ATI - Outline

Overview of Cardiac Monitoring

Cardiac electrical activity can be monitored using an electrocardiogram (ECG) to assess heart rhythm and detect abnormalities.

Types of Cardiac Monitoring

1. 12-Lead ECG

   • Provides a comprehensive view of the heart's electrical activity from 12 different angles.

   • Commonly used in emergency and diagnostic settings.

2. Ambulatory ECG (Holter Monitoring)

   • Portable device worn by the client to monitor heart activity continuously for 24-48 hours or longer.

   • Used to detect intermittent arrhythmias.

3. Continuous Cardiac Monitoring

   • Used in critical care settings to monitor the heart's rhythm and electrical activity in real-time.

4. Telemetry

   • Remote monitoring system that allows healthcare providers to observe the heart's electrical activity from a distance.

Indications for Cardiac Monitoring

Cardiac monitoring is used to:

• Diagnose dysrhythmias, chamber enlargement, myocardial ischemia, injury, or infarction.

• Monitor the effects of electrolyte imbalances or medication administration.

Electrocardiography (ECG)

• Records the electrical activity of the heart over time.

• Does not detect symptoms like shortness of breath (SOB), chest pain, or other manifestations of acute coronary syndrome.

Client Education:

• Clients should report any new or worsening manifestations immediately.

Indications for Dysrhythmias

Common dysrhythmias include:

• Sinus bradycardia and sinus tachycardia

• AV block

• Atrial fibrillation

• Ventricular asystole

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

• Supraventricular tachycardia (SVT)

• Ventricular fibrillation

Client Presentation (Risk Factors for Dysrhythmias)

• Cardiac disease

• Myocardial infarction (MI)

• Hypoxia

• Acid-base imbalance

• Electrolyte imbalances

• Kidney failure, liver disease, or lung disease

• Pericarditis

• Drug or alcohol use

• Hypovolemia

• Shock

Considerations for ECG Procedures

Preprocedure

Nursing Actions:

• Prepare client for 12-lead ECG.

• Position the client supine with chest exposed.

• Wash the client’s skin to remove oils.

• If the client is hairy, clip (do not shave) the area to ensure skin adherence and electrical conduction.

• Attach one electrode to each of the client's extremities on flat surfaces above the wrists and ankles.

• Place the other six electrodes on the chest, avoiding chest hair.

Electrode Placements:

• Right Arm (RA)

• Right Leg (RL)

• Left Arm (LA)

• Left Leg (LL)

Intraprocedure

Nursing Actions:

• Monitor for manifestations of dysrhythmias (e.g., chest pain, decreased LOC, SOB, hypoxia).

Client Education:

• Instruct the client to remain still and breathe normally during the ECG.

Postprocedure

Nursing Actions:

• Remove leads from the client, print the ECG report, and notify the provider.

• Apply a Holter monitor if the client requires continuous cardiac monitoring or is on a telemetry unit.

• Continue to monitor the client for dysrhythmias.

Rhythm Analysis Steps:

1. Determine heart rate (HR).

2. Determine whether the HR is regular or irregular.

3. Analyze the P waves for regularity and shape.

4. Measure the PR interval for consistency (normal: 0.12 to 0.20 seconds).

5. Measure the QRS duration for consistency in appearance.

6. Examine the ST segment; depression or elevation is unexpected.

7. Assess the T wave.

8. Measure the QT interval.

Cardioversion

• Elective treatment for atrial dysrhythmias, supraventricular tachycardia, and ventricular tachycardia with a pulse.

• Preferred treatment for symptomatic patients.

Defibrillation

• Indicated for ventricular fibrillation or pulseless ventricular tachycardia.

Considerations

Preprocedure

• Clients with atrial fibrillation of unknown duration require at least 3 weeks of anticoagulation before cardioversion to reduce thromboembolism risk.

Nursing Actions:

• Explain the procedure and obtain informed consent.

• Administer oxygen.

• Document the preprocedural rhythm.

• Ensure emergency equipment is available.

• Hold digoxin for 48 hours prior to elective cardioversion.

Intraprocedure

Nursing Actions:

• Administer sedation.

• Ensure proper placement of leads and correct joule settings.

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

• Ensure all staff stand clear when delivering a shock.

• Cardioversion requires activation of the synchronizer button to ensure the shock aligns with the client's rhythm; failure to synchronize can lead to lethal dysrhythmias like ventricular fibrillation.

• Perform CPR if the client develops asystole or ventricular rhythms.

• Defibrillate immediately for ventricular fibrillation.

• Administer prescribed antidysrhythmic agents or other medications as ordered.

• Monitor for pulmonary or systemic emboli post-cardioversion.

Postprocedure

Nursing Actions:

• Monitor vital signs, airway patency, and obtain an ECG.

• Provide oxygen.

• Assess level of consciousness (LOC).

• Administer prescribed medications.

• Check for chest burns under electrodes.

• Offer reassurance and emotional support to the client and family.

Documentation:

• Record the postprocedure rhythm.

• Document the number of attempts, energy settings, time, and client’s response.

• Note the client’s condition and consciousness following the procedure.

• Assess the client’s skin condition under the electrodes.

Client Education

• Follow instructions on checking your pulse.

• Report any palpitations or irregularities.

Complications

Embolism

• Cardioversion may dislodge clots, leading to:

  • Pulmonary embolism: Dyspnea, chest pain, air hunger, and decreased SaO2.

  • Cerebrovascular accident (CVA): Decreased LOC, slurred speech, and muscle weakness/paralysis.

  • Myocardial infarction (MI): Chest pain, ST segment changes.

Nursing Action:

• Administer therapeutic anticoagulation for clients with dysrhythmias.

Decreased Cardiac Output and Heart Failure

• Cardioversion may impair heart function, causing:

  • Hypotension, syncope, and increased HR.

  • Symptoms of heart failure: Dyspnea, productive cough, edema, venous distention.

Nursing Actions:

• Administer medications to increase output (e.g., inotropic agents).

• Provide medications to reduce cardiac workload.

Dysrhythmias Treatment

Bradycardia

• Medications: Atropine, dopamine, or epinephrine infusion if unresponsive to atropine.

• Electrical Management: Pacemaker.

Atrial Fibrillation, Supraventricular Tachycardia (SVT), and Ventricular Tachycardia (with a pulse)

• Medications: Amiodarone, adenosine, and verapamil.

• Electrical Management: Synchronized cardioversion.

Ventricular Tachycardia (without a pulse) or Ventricular Fibrillation

• Medications: Amiodarone, lidocaine, and epinephrine.

• Electrical Management: Defibrillation.