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Case Study 1 (Part B) Management of Patients with Dysrhythmias and Conduction Problems

1. Janis White, 21 years of age, is a female patient who received a permanent atrioventricular pacemaker for the diagnosis of sick sinus rhythm, a disorder that leads to periods of tachycardia and periods of extreme bradycardia or sinus arrest. The nurse received the end-of-shift report and arrives at Ms. White’s room where she assesses the patient’s incision dressing on the upper left chest and it is dry. The patient’s left arm is edematous and ecchymotic and twice the size of the other arm. The patient states that her left arm feels numb and tingling. The distal pulses are present and at baseline. None of the findings were noted in the end-of-shift report.

a. What nursing management should the nurse provide immediately? Immediately get an extra set of hands. Take vital signs, make sure to measure the BP on the unaffected side. Get an ECG. Get the provider.

b. Explain the general care of the patient after receiving an implanted pacemaker.

After placement of a pacemaker, the ECG should be observed very carefully to detect pacemaker malfunction. The following data should be noted on the patients record: model of pacemaker, type of generator, date and time of insertion, location of pulse generator, stimulation threshold, and pacer setting (rate, energy output, sensitivity, and duration of interval between atrial and ventricular impulses). (Hinkle 2018, p. 744). Obtain chest x ray to access lead placement and for pneumothorax, hemothorax, or pleural effusion, provide analgesia as prescribed, try to minimize shoulder movement initially, and don a sling to provide support. If prescribed to allow leads to anchor, Monitor the incision site for bleeding, hematoma formation, and infection. Assess for hiccups, which can indicate that the generator is pacing the diaphragm. Following transcutaneous pacing, inspect the skin under the electrodes for the thermal burns. (RN Med Surg 2017, P.177). After all this care it is also crucial to give patient education.

2. The nurse on the telemetry unit responds to the cardiac monitor alarm on a patient recovering from a myocardial infarction. Upon entering the room, the nurse notes the rhythm on the monitor appears to be ventricular tachycardia.

a. What action should the nurse take first? assess the patient pulses, bilaterally. to know if it is pulseless VT or not. If there is no palpable pulse, then the treatment of choice would be Defibrillation. The nurse should call for the crash cart and prepare the defibrillator to use. When ECG shows ventricular fibrillation or pulseless ventricular tachycardia, immediate defibrillation is the treatment of choice. The survival time decreases for every minute that defibrillation is delayed. Following defibrillation, high quality CPR is resumed immediately (Hinkle 2018, p 837). If the patient is stable which means if the patient has a pulse and is not showing any sign and symptoms is decreased cardiac output. In this case the patient should be administered oxygen and give antidysrhythmic medication as prescribed. Defibrillation is not used for patients who are conscious or have a pulse. (Hinkle 2018, p.738).

b. The nurse notes the patient has no pulse and tells someone to get the code cart and another to call the hospital’s code team. Upon arrival of the code cart, the nurse prepares the defibrillator for use. At what energy level does the nurse set the biphasic defibrillator for the first shock?

If the patient has pulseless ventricular tachycardia, the energy setting for the initial and subsequent shocks using a monophasic defibrillator should be set at 360 joules (Link 2015). The energy setting for the initial shock using a biphasic defibrillator may be set at 150 to 200 joules, with the same or an increasing dose with subsequent shocks (Link 2015).

c. After defibrillation, the nurse assesses the patient, finds him pulseless, and initiates cardiopulmonary resuscitation. The code team has arrived, and epinephrine is administered. What is the rationale for this medication in this emergency situation?

Epinephrine is a vasopressor which is given after initial unsuccessful defibrillation to make it easier to convert the dysrhythmia to a normal rhythm with the next defibrillation. This medication may also increase cerebral and coronary artery blood flow. (Hinkle 2017 p.738). It is used to optimize BP and cardiac output; improves perfusion and myocardial contractility. (Hinkle 2017 p.839). Antiarrhythmic medications such as amiodarone, lidocaine, or magnesium may be administered if ventricular dysrhythmia persists. This treatment with continuous CPR, medication administration, and defibrillation continues until a stable rhythm resumes or until it is determined that the patient cannot be revived. (Hinkle 2017 p.738).

d. What is the difference between monophasic and biphasic defibrillators?

Monophasic defibrillators deliver electric current in only one direction and require increased energy levels. Newer Biphasic defibrillators delivers an electrical charge from one paddle that then automatically redirects its charge back to the original paddle. (Hinkle 2017 p. 737). These defibrillators require lower possibly non-progressive energy levels which potentially produce less myocardial damage.

References

Henry, N., et al. (2016). Adult Medical Surgical Nursing 10th edition, Kansas City. ATI Nursing education. pg 177 Hinkle, J.L. & Cheever, K.H. (2017). Brunner & Suddharth’s Textbook of Medical Surgical Nursing. (14th Ed). Philadelphia pg 737- 839 Link, M. S., Berkow, L. C., Kudenchuk, P. J., et al. (2015). Part 7: Adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 132(18 supp 2), S444–S464....