Electrocardiography and Dysrhythmia Monitoring Unit 4 chapter 32 Nursing Care of Clients with Cardiovascular Disorders SectionDiagnostic and Therapeutic Procedures Chapter 32 Electrocardiography and Dysrhythmia Monitoring Overview в—Џв—Џ Cardiac electrical activity can be monitored by using an ECG. The heartвЂ™s electrical activity can be monitored by a standard 12-lead ECG (resting ECG), ambulatory ECG (Holter monitoring), continuous cardiac monitoring, or by telemetry. View Media Supplement: в—Џв—Џ в—Џв—Џ ECG Strip (Image) Cardiac dysrhythmias are heartbeat disturbances (beat formation, beat conduction, or myocardial response to beat). Nurses should be familiar with cardioversion and defibrillation procedures for treating dysrhythmias. Electrocardiography в—Џв—Џ Electrocardiography uses an electrocardiograph to record the electrical activity of the heart over time. The electrocardiograph is connected by wires (leads) to skin electrodes placed on the chest and limbs of a client. в—Їв—Ї в—Їв—Ї в—Џв—Џ Continuous cardiac monitoring requires the client to be in close proximity to the monitoring system. Telemetry allows the client to ambulate while maintaining proximity to the monitoring system. Indications View Media Supplement: (Images) в—Їв—Ї в¦Ѓ Premature Atrial Contractions в¦Ѓ Premature Ventricular Contractions в¦Ѓ Ventricular Tachycardia в¦Ѓ Atrial Fibrillation Diagnoses в– в– Bradycardia в– в– Heart block rn adult medical surgical nursing 371 ELECTROCARDIOGRAPHY AND DYSRHYTHMIA MONITORING в—Їв—Ї в—Џв—Џ в– в– Atrial fibrillation в– в– Supraventricular tachycardia в– в– Ventricular tachycardia в– в– Ventricular fibrillation Client presentation в– в– Cardiovascular disease в– в– MI в– в– Hypoxia в– в– Acid-base imbalances в– в– Electrolyte disturbances в– в– Chronic renal failure, liver, or lung disease в– в– Pericarditis в– в– Drug or alcohol abuse в– в– Hypovolemia в– в– Shock Preprocedure в—Їв—Ї Nursing actions в– в– Prepare the client for a 12-lead ECG by: в�ђв�ђ Positioning the client in a supine position with chest exposed. в�ђв�ђ Washing the clientвЂ™s skin to remove oils. в�ђв�ђ Attaching one electrode to each of the clientвЂ™s extremities by applying electrodes to flat surfaces above the wrists and ankles and the other six electrodes to the chest, avoiding chest hair. (Chest hair may need to be shaved on male clients). View Media Supplement: ECG Lead Placement (Image) в—Џв—Џ Intraprocedure в—Їв—Ї Nursing actions в– в– в– в– 372 Instruct the client to remain still and breathe normally while the 12-lead ECG is performed. Monitor the client for signs and symptoms of dysrhythmia (chest pain, decreased level of consciousness, and shortness of breath) and hypoxia. RN ADULT MEDICAL SURGICAL NURSING electrocardiography and Dysrhythmia monitoring в—Џв—Џ Postprocedure в—Їв—Ї Nursing actions в– в– в– в– в– в– в– в– Remove leads from client, print ECG report, and notify the primary care provider. Apply a Holter monitor if the client is on a telemetry unit and/or needs continuous cardiac monitoring. Continue to monitor the client for symptoms of dysrhythmia (chest pain, decreased level of consciousness, and shortness of breath) and hypoxia. Dysrhythmia treatment is based on the clientвЂ™s symptoms and the cardiac rhythm, which can require cardioversion or defibrillation after an ECG has been completed and a diagnosis has been found. Dysrhythmias в—Џв—Џ Dysrhythmias are classified by the: в—Їв—Ї Site of origin вЂ“ sinoatrial (SA) node, atria, atrioventricular (AV) node, or ventricle. в– в– в—Їв—Ї в—Џв—Џ в—Џв—Џ в—Џв—Џ в—Џв—Џ Electrophysiological study determines the area of the heart causing the dysrhythmia. Ablation of the area is possible. Effect on the rate and rhythm of the heart вЂ“ bradycardia, tachycardia, heart block, premature beat, flutter, fibrillation, or asystole. Dysrhythmias can be benign or life-threatening. The life-threatening effects of dysrhythmias are generally related to decreased cardiac output and ineffective tissue perfusion. Cardiac dysrhythmias are a primary cause of death in clients suffering acute MI and other sudden death disorders. Rapid recognition and treatment of serious dysrhythmias is essential to preserve life. Dysrhythmia Medication Electrical Management Bradycardia (any rhythm < 60/min) Treat if the client is symptomatic Atropine and isoproterenol Pacemaker Atrial fibrillation, supraventricular tachycardia (SVT), or ventricular tachycardia with pulse Amiodarone, adenosine, and verapamil Synchronized cardioversion Ventricular tachycardia without pulse or ventricular fibrillation Amiodarone, lidocaine, Defibrillation and epinephrine в—Џв—Џ Dysrhythmias can present atypically in older adult clients. в—Џв—Џ Risks for heart disease, hypertension, dysrhythmias, and atherosclerosis increase with age. rn adult medical surgical nursing 373 Electrocardiography and dysrhythmia Monitoring Cardioversion and Defibrillation в—Џв—Џ в—Џв—Џ в—Џв—Џ Cardioversion is the delivery of a synchronized, direct countershock to the heart. Defibrillation is the delivery of an unsynchronized, direct countershock to the heart. Defibrillation stops all electrical activity of the heart, allowing the SA node to take over and re-establish a perfusing rhythm. Indications в—Їв—Ї в—Їв—Ї в—Џв—Џ The clientвЂ™s heart will return to a normal rhythm. Preprocedure в—Їв—Ї в—Їв—Ї в—Џв—Џ Defibrillation вЂ“ ventricular fibrillation or pulseless ventricular tachycardia. Client Outcome в—Їв—Ї в—Џв—Џ Cardioversion вЂ“ elective treatment of atrial dysrhythmias, supraventricular tachycardia, and ventricular tachycardia with a pulse. Cardioversion is the treatment of choice for clients who are symptomatic. Clients who have atrial fibrillation of unknown duration must receive adequate anticoagulation prior to cardioversion therapy to prevent dislodgement of thrombi into the bloodstream. Nursing actions в– в– Prepare the client for cardioversion, if prescribed. в– в– Explain the procedure to the client and obtain consent. в– в– Administer oxygen. в– в– Document preprocedure rhythm. в– в– Have emergency equipment available. Intraprocedure в—Їв—Ї Nursing actions в– в– Administer sedation as prescribed. в– в– Administer a prescribed antidysrhythmic agent or other prescribed medications. в– в– Monitor the client in a lead that provides an upright QRS complex. в– в– в– в– 374 All staff must stand clear of the client, equipment connected to the client, and the bed when a shock is delivered. Cardioversion requires activation of the synchronizer button in addition to charging the machine. This allows the shock to be in sync with the clientвЂ™s underlying rhythm. Failure to synchronize can lead to development of a lethal dysrhythmia, such as ventricular fibrillation. в– в– Perform CPR for cardiac asystole or other pulseless rhythms. в– в– Defibrillate the client immediately for ventricular fibrillation. в– в– Monitor the client for pulmonary or systemic emboli following cardioversion. rn adult medical surgical nursing electrocardiography and Dysrhythmia monitoring в—Џв—Џ Postprocedure в—Їв—Ї Nursing actions в– в– After cardioversion or defibrillation, check the clientвЂ™s vital signs, assess airway patency, and obtain an ECG. в– в– Provide the client/family with reassurance and emotional support. в– в– Document в�ђв�ђ в�ђв�ђ в—Їв—Ї в—Џв—Џ Postprocedure rhythm Number of defibrillation or cardioversion attempts, energy settings, time, and response в�ђв�ђ The clientвЂ™s condition and state of consciousness following the procedure в�ђв�ђ Skin condition under the electrodes Client education в– в– Teach the client and family how to assess pulse. в– в– Advise the client to report palpitations or irregularities. Complications в—Їв—Ї Embolism в– в– Cardioversion can dislodge blood clots, potentially causing: в�ђв�ђ в�ђв�ђ в�ђв�ђ в– в– A cerebrovascular accident (evidenced by decreased level of consciousness, slurred speech, and muscle weakness/paralysis). An MI (evidenced by chest pain and ST segment depression or elevation). Nursing actions в�ђв�ђ в—Їв—Ї A pulmonary embolism (evidenced by dyspnea, chest pain, air hunger, and decreasing SaO2). Provide therapeutic anticoagulation for clients who have dysrhythmias. Decreased cardiac output and heart failure в– в– Cardioversion may damage some heart tissue and impair heart function. в– в– Nursing actions в�ђв�ђ в�ђв�ђ Monitor the client for signs of decreased cardiac output (hypotension, syncope, and increased heart rate) and heart failure (dyspnea, productive cough, edema, and venous distention). Provide medications to increase output (inotropic agents) and to decrease cardiac workload. rn adult medical surgical nursing 375 Electrocardiography and dysrhythmia Monitoring Chapter 32: Electrocardiography and Dysrhythmia Monitoring Application Exercises Scenario: A nurse is caring for a client who reports feeling lightheaded. Assessment of his vital signs reveals a heart rate at 144/min and irregular, blood pressure of 84/49 mm Hg, and an SaO2 reading of 95%. An ECG reveals atrial fibrillation with a rapid ventricular response. Synchronized cardioversion is performed at 50 joules. 1. Which of the following observations should the nurse include in documentation? (Select all that apply.) The client feels lightheaded The client is short of breath. The clientвЂ™s ECG reveals atrial fibrillation with a rapid ventricular response The clientвЂ™s vital signs are within the expected reference range The client is synchronized with cardioversion at 50 joules The clientвЂ™s oxygen saturation is 95% 2. Two hours after the clientвЂ™s cardioversion he develops ventricular fibrillation. What is the expected treatment? 3. Which of the following clients are at risk for the development of dysrhythmias? (Select all that apply.) 376 Metabolic alkalosis A client who has a serum potassium level of 4.3 mEq/L A client who has an SaO2 of 96% A client who has COPD A client who is 3 hr post MI rn adult medical surgical nursing electrocardiography and Dysrhythmia monitoring Chapter 32: Electrocardiography and Dysrhythmia Monitoring Application Exercises Answer Key Scenario: A nurse is caring for a client who reports feeling lightheaded. Assessment of his vital signs reveals a heart rate at 144/min and irregular, blood pressure of 84/49 mm Hg, and an SaO2 reading of 95%. An ECG reveals atrial fibrillation with a rapid ventricular response. Synchronized cardioversion is performed at 50 joules. 1. Which of the following observations should the nurse include in documentation? (Check all that apply.) X The client feels lightheaded The client is short of breath. X The clientвЂ™s ECG reveals atrial fibrillation with a rapid ventricular response The clientвЂ™s vital signs are within the expected reference range X The client is synchronized with cardioversion at 50 joules X The clientвЂ™s oxygen saturation is 95% The client who is feeling lightheaded, an ECG revealing atrial fibrillation with rapid ventricular response, a client who is synchronized with cardioversion at 50 joules, and a client who has an oxygen saturation of 95% would all be included in the nurseвЂ™s documentation. A client who reports shortness of breath and vital signs that are within expected reference range are inaccurate findings and should not be documented by the nurse. NCLEXВ® Connection: Reduction of Risk Potential, Therapeutic Procedures 2. Two hours after the clientвЂ™s cardioversion he develops ventricular fibrillation. What action should the nurse take first? When a client has a lethal rhythm such as ventricular fibrillation, the first intervention should be defibrillation. NCLEXВ® Connection: Physiological Adaptation, Hemodynamics rn adult medical surgical nursing 377 Electrocardiography and dysrhythmia Monitoring 3. Which of the following clients are at risk for the development of dysrhythmias? (Select all that apply.) X Metabolic alkalosis A client who has a serum potassium level of 4.3 mEq/L A client who has an SaO2 of 96% X A client who has COPD X A client who is 3 hr post MI These ABG results, COPD, and a recent MI are risk factors for developing a dysrhythmia. A potassium level of 4.3 mEq/L (expected reference range) and an oxygen saturation of 96% (expected reference range) do not increase the risk for developing dysrhythmias. NCLEXВ® Connection: Physiological Adaptation, Hemodynamics 378 rn adult medical surgical nursing