Exhaustive Guide to Cardiac Care, Arrhythmias, and Transmission-Based Precautions

Calcium Channel Blockers (CCBs)

General Concept: CCBs are described as "Valium for the heart." They function to relax and slow down cardiac activity.
Physiological Effects: These medications exert negative inotropic, chronotropic, and dromotropic effects.
Key Definitions (Positive Effects): * Positive Inotropy: Increases cardiac contractile force. This leads to the ventricles emptying more completely, which improves cardiac output ( $CO$ ). * Positive Chronotropy: Increases the rate of impulse formation at the SA node, which accelerates the heart rate ( $HR$ ). * Positive Dromotropy: Increases the speed at which impulses travel from the SA node to the AV node (increases conduction velocity).
Key Definitions (Negative Effects): * Negative Inotropy: Weakens or decreases the force of myocardial contraction. * Negative Chronotropy: Decreases the rate of impulse formation at the SA node, thereby decelerating the heart rate. * Negative Dromotropy: Decreases the speed at which impulses travel from the SA node to the AV node (decreases conduction velocity).
Indications for Use ("A, AA, AAA"): * A: Antihypertensive (treats high blood pressure). * AA: AntiAnginal drugs (manages chest pain by decreasing oxygen demand). * AAA: AntiAtrialArrhythmia (specifically for treating arrhythmias of atrial origin).
Side Effects: The primary side effects are headache and hypotension.
Nomenclature: Names typically end in the suffix "-dipine" (note: must be "-dipine," not just "-pine"). * Exceptions/Examples: Verapamil and Cardizem (diltiazem). * Administration: Cardizem (diltiazem) is administered as a continuous IV drip.
Nursing Assessment: Assess Blood Pressure ( $BP$ ) before administration. The medication must be held if the Systolic Blood Pressure ( $SBP$ ) is less than $100$ .

Cardiac Arrhythmias: Identification and Interpretation

Essential Cardiac Rhythms to Recognize by Sight: 1. Normal Sinus Rhythm: Characterized by a P wave followed by a QRS complex, followed by a T wave for every complex. The peaks of the P wave are equally distant to the QRS and fall within $5$ small boxes. 2. Ventricular Fibrillation (V-fib): Characterized by a chaotic rhythm with no discernible pattern. 3. Ventricular Tachycardia (V-tach): Characterized by sharp peaks with a discernible pattern (described as "bizarre"). 4. Asystole: Represented by a flat line.
Terminology for Interpretation: * QRS Depolarization: Refers to Ventricular activity. * P Wave: Refers to Atrial activity.
The 6 Most Tested Rhythms on the NCLEX: 1. Asystole: A lack of QRS complexes; a flat line. 2. Atrial Flutter: P waves appearing in a saw-tooth pattern. 3. Atrial Fibrillation (a-fib): Chaotic P wave patterns. (The word "chaotic" is specifically used to describe fibrillation). 4. Ventricular Fibrillation (v-fib): Chaotic QRS complexes. 5. Ventricular Tachycardia (v-tach): Bizarre QRS complexes. (The word "bizarre" is specifically used to describe tachycardia). 6. Premature Ventricular Contractions (PVCs): Periodic wide, bizarre QRS complexes. Short runs of V-tach are referred to as "Salvos of PVCs."
Prioritizing PVCs: * Usually considered low priority. * Moderate Priority Circumstances: * More than $6$ PVCs occur in a single minute. * More than $6$ PVCs occur in a row. * The R on T phenomenon occurs (a PVC falls specifically on a T wave). * Note: PVCs occurring after a Myocardial Infarction ( $MI$ ) are common and remain low priority.
Lethal Arrhythmias: High priority; can lead to death in $8$ minutes or less. * Include: Asystole and Ventricular Fibrillation (V-fib). * Pathophysiology: Both result in low or no cardiac output ( $CO$ ), leading to inadequate brain perfusion, confusion, and death.
Potentially Lethal Arrhythmias: Ventricular Tachycardia (V-tach) is potentially lethal but is distinguished by the fact that it still possesses cardiac output ( $CO$ ).
Clinical Presentation of Cardiac Output ( $CO$ ): * Absent $CO$ : No pulse. * Present $CO$ : Pulse is present.

Treatment and Management of Cardiac Arrhythmias

Ventricular Arrhythmias (PVCs and V-tach): * Primary treatment is Lidocaine. * Amiodarone is the preferred answer for the NCLEX board in modern practice.
Supraventricular (Atrial) Arrhythmias: (Note: "Supra" means above the ventricle). Treated with the "ABCDs": * A: Adenocard (Adenosine): Administered via fast IV push (less than $8$ seconds) followed immediately by a $20\,mL$ Normal Saline ( $NS$ ) flush. Patients will typically go into asystole for approximately $30\,seconds$ before recovering. * B: Beta-blockers: Names end in "-olol." These have negative inotropic, chronotropic, and dromotropic effects and treat "A, AA, AAA." Side effects include headache and hypotension. * C: Calcium Channel Blockers (CCBs). * D: Digitalis (digoxin): Also includes Lanoxin (a digitalis analog).
Lethal Rhythm Specifics: * Ventricular Fibrillation (V-fib): Treatment is Defibrillation ("Defib = Shock em!"). * Asystole: Treatment involves Epinephrine and Atropine.
Quick Treatment Summary: * Atrial: Adena, Beta, Calcium, Dig. * Ventricular: Lidocaine, Amiodarone.

Chest Tubes: Physiology and Management

Purpose: To reestablish negative pressure in the pleural space. Negative pressure allows the lung to stick to the chest wall, facilitating expansion when the chest wall expands.
Anatomy: The pleural space is the area between the visceral pleura (lining the lung) and the parietal pleura (lining the chest wall).
Terminology: * Pneumothorax: Presence of air; chest tube removes air. * Hemothorax: Presence of blood; chest tube removes blood. * Hemopneumothorax: Presence of both air and blood; chest tube removes both.
Chest Tube Placement Locations: * Apical (Top): Designed to remove Air (which rises). * Basilar (Base): Designed to remove Blood or fluid (which settles due to gravity).
Expected Findings vs. Alarms: * Apical Tube: Bubbling (air) is expected; drainage is not. Reporting $300\,mL$ of drainage in the first hour is a bad sign. Reporting no bubbling is a bad sign. * Basilar Tube: Drainage is expected; bubbling is not. Reporting $200\,mL$ of drainage in the first hour is expected. Reporting no bubbling is a good sign.
Surgery and Trauma Considerations: * Unilateral Hemopneumothorax: Requires an apical tube for air and a basilar tube for blood on the affected side. * Bilateral Pneumothorax: Requires two apical tubes (one right, one left). * Trauma/Surgery: Always assume the condition is unilateral unless specified otherwise. * Pneumonectomy (Right side): Does not require a chest tube because the entire lung was removed. Tubes are used for lobectomies or wedge resections.
Closed Chest Drainage Devices: Examples include Jackson-Pratt, Emisson, pneumovac, and hemovac. * Knocked Over Device: This is not a medical emergency. The nurse should ask the patient to take a deep breath and then simply set the device back up.

Chest Tube Troubleshooting and Emergency Protocols

Water Seal Break Protocol: If the water seal breaks, actions must be completed in $15\,seconds$ or less: 1. Clamp the tube (to prevent air from entering the chest). 2. Cut the tube away from the broken device. 3. Submerge the end of the tube under sterile water (reestablishes the seal; allows things out but not in). 4. Unclamp the tube (to allow drainage/air to exit).
Management Choices (Priority vs. First Step): * First Action: Clamp the tube. * Best/Priority Action: Submerge the end of the tube under sterile water.
Tube Dislodgement: If a chest tube is pulled out: 1. First Step: Cover the opening with a gloved hand. 2. Best Step: Cover with sterile Vaseline gauze and tape on $3$ sides.
Bubbling Assessment: Ask "Where?" and "When?" * Water Seal Chamber: * Intermittent: Good (document it). * Continuous: Bad (indicates a leak/break in the system; must find and tape it). * Suction Control Chamber: * Intermittent: Bad (suction pressure is too low; increase at the wall until continuous). * Continuous: Good (document it).
Rules for Clamping: * Maximum duration: $15\,seconds$ (unless there is a physician's order). * Equipment: Use rubber-tooth double clamps to avoid puncturing the tubing.
Clinical Analogies: * Thoracentesis is to a Chest Tube as a Straight Catheter is to a Foley Catheter. * Chest tubes and Foley catheters carry a higher risk of infection because they are left in place.

Congenital Heart Defects

General Classification: Defects either cause a lot of "TRouBLe" or no trouble at all.
"TRouBLe" Defects (Mnemonic): * T: All defects starting with "T" are trouble (e.g., Tetralogy of Fallot, Truncus arteriosus, Transposition of the great vessels, Tricuspid atresia, Totally anomalous of pulmonary vasculature (TAPV)). * R-L: Shunts blood Right to Left. * B: Patient is Blue (cyanotic). * Exception: Left ventricular hypoplastic syndrome is a "Trouble" defect despite not starting with "T."
Clinical Signs of "TRouBLe" Defects: * Requires immediate or early surgery. * Slowed or delayed growth/development (failure to thrive). * Shortened life expectancy. * High parental stress (grief, financial, emotional). * Patient discharged on cardiac monitors. * Extended initial hospital stays (weeks).
No "TRouBLe" Defects: Examples include Ventricular septal defect (VSD), Patent ductus arteriosus (PDA), Patent foramen ovale, Atrial septal defect, and Pulmonic stenosis.
Universal Features: Every child with a congenital heart defect (Trouble or No Trouble) will have a murmur and will require an echocardiogram to determine the cause.
Tetralogy of Fallot Defects ("PROVe"): 1. P: Pulmonary artery stenosis. 2. R: RVH (Right Ventricular Hypertrophy). 3. O: Overriding aorta. 4. V: VSD (Ventricular Septal Defect).

Infectious Disease and Transmission-Based Precautions

Contact Precautions: * Indications: Enteric (GI, fecal/oral) diseases such as C. diff., Hepatitis A, E. coli, cholera, and dysentery. Also Staph, RSV (droplets on objects), and Herpes. * PPE/Protocol: Private room preferred (can cohort based on culture, not symptoms). Hand washing, then Gown, then Gloves. Use disposable supplies (paper plates, plastic utensils) and dedicated equipment (stethoscope, BP cuff stayed in room).
Droplet Precautions: * Indications: Bugs traveling on large particles via coughing/sneezing to less than $3\,feet$ . Examples: Meningitis, H. influenza b (e.g., epiglottitis). * PPE/Protocol: Private room preferred (can cohort based on culture and symptoms). Hand washing, then Mask, then Goggle or Face shield, then Gloves. Disposable supplies and dedicated equipment.
Airborne Precautions ("Air MTV"): * Indications: MMR, TB, and Varicella (chickenpox). * PPE/Protocol: Private room preferred (can cohort based on culture/symptoms). Hand washing, Goggle/Face shield, Gloves. Wear a mask when leaving the room. Keep door closed. Negative airflow is required.

Personal Protective Equipment (PPE) Protocols

Order of Donning (Putting on): 1. Gown 2. Mask 3. Goggle 4. Gloves
Order of Doffing (Taking off): (Alphabetical Order) 1. Gloves 2. Goggle 3. Gown 4. Mask

Nursing Math and Questions & Discussion

Dosage Calculations (IV Drip Rates): $IV drip rates = \frac{\text{Volume} \times \text{Drop factor}}{\text{Time}}$ * Micro/Mini drip: $60\,\text{drops/mL}$ . * Macro drip: $10\,\text{drops/mL}$ .
Pediatric Sizing: $2.2\,\text{lbs} = 1\,\text{kg}$ .

Questions & Discussion

Scenario 1: Hemothorax Assessment * Question: A chest tube is placed in a pt for a hemothorax (blood). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? * Options: (a) Chest tube is not bubbling, (b) Chest tube drains $800\,mL$ in the first $10\,hours$ , (c) Chest tube is not draining, (d) Chest tube is intermittently bubbling. * Answer: (c) Chest tube is not draining. A hemothorax tube is supposed to drain blood; if it is not, there is a malfunction.
Scenario 2: Pneumothorax Assessment * Question: A chest tube is placed in a pt for a pneumothorax (air). What would you (the LPN) report to the nurse? Or, what would you (the RN) report physician? * Logic: Bubbling is expected. If it's a pneumothorax, excessive blood ( $800\,mL$ over $10\,hours$ , or $80\,mL/hr$ ) is abnormal and must be reported. Also, if there is no bubbling in a pneumothorax tube, it is a bad sign.
Scenario 3: Water Seal Break Actions * First Action Question: The water seal chamber breaks. What is the first course of action? * Answer: Clamp the tube. * Priority Action Question: The water seal chamber breaks. What is the priority (best) action? * Answer: Submerge the end of the tube under sterile water.
Scenario 4: V-fib Response * Question: You notice V-fib on the monitor. Pt is unresponsive with no pulse. What is the first step? * Answer: Start chest compression. "Best" refers to priority, and chest compressions are the priority action.
Scenario 5: Tetralogy of Fallot Teaching * Question: Nurse is teaching parents of an infant with Tetralogy of Fallot. What topics should be included? * Answer: In this context, everything associated with "TRouBLe" defects: surgery needs, growth delays, monitor use, and cardiologist referrals.