Cardiac dysrhythmias associated with altered myocardial automaticity, conductivity or contractility can effect cardiac output. Reduced cardiac output increases the risk of ineffective tissue perfusion.
Assess for signs of ineffective tissue perfusion by system:
- Renal
- oliguria or anuria
- Gastrointestinal
- nausea
- hypoactive or absent bowel sounds
- Peripheral
- edema
- altered skin color, temperature, sensation or integrity
- weak or absent pulse
- Cerebral
- dizziness
- altered mental status [anxiety, confusion, syncope]
- altered pupillary response
- speech abnormalities
- Cardiopulmonary
- hypotension
- abnormal respiratory rate
- capillary refill >3 seconds
- chest pain
- dyspnea, crackles & wheezes
- jugular vein distention
Nursing Intervention for Ineffective Tissue Perfusion
- Assess for and report signs/symptoms of cardiac dysrhythmias [e.g. irregular apical pulse, adult pulse rate below 60 or above 100 beats/minute, apical-radial pulse deficit, syncope, palpitations].
- Reduce
cardiac workload
- Position patient to minimizes discomfort and facilitate respiration.
- Minimize anxiety with calm reassurance and education.
- Communicate rationale for monitoring and treatments.
- Discuss the benefits calm with the patient and family.
- Initiate EKG monitor and pulse oximetry per policy.
- IV access, O2, medication and 12 lead-EKG as ordered, monitor vital signs.
- Positive inotropic agents [e.g. dobutamine, dopamine] to increase myocardial contractility
- Vasodilators [e.g. nitroglycerin] to decrease cardiac workload
- ACE inhibitors [e.g. captopril, ramipril] to decrease cardiac workload
- Diuretics for elevated capillary wedge pressure
- Morphine sulfate to reduce pain, preload and anxiety.
- Anticipate the need to initiate cardiopulmonary resuscitation.
- Assess for contributing factors: pain, fluid and electrolyte imbalance, drug toxicity [especially digoxin], medication non-adherence.
- Provide psychosocial support for patient and family members.
- If the dysrhythmia is a life-threatening type, encourage the family unit to calmly formulate a plan of action.
- Reassure the patient will receive the best care in keeping with his written directives or medical power of attorney.
- Communicate the availability and value of social services as needed.
- Patient teaching:
- Importance of reporting chest pain, dyspnea, loss of consciousness, confusion, etc.
- Educate and prepare
patient for planned treatments such as:
- Echo-cardiogram
- Cardioversion
- Pacemaker insertion
- Catheter ablation
- Central Venous Catheter insertion
- Wellness teaching includes: smoking cessation, stress reduction, weight reduction, heart healthy diet, drug regimen, relaxation as well as home blood pressure, pulse and weight monitoring.
ECG
tracings normally consist of three identifiable waveforms: the P wave, the QRS complex, and the T wave. The P wave depicts atrial depolarization; the QRS complex, ventricular depolarization; and the T wave, ventricular repolarization.
Computerized ECG machines use small electrode tabs that peel off a sheet and adhere to the patient’s skin. The entire ECG tracing is displayed on a screen so abnormalities can be corrected before printing; then it’s printed on one sheet of paper. Electrode tabs can remain on the patient’s chest, arms, and legs to provide continuous lead placement for serial ECG studies.
Purpose of Electrocardiography [ECG]
- To help identify primary conduction abnormalities, cardiac arrhythmias, cardiac hypertrophy, pericarditis, electrolyte imbalances, myocardial ischemia, and the site and extent of myocardial infarction.
- To monitor recovery from an MI.
- To evaluate the effectiveness of cardiac medication.
- To assess pacemaker performance
- To determine effectiveness of thrombolytic therapy and the resolution of ST-segment depression or elevation and T-wave changes.
Electrocardiography [ECG] Procedure
Patient Preparation for Electrocardiography [ECG]
- Explain to the patient the need to lie still, relax, and breathe normally during the procedure.
- Note current cardiac drug therapy on the test request form as well as any other pertinent clinical information, such as chest pain or pacemaker.
- Explain that the test is painless and takes 5 to 10 minutes.
Implementation
- Place the patient in a supine or semi-Fowler’s position.
- Expose the chest, ankles, and wrists.
- Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower legs, and on the chest.
- After all electrodes are in place, connect the lead wires.
- Press the START button and input any required information.
- Make sure that all leads are represented in the tracing. If not, determine which electrode has come loose, reattach it, and restart the tracing.
- All recording and other nearby electrical equipment should be properly grounded.
- Make sure that the electrodes are firmly attached.
Nursing Interventions
- Disconnect the equipment, remove the electrodes, and remove the gel with a moist cloth towel.
- If the patient is having recurrent chest pain or if serial ECG’s are ordered, leave the electrode patches in place.
Interpretations
Normal Results
- P wave that doesn’t exceed 2.5 mm [0.25 mV] in height or last longer than 0.12 second.
- PR interval [includes the P wave plus the PR segment] persisting for 0.12 to 0.2 second for heart rates above 60 beats/min.
- QT interval that varies with the heart rate and lasts 0.4 to 0.52 second for heart rates above 60 beats/min.
- Voltage of the R wave leads V1 through V6 that doesn’t exceed 27 mm.
- Total QRS complex lasting 0.06 to 0.1 second.
Abnormal Results
- Myocardial infarction [MI], right or left ventricular hypertrophy, arrhythmias, right or left bundle-branch block, ischemia, conduction defects or pericarditis, and electrolyte abnormalities.
- Abnormal wave forms during angina episodes or during exercise.
Precautions
- The recording equipment and other nearby electrical equipment should be properly grounded to prevent electrical interference.
- Double-check color codes and lead markings to be sure connectors march.
- Make sure that the electrodes are firmly attached, and reattached them if loose skin contact is suspended. Don’t use cables that are broken, frayed, or bare.
Interfering Factors
- Improper lead placement.
Complications
- Skin sensitivity to the electrodes.
Daisy Jane Antipuesto RN MN
Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator [Level II], caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.
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