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Transcript
Adult Medical-Surgical Nursing CARDIOVASCULAR MODULE: DYSRHYTHMIAS Dysrhythmias Dysrhythmias are disorders of: Formation (and/ or) Conduction of electrical impulses through the heart Normal Conduction Impulses arise in the SA node (physiological pacemaker of the heart) → AV node → Bundle of His → Left and right bundle branches → Purkinje fibres Impulses stimulate depolarisation of the myocardial cells Dysrhythmias: Classification Sinus tachycardia (> 100/ min) Sinus bradycardia (< 60/ min) Atrial flutter } (supraventricular Atrial fibrillation } tachycardia) First, second, third degree block Ventricular tachycardia Ventricular fibrillation Asystole Dysrhythmias: Aetiology Congenital anomalies May occur as a complication: Post myocardial infarction Post cardiac surgery In relation to acid/ base imbalance In relation to electrolyte/ mineral imbalance Dysrhythmias: Pathophysiology Disorganised stimulation of the myocardial cells leads to: ↓ cardiac output ↓ BP Inadequate perfusion An ineffective cardiac pump, inco-ordinated and weak Pathophysiology (Tachycardia) If tachycardia presents: Inadequate repolarisation and insufficient filling time (↓ refractory period) leads to: ↓ contractility and ↓ cardiac output ↓ filling of coronary arteries: can cause myocardial infarction (MI) Pathophysiology (Bradycardia) If bradycardia presents: The heart rate is insufficient to maintain cardiac output Pathophysiology (Fibrillation) Where fibrillation occurs: There is risk of thrombus and emboli leading to: Cerebral → stroke Peripheral → arterial occlusion and ischaemia Dysrhythmias: Clinical Manifestations Chest pain and tightness Dyspnoea Palpitations Faintness/ dizziness (may lead to loss of consciousness from ↓ cardiac output) Hypotension Weak pulse (fast or slow; regular or irregular) Dysrhythmias: Diagnosis Patient history Clinical examination ECG/ cardiac monitoring Dysrhythmias: Management Medications Pacemaker Catheter ablation therapy Cardioversion/ defibrillation Medications Drugs to increase contractility and slow heart rate: Cardiac glycosides β-blockers Calcium-channel blockers Vasopressin (ADH) (symptom relief) Medications Drugs to increase the refractory period (diastole): Drugs aim to allow adequate filling and coronary perfusion Amiodorone is such a drug of choice Medications Drugs to correct bradycardia: Inhibit parasympathetic (vagal) activity on the SA node Atropine most commonly used Medications If fibrillation present: Drugs to reduce the risk of thrombus formation and emboli Anticoagulants or Anti-platelet aggregates Pacemaker A pacemaker is a generator with a battery and leads used to stimulate the SA node at a regular normal rate Pacemaker Used for bradycardia (and sometimes atrial fibrillation) Promotes adequate cardiac output A pacemaker: Senses the heart rate Regulates the heart rate Implanted defibrillator used if risk of ventricular fibrillation Types of Pacemaker Temporary: used following MI or cardiac surgery if dysrhythmia arises Permanent: External (battery outside the skin) Internal (implanted under the skin) Within endocardium of right ventricle Implanted cardioverter defibrillator (ICD): detects/ corrects Ventricular Fibrillation (VF) and Ventricular Tachycardia (VT) Pacemaker: Instructions to Patients Carry a card with the details Avoid MRI Avoid holding a mobile phone close to pacemaker Avoid electronic security scanners Will require battery change Catheter Ablation Therapy Used in some cases of tachydysrhythmia Follows an electro-physiological study (EP) to evaluate dysrhythmia Performed under light sedation Ablation (destruction) of the specific cells responsible for mal-conduction Radiofrequency, cryoablation or electrical ablation used Cardioversion and Defibrillation An electrical shock to the myocardial cells intended to restart sinus rhythm from the SA node Used for dysrhythmias with increased heart rate not responding to medication Defibrillation as emergency action Cardioversion An elective procedure Patient is fasting under conscious sedation Anticoagulation prior to procedure Shock is programmed with the QRS complex (R wave) of the ECG Defibrillation An emergency procedure (VT or VF) The heart muscle must have some activity before defibrillation CPR is performed to stimulate activity (not to be used in asystole) Nursing Considerations Ensure correct drugs and monitor effect Ensure patient awareness about medication Specific advice on anticoagulant therapy Special precautions for a patient with a pacemaker Assist and monitor patient during cardioversion or defibrillation