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Monitoring & Intervening
Key Points
 Cardiac electrical activity can be monitored by using an
electrocardiogram (ECG); a standard 12-lead ECG (resting
ECG), ambulatory ECG (Holter monitoring), continuous
cardiac monitoring, or by telemetry
 Cardiac dysrhythmias are heartbeat disturbances (beat
formation, beat conduction, myocardial response to beat).
 Dysrhythmias are classified by the:
 Site of origin: SA node, atria, atrioventricular (AV) node,
or ventricle.
 Effect on heart’s rate and rhythm: Bradycardia,
tachycardia, heart block, premature beat, flutter,
fibrillation, or asystole.
Key Points
 Dysrhythmias may be benign or life-threatening; decreased cardiac output
and ineffective tissue perfusion.
 Cardiac dysrhythmias are 1ry cause of death in clients suffering acute MI,
and other sudden death disorders.
 Therefore, rapid Dx & Rx of serious dysrhythmias is essential to preserve
 Dysrhythmia treatment is based on the client’s symptoms and the cardiac
 Cardioversion is the delivery of synchronized direct countershock to the
heart for the elective treatment of atrial dysrhythmias or ventricular
tachycardia with pulse.
 Defibrillation is the delivery of an unsynchronized, direct countershock
to the heart during ventricular fibrillation or pulseless ventricular
Defibrillation stops all electrical activity of the heart, allowing the
sinoatrial (SA) node to take over and reestablish a perfusing rhythm.
Bradycardia (any rhythm < 60
Treat if client is symptomatic
Atrial Fibrillation,
Supraventricular Tachycardia
(SVT), or Ventricular
Tachycardia with pulse
adenosine, verapamil
Ventricular Tachycardia
without pulse or
Ventricular Fibrillation
Amiodarone, lidocaine,
Risk Factors for Dysrhythmias
Cardiovascular disease
Acid-base imbalances
Electrolyte disturbances
Chronic renal, hepatic, or lung disease
Drug use or abuse
Nursing Interventions
 Perform 12-lead ECG by:
 Monitor for S & Sx of decreased perfusion (chest pain, decreased level of
consciousness, SOB) and hypoxia.
 Prevention
 Reduce risk factors for CAD.
 Correct electrolyte imbalances.
 Treat substance abuse.
 Manage stress, fever, and anxiety.
 Assess/monitor for signs of decreased cardiac output (hypotension, irregular
heart beats, fatigue, dyspnea, chest pain, syncope).
 Monitor for pulmonary or systemic emboli following cardioversion.
 Administer oxygen.
Nursing Interventions
 Administer prescribed antidysrhythmic agent or other prescribed
 Perform CPR for cardiac asystole or other pulseless rhythms.
 Defibrillate immediately for ventricular fibrillation
 Prepare the client for cardioversion if prescribed.
 Cardioversion is the treatment of choice for symptomatic clients.
 Clients with atrial fibrillation of unknown duration must receive
adequate anticoagulation prior to cardioversion therapy.
 Administer oxygen and sedation as prescribed.
 Cardioversion requires activation of the synchronizer button in addition
to charging the machine. Failure to synchronize can lead to development
of a lethal dysrhythmia, such as ventricular fibrillation.
 After defibrillation or cardioversion, check vital signs, assess airway
patency, and obtain an ECG.
 Provide reassurance and emotional support to the client and family.
Nursing Interventions
Client’s condition prior to intervention
Pre- and postprocedure rhythm
Number of defibrillation or cardioversion attempts, energy settings,
time, and response
Vital signs
Emergency medications administered including times and dosages
The client’s condition and state of consciousness following the
Teach the client and family regarding the need for compliance with
prescribed medication regimen.
Teach the client and family how to assess pulse.
Complications and Nursing Implications
 Embolism
 PE – dyspnea, chest pain, air hunger, decreasing SaO2
 CVA – decreased level of consciousness, slurred speech, muscle
 MI – chest pain, ST segment depression or elevation
 Provide therapeutic anticoagulation for clients with dysrhythmias.
 Decreased Cardiac Output and Heart Failure
 Monitor for signs of decreased cardiac output (hypotension, syncope,
increased heart rate) and of heart failure (dyspnea, productive cough,
edema, distention).
 Provide medications to increase output (inotropic agents) and to
decrease cardiac workload.
Heart Failure and
Key Points
HF: inability of the heart to maintain adequate circulation to
meet tissue needs for oxygen and nutrients.
Heart failure occurs when the heart muscle is unable to pump
effectively, resulting in:
 inadequate cardiac output,
 myocardial hypertrophy, and
 pulmonary/systemic congestion.
Heart failure is the result of: an acute or chronic cardiopulmonary
problem, such as systemic HTN, PE, pulmonary HTN,
dysrhythmias, valvular heart disease, pericarditis, and
Key Points
 Severity of heart failure is graded on classification scale indicating how little, or
how much, activity it takes to make the client symptomatic (chest pain, SOB).
 Class I: Client exhibits no symptoms with activity.
 Class II: Client has symptoms with ordinary exertion.
 Class III: Client displays symptoms with minimal exertion.
 Class IV: Client has symptoms at rest.
 Cardiomyopathy is a change in the structure of cardiac muscle fibers that
causes impaired cardiac function leading to heart failure.
 Blood circulation is impaired to the lungs or body when the cardiac pump is
 There are three main types:
 Dilated – decreased contractility and increased ventricular filling pressures.
 Hypertrophic – increased thickness of ventricular and/or septal muscles.
 Restrictive – ventricles become rigid and lose their compliance.
Key Points
 Low output heart failure can initially occur on either Lt/Rt side of
the heart.
 Left-sided heart (ventricular) failure results in inadequate left
ventricle (cardiac) output and consequently in inadequate tissue
 Right-sided heart (ventricular) failure results in inadequate right
ventricle output and systemic venous congestion (for example,
peripheral edema).
Key Factors
 Risk Factors/Causes: Left-Sided Heart (Ventricular) Failure
 Hypertension
 CAD, angina, myocardial infarction (MI)
 Valvular disease (mitral and aortic)
 Risk Factors/Causes: Right-Sided Heart (Ventricular) Failure
 Left-sided heart (ventricular) failure
 Right ventricular myocardial infarction
 Pulmonary problems (COPD, ARDS)
 Risk Factors/Causes: Cardiomyopathy
 Coronary artery disease
 Infection or inflammation of the heart muscle
 Various cancer treatments
 Prolonged alcohol abuse
 Heredity
Diagnostic Procedures and Nursing Interventions
 Hemodynamic Monitoring: Increased CVP, increased
right arterial pressure, increased pulmonary artery
pressure (PAP), and decreased cardiac output (CO)
 Ultrasound (echocardiogram): 2D or 3D to measure
both systolic and diastolic function of the heart.
 Chest x-ray can reveal cardiomegaly and pleural
 Electrocardiogram (ECG), cardiac enzymes,
electrolytes, and arterial blood gases:
 Assess factors contributing to heart failure and/or
the impact of heart failure.
Therapeutic Procedures and Nursing Interventions
 A ventricular assist device (VAD) is a mechanical pump that
assists a heart that is too weak to pump blood through the body.
 A VAD is used in clients who have severe end-stage congestive
heart failure and are not candidates for heart transplants.
 Heart transplantation is the treatment of choice for clients with
severe dilated cardiomyopathy.
 Heart transplantation is a possible option for clients with end-stage
heart failure.
 Immunosuppressant therapy is required post transplantation to
prevent rejection.
 S & Sx of Left-sided failure
Dyspnea, orthopnea, nocturnal dyspnea
Displaced apical pulse (hypertrophy)
S3 heart sound (gallop)
Pulmonary congestion (dyspnea, cough, bibasilar crackles)
Frothy sputum (may be blood-tinged)
Altered mental status
Symptoms of organ failure, such as oliguria
 Hemodynamic findings:
 CVP/right atrial pressure (normal = 1 to 8 mm Hg): Normal or
 Pulmonary Artery Pressure (normal = 15 to 26 mm Hg/5 to 15 mm
Hg): Elevated
 CO (normal = 4 to 7 L/min): Decreased
 Right-sided failure
Jugular vein distention
Ascending dependent edema (legs, ankles, sacrum)
Abdominal distention, ascites
Fatigue, weakness
Nausea and anorexia
Polyuria at rest (for example, nocturnal)
Liver enlargement (hepatomegaly) and tenderness
Weight gain
Hemodynamic findings
 CVP/right atrial pressure (normal = 1 to 8 mm Hg): Elevated
 Cardiomyopathy
 Fatigue, weakness
 Heart failure (left with dilated type, right with restrictive
 Dysrhythmias (for example, heart block)
 S3 gallop
 Cardiomegaly
Oxygen saturation
Heart rhythm
Lung sounds for crackles, wheezes
Level of dyspnea upon exertion
Serum electrolytes (especially potassium if receiving
Daily Wt
Changes in LOC
For signs of drug toxicity
Coping ability of client and family
NANDA Nursing Diagnoses
 Impaired gas exchange
 Decreased cardiac output
 Activity intolerance
 Excess fluid volume
 Ineffective tissue perfusion (cerebral)
 Risk for ineffective tissue perfusion
Nursing Interventions
 Place the client in high-Fowler’s, if a client is experiencing respiratory
 O2 as prescribed.
 Encourage bed rest until the client is stable.
 Encourage energy conservation by assisting with care and ADL
 Maintain dietary restrictions (restricted fluid intake, restricted sodium
 Administer medications as prescribed.
Diuretics: To decrease preload
Loop diuretics, such as furosemide (Lasix), bumetanide (Bumex)
Thiazide diuretics, such as hydrochlorothiazide (HydroDIURIL)
Potassium-sparing diuretics, such as spironolactone (Aldactone)
 Teach the client taking loop or thiazide diuretics to ingest foods and
drinks that are high in potassium to counter hypokalemia effect.
 Potassium supplementation may be required. Administer IV furosemide
(Lasix) no faster than 20 mg/min.
Nursing Interventions
 Afterload-Reducing Agents
 ACE inhibitors, such as enalapril (Vasotec), captopril (Capoten);
monitor for initial dose hypotension.
 Beta-blockers, such as carvedilol (Coreg), metoprolol (Lopressor
 Angiotensin receptor II blockers, such as losartan (Cozaar)
 Inotropic agents, such as digoxin (Lanoxin), dopamine,
dobutamine (Dobutrex), milrinone (Primacor): To increase
contractility and thereby improve cardiac output
 Vasodilators, such as nitrates: To decrease preload and afterload
Nursing Interventions
 Anticoagulants, such as warfarin (Coumadin), heparin, clopidogrel: To
 prevent thrombus formation (risk associated with congestion/stasis and
associated atrial fibrillation)
 Teach clients who are self-administering digoxin (Lanoxin) to:
 Count pulse for one full minute before taking the medication. If the pulse
rate is irregular or less than 60 or greater than 100), instruct the client to
hold the dose and to contact the primary care provider.
 Take digoxin (Lanoxin) dose at same time each day.
 Do not take digoxin at the same time as antacids (Separate by 2 hr).
 Report signs of toxicity, including fatigue, muscle weakness, confusion,
and loss of appetite.
 Regularly have digoxin and potassium levels checked.
 Provide emotional support to the client and family.
Client Education
 Take medications as prescribed.
 Take diuretics in early morning and early afternoon.
 Maintain fluid and sodium restriction – a dietary consult may
be useful.
 Increase dietary intake of potassium (?) if taking potassiumlosing diuretics such as loop diuretics and thiazide diuretics.
 Weigh self daily at the same time and notify the primary care
provider for weight gain of 1kg in 24 hr or 2.5 in 1 week.
 Schedule regular follow-ups with the primary care provider.
 Get vaccinations (pneumococcal vaccine and yearly influenza
Complications and Nursing Implications
 Acute pulmonary edema is a life-threatening medical emergency, ( anxiety,
tachycardia, ARDS, dyspnea at rest, change in LOC, and an ascending fluid
level within lungs (crackles, cough productive of frothy, blood-tinged
 Urgent Rx:
 Positioning the client in high-Fowler’s position.
 Administration of oxygen, positive airway pressure, and/or intubation and
mechanical ventilation.
 IV morphine (to decrease anxiety, respiratory distress, and decrease venous
 IV administration of rapid-acting loop diuretics, such as furosemide
 Effective intervention should result in diuresis (carefully monitor output),
reduction in respiratory distress, improved lung sounds, and adequate
Complications and Nursing Implications
 Cardiogenic shock is a serious complication of pump failure. It is a class IV
heart failure. Symptoms include tachycardia, hypotension (BP less than 90 mm
Hg or less than 30 mm Hg from baseline BP), inadequate urinary output (less
than 30 mL/hr), altered LOC, respiratory distress (crackles, tachypnea), cool
clammy skin, decreased peripheral pulses, and chest pain.
 Intervention
 oxygen; possible intubation and ventilation; IV
 administration of morphine, diuretics, and/or nitroglycerin to decrease
 and IV administration of vasopressors and/or positive inotropes to increase
cardiac output and to maintain organ perfusion.
 Other possible emergency interventions include use of an intra-aortic balloon
pump and/or emergency coronary artery bypass surgery CABAG.
Complications and Nursing Implications
 Pericardial effusion and pericardial tamponade is an
accumulation of fluid within the pericardial sac.
Immediate intervention, such as a pericardiocentesis, sternotomy,
and creation of a pericardial window, may be necessary in
addition to measures to improve cardiac output.
Administer anti-inflammatory medications as prescribed.
 Systemic and pulmonary emboli are possible complications due to
decreased cardiac output and systemic congestion.
 New onsets of atrial fibrillation need to be reported.
 Organ failure, such as renal failure, is possible due to tissue