Management of Patients with Arrhythmias and Conduction Problems

Arrhythmias

• Disorders of the formation or conduction (or both) of electrical impulses within the 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.

Normal Electrical Conduction

• SA node (sinus node)
• AV node
• Conduction
• Bundle of His
• Right and left bundle branches
• Purkinje fibers
• Depolarization = stimulation = systole
• Repolarization = relaxation = diastole

ECG Electrode Placement

• 12-Lead
• 3-Lead

The Electrocardiogram (ECG)

• Electrode placement
  • Electrode adhesion
• Types of ECG
• ECG interpretation
  • P wave
  • QRS complex
  • T wave
  • U wave
  • PR interval
  • ST segment
  • QT interval
  • TP interval
  • PP interval

Analyzing the ECG Rhythm Strip

• Normal sinus rhythm
• Sinus node arrhythmias
  • Sinus bradycardia
  • Sinus tachycardia

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Tachycardia

Atrial Fibrillation Pathophysiology

• P wave: No discernible P waves; irregular undulating waves that vary in amplitude and shape are seen and referred to as fibrillatory or f waves
• PR interval: Cannot be measured
• P:QRS ratio: Many:1
• Assessment:
  • 12-lead ECG
  • Transesophageal echocardiogram
  • Laboratory Test
• Medical Management:
  • Reversal
  • Prevention
  • Management

Question #1

• 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?
• Answer: B. Clip the chest hair with the patient’s permission before applying the leads
• Rationale: Clipping the patient’s hair would provide access to the skin to assist with adhesion. 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. 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.

Assessment of the Patient with an Arrhythmia #1

• Causes of arrhythmia, contributing factors, the arrhythmia’s effect on the heart’s ability to pump an adequate blood volume
• Assess indicators of cardiac output and oxygenation
• Health history: previous occurrences of decreased cardiac output, possible causes of the arrhythmia
• All medications (prescribed and over-the-counter)
• Psychosocial assessment: patient’s “perception” of arrhythmia

Assessment of the Patient with an Arrhythmia #2

• Physical assessment include
  • Skin (pale and cool)
  • Signs of fluid retention (JVD, lung auscultation)
  • Rate, rhythm of apical, peripheral pulses
  • Heart sounds
  • Blood pressure, pulse pressure

Collaborative Problems and Potential Complications

• Cardiac arrest
• Heart failure
• Thromboembolic event, especially with atrial fibrillation

Planning and Goals for the Patient with an Arrhythmia

• Goals
  • Eradicating or decreasing occurrence of arrhythmia to maintain cardiac output
  • Minimizing anxiety
  • Acquiring knowledge about arrhythmia and its treatment

Nursing Interventions for the Patient with an Arrhythmia

• Monitor and manage the arrhythmia
• Reduce anxiety
• Promote home- and community-based care
• Educate the patient about self-care
• Continuing care

Nursing Intervention: Minimize Anxiety

• Stay with patient
• Maintain safety and security
• Discuss emotional response to arrhythmia
• Help patient develop a system to identify factors that contribute to episodes of the arrhythmia
• Maximize the patient’s control

Nursing Intervention: 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 arrhythmia
  • Measures to decrease recurrence
  • Plan of action in case of an emergency
  • CPR (family)

Implanted Transvenous Pacemaker

• Purpose
• Design and types
• Functionality
• Surveillance

Implantable Cardioverter Defibrillator (ICD)

• Device that detects and terminates life-threatening episodes of tachycardia and fibrillation
• NASPE-BPEG code
• Antitachycardia pacing

Complications of Permanent Electronic Device

• Infection
• Bleeding or hematoma formation
• Dislocation of lead
• Skeletal muscle or phrenic nerve stimulation
• Cardiac tamponade
• Pacemaker malfunction

Nursing Management of the Patient with a Permanent Electronic Device

• 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