Download Cardiac Dysrhythimia and Code Management

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UNIT 5B - PROBLEMS OF CARDIAC OUTPUT AND TISSUE PERFUSION
STUDY GUIDE 5B.1
Cardiac Dysrhythimia and Code Management
CASE STUDY/CRITICAL THINKING EXERCISES
Dysrhythmia Interpretation
1. You are working in the intensive care unit, and your patient’s heart rate suddenly
decreases from 88 to 50 beats per minute. What may be some of the reasons for
decreased heart rate? What assessments will you make?
Hypoxia, increased vagal stimulation (Valsalva’s maneuver, gagging, suctioning, and
vomiting), drug effects, SA or AV node ischemia, or increased intracranial pressure.
It is often present in athletes as a normal finding.
2. Discuss why patients with pulmonary disease are prone to atrial dysrhythmias.
Patients with pulmonary disease develop pulmonary hypertension. The right side of
the heart compensates by dilation and hypertrophy. Right atrial dilation can lead to
atrial rhythm disturbances.
3. A 65-year-old woman with type 2 diabetes presents to the emergency department; she
is short of breath and complaining of neck and shoulder pain. Her blood pressure is
185/95, and her heart rate is 155.
a. How will you initially manage this patient?
Start oxygen 4 L/min; establish IV access, attach pulse oximeter, 12-lead ECG,
perform problem-focused history and physical exam, and continue monitoring
vital signs
Chest x-ray, initial electrolyte and coagulation profile, complete blood count
b. What medical intervention would you anticipate?
Initial management aimed at cardiac diagnosis chest pain r/o myocardial
infarction and treatment of the heart rate.
Aspirin 160 to 325 mg, nitroglycerine 0.4 mg SL repeat × 2 at 5 minute intervals,
morphine 2 to 4 mg IV, beta blocker agents
c. List serious signs and symptoms of hemodynamic instability in a patient with a
tachycardia dysrhythmia.
Impaired consciousness or hypoperfusion (such as shortness of breath, pulmonary
edema, and chest pain), hypotension, pale, cool and clammy skin.
4. Why does tachycardia sometimes lead to heart failure?
Cardiac output = Heart rate × stroke volume. During tachycardia, the stroke volume
(filling time) is reduced. Despite the higher heart rate, the cardiac output may
decrease and lead to heart failure.
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Code Management
1. Discuss nursing strategies to be implemented during and after a code to provide
psychosocial support to family members of patients suffering a cardiopulmonary
arrest.
Most importantly, keep the family informed of the patient's condition and progress. If
possible, contact a chaplain or volunteer on staff to stay with the family. Provide a
room away from other visitors for privacy. If the family is in the room during the
code and wishes to remain there, consider their safety, given the possibility of
defibrillator use. Ask them to stand in an area, which will not interrupt care to their
family member while enabling them to witness the events. A chaplain or volunteer
should remain with them in this situation as well.
If the resuscitation is successful, let the family members see their loved one as soon
as possible if they were not in the room, and inform them of events and the plan of
care. If they were present during the code, they still must be kept informed of the plan
of care. The sequence of events during the code may have been overwhelming and
family members may benefit from discussing their perceptions with the nurse or
chaplain.
2. A surgical patient on a general nursing unit has just been successfully defibrillated
with the use of an AED by the nursing staff. He is being manually ventilated with a
BVD. Identify the current nursing priorities and their rationales.
The code team still needs to respond and assume responsibility. The priority is to
institute ACLS protocol (e.g., attach the patient to a monitor/defibrillator to
continuously monitor the patient's heart rate and rhythm). Assess the airway and
ensure the patient is intubated, if necessary, prior to transfer. Implement the
appropriate ACLS algorithm and, as soon as is feasible, transfer the patient to a
critical care unit.
3. You are the second nurse to respond to a code. The first nurse is administering CPR.
Describe your first actions and their rationales.
Call for additional help, if no one else has yet responded. Then perform the secondary
survey and assist in implementing the appropriate ACLS protocol. Use the crash cart
monitor/defibrillator to identify the underlying cardiac rhythm and treat according to
the appropriate ACLS protocol. If ventricular fibrillation is identified, defibrillate the
patient immediately. If pulseless electrical activity (PEA), consider underlying
causes, administer epinephrine, etc. Throughout these interventions, qualified
personnel continue CPR.
4. Your patient has a permanent pacemaker or ICD. How would care and treatment of
this patient differ in a code situation?
By the time VF/VT is recognized on the monitor, the rhythm should have been
recognized by the ICD. Personnel should proceed with standard code management if
successful countershock by the ICD has not occurred. Avoid placing the external
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defibrillator pads or paddles near the ICD generator. Although damage to the device
is not likely, the generator may absorb much of the current and reduce the chance of
successful defibrillation. If external defibrillation is unsuccessful, changing the
placement of the paddles on the chest may be helpful. Anterior-posterior paddle
placement may be more effective than anterior-apex placement.
5. Some hospitals are now considering allowing family members to be present during a
code.
a. How could the presence of family members affect the management of the code?
The presence of family members during a code may initially be uncomfortable for
staff not accustomed to this practice. It is best to have the family in an area of the
room where they are able to view events but will not hamper the efforts of the
staff. It may also be helpful to assist with the decision to terminate a code if the
family is present and is able to visualize the efforts of the staff. Personnel will
have to remain cognizant of the family's presence and keep them informed of
events as their background may be of limited medical/nursing knowledge. It is
essential to maintain professional conduct during these tense and stressful
moments.
b. What factors should you consider before permitting family members to be
present?
The emotional stability of the family is considered before allowing them to be
present. A hysterical family member will impede the resuscitation efforts, as will
inappropriate behavior (anger and attempts to physically participate or disrupt
interventions implemented by the team leader). The family is given clear
instructions as to where they stand or sit in the room, and what is expected from
them so as not to hinder resuscitation efforts. Compassionate communication is
essential.