b io crisis

8/14/2019 b io crisis

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BI OLOG IC CRI SI SI OLOG IC CRI SI SDr. Anthony Toledo MD,RNDr. Antho

ny Toledo MD,RN


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Wh at is Sh ock ?h at is Sh ock ? A condition in which systemic BP is adequate toA condition in which systemic BP is adequate to

deliver oxygen and nutrients to support vitaldeliver oxygen and nutrients to support vitalorgans and cellular functions.organs and cellular functions.

Maintenance of tissue perfusion depends onMaintenance of tissue perfusion depends onadequate cardiac pump, effective vasculature oradequate cardiac pump, effective vasculature orcirculating system and sufficient blood volume.circulating system and sufficient blood volume.

Widespread serious reduction of tissueWidespread serious reduction of tissueperfusion ( lack of O2 )perfusion ( lack of O2 )


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Cla ss ifica tion of s hockla ss ifica tion of s hock A.. HY PO VO LEMI C SHO CKY PO VO LEMI C SHO CK Loss of circulating volume due to excessiveLoss of circulating volume due to excessive

blood loss, loss of body fluids and third spacingblood loss, loss of body fluids and third spacingof fluids.of fluids.

Most common type of shock.Most common type of shock.

Characterized by decreased intravascularCharacterized by decreased intravascularvolume of 15-25%.volume of 15-25%.


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HYP OVO LEM IC SH OCK


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Predi spos in g fa ct or s:redi spos in g fa ct or s:External:FluidLossExternal:FluidLoss

Internal:FluidShiftInternal:FluidShift

trauma a. hemorrhagetrauma a. hemorrhage

surgery b. burnssurgery b. burns

vomiting c. ascitevomiting c. ascite

diarrhea d. peritonitisdiarrhea d. peritonitis

diuresis e. dehydrationdiuresis e. dehydration

diabetes insipidusdiabetes insipidus


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Med ica l M an agemen ted ica l M an agemen tGOALS:GOALS: restore intravascular volumerestore intravascular volume redistribute fluid volumeredistribute fluid volume correct the underlying causecorrect the underlying cause

Fl ui d and Bl ood re plac ement : Lactated Ringers solution, colloid, and 0.9% NaCl (normal saline) to restore intravascularvolume.

Blood replacement for extensive and rapid blood loss; auto-transfusion methods may beconsidered for closed cavity hemorrhage.

Red ist ri but ion of Flui ds Patients is positioned in trendelenburg to assist in fluid redistribution.

Military antishock trousers (MAST) are used in extreme emergency situations when bleedingcannot be controlled


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Ph arma colog ic Ex amh arma colog ic Ex am DesmopressinDesmopressin

InsulinInsulin Anti-emeticAnti-emetic

Anti-diarrealAnti-diarreal


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Ca rdiog en ic Sh oc ka rdiog en ic Sh oc k


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Pa th oph ysi o o f C ar di ogen ica th oph ysi o o f C ar di ogen icShockhock


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Clin ica l M anif estation :lin ica l M anif estat ion : Dysrhythmias are common and result from a decrease inDysrhythmias are common and result from a decrease in

oxygen to the myocardium.oxygen to the myocardium.

Angina painAngina pain

Hemodynamic instabilityHemodynamic instability

Classic sign like low blood pressure, rapid and weak pulse.Classic sign like low blood pressure, rapid and weak pulse.

Cerebral hypoxia and manifested by confusion and agitation.Cerebral hypoxia and manifested by confusion and agitation.

Deceased urinary output and cold clammy skin.Deceased urinary output and cold clammy skin.


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Med ica l M an agemen ted ica l M an agemen t correction of underlying causecorrection of underlying cause initiation of first line treatmentinitiation of first line treatment

supplemental oxygen supplemental oxygen

controlling chest pain controlling chest pain

selected fluids support selected fluids support vasoactive medications vasoactive medications

controlling heart rate controlling heart rate

mechanical cardiac support mechanical cardiac support

e.g intra-aortic balloon counterpulsation, ventriculare.g intra-aortic balloon counterpulsation, ventricular

assist sysytem.assist sysytem. Coronary cardiogenic shock is treated with thrombolytic theraphy,Coronary cardiogenic shock is treated with thrombolytic theraphy,

angioplasty, or CABGangioplasty, or CABG Noncoronary cardiogenic shock is treated with cardiac valveNoncoronary cardiogenic shock is treated with cardiac valve

replacement or correction of dysrhythmias.replacement or correction of dysrhythmias.


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Ph arma colog ich arma colog ic DobutamineDobutamine

DopamineDopamine

Anti-arrythemic medsAnti-arrythemic meds

NitroglycerineNitroglycerine

Vasoactive medsVasoactive meds


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Nu rs in g M anagemen tu rs in g M anagemen t Preventing cardiogenic shockPreventing cardiogenic shock

Administering meds and IV fluidsAdministering meds and IV fluids

Maintaining mechanical devicesMaintaining mechanical devices

Enhancing safety and comfortEnhancing safety and comfort


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Distri buti ve Sho ck / V aso genicistri buti ve Sho ck / V aso genicShock ( Ci rcu latoryhock ( Ci rcu latory Shock )Shock )

Result from profound vasodilationResult from profound vasodilation

Three classification of distributive shock:Three classification of distributive shock:Septic shock, Anaphylactic shock andSeptic shock, Anaphylactic shock andNeurologic shockNeurologic shock


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Sep tic Sh ockep tic Sh ock The most common type of distributive shock,The most common type of distributive shock,

is caused by widespread infection.is caused by widespread infection.

Gram-negative bacteria are the most commonGram-negative bacteria are the most common

pathogens.pathogens.

Gram-positive bacteria and viruses and fungi,Gram-positive bacteria and viruses and fungi,

can also cause septic shockcan also cause septic shock


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Ris k f act or s:is k f act or s: ImmunosuppressionImmunosuppression Extremes of age ( younger than 1y/l and olderExtremes of age ( younger than 1y/l and older

than 65y/o)than 65y/o) AlcoholismAlcoholism Extensive trauma of burnsExtensive trauma of burns MalnutritionMalnutrition DiabetesDiabetes

MalignancyMalignancy Chronic illnessChronic illness Invasive proceduresInvasive procedures


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Pathop hysiolog yathop hysiolog y Microorganism invasion causes immune response thatMicroorganism invasion causes immune response that

activates biochemical mediators associated withactivates biochemical mediators associated with

inflammatory response and produces a variety ofinflammatory response and produces a variety ofeffects leading to shock.effects leading to shock.

There is an increase in the capillary permeability, withThere is an increase in the capillary permeability, with

fluid loss from the capillaries and vasodilatation,fluid loss from the capillaries and vasodilatation,result in inadequate perfusion of oxygen andresult in inadequate perfusion of oxygen and

nutrients to the tissue and cell.nutrients to the tissue and cell.


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Clin ica l M anifes tatio nlin ica l M anifes tatio nFir st ph as e: Hyperd ynami c o r Prog res sive phas eir st ph as e: Hyperd ynami c o r Prog res sive phas e High cardiac output with vasodilationHigh cardiac output with vasodilation Hyperthermia (febrile) with warm, flushed skin, bounding pulsesHyperthermia (febrile) with warm, flushed skin, bounding pulses Heart and respiratory rate elevatedHeart and respiratory rate elevated Blood pressure may remain within normal limits, or subtle changes in mentalBlood pressure may remain within normal limits, or subtle changes in mental

status.status. Decreased urinary output or normalDecreased urinary output or normal Gastrointestinal status compromised (eg, decreased bowel sounds, n/v orGastrointestinal status compromised (eg, decreased bowel sounds, n/v or

diarrhea)diarrhea)

Late ph as e: Hypody namic or Ir re vers ib le p haseate ph as e: Hypody namic or Ir re vers ib le p hase Low cardiac output with vasoconstrictionLow cardiac output with vasoconstriction Decreased blood pressureDecreased blood pressure Skin cool and paleSkin cool and pale Temperature normal or below normalTemperature normal or below normal Rapid respiratory and heart rateRapid respiratory and heart rate Anuria and multiple organ dysfunctionAnuria and multiple organ dysfunction


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Med ica l M an agemen ted ica l M an agemen t Urine, blood, sputum, and wound drainage specimensUrine, blood, sputum, and wound drainage specimens

are collected to identify and eliminate the causes ofare collected to identify and eliminate the causes ofinfection.infection.

Begins immediately a broad-spectrum antibioticBegins immediately a broad-spectrum antibiotictherapytherapy

Fluid replacement and aggressive nutritionalFluid replacement and aggressive nutritionalsupplement (high protein) is provided. Enteralsupplement (high protein) is provided. Enteralfeedings are preferred.feedings are preferred.


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Nu rs in g M anagemen tu rs in g M anagemen t Identify px at risk for sepsis and septic shockIdentify px at risk for sepsis and septic shock

Monitor for sign of infection at intravenous lines, arterial and venousMonitor for sign of infection at intravenous lines, arterial and venouspuncture sites, surgical incisions, trauma wounds, urinary catheters andpuncture sites, surgical incisions, trauma wounds, urinary catheters andpressure ulcerpressure ulcer

Reduce px temp. when ordered for temp above 104.8F (40.8C) monitorReduce px temp. when ordered for temp above 104.8F (40.8C) monitorclosely for shiveringclosely for shivering

Administered prescribed intravenous fluids and medicationsAdministered prescribed intravenous fluids and medications

Monitor and report blood levels (antibiotics, BUN, creatinine, WBC ) andMonitor and report blood levels (antibiotics, BUN, creatinine, WBC ) andhemodynamic status, fluid IO and nutritional status.hemodynamic status, fluid IO and nutritional status.

Monitor daily wts. And serum albumin levels to determine daily proteinMonitor daily wts. And serum albumin levels to determine daily proteinrequirementsrequirements


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NE UR OLOG IC SHO CK / S PI NALE UR OLOG IC SHO CK / S PI NALSHOCKHOCK There is loss of vasomotor tone thatThere is loss of vasomotor tone that

includes arteriolar and venousincludes arteriolar and venousdilatation .dilatation .


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Predi spos in g fa ct or s:redi spos in g fa ct or s: Spinal cord injurySpinal cord injury

Spinal anesthesiaSpinal anesthesia

Depressant medsDepressant meds

HypoglycemiaHypoglycemia


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Med ica l M an agemen ted ica l M an agemen t Restoring sympathetic toneRestoring sympathetic tone


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Nu rs in g M anagemen tu rs in g M anagemen t Elevate the head of the bed 30 degrees ( in spinal / epidural anesthesia )Elevate the head of the bed 30 degrees ( in spinal / epidural anesthesia )

Immobilize the patient ( in spinal cord injury )Immobilize the patient ( in spinal cord injury )

Elastic compression stockingsElastic compression stockings

Feet elevationFeet elevation

Heparin / low molecular weight heparinHeparin / low molecular weight heparin

Pneumatic compression of the legsPneumatic compression of the legs

Passive ROMPassive ROM


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An aphylactic S hockn aphylactic S hock


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An aphylactic S hockn aphylactic S hock

An antigen-antibody reaction brought about byAn antigen-antibody reaction brought about by

severe allergenic reaction provokes mast cell tosevere allergenic reaction provokes mast cell torelease chemical mediators like histamine andrelease chemical mediators like histamine and

bradykinin widespread vasodilatation and capillarybradykinin widespread vasodilatation and capillary

permeability.permeability.


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Predi spos in g fa ct or s:redi spos in g fa ct or s: Drug sensitivityDrug sensitivity

Transfusion reactionTransfusion reaction

Bee sting allergyBee sting allergy

Latex sensitivityLatex sensitivity


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Med ica l M an agemen ted ica l M an agemen t Rremoval of causative agentRremoval of causative agent

Restore vascular tone ( epinephrine )Restore vascular tone ( epinephrine )

Antihistamines and bronchodilatorsAntihistamines and bronchodilators


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Nu rs in g M anagemen tu rs in g M anagemen t Assess for previous hypersensitivity reactionsAssess for previous hypersensitivity reactions

Prevention of future exposure to antigensPrevention of future exposure to antigens

Identification of new antigensIdentification of new antigens

Patient educationPatient education


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Sta ges of Sh ockta ges of Sh ockINITI AL STAG E / C OMP EN SATED / NONPR OGRESS IVENITI AL STAG E / C OMP EN SATED / NONPR OGRESS IVESHOCKHOCK BP is maintained within normal limits due to the effectBP is maintained within normal limits due to the effect

of normally functioning regulatory mechanismsof normally functioning regulatory mechanisms

Blood loss less than 10%Blood loss less than 10%


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Sig ns an d Symp tom sig ns an d Symp tom s Apprehension and restlessness ( 1st sign ofApprehension and restlessness ( 1st sign of

shock )shock )

Increase heart rateIncrease heart rate Cool, pain skinCool, pain skin Metabolic acidosisMetabolic acidosis FatigueFatigue TachypneaTachypnea Mental status changeMental status change


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Med ica l M an agemen ted ica l M an agemen t Identify the cause of shockIdentify the cause of shock

Correction of shockCorrection of shock

Support of the regulatorySupport of the regulatory

mechanismsmechanisms


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Nu rs in g M anagemen tu rs in g M anagemen t Monitoring tissue perfusionMonitoring tissue perfusion

LOC LOC

V/S V/S Urine output Urine output

Skin Skin

Laboratory values Laboratory values Reducing anxietyReducing anxiety

Promoting safetyPromoting safety


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Pr ogr essi ve Sta ge /r ogr essi ve Sta ge /Dec om pen sa te dec om pen sa te d Exhaustion of the compensatory mechanismExhaustion of the compensatory mechanism

Myocardial depressionMyocardial depression

Increased capillary permeabilityIncreased capillary permeability


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Sign s an d Sy mptomsign s an d Sy mptomsA. Re spi ra tory ef fect s. Re spi ra tory ef fect s hypoxemia and hypercarbia hypoxemia and hypercarbia intense inflammatory response intense inflammatory response

decreased surfactant production decreased surfactant production

acute respiratory distress syndrome ( acute lung injury, shock acute respiratory distress syndrome ( acute lung injury, shocklungs, non cardiogenic pulmonary edema )lungs, non cardiogenic pulmonary edema )

B. Ca rd iova scu la r ef fect s. Ca rd iova scu la r ef fect s dyshrythmias dyshrythmias

myocardial infraction myocardial infraction

cardiac depression cardiac depression

C. Neu rologi c ef fec ts. Neu rologi c ef fec ts decreased cerebral perfusion decreased cerebral perfusion

mental status change mental status change

behavioral change behavioral change

papillary dilation papillary dilation


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Med ica l M an agemen ted ica l M an agemen t

Depends on the type of shockDepends on the type of shock

Depends of the decompensation of theDepends of the decompensation of the

organ systemsorgan systems


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Irr ev ersib le St agerr ev ersib le St age Sever organ damageSever organ damage

Can no longer respond to treatmentCan no longer respond to treatment

Survival is less likelySurvival is less likely


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Same with progressive stageSame with progressive stage


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Nu rs in g M anagemen tu rs in g M anagemen t

Same with progressive shockSame with progressive shock

Moral support to the familyMoral support to the family

Ethical issue ( living will )Ethical issue ( living will )


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As ses smen tss ses smen tsA. Early stages. Early stages

Restlessness, confusion Restlessness, confusion

Increase RR and PR, respiratory alkalosis Increase RR and PR, respiratory alkalosis

Diaphoresis, cool clammy skin/warm, flushed skin in septic shock Diaphoresis, cool clammy skin/warm, flushed skin in septic shock

Normal to decreased urine output, thirst, dry mucous membrane Normal to decreased urine output, thirst, dry mucous membrane

Hypokalemia Hypokalemia

B. Late stages. La te s ta ges Shallow respiration, decreased BP, increased PR, hypothermia Shallow respiration, decreased BP, increased PR, hypothermia

Oliguria, Anuria Oliguria, Anuria

Hyperkalemia Hyperkalemia

Metabolic acidosis Metabolic acidosis

Edema Edema Cool clammy skin- hypovolemic, cardiogenic and septic shock Cool clammy skin- hypovolemic, cardiogenic and septic shock

Lethargy, dilated pupils Lethargy, dilated pupils

Decreased bowel sounds Decreased bowel sounds

Cyanosis Cyanosis

DIC DIC


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Interv en tion snterv en tion sA. Promoti ng f lu id s balance. Promoti ng flu id s balance

Blood transfusions Blood transfusions

IV fluids IV fluids

B. A ssistin g wit h car diac support. A ssistin g wit h car diac support Intraaortic balloon pump ( IABP) Intraaortic balloon pump ( IABP) Medical anti-shock trousers Medical anti-shock trousers

Modified trendelenburg position Modified trendelenburg position

C. Assis ti ng res pira to ry suppo rt. As sis ti ng res pira to ry suppo rt O2 therapy O2 therapy Mechanical ventilator Mechanical ventilator

Deep breathing, coughing excercises Deep breathing, coughing excercises

Suction as necessary Suction as necessary


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In terven tion sn terven tion sD. Ass is tin g wi th renal support. Ass is tin g wi th renal support

Monitor I and O, BUN and creatinine Monitor I and O, BUN and creatinine

Diuretics Diuretics

E. Ass is tin g with GI sup port. Ass is tin g with GI sup port NGT NGT

H2 blockers and antacids H2 blockers and antacids

F. P romotin g sa fety. Promotin g sa fety Soft restraints as needed Soft restraints as needed Practice strict asepsis Practice strict asepsis

Prevent complications of immobility Prevent complications of immobility

Protect from chills Protect from chills


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Drug Th er apyrug Th er apy Vas oco nst ri ct ors:as oco nst ri ct ors:Norepi ne phr ine / epi nep hri ne, do pa min e, dobu taNorepi ne phr ine / epi nep hri ne, do pa min e, dobu ta Vaso dila tors:aso dila tors:Nitr ate s lik e nitr ogly cer ine an d Iso so rb ideNitr ate s lik e nitr ogly cer ine an d Iso so rb ide Na+ bicarbonate to reverse acidosisNa+ bicarbonate to reverse acidosis Antibiotics to control sepsisAntibiotics to control sepsis Heparin to treat DICHeparin to treat DIC Steroids to reduce inflammationSteroids to reduce inflammation

H2 antihistamines, Ranitidine, cimetidineH2 antihistamines, Ranitidine, cimetidine Glucose 50% or glucagons to increased blood sugarGlucose 50% or glucagons to increased blood sugar Narcotics for painNarcotics for pain Antidysrrhythamic drugsAntidysrrhythamic drugs

End ofthe slides


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Arrh yth mia srrh yth mia s


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Card ia c Arr hythmia sard ia c Arr hythmia s

It is an abnormal electrical conductionIt is an abnormal electrical conduction

or automaticity causing changes inor automaticity causing changes inthe heart rate and rhythm.the heart rate and rhythm.


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Predi spos in g fa ct or s:redi spos in g fa ct or s: CongenitalCongenital

Myocardial IschemiaMyocardial Ischemia

MIMI

Organic heart diseaseOrganic heart disease

Drug effect and toxicityDrug effect and toxicity

Conductive tissue degenerationConductive tissue degeneration

Electrolyte imbalanceElectrolyte imbalance Acid-base imbalanceAcid-base imbalance

Cellular hypoxiaCellular hypoxia


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Pathop hysiolog yathop hysiolog y Result in the disturbance in the excitability,Result in the disturbance in the excitability,

automaticity, or conductivityautomaticity, or conductivity

Heart rate and rhythm are altered, reducingHeart rate and rhythm are altered, reducing

cardiac outputcardiac output


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Assessmentssessment AsymptomaticAsymptomatic

PalpitationPalpitation

Chest painChest pain

DizzinessDizziness Weakness, fatigueWeakness, fatigue

Feeling of impending doomFeeling of impending doom

Irregular heart rhythmIrregular heart rhythm

Bradycardia or tachycardiaBradycardia or tachycardia hypotensionhypotension

SyncopeSyncope

LOCLOC

DiaphoresisDiaphoresis

PallorPallor N/VN/V

Cold, clammy skinCold, clammy skin

Life-threatening:Life-threatening:

pulselessness, (-)pulselessness, (-)respiration, no palpablerespiration, no palpable

blood pressureblood pressure


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Diagnosisiagnosis

ECG- change in heart rate, rhythmECG- change in heart rate, rhythm

Blood chemistry : electrolyteBlood chemistry : electrolyte

imbalanceimbalance


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Nor ma l Sin us R hyth mor ma l Sin us R hyth m


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Ch aract erist ics :h aract erist ics : Vent ri cula r and a tri al ra teent ri cula r and a tri al ra te : 60 to 100 in: 60 to 100 in

adultadult Vent ri cula r and a tri al rhyt hment ri cula r and a tri al rhyt hm : Regular: Regular QR S d ura tion:R S d ura tion: Usually normal, but may beUsually normal, but may be

regularly abnormalregularly abnormal P w avewave : Normal and consistent shape; always: Normal and consistent shape; always

in front of QRSin front of QRS

PR int erva l:R int erva l: Consistent interval between 0.12Consistent interval between 0.12and 0.20 secondsand 0.20 seconds

P:: QRS ratio 1:1QRS ratio 1:1


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Typ es o f S inus n odeyp es o f S inus n odeDy srh ythm iasy srh ythm iasA. Sinus Bra dyc ar dia. Sinus Bra dyc ar dia

occurs when the sinus node creates an impulseoccurs when the sinus node creates an impulse

at a slower rate than normal.at a slower rate than normal.


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Ch aract erist ics :h aract erist ics : Vent ri cula r a nd atr ia l r ateent ri cula r a nd atr ia l r ate : Less than 60 in: Less than 60 in

adultadult

Vent ri cula r a nd atr ia l r hyt hment ri cula r a nd atr ia l r hyt hm : Regular: Regular QR S d ura tion:R S d ura tion: Usually normal but may beUsually normal but may be

regularly abnormalregularly abnormal

P wave :wave: Normal and consistentNormal and consistentinterval between 0.12 andinterval between 0.12 and0.20 seconds0.20 seconds



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Sin us B rad yca rdiain us B rad yca rdia


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Managemen tanagemen t The urgency of treatment depend is on the effect of theThe urgency of treatment depend is on the effect of the

slow rate on maintenance of Cardiac outputslow rate on maintenance of Cardiac output

Atropines, 0.5 to 1.0 mg given IV push block vagalAtropines, 0.5 to 1.0 mg given IV push block vagal

stimulation to the SA Node & therefore accelerate heartstimulation to the SA Node & therefore accelerate heart

rate.rate.

If the bradycardia persists a pacemaker may beIf the bradycardia persists a pacemaker may be

required.required.

Types of Sinus NodeT

ypes of Sinus Node


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B. Sinus Tac hyc ar dia. Sinus Tac hyc ar dia Occur when the sinus node createOccur when the sinus node create

an impulse at a faster than normalan impulse at a faster than normal

rate. It may be caused by acuterate. It may be caused by acute

blood loss, anemia, shock,blood loss, anemia, shock,

hypervolemia, hypovolemia CHF,hypervolemia, hypovolemia CHF,

pain, hypermetabolic states, fever,pain, hypermetabolic states, fever,

anxiety or sympathomimeticanxiety or sympathomimeticmedication.medication.

Types of Sinus NodeTypes of Sinus Node

DysrhythmiasDysrhythmias

C i i


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Ventricular and atrial rate:entricular and atrial rate: GreaterGreaterthan 100 in the adultthan 100 in the adult

Vent ic ula r and atr ia l rhyt hm :ent ic ula r and atr ia l rhyt hm : RegularRegular QRS dura tio n:RS dura tio n: Usually normal, but mayUsually normal, but may

be regularly abnormalbe regularly abnormal P wave:wave: Normal and consistent shape,Normal and consistent shape,

always in front of the QES, but may bealways in front of the QES, but may beburied in the preceding T wave.buried in the preceding T wave.


Characteristics:

Si T h di


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As the heart rate increases, the diastolic falling time decreases, result inAs the heart rate increases, the diastolic falling time decreases, result in

reduced cardiac output and subsequent symptoms of syncope and lowreduced cardiac output and subsequent symptoms of syncope and low

blood pressure. If the heart cannot compensate for the decreasedblood pressure. If the heart cannot compensate for the decreased

ventricular falling the px may develop acute pulmonary edemaventricular falling the px may develop acute pulmonary edema

Sinus TachycardiaSinus Tachycardia


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Ma nag eme nta nag eme nt It is usually directed at abolishing itsIt is usually directed at abolishing its

causes.causes.

Calcium channel blockers and Beta-blockersCalcium channel blockers and Beta-blockersmay be used to reduce the heart ratemay be used to reduce the heart ratequickly.quickly.


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C. Si nus Ar rhyt hmi as. Si nus Ar rhyt hmi as

Occur when the sinus node create anOccur when the sinus node create animpulse at an irregularly rhythm; the rate usuallyimpulse at an irregularly rhythm; the rate usuallyincrease with inspiration and decrease withincrease with inspiration and decrease withexpiration. Non respiratory cause includes heartexpiration. Non respiratory cause includes heart

disease and valvular disease, but these are rarelydisease and valvular disease, but these are rarelyseen.seen.

Ty pes of Sin us n od ey pes of Sin us n od eDysrhythmiasysrhythmias


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Ven tricu lar an d at ria l rat een tricu lar an d at ria l rat e : 60 to 100 in the adult: 60 to 100 in the adult Ven tricu lar an d at ria l rhyt hmen tricu lar an d at ria l rhyt hm : Irregular: Irregular QRS du rat io n:RS du rat io n: Usually normal, but may be regularlyUsually normal, but may be regularly

abnormalabnormal P wavewave : Normal and consistent shape, always in front of: Normal and consistent shape, always in front of

the QRS.the QRS. PR i nter va lR i nter va l : Consistent interval between 0.12 and 0.20: Consistent interval between 0.12 and 0.20

secondsecond P:: QRS ratio: 1:1QRS ratio: 1:1*Sinus Arrhythmia does not cause any significant hemodynamic*Sinus Arrhythmia does not cause any significant hemodynamiceffect and usually is not treated.effect and usually is not treated.

Ch aract eris tics :


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Atria l D ysrhythmia stria l D ysrhythmia s A. Premature Atrial Complex. Premature Atrial Complex Premature Atrial Complex Is a single ECG complex thatPremature Atrial Complex Is a single ECG complex that

occur when an electrical impulse start in the atriumoccur when an electrical impulse start in the atriumbefore the next normal impulse of the sinus node.before the next normal impulse of the sinus node.

The PAC may be caused by caffeine, alcohol, nicotine,The PAC may be caused by caffeine, alcohol, nicotine,

stretched atrial myocardium, anxiety hypokalemia (lowstretched atrial myocardium, anxiety hypokalemia (lowpotassium level), hyper metabolic states or atrialpotassium level), hyper metabolic states or atrial

ischemia, injury or infarction.ischemia, injury or infarction.


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Ch aract erist ics : Ven tricu lar an d at ria l rat een tricu lar an d at ria l rat e : Depend on the underlying: Depend on the underlying

rhythmrhythm Ven tricu lar an d at ria l rhyt hmen tricu lar an d at ria l rhyt hm : Irregular: Irregular QRS du rat io n:RS du rat io n: The QRS that follows the early P wave isThe QRS that follows the early P wave is

usually normal, but it may be abnormal.usually normal, but it may be abnormal. P wavewave : An early and different P wave may be seen or: An early and different P wave may be seen or

may be hidden in the T wave;may be hidden in the T wave; Other P wave in the strip is consistent.Other P wave in the strip is consistent. PR i nter va l:R i nter va l: The early P wave has a shorter than normalThe early P wave has a shorter than normal

PR interval, but still betweenPR interval, but still between 0.12 And 0.20 seconds0.12 And 0.20 seconds P: QRS ratio: Usually 1:1: QRS ratio: Usually 1:1


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Managemen tanagemen t If PACs are in frequent, no treatment is necessary. IfIf PACs are in frequent, no treatment is necessary. If

they are frequent (more tan 6 per minute) this maythey are frequent (more tan 6 per minute) this may

herald a worsening diseases state or the onset ofherald a worsening diseases state or the onset of

more serious dysrhythmias, such as atrial fibrillation.more serious dysrhythmias, such as atrial fibrillation.Treatment is directed toward the cause.Treatment is directed toward the cause.

PACs should be monitored for increasing frequencyPACs should be monitored for increasing frequency


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At ria l F lu ttert ria l F lu tter


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Ch aract erist ics :h aract erist ics : Vent ri cula r a nd atr ia l r ate:ent ri cula r a nd atr ia l r ate: Atrial rangeAtrial range

between 250 and 400 ventricular rates usuallybetween 250 and 400 ventricular rates usually Range between 75 and 150Range between 75 and 150

Vent ri cula r a nd atr ia l r hyt hment ri cula r a nd atr ia l r hyt hm : Usually: UsuallyRegularRegular

P wave :wave: Saw toothed shape. These wavesSaw toothed shape. These wavesreferred to as F wavereferred to as F wave

PR i nt erva l;R i nt erva l; Multiple F waves may make itMultiple F waves may make itdifficult to determine the PR interval.difficult to determine the PR interval.

P: QRS ratio: 2:1, 3:1, or 4:1: QRS ratio: 2:1, 3:1, or 4:1


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Sign and Sy mptomsign and Sy mptoms

Chest painChest pain

Shortness of breathShortness of breath Low blood pressure.Low blood pressure.


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Ma nag emen ta nag emen t The urgency of treatment depend on the ventricular response rate&The urgency of treatment depend on the ventricular response rate&

resultant symptomsresultant symptoms

A Calcium channel blocker such as Diltiazem (cardizem) may be use toA Calcium channel blocker such as Diltiazem (cardizem) may be use to

slow AV Nodal conduction used with caution in the patient with CHF,slow AV Nodal conduction used with caution in the patient with CHF,hypotensionhypotension

Digitalis & Quinidine preparation may be used.Digitalis & Quinidine preparation may be used.

A beta adrenergic block drug such as Esmolol may be used.A beta adrenergic block drug such as Esmolol may be used.

If drug therapy is un successful, trial flutter will often respond toIf drug therapy is un successful, trial flutter will often respond tocardivertion.cardivertion.

Small doses of electrical current are often successfulSmall doses of electrical current are often successful


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At ria l Fi brilla t iont r ia l Fi brilla t ion


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Atria l Dysrhythmia stria l Dysrhythmia sC. Atrial Fibrillation. Atrial Fibrillation May occur for a very short time (paroxysmal) or it may be chronicMay occur for a very short time (paroxysmal) or it may be chronic It is the most common dysrhythmias that cause patients seek medicalIt is the most common dysrhythmias that cause patients seek medical

attentionattention

The shorter time in diastole reduce the time available for coronaryThe shorter time in diastole reduce the time available for coronary

artery perfusion, there by increasing the risk for myocardial ischemia.artery perfusion, there by increasing the risk for myocardial ischemia.

The erratic atrial contraction promotes the formation of a thrombusThe erratic atrial contraction promotes the formation of a thrombus

within the atria increasing the risk of stroke (brain attack).within the atria increasing the risk of stroke (brain attack).


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Ch aract erist ics :h aract erist ics : Vent ri cula r a nd atr ia l r ate:ent ri cula r a nd atr ia l r ate: Atrial rate is 300Atrial rate is 300

and 600 in untreated atrial fibrilationand 600 in untreated atrial fibrilation Vent ri cula r a nd atr ia l r hyt hment ri cula r a nd atr ia l r hyt hm : Highly irregular: Highly irregular QR S s ha pe a nd d ura tion:R S s ha pe a nd d ura tion: usually normal butusually normal butmay be abnormalmay be abnormal P wave :wave: No discernible P waves; irregularNo discernible P waves; irregular

undulating waves are seen and are referred to asundulating waves are seen and are referred to as

fibrillatory or waves.fibrillatory or waves. PR i nt erva l:R i nt erva l: Cannot be measuredCannot be measured P: QRS ratio: many:1: QRS ratio: many:1


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Managemen tanagemen t Cardiovertion may be indicated for atrial fibrillation that has been present for lessCardiovertion may be indicated for atrial fibrillation that has been present for less

than 48 hours, a condition termed acute onset of atrial fibrillationthan 48 hours, a condition termed acute onset of atrial fibrillation

Acute onset, the medication quinidine,Acute onset, the medication quinidine,

Ibutilide,flecanide, dofetilide, profafenon, procanamide, dysopyramide orIbutilide,flecanide, dofetilide, profafenon, procanamide, dysopyramide or

amiodirone may be given to achieve convertion to sinus rhythmamiodirone may be given to achieve convertion to sinus rhythm

Intravenouse adenosine (adenocard,adenescan) has also been use for convertion,Intravenouse adenosine (adenocard,adenescan) has also been use for convertion,as well as to assist in the diagnosis.as well as to assist in the diagnosis.

Calcium channel blocker and beta blocker are effective in controlling theCalcium channel blocker and beta blocker are effective in controlling the

ventricular rate in atrial fibrillationventricular rate in atrial fibrillation

Use Digoxin is recommended to control the ventricular rate those patient withUse Digoxin is recommended to control the ventricular rate those patient withpoor cardiac functionpoor cardiac function

Aspirin may be substituted for warfarin.Aspirin may be substituted for warfarin.


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At ria l Fi brilla t iont r ia l Fi brilla t ion


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Juncti onal D ys rh ythmiasuncti onal D ys rh ythmiasA.. Pr emat ure Junc ti on Co mpl exr emat ure Junc ti on Co mpl ex Is an impulse that starts in the AV nodal before the next normal sinusIs an impulse that starts in the AV nodal before the next normal sinus

impulse reaches the AV node Premature junction complex are less commonimpulse reaches the AV node Premature junction complex are less commonthan PACsthan PACs

The criteria for premature junction complex are the same as for PACs exceptThe criteria for premature junction complex are the same as for PACs except

for the Pwave and the PR interval. The Pwave may be absent QRS, or mayfor the Pwave and the PR interval. The Pwave may be absent QRS, or may

occur before the QRS but with a PR interval of less than 0.12 secondoccur before the QRS but with a PR interval of less than 0.12 second

Treatment for frequency premature junction complexes is the same as forTreatment for frequency premature junction complexes is the same as for

frequent PACs.frequent PACs.


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Premat ure J unct ionremat ure J unct ion


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Juncti onal D ys rh ythmiasuncti onal D ys rh ythmiasB. J un ct io nal Rhy thm. J un ct io nal Rhy thm

Jucntional or idionodal rhythm occur when the AVJucntional or idionodal rhythm occur when the AVnode, instead of the sinus node, become thenode, instead of the sinus node, become thepacemaker of the heart.pacemaker of the heart.


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Ch ara ct eris tics :h ara ct eris t ics : Vent ricul ar a nd a tri al ra te:ent ricul ar a nd a tri al ra te: 40 to 6040 to 60 Vent ricul ar r hyth ment ricul ar r hyth m : Regular: Regular QR S dura tion:R S dura tion: Usually normal but may beUsually normal but may be

abnormalabnormal P wave :wave: May be absent, after the QRS complex,May be absent, after the QRS complex,

or before the QRS; may be invented, especially inor before the QRS; may be invented, especially inlead IIlead II

PR int erva l:R int erva l: If P wave is in front of the QRS, PRIf P wave is in front of the QRS, PRinterval is less than 0.12 secondinterval is less than 0.12 second

P:: QRS ratio1:1 or 1:1QRS ratio1:1 or 1:1


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Juncti onal D ys rh ythmiasuncti onal D ys rh ythmiasC.. At ri ove nti cul ar Noda l Reentr yt ri ove nti cul ar Noda l Reentr yTachyc ardi aachyc ardi a Occurs when an impulse is conducted to an area in the AV nodeOccurs when an impulse is conducted to an area in the AV node

that causes the impulse to be rerouted back into the same area overthat causes the impulse to be rerouted back into the same area over

and over again at a very fast rate.and over again at a very fast rate.

It has an abrupt onset and an abrupt cessation with a QRS of normalIt has an abrupt onset and an abrupt cessation with a QRS of normalduration had been called paroxysmal atrial tachycardia (PAT)duration had been called paroxysmal atrial tachycardia (PAT)


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Ch aract erist ics :h aract erist ics : Vent ricul ar a nd a tri al ra te:ent ricul ar a nd a tri al ra te: atrial rate 150-atrial rate 150-

250; vent rate: 75-250250; vent rate: 75-250 Vent ricul ar a nd a tri al rhyt hment ricul ar a nd a tri al rhyt hm : Regular;: Regular;

sudden onset and termination of the tachycardiasudden onset and termination of the tachycardia QR S dura tion:R S dura tion: Usually normal but may beUsually normal but may be

abnormalabnormal P wave :wave: usually very difficult to discernusually very difficult to discern PR int erva l:R int erva l: If P wave is in front of the QRS, PRIf P wave is in front of the QRS, PR

interval is less than 0.12 secondinterval is less than 0.12 second P:: QRS ratio1:1 or 2:1QRS ratio1:1 or 2:1

Ven tri cu laren tri cu lar


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Dysrhyt hmia sysrhyt hmia sA. Pr emat ure Ven tricu lar Co mp lex. Pr emat ure Ven tricu lar Co mp lex Caused by acute MI other form of heart disease, pulmonary disease,Caused by acute MI other form of heart disease, pulmonary disease,

electrolyte disturbance, metabolic instability and drug abuseelectrolyte disturbance, metabolic instability and drug abuse

The wave of impulse originates from an ectopic Focus (Foci) within theThe wave of impulse originates from an ectopic Focus (Foci) within theventricles at rate faster than the next normally occurring beat.ventricles at rate faster than the next normally occurring beat.

Because the normal conduction pathway is by passed configuration ofBecause the normal conduction pathway is by passed configuration of

the PVC is wider than normal and is distorted in appearance.the PVC is wider than normal and is distorted in appearance.

PVCs may occur in regular sequence with normal rhythm.PVCs may occur in regular sequence with normal rhythm.

Prem ature Ve ntricu la rrem ature Ve ntricu la r


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Complexomplex


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Ch aract erist ics :h aract erist ics : Vent ricul ar a nd a tri al ra te:ent ricul ar a nd a tri al ra te: Depend on theDepend on the

underlying rhythm.underlying rhythm.

Vent ricul ar a nd a tri al rhyt hm:ent ricul ar a nd a tri al rhyt hm: IrregularIrregular QR S dura tion:R S dura tion: 0.12 second or longer shape is0.12 second or longer shape is

bizarre and abnormalbizarre and abnormal

P w avewave : none: none PP intervalP interval : If the P wave is in front of the QRS,: If the P wave is in front of the QRS,the PR interval is less than 0.12 secondthe PR interval is less than 0.12 second P: QRS ratio 0:1, 1:1: QRS ratio 0:1, 1:1


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Ch aract erist ics :h aract erist ics : Vent ri cu lar and atri al rate:ent ri cu lar and atri al rate: 100to200100to200

beat per minutebeat per minute

Ventricular and atrial rhythmentricular and atrial rhythm : Usually: UsuallyRegularRegular

P wave:wave: so atrial rate and rhythm may beso atrial rate and rhythm may beindeterminable.indeterminable.

PR int erva l:R int erva l: Very IrregularVery Irregular P:: QRS ratio: difficult to determineQRS ratio: difficult to determine


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Ven tri cu lar Ta ch yca rdiaen tri cu lar Ta ch yca rdia


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Managemen tanagemen t

Cardiovertion may be the treatment of choice,Cardiovertion may be the treatment of choice,

especially if the patient is unstable.especially if the patient is unstable.

VT in a patient who is unconscious and without aVT in a patient who is unconscious and without a

pulse treated in the same manner as ventricularpulse treated in the same manner as ventricular

fibrillation immediate defibrillation is the action offibrillation immediate defibrillation is the action ofchoicechoice..


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Ventr icu la r Fib ril lat ionentricu la r Fib ril lat ion


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Ch aract erist ics :h aract erist ics : Ven tri cula r rat e: Great er thanen tri cula r rat e: Great er than

300 per minute300 per minute

Ven tri cula r and a tri al rhyt m:en tri cula r and a tri al rhyt m: Extremely irregularExtremely irregular

QRS dura tio nRS dura tio n IrregularIrregular


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Managemen tanagemen t Immediately fibrillation and activation of emergency serviceImmediately fibrillation and activation of emergency service

The importance of defibrillation is evident in one of the recent changeThe importance of defibrillation is evident in one of the recent changein basic life support.in basic life support.

Placing a call for emergency assistant and calling for a defibrillatorPlacing a call for emergency assistant and calling for a defibrillatortakes precedence over initiating Cardio pulmonary resuscitation intakes precedence over initiating Cardio pulmonary resuscitation inadult victim.adult victim.

Application of an automatic external defibrillator AED is included inApplication of an automatic external defibrillator AED is included inbasic life support classesbasic life support classes

Administering Vaso active and anti arrhythmia medication alternatingAdministering Vaso active and anti arrhythmia medication alternatingwith defibrillation are treatment used to try convert the rhythm towith defibrillation are treatment used to try convert the rhythm tonormal sinus rhythm.normal sinus rhythm.



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Dysrhyt hmia sysrhyt hmia sD. Idio vent ric ul ar Rhyt hm. Idio vent ric ul ar Rhyt hm Is also called ventricular escape rhythm, occur when the impulse starts inIs also called ventricular escape rhythm, occur when the impulse starts in

the conduction system below the AV node.the conduction system below the AV node.

Commonly cause the patient to lose consciousness and experience otherCommonly cause the patient to lose consciousness and experience other

sign and symptoms of reduced cardiac out put . Intervention may includesign and symptoms of reduced cardiac out put . Intervention may include

identify the underlying cause, administeringidentify the underlying cause, administering

Intravenous atropine and vasopressor medication. Initiating emergencyIntravenous atropine and vasopressor medication. Initiating emergencytranscutaneous pacing.transcutaneous pacing.

Bed rest is prescribed so as not to increase the cardiac work loadBed rest is prescribed so as not to increase the cardiac work load


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Ch aract erist ics :h aract erist ics : Ven tri cula r and a tri al ra teen tri cula r and a tri al ra te : Between: Between

20and 40 if the rate exceeds 40, is known20and 40 if the rate exceeds 40, is known

(AIVR)(AIVR) Ven tri cula r and a tri al rhyt hm:en tri cula r and a tri al rhyt hm:

RegularRegular

QRS dura tio nRS dura tio n : Bizarre, abnormal,: Bizarre, abnormal,duration is 0.12 second or more.duration is 0.12 second or more.



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Dysrhyt hmia sysrhyt hmia sE. Vent ric ular As ys tol e. Vent ric ular As ys tol e Commonly called flat line, ventricular a systole characterizedCommonly called flat line, ventricular a systole characterized

by QRS complexes, all though P wave may be apparent for aby QRS complexes, all though P wave may be apparent for ashort duration is two different leads. There is no heart beat,short duration is two different leads. There is no heart beat,no palpable pulse and no respiration.no palpable pulse and no respiration.

Assessment to identify the possible cause which may beAssessment to identify the possible cause which may behypoxia, acidosis, severe electrolyte imbalance, drug overdosehypoxia, acidosis, severe electrolyte imbalance, drug overdoseor hypothermia.or hypothermia.


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Ven tricu la r As ystoleen tricu la r As ystole


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Managemen tanagemen t CPR and emergency service as necessary toCPR and emergency service as necessary to

keep the patient alive.keep the patient alive.

Transcutaneuos pacing may be attempted. ATranscutaneuos pacing may be attempted. A

bolus of intravenous epinephrine should be adbolus of intravenous epinephrine should be ad

minister and repeated 3to5 minutes intervalminister and repeated 3to5 minutes interval

End ofthe slides


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HEAR T BL OCK

onduct ion Ab norm alit ies


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Conduct ion Ab norm alit ies The nurse first to identify is the underlying rhythm.(eg, sinusThe nurse first to identify is the underlying rhythm.(eg, sinus

rhythmia) then the PR interval is assessed for the possibility of anrhythmia) then the PR interval is assessed for the possibility of anAV block.AV block.

AV block occur when the conduction of impulse through the AVAV block occur when the conduction of impulse through the AVnodal are is decreased or stopped. These block can caused bynodal are is decreased or stopped. These block can caused bymedication (eg,digitalis, calcium channel blockers, beta blocker).medication (eg,digitalis, calcium channel blockers, beta blocker).

The Clinical sign and symptoms of a heart block vary with theThe Clinical sign and symptoms of a heart block vary with theresulting ventricular rate and the severity of any underlyingresulting ventricular rate and the severity of any underlyingdisease processes.disease processes.

The treatment is based on the hemodynamic effect of the rhythmThe treatment is based on the hemodynamic effect of the rhythm

Types ofypes of Con duct ionon duct ion


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Ab normalit iesb normalit ies

A. Fir st Degree Bloc k. Fir st Degree Bloc kOccur when all the atrial impulseOccur when all the atrial impulse

are conducted through the AV node intoare conducted through the AV node into

the ventricle at a rate slower than normalthe ventricle at a rate slower than normal

h aract erist ics :


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Ch aract erist ics : Vent ri cu lar and atri al ra te:ent ri cu lar and atri al ra te: DependDepend

on the underlying rhythm.on the underlying rhythm.

Ventricular and atrial rhythmentricular and atrial rhythm : Depend: Dependon the underlying rhythm.on the underlying rhythm.

QRS dura tio nRS dura tio n ; usually normal; usually normal P wave:wave: In front of QRS complex; showsIn front of QRS complex; shows

sinus rhythm, regular shape.sinus rhythm, regular shape.

P: QRS: QRS ratio1:1ratio1:1

Fir st D eg ree A V Blockir st D eg ree A V Block


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Types ofypes of Con duct ionon duct ion


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Ab normalit iesb normalit iesB.1 Seco nd Deg re e Atri oven tricu la r Block Type I.1 Seco nd Deg re e Atri oven tr icu la r Block Type I

Second degree type I heart block occurs when all but one of theSecond degree type I heart block occurs when all but one of theatrial impulse are conducted. Through the AV node into the ventricles.atrial impulse are conducted. Through the AV node into the ventricles.Each atrial impulse a take longer time for conduction than the oneEach atrial impulse a take longer time for conduction than the one

before, until one impulse is fully blocked.before, until one impulse is fully blocked.

Ch aract erist ics :h aract erist ics :


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Ven tricu lar an d at ria l rat e:en tricu lar an d at ria l rat e: Depend on the underlyingDepend on the underlyingrhythmrhythm

Ven tricu lar an d at ria l rhyt hm:en tricu lar an d at ria l rhyt hm: The PP interval isThe PP interval isregular if the patient has an underlying normal sinusregular if the patient has an underlying normal sinus

rhythm; the RR interval characteristically reflect a patternrhythm; the RR interval characteristically reflect a patternof change .of change . QRS duration:RS duration: Normal may be abnormalNormal may be abnormal P wave:wave: In front of the QRS complex; shape depend onIn front of the QRS complex; shape depend on

underlying rhythmunderlying rhythm

PR i nter va l:R i nter va l: PR interval become longer with eachPR interval become longer with eachsucceeding ECG complex until there is a P wave notsucceeding ECG complex until there is a P wave notfollowed by a QRS.followed by a QRS.

P:: QRS ratio 3; 2, 4:3, 5:4,QRS ratio 3; 2, 4:3, 5:4, Second D egr ee A tri oventr ic ul arecond D egr ee A tri oventr ic ul ar


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Bl oc k Typ e Il oc k Typ e I


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Se con d De gr ee Atriove nt ric ulare con d De gr ee Atriove nt ric ular


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Block T ype IIlock T ype II



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Ventricular and atrial rate: Depend on theVentricular and atrial rate: Depend on the

underlying rhythmunderlying rhythm

Ventricular and atrial rhythm. The PP intervalVentricular and atrial rhythm. The PP interval

is regular if the patient has an underlyingis regular if the patient has an underlying

normal sinus rhythm.normal sinus rhythm.

Types o fypes o f Con ductionon duction


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Ab normali tiesb normali tiesC. Thi rd Degree Atrio ve nt ri cular B lo ck. Thi rd Degree Atrio ve nt ri cular B lo ck

Occur when no atrial impulse isOccur when no atrial impulse isconducted through the AV node into theconducted through the AV node into theventricle In the third degree heart block , twoventricle In the third degree heart block , twoimpulse stimulate the heart :one stimulate theimpulse stimulate the heart :one stimulate the

ventricle ,represent by the QRS complex, andventricle ,represent by the QRS complex, andone stimulate the atria .one stimulate the atria .


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Vent ri cula r a nd a tri al ra te:ent ri cula r and a tri al ra te: Depend on theDepend on theescape and underlying atrial rhythm.escape and underlying atrial rhythm.

Vent ri cula r and a tri al rhyt hment ri cula r and a tri al rhyt hm :The PP:The PPinterval is regular and the RR interval is regular;interval is regular and the RR interval is regular;however the PP interval is not Equal to the RRhowever the PP interval is not Equal to the RR

interval.interval.

QR S d ura tionR S d ura tion : Depend on the escape of: Depend on the escape ofrhythmrhythm P w avewave : Depend on the underlying rhythm: Depend on the underlying rhythm P:: QRS ratio: More P wave than QRS complexesQRS ratio: More P wave than QRS complexes

Managemen tanagemen t


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IF the patient is short of breath, complains ofIF the patient is short of breath, complains ofchest pain or lightheadedness, or has low BP:chest pain or lightheadedness, or has low BP:Intravenous bolus of Atropine is the initialIntravenous bolus of Atropine is the initialtreatment of choice.treatment of choice.

If the patient does not respond to atropine or hasIf the patient does not respond to atropine or hasacute MI, trascutaneous pacing should be started.acute MI, trascutaneous pacing should be started.

A permanent pacemaker may be necessary if theA permanent pacemaker may be necessary if theblock persist.block persist.

Nur si ng A ss ess mentur si ng A ss ess ment


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Major assessment include all possible cause of theMajor assessment include all possible cause of thedysrhythmia and the dysrhythmias effect on the heartsdysrhythmia and the dysrhythmias effect on the heartsability to pumped an adequate blood volume.ability to pumped an adequate blood volume.

When cardiac output is reduced, the amount of O2 reachingWhen cardiac output is reduced, the amount of O2 reaching

the tissue and vital organ is diminished. This diminishedthe tissue and vital organ is diminished. This diminishedoxygenation produces the s/sx associated with dysrhythmia.oxygenation produces the s/sx associated with dysrhythmia.

A health history is obtained to identify any previousA health history is obtained to identify any previousoccurrence of decreased cardiac output such as syncopeoccurrence of decreased cardiac output such as syncope

(fainting), lightheadedness , dizziness , fatigue, chest(fainting), lightheadedness , dizziness , fatigue, chestdiscomfort and palpitationdiscomfort and palpitation

Coexisting condition that could be a possible cause of heartCoexisting condition that could be a possible cause of heart

block or dysrhythmia (heart disease, chronic obstructiveblock or dysrhythmia (heart disease, chronic obstructive

Nur si ng A ssess me ntur si ng A ssess me nt


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All medications prescribed and over the counterAll medications prescribed and over the counter(supplements herbs and nutritional) may be reviewed.(supplements herbs and nutritional) may be reviewed.

The nurse conducts physical assessment to the patientThe nurse conducts physical assessment to the patient

with diminished cardiac output especially the level of LOCwith diminished cardiac output especially the level of LOC. the nurse directs attention to the skin which may be. the nurse directs attention to the skin which may bepale and cool. Sign of fluid retention, such as neck veinpale and cool. Sign of fluid retention, such as neck veindistention and crackles and wheezes auscultated in thedistention and crackles and wheezes auscultated in thelungs.lungs.

The nurse auscultates for extra heart sounds ( especiallyThe nurse auscultates for extra heart sounds ( especiallyS3 and S4 ) and for heart murmur, measure bloodS3 and S4 ) and for heart murmur, measure bloodpressure indicates reduced cardiac output.pressure indicates reduced cardiac output.

Nu rs in g D ia gnos isu rs in g D ia gnos is


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Decreased cardiac outputDecreased cardiac output

Anxiety related to fear of the unknownAnxiety related to fear of the unknown

Deficient knowledge about the dysrhythmias and its relatedDeficient knowledge about the dysrhythmias and its related

treatment.treatment.

Collaborative Problems and Potential ComplicationCollaborative Problems and Potential Complication May developed over time a heart failureMay developed over time a heart failure

ThromboembolicThromboembolic

Nu rs in g I nter ven tionu rs in g I nter ven tion


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1. Mo ni torin g an d man ag in g the dy sr hyt hmia s. Mo ni torin g an d man ag in g the dy sr hyt hmia s Regularly evaluate the blood pressure, pulse rate and rhythm, rate andRegularly evaluate the blood pressure, pulse rate and rhythm, rate and

depth of respiration and breath sounds to determine the hemodynamicdepth of respiration and breath sounds to determine the hemodynamiceffects.effects.

Obtain a 12 lead ECG, continuously monitor the patient and analyzeObtain a 12 lead ECG, continuously monitor the patient and analyzerhythm of the strips to track dysrhythmias.rhythm of the strips to track dysrhythmias.

Use an antiarrhythmias medications and the nurse assess and observeUse an antiarrhythmias medications and the nurse assess and observe

for the beneficial and adverse effects of each medications adfor the beneficial and adverse effects of each medications adprescribed.prescribed.

Assist the patient in developing a plan to make a lifestyle change thatAssist the patient in developing a plan to make a lifestyle change thateliminates or reduced the risk factors.eliminates or reduced the risk factors.

Nu rsing In terv en tionu rsing In terv en tion


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2. Mi nimi ze anxie ty. Mi nimi ze anxie ty Maintain a calm and reassuring attitudeMaintain a calm and reassuring attitude

Emphasized with the patient to promote a sense of confidence in livingEmphasized with the patient to promote a sense of confidence in living

the disease.the disease.

Goal is to maximize the clients controls and to make the unknown lessGoal is to maximize the clients controls and to make the unknown lessthreatening.threatening.

3. Pr omo ti ng Home and Commu ni ty Based Car e. Pr omo ti ng Home and Commu ni ty Based Car e Explain the importance of maintaining therapeutic serum levels of theExplain the importance of maintaining therapeutic serum levels of the

medications so that the patients understand why medications should bemedications so that the patients understand why medications should betaken regularly each day.taken regularly each day.

Adju ncti ve M oda li ti es a nddju ncti ve M oda li ti es a nd


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Man agemen tan agemen t Pacema ker the rapyacema ker the rapy is an electronic device is an electronic device

that provide electrical stimulation to the heartthat provide electrical stimulation to the heart

muscles. Used when the patient has a slowermuscles. Used when the patient has a slower

than normal impulse formation or conductionthan normal impulse formation or conductiondisturbance causing symptoms.disturbance causing symptoms. Permanent pacemaker- are used commonlyPermanent pacemaker- are used commonly

irreversible complete heart block.irreversible complete heart block.

Temporary pacemaker- are used to supportTemporary pacemaker- are used to supportpatients until they improve or receive a permanentpatients until they improve or receive a permanent

pacemaker.pacemaker.

Pa cema ker D es ig n a nda cema ker D es ig n a nd


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typesypes Pacemaker consist of 2 components : an electronic pulse generator andPacemaker consist of 2 components : an electronic pulse generator and

pacemaker electrodes, which are located on leads or wire. Thepacemaker electrodes, which are located on leads or wire. Thegenerator contains the circuitry and batteries that generate the rategenerator contains the circuitry and batteries that generate the rateand strength of the electrical impulse delivered to the heart.and strength of the electrical impulse delivered to the heart.

The pacemaker electrodes convey the hearts electrical activity throughThe pacemaker electrodes convey the hearts electrical activity througha lead to the generator ; the generators electrical response to thea lead to the generator ; the generators electrical response to theinformation received is then transmitted to the heart.information received is then transmitted to the heart.

Leads can be threaded through a major veins into the right ventriclesLeads can be threaded through a major veins into the right ventricles(endocardial leads) or they can be lightly sutured onto the outside the(endocardial leads) or they can be lightly sutured onto the outside theheart and brought the chest wall during open heart surgery.heart and brought the chest wall during open heart surgery.

Pa cema ker D es ig n a nda cema ker D es ig n a nd


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typesypes Epicardial wires are always temporary and are removed byEpicardial wires are always temporary and are removed by

a gentle tug within a few daysafter surgery.a gentle tug within a few daysafter surgery.

Endocardial leads may be temporarily placed withEndocardial leads may be temporarily placed withcatheters through the femoral, antecubical, brachial orcatheters through the femoral, antecubical, brachial orjugular veins, usually guided by fluoroscopy.jugular veins, usually guided by fluoroscopy.

The energy source for permanent generators are:The energy source for permanent generators are:

mercury-zinc batteries (which last 3 to 4 years), lithiummercury-zinc batteries (which last 3 to 4 years), lithiumcell units (up to 10 years), nuclear powered source suchcell units (up to 10 years), nuclear powered source suchas plutonium (up to 20 years).as plutonium (up to 20 years).

Clin ica l M anifes tatio nlin ica l M anifes tatio n


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Block AV block usually 3 bundle branchBlock AV block usually 3 bundle branch

blockblock

Symptomatic BradycardiaSymptomatic BradycardiaArrhythmia during surgeryArrhythmia during surgery

Sick sinus syndromeSick sinus syndrome



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Mo nito ri ng Pacema ke r fun ct io n-o nito ri ng Pacema ke r fun ct io n- observe theobserve thepresence of the pacemaker spikes in the ECG,presence of the pacemaker spikes in the ECG,monitor for the pacemaker malfunctions, weakness,monitor for the pacemaker malfunctions, weakness,dizziness, fainting, hypotension, shortness ofdizziness, fainting, hypotension, shortness of

breath, chest pain, ankle swelling.breath, chest pain, ankle swelling.

Pr ev en t in fecti ons-r ev en t in fecti ons- changes the dressingchanges the dressingregularly and inspects the insertion site for redness,regularly and inspects the insertion site for redness,swelling, soreness or any unusual drainage andswelling, soreness or any unusual drainage and

increase the temperature should be noted.increase the temperature should be noted.



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Cl ie nt t each in g ab out pace make r-l ie nt t each in g ab out pace make r- instruct the patient how to check pulse at home, inform toinstruct the patient how to check pulse at home, inform to

report any changes in the heart rate, avoid contact sports,report any changes in the heart rate, avoid contact sports,

carry ID, instruct to report sign of battery failure, wear loosecarry ID, instruct to report sign of battery failure, wear loosefitting clothes, remind that most electrical appliances can befitting clothes, remind that most electrical appliances can beused without interference the functions of the pacemaker,used without interference the functions of the pacemaker,avoid MRI, transmitter tower and anti theft device, move awayavoid MRI, transmitter tower and anti theft device, move awayfrom electrical appliances that cause disturbances andfrom electrical appliances that cause disturbances andemphasize regular follow up check up.emphasize regular follow up check up.

End ofthe slides


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STROKE

Stroketroke


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Disrup tion of cereb ral circul at ion that resul ts in mot or and sensor y de fici tsisrup tion of cereb ral circul at ion that resul ts in mot or and sensor y de fici tsCaus es:aus es: Cerebral arteriosclerosisCerebral arteriosclerosis

SyphilisSyphilis

TraumaTrauma

HypertensionHypertension

ThrombosisThrombosis

EmbolismEmbolism

HemorrhageHemorrhage

VasospasmVasospasm

Ty pes of S trok ey pes of S trok e


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1. Ische mic St roke. Ische mic St roke Larg e Artery Thr omb otic St rokes -arg e Artery Thr omb otic Strokes - are due to atheroscleroticare due to atherosclerotic

plaques in the large blood vessel of the brain. Thrombus formation andplaques in the large blood vessel of the brain. Thrombus formation and

occlusion at the site of the atherosclerosis result in ischemia andocclusion at the site of the atherosclerosis result in ischemia andinfraction and occur in older patients.infraction and occur in older patients.

Sma ll Penetratin g Artery Thr omb otic Strokes -ma ll Penetratin g Artery Thr omb otic Strokes - affect oneaffect oneor more vessels are the most common type of ischemic stroke. Alsoor more vessels are the most common type of ischemic stroke. Also

called lacunar strokes. Occur in young ones.called lacunar strokes. Occur in young ones.

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Ca rd iogen ic Emb oli c Stroke s-a rd iogen ic Emb oli c Stroke s- are associated with cardiac dysrhythmias, usually atrial fibrillation.are associated with cardiac dysrhythmias, usually atrial fibrillation.Emboli originated from the heart and circulate to the cerebralEmboli originated from the heart and circulate to the cerebralvasculature, most commonly in the left middle cerebral artery,vasculature, most commonly in the left middle cerebral artery,resulting in a stroke. Embolic strokes may be prevented by the useresulting in a stroke. Embolic strokes may be prevented by the useof anticoagulant therapy in patients with atrial fibrillation.of anticoagulant therapy in patients with atrial fibrillation.

Cryptogenic Stroke-ryptogenic Stroke- which have no known cause andwhich have no known cause andother stroke from cause of cocaine used, coagulopathies, migraineother stroke from cause of cocaine used, coagulopathies, migraine

and spontaneous dissections of the carotid or vertebral arteries.and spontaneous dissections of the carotid or vertebral arteries.

Clin ica l M anifes tatio nlin ica l M anifes tatio n


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Numbness or weakness of the face, arm or leg especially on one side of theNumbness or weakness of the face, arm or leg especially on one side of thebody.body.

Confusion or change in mental statusConfusion or change in mental status

Trouble speaking or understanding speechTrouble speaking or understanding speech

Visual disturbanceVisual disturbance

Difficulty walking, dizziness or loss of balance or coordinationDifficulty walking, dizziness or loss of balance or coordination

Sudden severe headacheSudden severe headache


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Clinical Man ifesta ti onlinical Man ifesta ti on


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Com munic ati on Lo ssom munic ati on Lo ss Dysa rthi aysa rthi a ( difficulty in speaking), caused by paralysis of the( difficulty in speaking), caused by paralysis of the

muscles responsible for producing speech.muscles responsible for producing speech.

Dysp ha si a or apha si aysp ha si a or apha si a (defective speech or loss of speech)(defective speech or loss of speech)which can bewhich can be ex pr es siv e aph asia , rece pt ive aphasia or globa lx pr es siv e aph asia , rece pt ive aphasia or globa l(m ixe d) aphasiam ixe d) aphasia

Apraxiapraxia ( inability to perform a previously learned action) as may be( inability to perform a previously learned action) as may beseen when a patient picks up a fork and attempts to comb.seen when a patient picks up a fork and attempts to comb.



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Percept ua l Di stur ba nceercept ua l Di stur ba nce Perception is the ability to interpret sensationPerception is the ability to interpret sensation Visual perceptual dysfunction are due to disturbance of the primary sensoryVisual perceptual dysfunction are due to disturbance of the primary sensory

pathways between the eye and visual cortex.pathways between the eye and visual cortex. Hemianopsia (loss of half of the visual fields) may be occur from the stroke andHemianopsia (loss of half of the visual fields) may be occur from the stroke and

may be temporary or permanent.may be temporary or permanent. Disturbance in visual spatial relation ( perceiving the relation of two or moreDisturbance in visual spatial relation ( perceiving the relation of two or more

objects in spatial areas) frequently seen in patient with right hemispheric damage.objects in spatial areas) frequently seen in patient with right hemispheric damage.Se nsory Losse nsory Loss Sensory loss from stroke may take the form of slightSensory loss from stroke may take the form of slight

impairment of touch or may be more severe, with loss ofimpairment of touch or may be more severe, with loss ofproprioception ( ability to perceive the position and motion ofproprioception ( ability to perceive the position and motion ofthe body parts) as well as difficulty in interpreting visual,the body parts) as well as difficulty in interpreting visual,tactile and auditory stimuli.tactile and auditory stimuli.



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Sensor y Lossensor y Loss Sensory loss from stroke may take theSensory loss from stroke may take the

form of slight impairment of touch or mayform of slight impairment of touch or maybe more severe, with loss ofbe more severe, with loss of

proprioception ( ability to perceive theproprioception ( ability to perceive the

position and motion of the body parts) asposition and motion of the body parts) aswell as difficulty in interpreting visual,well as difficulty in interpreting visual,

tactile and auditory stimuli.tactile and auditory stimuli.



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Cogni ti ve Im pairm entogni ti ve Im pairm ent

Such dysfunction may be attention span,Such dysfunction may be attention span,difficulties in comprehension, forgetfulness anddifficulties in comprehension, forgetfulness and

lack of motivation, which cause these patients tolack of motivation, which cause these patients to

become frustrated in their rehabilitationbecome frustrated in their rehabilitation

program.program.


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Nu rs in g D ia gnos isu rs in g D ia gnos is


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Disturbed thought process related to brain damage, confusion orDisturbed thought process related to brain damage, confusion orinability to follow instruction.inability to follow instruction.

Impaired verbal communication related to brain damageImpaired verbal communication related to brain damage

Risk for impaired skin integrity related to hemiparesis/ hemiplegia orRisk for impaired skin integrity related to hemiparesis/ hemiplegia ordecreased mobility.decreased mobility.

Interrupted family process related to catastrophic illness and care givingInterrupted family process related to catastrophic illness and care givingburdensburdens

Sexual dysfunction related to neurologic deficit or fear of failureSexual dysfunction related to neurologic deficit or fear of failure

Di ag nos ic Te st F in din gsi ag nos ic Te st F in din gs


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LP:P: increase pressure, bloody CSFincrease pressure, bloody CSF CT scan:T scan: intracranial bleeding, infarct, or shiftintracranial bleeding, infarct, or shift

of midline structuresof midline structures..

EEG:EG : focal slowing in area of lesionfocal slowing in area of lesion MRI:RI : intracranial bleeding, infarct, or shift ofintracranial bleeding, infarct, or shift of

midline structuresmidline structures

Brain scan:rain scan: decreased perfusiondecreased perfusion Digit al subtr acti on Ang iography:igit al subtr acti on Ang iography:

occlusion or narrowing of vesselocclusion or narrowing of vessel



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Platelet inhibiting medication decrease the incidence of cerebralPlatelet inhibiting medication decrease the incidence of cerebralinfraction in patients who have experience TIA from embolic orinfraction in patients who have experience TIA from embolic orthrombotic causethrombotic cause

Thrombolytic agents are used to treat ischemic by dissolving theThrombolytic agents are used to treat ischemic by dissolving theblood clot that is blocking blood flow to the brain. Recombinant t-PA isblood clot that is blocking blood flow to the brain. Recombinant t-PA is

genetically engineered form t-PA thrombolytic substance madegenetically engineered form t-PA thrombolytic substance madenaturally by the body. It works by binding to fibrin and convertingnaturally by the body. It works by binding to fibrin and convertingplasminogen to plasmin which stimulate fibrinolysis of theplasminogen to plasmin which stimulate fibrinolysis of theatherosclerosis lesion.atherosclerosis lesion.

The dose of t-PA minimum dose is 0.9mg/kg, the maximum dose is 90The dose of t-PA minimum dose is 0.9mg/kg, the maximum dose is 90

mg. The loading dose is 10% of the calculated dose and ismg. The loading dose is 10% of the calculated dose and isadministering over 1min. the remaining dose is administered over 1 hradministering over 1min. the remaining dose is administered over 1 hrvia an infusion pump. Then flushed the line with 20 ml of normal salinevia an infusion pump. Then flushed the line with 20 ml of normal salinesolution.solution.



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Vital sign monitored q 15min for the first 2 hrs,q30 min for the next 6Vital sign monitored q 15min for the first 2 hrs,q30 min for the next 6hrs.hrs.

Bleeding is the most common side effects of t-PA administration andBleeding is the most common side effects of t-PA administration andthe patient should be closely monitored.the patient should be closely monitored.

Other treatment are anticoagulant administration for ischemic strokeOther treatment are anticoagulant administration for ischemic strokeand careful maintenace of cerebral hemodynamics to maintain cerebraland careful maintenace of cerebral hemodynamics to maintain cerebralperfusion. Elevation of the head of the bed to promote venousperfusion. Elevation of the head of the bed to promote venousdrainage and to lower increased ICP.intubation with an endotrachealdrainage and to lower increased ICP.intubation with an endotrachealtube to established a patent airway.tube to established a patent airway.

Endarterectomy for prevention of ischemic stroke is the removal of anEndarterectomy for prevention of ischemic stroke is the removal of anatherosclerotic plaques orthrombus from the carotid artery to preventatherosclerotic plaques orthrombus from the carotid artery to preventstroke in patients with occlusive disease of the ectracranial cerebralstroke in patients with occlusive disease of the ectracranial cerebralarteriesarteries



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1.. Imp rovi ng mo bi li ty and pr even ting jo intmp rovi ng mo bi li ty and pr even ting jo intdeformitieseformities correct positioning is important to prevent contracturescorrect positioning is important to prevent contractures Prevent adduction of the affected shoulder while the patients is in bed, aPrevent adduction of the affected shoulder while the patients is in bed, a

pillow is placed in the axilla when where is limited external rotation; thispillow is placed in the axilla when where is limited external rotation; this

keep the arm away from the chest.keep the arm away from the chest. Positioning the finger so that they are flexed while the hand placed onPositioning the finger so that they are flexed while the hand placed on

slight supination which it is most functional position.slight supination which it is most functional position. The patients position should be changed every 2 hrs. toplace a patient in aThe patients position should be changed every 2 hrs. toplace a patient in a

lateral position position, a pillow is placed between the legs before thelateral position position, a pillow is placed between the legs before thepatients is turned.patients is turned.

A full range of motion 4 to 5 times a day to maintain joint mobility andA full range of motion 4 to 5 times a day to maintain joint mobility andregain motor control, prevent contractures, prevent further deterioration ofregain motor control, prevent contractures, prevent further deterioration ofthe neurovascular systemthe neurovascular system

Preparing for ambulation, the patient is taught to maintain balance whilePreparing for ambulation, the patient is taught to maintain balance whilesitting and then learn to balance while standing in a gradual manner untilsitting and then learn to balance while standing in a gradual manner untilthe patient can walk.the patient can walk.



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1 Prev ent ing Shoul der pa inrev ent ing Shoul der pa in To prevent shoulder pain, the nurse should never lift the patientTo prevent shoulder pain, the nurse should never lift the patient

by the flaccid shoulder or pull on the affected arm shoulder. If theby the flaccid shoulder or pull on the affected arm shoulder. If thearm is paralyzed, subluxation at the shoulder can occur from overarm is paralyzed, subluxation at the shoulder can occur from overstretching the joint capsule and masculature by the force of gravity.stretching the joint capsule and masculature by the force of gravity.

Amitriptyline hydrochloride used because of its sedating effects.Amitriptyline hydrochloride used because of its sedating effects.

Some clinicians advocate the use of a properly worn sling when theSome clinicians advocate the use of a properly worn sling when thepatients first becomes ambulatory to prevent upper extremity frompatients first becomes ambulatory to prevent upper extremity fromdangling without support.dangling without support.

ROM is important in preventing painful shoulderROM is important in preventing painful shoulder



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3. M an ag e D ysph agia. M an ag e D ysph agia ETT is reduced the risk of aspiration while the patient is inis reduced the risk of aspiration while the patient is in

ET tube elevate the head of the bed at least 30 degree toET tube elevate the head of the bed at least 30 degree to

prevent aspiration, check the proper position of the ET tubeprevent aspiration, check the proper position of the ET tube

before feeding the patients, ensure the cuff of ET is inflatedbefore feeding the patients, ensure the cuff of ET is inflated

and give the formula slowly.and give the formula slowly.

Intermittent catheterization is used with patient withIntermittent catheterization is used with patient with

bladder distention. And increased high fiber diet andbladder distention. And increased high fiber diet and

adequate fluid intake with patient with constipationadequate fluid intake with patient with constipation

STRO KETRO KE


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ISCHEMIC STROKE

HEMORRHAGIC STROKE


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Hemor rh agic St ro keemor rh agic St ro ke


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Pathop hysiolog yathop hysiolog y


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I ntr a cere b ral h emorrh a g entr a cere b ral h emorrh a g e Bleeding into the brain substance, common in patients with hypertension andBleeding into the brain substance, common in patients with hypertension and

cerebral atherosclerosis that causes rupture of the vesselcerebral atherosclerosis that causes rupture of the vessel

Brain tumor and the use of medicines( oral anticoagulants, amphetamines andBrain tumor and the use of medicines( oral anticoagulants, amphetamines and

illicit drugs such as crack and cocoaine).illicit drugs such as crack and cocoaine).

Bleeding occur mostly in the cerebral lobes, basal ganglia, thalamus, brainBleeding occur mostly in the cerebral lobes, basal ganglia, thalamus, brainstem (mostly pons) and cerebellumstem (mostly pons) and cerebellum

In tr ac rani al (Cereb ral) An eury smntr ac rani al (Cereb ral) An eury sm Dilation of cerebral artery wall causes of weakness in the arterial walls.Dilation of cerebral artery wall causes of weakness in the arterial walls.

An aneurysm due to atherosclerosis, vascular disease, head trauma orAn aneurysm due to atherosclerosis, vascular disease, head trauma oradvance aging.advance aging.

Pathop hysiolog yathop hysiolog y


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Art e ri oven ous Ma l fo rmat i onrt e ri oven ous Ma l fo rmat i on Due to an abnormality in embryonal development that leads to a tangleDue to an abnormality in embryonal development that leads to a tangle

of arteries and viens in the brain without acapillary bed. A cause ofof arteries and viens in the brain without acapillary bed. A cause ofhemorrhagic in young peoples.hemorrhagic in young peoples.

Sub ara ch no id H emorrh ag eub ara ch no id H emorrh ag e May occur as a result of an AVM, intracranial, aneurysm, trauma orMay occur as a result of an AVM, intracranial, aneurysm, trauma or

hypertensionhypertension

There is a leaking aneurysm in the area of the circle of Willis or aThere is a leaking aneurysm in the area of the circle of Willis or acongenital AVM of the brain.congenital AVM of the brain.


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Clin ica l man if es tati onsl in ica l man if es tati ons


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Sudden, unusually severe headache and often loss ofSudden, unusually severe headache and often loss ofconsciousness for a variable period.consciousness for a variable period.

Pain and rigidity at the bask of the neck (nuchal rigidity)Pain and rigidity at the bask of the neck (nuchal rigidity

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