115-NCLEX-RN Review Made Incredibly Easy, Fifth Edition (Incredibly Easy...

Polish up on client care 39

If the clients pulse is abnormally rapid, slow, or irregular, watch for signs of hypop-erfusion, such as hypotension and altered mental status, to prevent such complications as cerebral anoxia. Document any arrhythmias in a monitored client to create a record of their occurrence. Assess for possible causes and effects so proper treatment can be instituted. When life-threatening arrhythmias develop, rapidly assess level of consciousness, respirations, and pulse to avoid or treat crisis. Initiate CPR, if indicated, to maintain cerebral perfusion until other ACLS measures are successful. Evaluate the client for altered cardiac output resulting from arrhythmias. Decreased cardiac output may cause inadequate perfusion of major organs, leading to irreversible damage. If trained, perform defibrillation early for VT and VF. Studies show that early defibrilla-tion intervention improves the clients chance of survival. Administer medications as needed, and prepare for medical procedures (for example, cardioversion) if indicated to ensure prompt treatment of life-threatening arrhythmias. Monitor for predisposing factors such as fluid and electrolyte imbalance and signs of drug toxicity, especially with digoxin. Drug toxicity may require withholding the next dose. Alleviating predisposing factors decreases the risk of arrhythmias. Provide adequate oxygen and reduce the hearts workload, while carefully maintain-ing metabolic, neurologic, respiratory, and hemodynamic status, to prevent arrhythmias in a cardiac client. Follow ACLS protocol for endotracheal intubation. Be prepared to assist with temporary pace-maker insertion or transcutaneous pacing, if necessary, to treat arrythmia. Restrict the clients activity after tem-porary or permanent pacemaker insertion. Monitor the pulse rate regularly, and watch for signs of decreased cardiac output. These measures avert permanent pacemaker malfunction. If the client has a permanent pacemaker, warn him about environmental hazards as indicated by the pacemaker manufacturer to avoid pacemaker malfunction.

NURSING DIAGNOSES Ineffective tissue perfusion: Cardiopulmonary Decreased cardiac output Impaired gas exchange

TREATMENTAtrial fibrillation Antiarrhythmics (if client is stable): amio-darone (Cordarone), digoxin (Lanoxin), diltiazem (Cardizem), procainamide, verapamil (Calan) Permanent pacemaker Radiofrequency catheter ablation Synchronized cardioversion (if client is unstable)

Asystole Cardiopulmonary resuscitation (CPR) Advanced cardiac life support (ACLS) pro-tocol for endotracheal intubation and possible transcutaneous pacing Antiarrhythmics: atropine, epinephrine per ACLS protocol Buffering agent: sodium bicarbonate

Ventricular fibrillation CPR Defibrillation ACLS protocol for endotracheal intubation Antiarrhythmics: amiodarone (Cord-arone), epinephrine, lidocaine (Xylocaine), magnesium sulfate, procainamide, vaso-pressin per ACLS protocol Implantable cardiac defibrillator Buffering agent: sodium bicarbonate

Ventricular tachycardia CPR, if pulseless Defibrillation Antiarrhythmics: amiodarone (Cord-arone), epinephrine, lidocaine (Xylocaine), magnesium sulfate, procainamide ACLS protocol for endotracheal intubation, if pulseless Implantable cardioverter-defibrillator

INTERVENTIONS AND RATIONALES Assess an unmonitored client for rhythm disturbances to promptly identify and treat life-threatening arrhythmias.

Fluid and electrolyte imbalances

can increase the risk of arrhythmias.

313419NCLEX-RN_Chap03.indd 39313419NCLEX-RN_Chap03.indd 39 4/8/2010 7:01:41 PM4/8/2010 7:01:41 PM

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