ATI - Electrocardiography and Dysrhythmia Monitoring

Cardiac electrical activity can be monitored by used electrocardiogram (ECG).

• 12 lead ECG

• Ambulatory ECG (Holter monitoring)

• Continours cardiac monitoring

• telemetry

Cardiac monitoring is used to diagnose dysrythmias, chamber nelargement myocardial ischemia, injury, or infarction, and to monitor efects of electrolyte imbalance or meciation administration.

Electrocardiography

• used to record the electrical activity of the heart overtime.

• It does not detect SOB, chest pain, or other manifestations of acute coronary syndrome.

  • Client should report new or worsening manifestations

Indications of dysrhythmias

• sinus bradycardia and tachycardia

• AV block

• Atrial fibrillation

• Ventricular asystole

• Premature atrial complexes (PACs) and premature centricular complexes (PVCs)

• Supraventricular tachycardia

• Ventricular fibrilation

Client Presentation

• Cardiac disease

• MI

• Hypoxia

• Acid base imbalance

• Electrolyte imbalances

• Kidney failure, liver, or lung disease

• Pericarditis

• Drug or alcohol

• Hypovolemia

• Shock

Considerations

• Preprocedure

  • Nursing actions - Prepare client for 12 lead ECG

    • Position patient in supine with chest exposed

    • Wash clients skin to remove oils

    • If patient is hairy, clip - do not shave - the area to provide skin adherence and electrical conduction

    • Attach one electrode to each of the clients extremeities by applying electrodes to flat surfaces above the wrists by applying electrodes to flat surfaces above the wrists and ankles and other six electrodes to the chest, avoiding chest hair.

      • PLACEMENTS: RIGHT ARM (RA), RIGHT LEG (RL), LEFT ARM (LA), LEFT LEG (LL)

• Intraprocedure

  • Nursing actions: monitor for manifestations of dysrhythmias (chest pain, decresed LOC, SOB, and hypoxia)

  • Client education: remain still and breathe normally while the 12 lead ecg is performed

• Postprocedure

  • Nursing actions

    • Remove lead from client, print ecg report, and notify the provider

    • apply a holter monitor for the patient (if patient is on a telemetry unit or needs continous cardiac monitoring)

    • Continue to monitor patient for dysrhythmias

    • To conduct rhythm analysis:

      • Determine HR

      • Determine weather the HR is regular or irregular

    • Analyze the P waves for regularity and shae

      • Measure the PR intervalas for consistency (0.12 to 0.20 seconds)

    • Measure the QRS duration and for consistency in appearance

      • Examine the ST segment. Depression or elevation is unexpected

    • Assess the T wave

      • Measure the QT intervals

Cardioversion and Defibrillation

• Cardioversion:

• Defibrillation:

Indications

• Cardioversion: elective treatment of atrial dysrhythmias, supraventricular tachycardia, and ventricular tachycardia with a pulse. Treatment of choice for patients who are symptomatic

• Defibrillation: ventricular fibrillation or pulseless ventricular tachycardia

Considerations

• Preprocedure

  • Patients who have atrial fibrillation of unknown duration must receive adequate anticoagulation for at least 3 weeks prior to cardioversion therapy to prevent dislodgement of thrombi into the bloodstream

  • Nursing action

    • explain the procedure to the client, obtain consent

    • Administer oxygen

    • Document preprocedural 1 rhythm

    • Have emergency equipment available

    • Digoxin is help for 48 hr prior to elective cardioversion

• Intraprocedure

  • Nursing action

    • administer sedation

    • ensure proper placement of leads and machine settings, including joules to be delivered.

    • Monitor the client in a lead that provides an upright QRS complex

    • All staff must stand clear, equipment connected to the client, and the bed when a shock is delivered

    • cardiocersion requires activation of the synchronizer button in addition to charging the machine. this allows shock to be in shock to be in sync with the clients underlying rhythm. Failure to synchornize can lead to deve;opment of a lethal dysthymia, sucha as ventricular fibrillation

    • perform cpr for cardiac asytole for ventricular rhythms

    • defibrillate the patient immedcately for ventricular fibrillation

    • administer a prescribed antidysrhythmic agent or other prescirbed medication

    • monitor patiens for pulmoney or systemic emoboli following cardioversion

• Postprocedure

  • Nursing action

    • after vardioversion or defibrillation, monitor vital signs, assess airway patency, and obtain an ecg

    • provide oxygen

    • assess LOC

    • administer medication as prescribed

    • check for chest burns for electrodes

    • provide family/patient with reassurance and emotional support

    • Document:

      • postprocedure rhythm

      • number of defibrillation or cardioversion attempts, energy settitng, time, and response

      • Condition and state of consciousnness following the procedure

      • skin condition under the electrode

  • Client education

    • Follow intrusctions on checking your pulse

    • report palpations or irregularities

Complications

• Embolism

  • Conversion can dislodge blood clots, potentially causing

    • a pulmonary emolism (evidneced by dyspnea, chest pain, air hunger, and decreasign SaO2)

    • Cerebrovascular accident (evidenced by decreased LOC, slurred speech, and muscle weakness or paralysis)

    • An MI (evidenced by chest pain, ST segment depression or elevation)

  • Nursing action: provide theapeaut anticvoagulation for clients who have dyshythmias

• Decreased cardiac output and heart failure

  • Crdioversion might damage heart tissue and impair heart function

  • Nursing action

    • Monitor manifestations of decreased cardiac output (hypotension, syncope, increased HR) and heart failure (dyspnea, productive cough, edema, venous distention)

    • Provide medications to increased output (inotropic agents) and to decrease cardiac workload

Dysrhythmias treatment

• Bradycardia

  • Medication: atropine, dopamine or epinephrine infusion if unresponsive to atropine

  • Electrical management: pacemaker

• Atrial fibrillation, supraventricular tachycardia, ventricular tachycardia with pulse

  • Medication: amiodarone, adenosine, and verapamil

  • Electrical management: synchronized cardioversion

• Ventricular tachycardia without pulse or ventricular fibrillation

  • Medication: amiodarone, lidocaine, and epinephrine

  • Electrical management: defibrillation