MedSurg 2 Exam 1

MSK, Cardio, EKGs

Osteomyelitis

Infection of bone

—usually staph aureus

………..

Hematogenous = spread to bone from bloodstream

—more common in children

Non-hematogenous = open fracture or bone trauma

—more common in adults

………..

Risk Factors

-Under 20, over 50

-Puncture wounds, pressure wounds, open wounds after injury/trauma

-Surgeries involving joints or implanted devices

-Weakened immune system

—sickle cell, diabetes, dialysis

…………

Clinical Manifestations

-pain not relieved by rest

-warmth, swelling, tenderness, fever

-nausea, malaise

…………

Diagnostics

-XR, CAT, MRI

-CBC, electrolytes, liver/kidney function

—bleeding?: Hg, RBC, Hct, platelet, PT, INR PTT

………….

Medications

Antibiotics ABX

-usually start broad, IV for 4-6week, bridge to oral

—penicillin PCN: PO, IM, IV

—cephalosporins: PCN allergy is contraindication, phlebitis, pain at IM injection site

—vancomycin: ototoxic, nephrotoxic, admin over 60min, blood test for trough levels, IV extravasation

—fluoroquinolones: with food but no dairy, Achilles tendon rupture, photosensitivity, caution in older adults

-culture before starting

-check bowel function & C.dif, contraceptives & pregnant & breastfeeding

..

Pain Control

-usually opioids

..

Multivitamins

-vitamin C, zinc, iron, thiamine, folic acid

…………………

Complications

-sepsis, amputations, tumors

—Assess: vitals, pain, wound, neurovascular, labs, cultures

…………………

Nursing Interventions

-thermal therapy

-gentle ROM exercises

—avoid contractures & atrophy

-education: meds, high protein diet

Neurovascular Assessment

When suspicious of compromised blood flow or nerve damage

………………………

Pain

Poikilothermic = different temp than rest of body

Paresthesia = numbness & tingling

Paralysis

Pulselessness

Pallor

Thermal Therapy

Heat: injuries after first 72 hr

-chronic pain, stiffness, soreness

—increase blood flow, relax muscles

………………..

Cold: acute injuries within first 72 hr

-injuries, inflammation

—restrict blood flow, reduce inflammation/swelling, pain

Amputations

Severing/removing extremity

………….

Closed = skin flap sutured over end of residual limb

Open = no skin flap, close at a later date

—active infection present, avoid osteomyelitis

…………

Risk Factors

-traumatic injury, thermal injury

-chronic disease: peripheral vascular disease, diabetes

-infection, malignancy

……………………………

Managing Traumatic

-life threatening

-control bleeding, tourniquet, blood transfusion

—no longer than 6 hr

-trauma assessment

Managing Elective

-last resort

—cultures, hyperbaric oxygen, percutaneous transluminal angioplasty, anticoagulants

…………………………….

Complications

-severe bleeding, hypoperfusion, hypovolemic shock

-infection, sepsis, death

-contractures, delayed wound healing

-phantom limb therapy

—weakens over time, push down toward bed supported on pillow

—antidepressants, anticonvulsants, mirror therapy

..

-neuromas = clumps of nerves regenerating after amputation

—can interfere with prothesis

..

-flexion contracture = due to improper position

—more likely at hip or knee

—prevent with ROM exercises & standing with good posture

…………………..

Nursing Interventions

-For Traumatic

—apply direct pressure, elevate about heart

—severed extremity in clean cloth, place in sealed bag, submerge in ice water

-assess for non-healing incision

—risk of osteomyelitis

…………..

Education

-wrapping limb with compression dressing

—1-3day post op

—figure 8 technique

Fractures

Close/simple = doesn’t break skin surface

Open/compound = disrupt skin integrity, open wound & tissue injury

..

Displaced = bone fragments are not in alignment

Non-displaced = bone fragments remain in alignment

..

Pathological = bone weak from disease

—osteoporosis, cancer

Fatigue/Stress = excess strain from activities

………………..

RED FLAG = lack of pulse/perfusion

-yellow, red drainage = concerning

…………………….

Diagnostics

-XR, CT, MRI, Bone Scan

Fracture Treatment

Treatment = depends on type/location

Reduction

-Closed = use traction pulling force to realign bone before immobilizing, usually under sedation

-Open = incision in skin, plates/screws/pints/rods, internal or external fixation

—External: pin care every 8-12hr, weeping clear fluid is normal for first 48-72 hr

…..

Weakness/discomfort for weeks to months

Restrict heavy lifting for 4-6 weeks

…………………..

Traction

-usually pre-OR to reduce swelling

-Orders: type of traction, amount of weight, can it be removed for nursing care?

—Weight comes off?: Notify provider

-Manual = pulling force applied by the hands

-Skin = pulling force applied by rope attached by straps/cuffss

—lighter weigh 5-10 lb

—Buck’s traction

-Skeletal = secured to bone with screws

—longer traction time than skin, heavier weights 15-30 lb

—Halo

…

Traction Nursing Interventions

-Assess neurovascular

—every 1 hr in first 24 hr, every 4 hr after 24 hr

-Weights are free hanging/not on floor

—accidentally displaced?: first replace, notify provider

-With halo: move as a unit without applying pressure to rods

-heat for muscle spasms

…………………..

Pin Care

-chlorohexidine, one swab for each pin

-once a shift

…………………….

Splints & Casts

-Splint = removable

—monitoring swelling & integrity

—support area until it can be casted once swelling decreases

-Cast = more effective since non-removable

—applied after swelling to prevent compartment syndrome

—plaster = heavy, not water resistant, takes 24-72hr to dry

—fiberglass, lighter, water resistant, 30min to dry, most common

…

Splints & Casts Nursing Interventions

-neurovascular every 1hr for first 24hr

-ice first 24-48 hr

-elevate cast during first 24-48hr to prevent edema

-one finger between skin & cast

-inspect cast every 8-12 hr

-monitor for drainage

…

Splint & Cast Teaching

-no foreign objects inside cast, no powder/deodorant

-itching relieved via blowing cool air from hair dryer on cast

-cover in plastic when bathing/showering

-if too loose post-swelling, may need replacement

-report areas under cast that are painful

—hot spot, increased drainage, warm to touch, odor, feels to tight, cast damage

Fracture Complications

Compartment Syndrome = EMERGENCY

-increased pressure, compress/restrict BV, tissue hypoxia

—hypoxia causes tissue death, increases capillary permeability causing more fluid

-neuromuscular damage occurs within 4-6hr

-permanent damage, loss of limb

..

-From external source or internal compartment

—tight cast, constrictive dressing

—blood/fluid in muscle compartment

..

Frequent neurovascular checks

Notify Ortho IMMEDIATELY

Relieve pressure on extremity

Prepare for surgery = fasciotomy

………………………………………………………….

Fat Embolism = rare

-most common in hip facture or 72hr post-pelvic fracture

—long bone fractures within 12-48 hr

-fat gets into circulation

-cutaneous petechiae on neck, chest, upper arms, abdomen

..

Notify provider

Bed rest

Oxygen, steroids, vasopressors, fluid, antianxiety

…………………………………………………………..

Rhabdomyolysis = crush/compression injuries

-muscle compression/ischemia, death, myoglobin released, kidneys can’t filter it & function effectively

—longer compression = more muscle breakdown, also too much exercise

..

Dark tea colored urine, flank pain

Fluids, monitor for myoglobin/CPK

-high CPK = rhabdo

-can cause other imbalances: hyperkalemia, hypo/hypercalcemia

Sprains & Strains

Strains = injury to muscle/tendon

-excessive stretching, pull muscle, tendon weak/unstable

-types

—first degree = mild, ROM not affected, mild inflammation, little bleeding

—second degree = moderate, partial tearing, impaired motor function

—third degree = severe, rupture of muscle/tendon, internal bleeding, surgical repair

…….

Sprains = excessive stretching of ligament

-types

—first degree = minimal tear, joint function intact, can still ambulate

—second degree = joint intact, difficulty with ambulation

—third degree = complete tear, unable to ambulate

…………………………….

Diagnosis & Treatment

-RICE

—rest for 72hr, ice 20min 3-5X day for first 72hr, compression, elevate

-Brace if ordered, typically 4-6 weeks

-surgery: immobilization & PT for 4-6 weeks

…………………………….

Complications

-chronically unstable joints

-bursitis = inflammation of bursa

-tendonitis = inflammation of tendon

-frequent recurrence

-altered mobility/ADLs

-compartment syndrome

Joint Replacement/Arthroplasty

Arthroplasty = surgical removal of joint & replacement with prosthetic/artificial component

-Total = replace all components of joint

-hemi = half joint replacement

—femoral neck fractures

………….

From degenerative disease or osteonecrosis

-arthritis is leading cause

…………

Typically lasts 10-15 yr

………..

Presentation pre-procedure

-pain with weight bearing on joint

-joint crepitus/stiffness

-joint swelling

……………………………………..

Contraindications:

-recent or active infection

-arterial impairment to affected extremity

-inability to follow postsurgical regimen

-Comorbidity

—uncontrolled diabetes/hypertension

—advanced osteoporosis

—progressive inflammatory condition

—unstable cardiac/respiratory conditions

…………………………………….

Complications

-hypotension, bleeding, hypovolemia

-wound infection, venous thromboembolism, heterotrophic ossification

-dislocation

………………………………………

Nursing Interventions

-anti-embolic stockings, SCDs

-avoid pillows behind knee = no flexion contracture

-abduction pillow

-float heels

-continuous passive motion CPM machine

—promote motion & circulation in knee & prevent scar tissue

—turn off during meals

…………………………………………

Education

-Before surgery

—scrub surgical site with antiseptic soap before & morning of

—clean clothes & clean sheets night before

—NPO

—autologous blood donation before

-Home Post-Op

—20-30min exercise 2-3X day during early stages

—raised toilet, pull bars in bathroom

—don’t flex hip past 90deg for 2-3month

Bone Cancer

Benign or malignant

..

Primary bone cancer more prevalent between 10-30

-Ewing’s sarcoma = most common in children, most malignant

Secondary more prevalent in elderly

..

Osteochondroma = benign tumor, most common bone cancer

Osteosarcoma = rare, poor prognosis

—men, older population, Paget’s disease

……………………………

Clinical Manifestations

-pain worsens with motion, unrelieved by rest, pain at night

-limping gait, decreased ROM

-swelling, redness

-fractures with patterns inconsistent with mechanism of injury

-fever malaise, weight loss when metastasizes

…………………………..

Diagnosis

-medical history, exposure to radiation

-CT, MRI, bone scan

-labs: alk phos, LD, ESR, calcium

-bone biopsy = DEFINITIVE diagnosis

………………………….

Complications

-amputation, osteomyelitis, surgical complication

-hypercalcemia

-metastasis, death

Paget’s Disease

second most common bone disease

-accelerated bone remodeling

—structurally abnormal bone, reduced in strength

—risk of fracture or deformities

—most common: skull, femur, tibia, pelvic bones, vertebrae

…………….

Risk Factors

-white, men, over 55yo, genetics

……………..

Clinical Manifestations

-80% initially asymptomatic

—usually not confirmed until fracture

-depends on severity & location

-pain & deformity in affected site

—bone deformity, nerve impingement, degenerative disease

-calcium & phosphate imbalance

—neuro & cardio issues

………………..

Diagnosis

-usually incidental

—high alkaline phosphatase, XR

-biochemical assay of bone turnover

-bone scan = MOST SENSITIVE TEST

-XR, CT

-thermography = noninvasive, painless

—infrared camera detects increased temp = increased blood flow

-check serum calcium

…………………

Management

-treat symptoms, not curative

—decrease pain, increase functionality, decrease fracture risk

-replacements, spinal decompression/stabilization, osteotomy, tumor removal

-calcitonin, bisphosphonates/zoledronic acid

………………..

Complications

-enlargement of bone: skull, mandible, maxilla

-bowleg/knock knee

—varus is knees out, valgus/valgum = knees together

-fractures

-secondary degenerative changes

-primary bone tumors = osteosarcoma

………………

Nursing Interventions

-therapy therapy

-exercise abs/back muscles

-vitamin D, calcium

…………….

…………………..

Cardiac Conduction System

SA node, AV node, Bundle of His, Purkinje fibers

-SA node = atria

-AV node = delay before ventricular systole

-Bundle of His = down interventricular septum

-Right Bundle = right ventricle, Left = left ventricle

—Purkinje fibers spread into ventricles

………..

Pacemaker Cells = automaticity, create action potential

-fastest rate of depolarization determines heart rhythm

-majority in SA node

—primary = generate impulse rate 60-100X a min, spread to surrounding myocytes

-AV node = 40-60 bpm, Bundle of His = 20-40 bpm

-latent = can’t complete depolarization before impulse travels from SA to AV node

……………..

Sympathetic = increase SA firing rate, increase HR

Parasympathetic = decrease SA firing rate & HR

Electrocardiogram EKG

Detects dysrhythmias, muscle damage, electrolyte abnormalities, cardiac hypertrophy

…………

5 Lead Placement

-white on right, over green

-brown chocolate near my heart

-black smoke over fire

…………..

Limb Lead Placement, 10 leads

-V1, V2, V4, V3, V5, V6

—V1 = 4th ICS, right of sternum

—V2 = 4th ICS, left of sternum

—V4 = 5th ICS, mid-clavicular line

—V3 = between V2 and V4

—V5 = level with V4, anterior axillary line

—V6 = level with V4, mid-axillary line

……………………………………………………

don’t place over implanted devices

clean, dry, free from oil/lotion

skin prep & gauze, clippers to remove hair

Heart Contraction

P wave = atrial depolarization

-initiated by SA node

-contraction occurs a millisecond after

-right then left

……

Impulse delayed by AV node

…….

Q wave = depolarization of interventricular septum

-moves downward, left to right

R wave = early ventricular depolarization

-largest wave

S wave = final ventricular depolarization

-moves from bottom of ventricles up

……..

T wave = ventricular repolarization

-last to depolarize = first to repolarize

Analyzing EKGs

Ticks = 3 second intervals

-5 large boxes = 1 sec

-1 small box = 0.04sec, 1mm high

………………………………………………………….

Regularity

-Tip of R wave to tip of R wave

—regular or irregular?

—varies by 1.5 SMALL boxes or less

…..

Rate

-For regular rhythms

—R to R = ventricular rate

—P to P = atrial rate

—1500/# small boxes = rate bpm

-For irregular rhythms

—count complexes in 6 sec, multiply by 10

…..

P Wave

-present?, one per QRS?, discernible?, upright/round?

—duration under 0.12sec

—amplitude under 2.5mm

……

PR Interval

-beginning of P wave to beginning of QRS

—normal = 3-5 small box, 0.12-0.2sec

-may vary between complexes

…….

QRS complex

-beginning of Q to end of S

—normal = 0.04-0.10 sec

EKG Irregularities

Tall P wave = right atrial strain

—right atrial enlargement, P pulmonale

—pulmonary hypertension

……………

Absent P wave = atrial fibrillation

……………

Widened QRS = over 0.12sec

—bundle branch block, electrolyte imbalance, drug toxicity

…………….

Peaked T wave = hyperkalemia

AV Blocks

1st Degree AV Block

-Normal rate & rhythm, P wave, QRS complex

-PR interval = prolonged, over 0.2sec

—prolonged delay at AV node, usually benign

-Causes: older age, MI, CAD, hyperthyroidism, electrolyte imbalance

—drugs = digoxin, beta blockers, calcium channel blockers

…………………………………………………………..

2nd Degree AV Block Type 1 = Wenckebach

-Irregular rate & rhythm

—under 60 bpm

-PR interval = longer, longer, longer, drop QRS

-QRS = normal shape & duration

-Causes: digoxin, beta blockers, CAD, myocardial ischemia, AV node ischemia

-Treatment

—Asymptomatic = transcutaneous pacemaker, vitals, EKG, O2

—Symptomatic = atropine, temporary pacemaker

……………………………………………………………..

2nd Degree AV Block Type 2 = Mobitz 2

—not all SA impulses conduct to ventricles

-slower rate, irregular rhythm

-P wave = excessive

-PR interval = prolonged, 1 for every QRS

-QRS = widened, preceded by 2+ P waves

-Causes: CAD, MI, rheumatic fever, drug toxicity

-Symptoms: poor perfusion symptoms

-Treatment = temporary pacemaker

—permanent if symptomatic: angina, hypotension

………………………………………………………….

3rd Degree AV Block

—no impulses from atria conducting to ventricles

—AKA complete heart block

-Rate

—atrial = 60-100, vent = under 40

-Rhythm = irregular, PR interval = inconsistent

-P wave = normal but no connection to QRS

-QRS = normal or widened, no connection to P wave

-Causes: CAD, MI, myocarditis, scleroderma, digoxin, beta blockers, CCBs

-Increased Risk of: Ischemia, HF, shock, asystole, death

-Treatment: PERMANENT PACEMAKER

—dopamine, epinephrine to increased HR until pacing

Atrial Fibrillation, Afib

Erratic electrical activity in atria

-quiver instead of contract effectively

-overwhelm AV node

—irregular, rapid heartbeat

……..

Over 65yo

Surgery/cardiac procedures

Severe mitral valve dx, acute MI, HTN, CAD

Thyrotoxicosis, CKD, obesity, diabetes, COPD

Pericarditis, Cardiomyopathy

………………………………………….

Decreased cardiac output

Chest pain, PALPITATIONS

Dizziness, lightheadedness, SYNCOPE

Diaphoresis, anxiety

Reduced exercise tolerance

SOB, weakness, fatigue

..

May be ASYMPTOMATIC

……………………………………….

Irregularly irregular rhythm

Atrial rate = 350-400 bpm, vent = variable but slower

P wave, PR interval = NOT DETECTABLE

QRS complex = usually normal

…

under 100 bpm = controlled afib

over 100 bpm = uncontrolled

—afib with rapid ventricular rate = afib with RVR = IMMEDIATE INTERVENTION

………………………………………..

Treatment

-Rate Control

—calcium channel blockers = slow AV node conduction

—beta blockers = slow HR, decrease workload, decrease O2

-Rhythm Control

—antiarrhythmic, amiodarone

—cardioversion: old digoxin 48hr prior, synchronized at peak R wave

-Oxygen therapy

……………………………………….

Complications

-thromboembolic risk = blood pooling in atria

—increased clot or stroke risk

-heart failure

—diastolic hf due to impaired ventricular filling

—systolic hf due to weakened ventricles

-Decreased cardiac output

—loss of atrial contraction/kick, reduce CO by 30%

-compensatory tachycardia

—try to maintain CO by increasing HR

—increased workload = ventricular hypertrophy/dilation

—remodeling weakens heart = CHF

Sinus Rhythms

Normal Sinus Rhythm

—originates in SA node

-60-100 bpm, regular rhythm

-P wave precedes each QRS

-PR interval = consistent, 0.12-0.2sec

-QRS following each P wave = under 0.12sec

………………….

Sinus Bradycardia

-Rate under 60bpm

-Symptoms = often asymptomatic

—dizziness, syncope, hypotension

—anxiety, chest pain, SOB, diaphoresis

-Causes

—hypoxia, hypothermia, sleep, athletes

—electrolyte imbalance

—med toxicity = digoxin, CCB

-Treatment

—supplemental oxygen

—atropine 0.5mg IV push to increase SA node

—pacemaker

………………………

Sinus Tachycardia

-Rate = 100-180 bpm

-Symptoms = can by asymptomatic

—dizziness, lightheadedness, syncope

—SOB, diaphoresis, anxiety, hypotension, palpitations

-Causes

—fever, infection, stimulants

—anemia, PE, MI

—hypotension, hypovolemia, electrolyte imbalance

-Treatment for HR under 150bpm

—observe for decompensation

-Treatment for over 150bpm

—vagal maneuvers = carotid massage

—beta blockers = decrease cardiac workload, O2 demand

—defibrillator pads

Tachycardias

Supraventricular Tachycardia SVT

-Regular rhythm, vent rate = 150-250 bpm

-P wave = not discernible, merged with T wave

—PR interval = not measurable

-QRS = normal, narrow

….

Life-threatening dysrhythmia

-death if felt untreated

Severe CO reduction

-maintain pulse & BP for limited time

….

Causes

-hypovolemia, hypoxia, hypothermia, hypoglycemia

-acidosis, hypo/hyperkalemia, toxins

-MI, PE, cardiac tamponade

….

Paroxysmal = intermittent, sudden onset, resolves quickly

…………………………………………………………..

Ventricular Tachycardia V-Tach

-Rhythm

—atrial = unmeasurable, vent = usually regular

-Vent Rate = 150-250 bpm

-P wave = absent, PR interval = unmeasurable

-QRS complex = 0.12sec +, wide & bizarre

…

Ventricular ectopic focus fires repeatedly

LIFE THREATENING

decreased cardiac output

…..

Causes

-MI, CAD, cardiomyopathy, PE, cardiac tamponage

-electrolyte imbalance, drug toxicity, acidosis

-CNS disorders

-hypovolemia, hypoglycemia, hypoxia, hypothermia

………………………………

Stable Patients = has pulse

-Symptoms

—dizziness, lightheadedness, syncope, hypotension

—diaphoresis, anxiety, SOB, palpitations

-Treatment

—vagal maneuvers

—antiarrhythmic meds

—cardioversion

….

Unstable Patients = no pulse

-Symptoms

—unresponsive, no pulse, no BP

-Treatment

—CPR, defibrillate, epinephrine

—vasopressin as alternate to epinephrine

—antiarrhythmic meds

Atrial Flutter

Rate = wide range

—tachydysrhythmia

-atrial = 250-300 bpm

-vent = varies, slower than atria

..

Rhythm = regular, QRS = normal

PR interval = unmeasurable

..

P wave = sawtooth pattern

…………………………………………………………

A flutter vs A fib

-same rhythm

-A flutter quivers slower so P waves are visible

—sawtooth pattern P waves

…………………………………………………….

Risk of blood clots due to blood pooling

…………………………………………………….

Causes

-CAD, hypertension, mitral valve disorders, PE, cardiomyopathy

-hyperthyroidism

-drugs: digoxin, epinephrine, quinidine

…………..

Treatment

-radiofreq catheter ablation

-cardioversion if unstable

…………..

Medications

-calcium channel blockers

-beta blockers

-antidysrhythmics

-anticoagulants

Premature Contractions

Premature Atrial Contractions PACs

-underly normal sinus NSR

-pacemaker cells near SA fire earlier than expected

—compensatory pause during reset

…

Causes

-hypoxia, CAD

-stimulants: caffeine, infection, digoxin tox

…

Treatment

-monitor frequency

-address/eliminate cause

…………………………………………………………

Premature Ventricular Contractions PVCs

-underly normal sinus NSR

-wide & bizarre QRS complexes

—early fire within ventricles

—compensatory pause during reset

..

Causes

-hypoxia, CAD, MI, cardiomyopathy, HTN

-electrolyte imbalances

-recreational drug use

-stimulants: caffeine, infection, digoxin tox

..

Symptoms

-dizziness/lightheadedness, syncope, hypotension

-SOB, diaphoresis, anxiety, palpitations

..

Treatment

-treat causes

-assess LOC, pulses, VS

Ventricular Fibrillation V-fib

No rate, P wave, PR interval, or QRS

Irregular & chaotic rhythm

…………………….

No CO

ventricles are quivering without contraction

…………………….

Signs & Symptoms

-unconscious

-No HR, BP, apneic

……………………..

Causes

-MI, PE, cardiac tamponade

-hypoxia, hypovolemia, hypothermia, hypoglycemia

-toxins, acidosis, hypo/hyper K

…………………….

Treatment

-immediate CPR, ACLS, O2

……………………

Medications

-epinephrine

—vasopressin as alternate

-amiodarone

-antiarrhythmics

Cardioversion VS Defibrillation

Synchronized Cardioversion

-delivers LOW dose synchronized shock during R wave of QRS complex

-V tach with pulse, a flutter, A fib

…………………………………..

Defibrillation

-asynchronous shock, HIGH dose

-V fib, pulseless V tach

……………………………………………………….

All clear before discharging

Never apply defib pads over pacemaker

Synchronizer switch only ON during cardioversion

Idioventricular Rhythm

When SA & AV nodes fail

-rhythm is generated by ventricles

…………………

Rhythm

-atrial = unmeasurable, vent = usually regular

Rate = under 40 bpm

-can be up to 100 in accelerated or AIVR

P wave = absent, PR interval = unmeasurable

QRS = 0.12sec or greater, wide & bizarre, uniform

…………………..

Causes

-MI, post-cardiac arrest, myocarditis, cardiomyopathy, congenital heart disease

-electrolyte imbalance, drug toxicities

……………………..

Symptoms

-dizziness, lightheadedness, syncope

-hypotension, decreased LOC

-SOB, diaphoresis, anxiety, palpitations

Asystole

FATAL if not converted

..

no measurable electrical activity

-can be confused with very fine V fib

—check more than 1 lead

……………

Symptoms

-Unresponsive, no HR, no BP

…………..

Treatment

-CPR, epinephrine

Pacemakers

Monitor vital signs, rhythm, & insertion site

………………………………………………………….

Transcutaneous = external, pads on skin

-spike BEFORE QRS

-sedation often needed

………………..

Transvenous = wire inserted into RV

-connects to external pacer via IJ vein

-spike BEFORE QRS
………………..

Transthoracic = surgically placed wire in atria or ventricle

-exits skin, connects to external pacer

-spike depends on atria or ventricles

—spike BEFORE P = atria

—spike BEFORE QRS = ventricular

…………………………………………………………….

Atrial Pacing = wire in atrium

-spike before P wave

….

Ventricular Pacing = wire in ventricle

-spike before QRS complex

…..

Biventricular Pacing = wires in BOTH ventricles

-double spikes before QRS complex

…..

Dual Chamber Pacing = wires in atria & ventricles

-spike before P wave & QRS

Dual Chamber pacemakers

AKA AV Pacemaker

…..

Coordinates atrial & ventricular contraction

-mimics normal AV sequence

-atrial lead spikes before P wave, ventricular lead spikes before QRS

……

Bradyarrhythmia, AV block, sinus node dysfunction

Bi-ventricular pacemakers

Cardiac Resynchronization Therapy CRT

…..

Synchronize right & left ventricular contraction

-leads in right atrium, right ventricle, & left ventricle

-DOUBLE SPIKES before QRS

……

heart failure, bundle branch block

Pacemaker Malfunction

Intermittent loss of capture = no EKG rhythm occasionally after pacemaker spikes

……….

Failure to capture FTC = no EKG rhythm EVER after pacemaker spikes

Cardiac Assessment

Symptomatic = immediate response & evaluation of cause

Asymptomatic = observe & evaluate

………………………………………

Decreased CO = hypotension

Compensatory SOB & tachypnea

SNS response = diaphoresis

Chest pain

Poor perfusion = weak pulses, weak extremities, delayed cap refill

Edema = due to poor contractile function

N/V = due to low-flow state, shunting from gut