating, turn synchronizer off

Do not charge device until ready to shock

Call "clear" three times;

I'm clear, you're clear, Oxygen clear

Ensure no one is in contact with patient, bed, or equipment

What must a patient with an automatic ICD do?

Continue to go through metal-detection devices at the airport

Call for assistance when blood pressure increases

Document events that trigger a shock sensation

Be compliant with all of the above-listed interventions

Document events that trigger a shock sensation

Rationale: The patient with an automatic ICD must document events that trigger a shock sensation. The patient must avoid magnetic fields such as metal-detection devices at the airport and should call for emergency assistance when feeling dizzy.

What are some Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias?

Electrophysiological studies

Ablation

Cardiac conduction surgery

Maze procedure: open heart surgical procedure for refractory atrial fibrillation. Small incisions made throughout the atria with scar tissue development=prevention of reentry conduction

Catheter ablation therapy