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Flashcards in Day I Deck (29)
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client presentation that could indicate need for an ECG

  • Cardiovascular dz
  • MI
  • Hypoxia
  • Acid base imbalances
  • Electrolyte disturbances
  • Kidney failure, liver, or lung dz
  • Pericarditis
  • Drug or alcohol use
  • Hypovolemia
  • Shock


ECG: preprocedure

  • Prepare client for 12 lead if prescribed
  • Position client in supine with chest exposed
  • Wash client’s skin to remove oils
  • Clip hair (do not shave)


ECG: intraprocedure

  • Instruct client to remain still and breathe normally
  • Monitor client for manifestations of dysrhythmias: chest pain, dec LOC, SOB, hypoxia


ECG: post procedure

  • Remove leads, print ECG, notify provider
  • Apply Holter monitor if client on tele
  • Monitor pt



  • Dysrhythmias can be life threatening or benign, but if life threatening it is usually related to decreased CO and ineffective tissue perfusion
  • Dysrhythmias are a primary cause of death in clients suffering acute MI and other sudden death disorders


what is cardioversion?

indications for cardioversion?

  • delivery of a direct countershock to the heart synchronized to the QRS complex
  • Indications:
    • Atrial dysrhythmias
    • SVT
    • V tach with a pulse
    • For clients who are symptomatic


what is defibrillation?

indications for defibrillation?

  • delivery of an unsynchronized, direct countershock to the heart
  • Stops all electrical activity of the heart, allowing the SA node to take over and re-establish a perfusing rhythm
  • Indications:
    • V fib
    • pulseless v tach


cardioversion/defib: preprocedure

  • Clients with afib of unknown duration must receive adequate anticoags for 4-6 weeks prior to cardioversion therapy to prevent dislodgement of thrombi into bloodstream
  • Explain procedure to client, obtain consent
  • Administer O2
  • Document preprocedure rhythm
  • Digoxin held 48 hrs prior to elective cardioversion


cardioversion/defib: intraprocedure

  • Administer sedation as needed
  • Ensure proper placement of leads
  • Monitor client in a lead that has an upright QRS
  • Stand clear of pt
  • Cardioversion requires activation of synchronizer button in addition to charging the machine
    • Allows shock to sync with underlying rhythm
    • Failure to sync can lead to development of lethal arrhythmia, like v fib
  • Perform CPR for asystole or other pulseless rhythms
  • Defibrillate immediately for v fib
  • Administer meds


cardioversion/defib: post procedure

  • Monitor V/S, assess airway, obtain ECG
  • Document:
    • Postprocedure rhythm
    • Number of defibrillation or cardioversion attempts
    • Client’s condition, state of consciousness
    • Skin condition


what are the 2 possible complications of cardioversion?

  • embolism
  • decreased cardiac output and HF


explain embolism as a complication of cardioversion

  • Embolism: can be dislodged by cardioversion
    • A PE evidenced by: dyspnea, chest pain, air hunger, dec SaO2
    • A CVA evidenced by: dec LOC, slurred speech, muscle weakness/paralysis
    • An MI evidenced by: chest pain and ST segment depression or elevation
  • Nursing actions: provide therapeutic anticoagulation for clients who have dysrhythmias


explain decreased cardiac output and HF as a complication of cardioversion

  • cardioversion may damage heart tissue and impair heart function
  • Nursing actions:
    • Monitor the client for signs of:
      • Dec CO: hypoTN, syncope, inc HR
      • HF: dyspnea, productive cough, edema, venous distention
    • Provide meds to increase output (inotropic agents) and to decrease cardiac workload


tx of bradycardia if the client is symptomatic

  • meds: atropine and isproterenol
  • electrical mgmt: pacemaker


tx of a fib, supraventricular tachycardia, and ventricular tachycardia with a pulse

  • meds: amiodarone, adenosine, verapamil (CCB)
  • electrical mgmt: cardioversion


tx of ventricular tachycardia w/o a pulse or ventricular fibrillation

  • meds: amiodarone, lidocaine, epinephrine
  • electrical mgmt: defibrillation


permanent pacemaker


  • Contains an internal pacing unit
  • Indicated for chronic or recurrent dysrhythmias due to sinus or AV node malfunction
  • Can be programmed to pace the atrial (A) or ventricular (V) chamber, or both (AV)


what are the pacemaker modes available on a permanent pacemaker?

  • Fixed rate (asynchronous): fires at a constant rate w/o regard for the heart’s electrical activity
  • Demand mode (synchronous): detects the heart’s electrical impulses and fires at a preset rate only if the heart’s intrinsic rate is below a certain level
    • Inhibited: pacemaker activity is inhibited/does not fire
    • Triggered: pacemaker activity is triggered/fires when intrinsic activity is sensed
  • Tachydysrhythmia function: can overpace a tachydysrhythmia and/or deliver an electrical shock


potential diagnoses that would be indication for a pacemaker

  • Symptomatic bradycardia
  • Complete heart block
  • Sick sinus syndrome
  • Sinus arrest
  • Asystole
  • Atrial tachydysrhythmias
  • Ventricular tachydysrhythmias


subjective presentation of a client that needs a pacemaker

  • Dizziness
  • Palpitations (racing heart)
  • Chest pain or pressure
  • Anxiety
  • Fatigue
  • Nausea
  • Breathing difficulties


objective presentation of a client that needs a pacemaker

  • Bradycardia or tachycardia
  • Abnormal ECG
  • Dyspnea, tachypnea
  • Restlessness
  • JVD
  • Vomiting
  • hypoTN
  • Diaphoresis
  • Dec CO


preprocedure considerations for a pacemaker

  • Nursing actions:
    • Assess the client’s knowledge of the procedure and need for pacemaker
    • Obtain informed consent
    • Prepare client’s skin (clean with soap and water, trim hair)
      • Do not shave, rub, or apply alcohol
  • Client edu: teach about type of pacemaker
    • Temporary pacemaker:
      • Explain that wires and pacemaker box will be on the client’s chest
      • Wires and box must be kept dry-->can’t shower
    • Permanent pacemaker:
      • Small incision made with local anesthetic and IV sedation
      • May be programmed externally after procedure
      • Pacemaker battery will last about 10 yrs


postprocedure nursing actions for a pacemaker

  • Document time and date of insertion, model, settings, rhythm strip, presence of pulse and BP, client response
  • Monitor HR and rhythm
  • CXR: to check lead placement and monitor for pneumothorax, hemothorax, pleural effusion
  • Provide pain meds
  • Minimize shoulder movement
  • Monitor incision site for bleeding, hematoma formation, or infection
  • Assess for hiccups: indicates that the generator is pacing the diaphragm
  • Maintain safety
    • Assess for thermal burns, dehydration
  • Provide client with pacemaker ID card


postprocedure client education for a pacemaker

  • Temporary pacemakers: used only in a controlled facility w/ telemetry for continuous ECG monitoring
  • Permanent pacemaker:
    • Carry ID card at ALL times
    • Prevent wire dislodgement: do not raise arm above shoulder for 1-2 weeks
    • Take pulse daily at same time
    • Report: dizziness, fainting, fatigue, weakness, chest pain, hiccupping, palpitations, difficulty breathing, weight gain
    • If have a pacemaker defibrillator: when device delivers a shock, anyone touching pt will feel electrical impulse
    • No contact sports or heavy lifting for 2 mos
    • Avoid direct blows or injury to generator site
    • Resume sexual activity as desired
    • Never place items that generate a magnetic field over the pacemaker (including garage door openers, strong magnets, stereo speakers)
    • MRI, heat therapy: contraindicated
    • Will set off airport security alarms


what are possible complications that occur due to pacemaker insertion?

  • infection or hematoma at site of insertion
  • pneumothorax or hemothorax
  • arrhythmias


infection or hematoma at pacemaker insertion site: nursing actions

  • Assess for redness, pain, drainage, swelling
  • Administer antibiotics
  • Monitor PT, PTT, CBC


pneumo/hemothorax as a result of pacemaker insertion: nursing actions

  • Assess breath sounds, chest mvmt
  • Monitor O2 sats
  • CXR


arrhythmias as a result of pacemaker insertion: nursing actions

  • related to ventricular irritation from pacemaker electrode
    • Monitor ECG and BP
    • Administer antiarrhythmics
    • Have emergency resuscitation equipment ready


pacemaker complications

  • relate to improper sensing or pacing electrical charge being outside the heart
    • Causes: insufficient pacemaker settings, lead wire placement and function, battery function, myocardial damage, electrolyte imbalance
    • Can often detect with ECG