Megacode Case Study: PTCA/Cardiac Cath
MegaCode Case Study
Chamberlain College of Nursing
Professor Amber Essman
Critical Care (NR 340)
July 11, 2013
MegaCode Case Study 1. Describe the preoperative and postoperative care of a client having PTCA/cardiac cath. What complications can occur post cardiac cath?
The goal of PCI (percutaneous Transluminal intervention) is to open the blockage in the coronary artery. By opening the area that is blocked, it will help to reperfuse the myocardium. The faster this is done will help limit the amount of damage. This procedure should be done within 90mins of the patient arriving in the ED. Preoperatively, the nurse will need to ensure that the patient understands the procedure and has signed a consent form. The nurse will also need to gather a medical and medication history and any reactions to medications. The nurse will also check for labs, such as blood urea nitrogen and creatinine levels. The patient will need an IV placed. The arterial pulses in both legs (femoral, popliteal, dorsalis pedis, and posterior tibial) should be checked and documented using a scale of 0 to 4. The nurse should also explain what the patient will be experiencing during the procedure. The patient will be awake but will receive analgesics and sedatives. …show more content…
They may feel some chest pain when the balloon is inflated.
During the procedure, the nurse will monitor vital signs and assess for chest pain, shortness of breath, s/s of bleeding, changes in cardiac rhythm and presence of ST segment or T wave abnormalities. The patient should also be checked for neurological changes and their peripheral vascular status should be checked.
Post operatively, the patient should be monitored for s/s of myocardial ischemia , thrombosis and bleeding. The patient should be assessed for chest pain, ST segment changes and shortness of breath. Vitals should be monitored and watched for a drop in oxygen saturation, a drop in blood pressure or a decrease or increase in heart rate. The patient needs to be assessed for signs of bleeding at the catheter insertion site, as well as other body orifices. A hematoma at the cath site can be a sign of internal bleeding. Vitals can also indicate signs of internal bleeding. Hemoglobin, hematocrit and platelet level should be monitored. The collagen sheath is a secure method of allows for hemostasis after a femoral artery puncture so that the patient may ambulate and discharge from the hospital earlier. The patient must also have their pulses checked to be sure that there is no ischemia or thrombosis. The patient must keep leg straight and be on bed rest from four to six hours until hemostasis occurs.
Complications that can occur post operatively include: myocardial ischemia, thrombosis, bleeding from cath/sheath site.
When discharging the patient, teach them to monitor for s/s of MI or angina, infection, bleeding. This includes fever, swelling, oozing or bruising around cath site. The patient should also report numbness, tingling or pain in the leg used for the procedure as this might indicate a thrombosis. The patient will be taking medication, such as: antiplatelet medication (aspirin or clopidogrel) a statin and a beta blocker. The patient should also be taught to avoid pressure on the cath site, avoid lifting things heavier than 10lbs for two weeks and not to drive for a few days after the
procedure. 2. Describe pharmacological management for the client with a myocardial infarction. What is the difference between a STEMI, NONSTEMI and Q wave myocardial infarction?
Pharmacological management for an MI patient includes: aspirin, oxygen, nitro, lopressor(beta 1 blocker), morphine sulfate (lowers BP).
A normal ECG will show the ST segment level with the isoelectric line. Any deviation of the ST segment from the isoelectric line will determine how much damage is done to the heart muscle. STEMI is an ST elevation that is above the isoelectric line. Any severe of prolonged elevation of the ST segment or new Q waves indicates a STEMI. A NSTEMI is most often associated with unstable angina. Q wave is a transmural MI that goes through the entire thickness of the heart. 3. Describe pharmacological management for the client with a Heart failure. State the mechanism of action for the following medications utilized in heart failure: Primacor, Dobutamine, Nipride, Ace inhibitors, Natrecor, Morphine sulfate?
Pharmacological treatment for a patient with heart failure includes medications to improve pump function and reduce cardiac workload. These medications include diuretics, ACE inhibitors/angiotensin receptor blockers, Digoxin, and Beta-blockers, and BNP. Dobutamine is a B1 adrenergic agonist, and helps strengthen cardiac contractions. Primacor is a potent vasodilator and improves cardiac contractions. Nipride has potent vasodilating effects in arterioles and venules. In the heart, nitric oxide reduces both total peripheral resistance as well as venous return, thus decreasing both preload and afterload. For this reason, it can be used in severe cardiogenic heart failure where this combination of effects can act to increase cardiac output. ACE inhibitors ACE inhibitors inhibit angiotensin-converting enzyme, which is a component of the blood pressure-regulating renin-angiotensin system, thereby decreasing the tension of blood vessels and blood volume, which ends up lowering the blood pressure. Natrecor is a recombinant form of human B-type natriuretic peptide (hBNP), a naturally occurring hormone secreted by the ventricles, and helps relieve shortness of breath. Morphine sulfate causes peripheral vasodilation, increasing venous capacitance and decreases venous return by depressing the responsiveness of alpha-adrenergic receptors. Since it decreases both preload and afterload it can decrease myocardial oxygen demand.
4. What are the symptoms of Beck’s Triad in Cardiac Tamponade and what is the treatment?
Cardiac Tamponade is an emergent medical condition where there is an excess of fluid or blood in the pericardial sac. This causes the heart to lose its ability to expand and contract properly resulting in insufficient blood flow to the body. Cardiac Tamponade can be a complication from a number of conditions such as a thoracic dissecting aortic aneurysm, end-stage lung cancer, acute myocardial infarction, heart surgery, pericarditis, wounds to the heart, etc. Early recognition of this syndrome is important. Cardiac Tamponade can be identified by Beck’s Triad which describes the three main clinical manifestations seen. These symptoms include jugular vein distention, muffled heart sounds, and hypotension. Other signs and symptoms include unstable angina, dyspnea, tachycardia, syncope, pallor, tachypnea, absent or weak peripheral pulses and edema. Treatment includes immediate pericardiocentesis which is a procedure where the excess fluid or blood in aspirated using a needle from the pericardial sac. The patient also may receive oxygen to decrease the workload of the heart, fluids to maintain a normal blood pressure, and vasopressors to increase blood pressure until pericardiocentesis can be performed. A surgical pericardiectomy or pericardial window may also be performed which includes removing part of the pericardium in order to drain the excess fluid or blood in the pericardial sac.
5. List the American Heart Association 2050 guidelines for CPR in an Adult in Established order. What is the CPR sequence? How many compressions to breaths, how many compressions per minute, depth? What is the management for a client in Asystole utilizing these guidelines?
A client in Asystole would be unresponsive and not breathing with a flat line on the ECG monitor if one was applied. One member of the health care team should get the AED/defibrillator while another member checks the clients pulse and defines whether one is present or not within 10 seconds. If no breathing, pulse or it is irregular, the health care member should begin cycles of 30 compressions at a rate of at least 100/min and at a depth of 2 inches (5 cm). They should allow for complete chest recoil after each compression. The airway should then be opened by tilting the clients head back slightly and two breaths should then be delivered while avoiding excessive ventilation. The acronym to use for this sequence is C-A-B (chest compressions, airway, and breathing). This sequence should be performed, alternating between health care providers in order to deliver maximum quality chest compressions for two minutes and until the AED/defibrillator arrives. The health care provider should then place the pads on the client’s bare, hairless chest. The client’s chest should be dry. One pad should be placed on the right center of the client’s chest above the nipple. The other pad should be placed slightly below the client’s other nipple to the left of their ribcage. The pads should be placed at least inch away from any metal piercings or devices implanted in the client’s body. Allow the machine to analyze the client’s rhythm and see if there is a shock-able rhythm. If there is a shock-able rhythm deliver 1 shock and resume CPR immediately for 2 minutes. If the rhythm is not shock-able the health member should immediately resume CPR for two minutes. The client’s rhythm should be assessed every two minutes. This should be continued until ALS providers take over or the client begins to move. * Name the appropriate treatment in sequence for each of the following rhythms V-Tach * With a pulse Treatment- Cardiologist (consultation), Synchronized cardioversion (sedation, sync mode, 50-100 joules on the r wave) * Without a pulse Treatment- CPR, Defibrillation, Epinephrine or Vasopressin, Amiodarone * V-Fib * Treatment: CPR, Defibrillation, Epinephrine 1mg or Vasopressin 40units, Amiodarone 300mg followed by 150mg (followed by continuous infusion if client converts) * 1st degree HB * Occurs when? – PR interval is >5 boxes, but regular * Treatment- Nothing, just watch it * 2nd degree HB I 2nd degree HBII * Occurs when? – Either QRS gets wider, wider, wider then drops OR there are more P waves than QRS * Treatment- If patient is asymptomatic then no treatment is necessary; If patient is symptomatic than drugs that may be contributing to this are discontinued, pacemakers may also be considered * 3rd degree HB * Occurs when? – The atria’s and ventricles are not communicating * Treatment- Pacemaker * Pulseless Electrical Activity (PEA): This is a rhythm on the monitor and no pulse * Cause: Hypoxia, Hypervolemia, Hypothermia, Acidosis (H ions), Hypo/Hyperkalemia, Tablets (overdose), Tamponade (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary) * Treatment- Treat the cause, CPR, Epinephrine or Vasopressin 6. Describe the mechanism of action, half-life, contraindications and dosing for the following medications:
A) Amiodarone- * Mechanism of Action: Slows the sinus rate; Increases PR and QT intervals; Decreases peripheral vascular resistance (Vasodilator) * Half-life: 13-107 days * Contraindications: Cardiogenic shock, severe sinus node dysfunction resulting in sinus bradycardia, second or third degree atrioventricular block, or symptomatic sinus bradycardia in the absence of an adequately functioning pacemaker. * Dosing: For pulseless V Fib/V Tach 300mg IV push, may repeat once after 3-5min with 150mg IV push
B) Epinephrine- * Mechanism of Action: Bronchodilation; Maintenance of blood pressure and heart rate; Localization/prolongation of local/spinal anesthetic * Half-life: Unknown * Contraindications: Hypersensitivity to adrenergic amines, Cardiac arrhythmias, Some products may contain bisulfites or fluorocarbons and should be avoided in patients with known hypersensitivity or intolerance * Dosing: 2-2.5mg
C) Vasopressin- * Mechanism of Action: Alters the permeability of the renal collecting ducts, allowing reabsorption of water. * Half-life: 10-20 minutes * Contraindications: Chronic renal failure with increased BUN, Hypersensitivity to beef or pork proteins * Dosing: Pulseless V Tach/V Fib, Asystole, or PEA 40units as a single dose
D) Adenosine- * Mechanism of Action: Restores natural sinus rhythm by interrupting re-entrant pathways in the AV node; Slows conduction time through the AV node; Coronary artery vasodilation * Half-life: < 10sec * Contraindications: Hypersensitivity; 2nd or 3rd degree AV block or sick sinus rhythm * Dosing: 6mg by rapid IV bolus; if no results, repeat 1-2 min later with 12mg rapid bolus. This dose may be repeated (single dose not to exceed 12mg)
E) Atropine- * Mechanism of Action: Inhibits action of acetylcholine at postganglionic sites located in smooth muscle, secretory glands, CNS; Increased heart rate; Decreased GI and respiratory secretions; Reversal of muscarinic effects * Half-life: 4-5 hours * Contraindications: Hypersensitivity, Angle-closure glaucoma, Acute hemorrhage, Tachycardia secondary to cardiac insufficiency or thyrotoxicosis, Obstructive disease of the GI tract * Dosing: Bradycardia- 0.5-1mg, may repeat as needed every 5 minutes, not to exceed a total of 2mg.
F) Norepinephrine- * Mechanism of Action: Peripheral vasoconstrictor and as an inotropic stimulator of the heart and dilator of coronary arteries; Constricting the blood vessels and increasing blood pressure and blood glucose levels * Half-life: 1-2 minutes * Contraindications: Hypotension due to blood volume deficit * Dosing: 8 to 12 mcg/min -titrate to BP (Usual target: SB: 80-100 or MAP=80). Usual maintenance: 2 to 4 mcg/min 7. The nurse is caring for a client that presented to the emergency room in symptomatic bradycardia. The client was placed on a transcutaneous pacer and sent to the cardiovascular interventional lab for a pacemaker. How will the nurse know when receiving the patient in recovery if the pacemaker is working?
A nurse is caring for a client coming to recovery after being placed on a pacemaker. The nurse would be able to tell that the pacemaker is working when the patient’s heart rate is equal to or greater than 60 beats per minute, the client denies any chest pains or shortness of breath, and the clients vital signs are within normal limits. The client 's LOC and pulses will be within normal limits. The nurse would also be able to monitor the ECG. Atrial and ventricular pacing can be seen on the electrocardiogram (ECG) as a pacing stimulus (spike) followed by a P wave or QRS complex, respectively. The ECG has the ability to show normal and abnormal pacemaker function. Other issues the nurse needs to be aware of are failure to capture and failure to sense.
Define the following elements:
Failure to Capture- Failure to capture (Noncapture) happens when the pacemaker fires, but the chamber (atria, ventricles, or both) in which is being paced do not depolarize. It can been seen on the ECG strip as a pacer spike that is not followed by a P-wave or QRS complex. Common reasons failure to capture happens is because of displacement of the pacing wires or the energy level is set too low. This patient may become hypotensive and bradycardic.
Failure to Sense- Failure to sense (Under sensing) happens when the pacer does not recognize or sense the hearts natural electrical activity. This can be seen by the pacer spike on the ECG occurring too closely behind the client 's QRS complex.
References:
ECG images retrieved from http://www.ambulancetechnicianstudy.co.uk/rhythms.html#.Ud8WFkHVAhw
Essman, A. (2012, Fall). Mega Code Guide. Retrieved from http://nursingonline.chamberlain.edu/re/DotNextLaunch.asp?courseid=8382524&userid=11040766&sessionid=7d97bd0e17&tabid=DcX0wcta9SUjH/BmfLeA9retkFdr9XxU+nENBbF6s3tsYaYnvUtTcd3Qjgu+pdDr&sessionFirstAuthStore=true&macid=yO/8SaRJiin9JQ3Ofaw4gP25aMCjUCzTGSMopN51xXADwjTaiLn+E0ARP1TPvnd/OxS8r18Co3cLP+QhjymCoaz/aeIKYKjJFXjxNAlXLaM13zXN18mgjUYNjjfzUn8nw0fDW3gXozzLCOnXQu7owA7c/54TO10JuArs4650UKUwjMcCX1lMD0k8RmizZ6bUVuRqDu83IUcc2BRHOeYCPbg9B+/TDEEtC4dQBLMKn8w=
Hazard, A., & Hopfer, J. (2009). Davis 's drug guide for nurses. (11th ed.). Philladelphia: F. A. Davis Company.
Hazinski, M. F. (n.d.). Retrieved from http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf
Perrin, K. (2009). "Chapter 7." understanding the essentials of critical care nursing. Upper Saddle River, NJ: Pearson Prentice Hall
Zieve, D., & Eltz, D. (n.d.). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000194.htm
Chamberlain College of Nursing
Professor Amber Essman
Critical Care (NR 340)
July 11, 2013
MegaCode Case Study 1. Describe the preoperative and postoperative care of a client having PTCA/cardiac cath. What complications can occur post cardiac cath?
The goal of PCI (percutaneous Transluminal intervention) is to open the blockage in the coronary artery. By opening the area that is blocked, it will help to reperfuse the myocardium. The faster this is done will help limit the amount of damage. This procedure should be done within 90mins of the patient arriving in the ED. Preoperatively, the nurse will need to ensure that the patient understands the procedure and has signed a consent form. The nurse will also need to gather a medical and medication history and any reactions to medications. The nurse will also check for labs, such as blood urea nitrogen and creatinine levels. The patient will need an IV placed. The arterial pulses in both legs (femoral, popliteal, dorsalis pedis, and posterior tibial) should be checked and documented using a scale of 0 to 4. The nurse should also explain what the patient will be experiencing during the procedure. The patient will be awake but will receive analgesics and sedatives. …show more content…
They may feel some chest pain when the balloon is inflated.
During the procedure, the nurse will monitor vital signs and assess for chest pain, shortness of breath, s/s of bleeding, changes in cardiac rhythm and presence of ST segment or T wave abnormalities. The patient should also be checked for neurological changes and their peripheral vascular status should be checked.
Post operatively, the patient should be monitored for s/s of myocardial ischemia , thrombosis and bleeding. The patient should be assessed for chest pain, ST segment changes and shortness of breath. Vitals should be monitored and watched for a drop in oxygen saturation, a drop in blood pressure or a decrease or increase in heart rate. The patient needs to be assessed for signs of bleeding at the catheter insertion site, as well as other body orifices. A hematoma at the cath site can be a sign of internal bleeding. Vitals can also indicate signs of internal bleeding. Hemoglobin, hematocrit and platelet level should be monitored. The collagen sheath is a secure method of allows for hemostasis after a femoral artery puncture so that the patient may ambulate and discharge from the hospital earlier. The patient must also have their pulses checked to be sure that there is no ischemia or thrombosis. The patient must keep leg straight and be on bed rest from four to six hours until hemostasis occurs.
Complications that can occur post operatively include: myocardial ischemia, thrombosis, bleeding from cath/sheath site.
When discharging the patient, teach them to monitor for s/s of MI or angina, infection, bleeding. This includes fever, swelling, oozing or bruising around cath site. The patient should also report numbness, tingling or pain in the leg used for the procedure as this might indicate a thrombosis. The patient will be taking medication, such as: antiplatelet medication (aspirin or clopidogrel) a statin and a beta blocker. The patient should also be taught to avoid pressure on the cath site, avoid lifting things heavier than 10lbs for two weeks and not to drive for a few days after the
procedure. 2. Describe pharmacological management for the client with a myocardial infarction. What is the difference between a STEMI, NONSTEMI and Q wave myocardial infarction?
Pharmacological management for an MI patient includes: aspirin, oxygen, nitro, lopressor(beta 1 blocker), morphine sulfate (lowers BP).
A normal ECG will show the ST segment level with the isoelectric line. Any deviation of the ST segment from the isoelectric line will determine how much damage is done to the heart muscle. STEMI is an ST elevation that is above the isoelectric line. Any severe of prolonged elevation of the ST segment or new Q waves indicates a STEMI. A NSTEMI is most often associated with unstable angina. Q wave is a transmural MI that goes through the entire thickness of the heart. 3. Describe pharmacological management for the client with a Heart failure. State the mechanism of action for the following medications utilized in heart failure: Primacor, Dobutamine, Nipride, Ace inhibitors, Natrecor, Morphine sulfate?
Pharmacological treatment for a patient with heart failure includes medications to improve pump function and reduce cardiac workload. These medications include diuretics, ACE inhibitors/angiotensin receptor blockers, Digoxin, and Beta-blockers, and BNP. Dobutamine is a B1 adrenergic agonist, and helps strengthen cardiac contractions. Primacor is a potent vasodilator and improves cardiac contractions. Nipride has potent vasodilating effects in arterioles and venules. In the heart, nitric oxide reduces both total peripheral resistance as well as venous return, thus decreasing both preload and afterload. For this reason, it can be used in severe cardiogenic heart failure where this combination of effects can act to increase cardiac output. ACE inhibitors ACE inhibitors inhibit angiotensin-converting enzyme, which is a component of the blood pressure-regulating renin-angiotensin system, thereby decreasing the tension of blood vessels and blood volume, which ends up lowering the blood pressure. Natrecor is a recombinant form of human B-type natriuretic peptide (hBNP), a naturally occurring hormone secreted by the ventricles, and helps relieve shortness of breath. Morphine sulfate causes peripheral vasodilation, increasing venous capacitance and decreases venous return by depressing the responsiveness of alpha-adrenergic receptors. Since it decreases both preload and afterload it can decrease myocardial oxygen demand.
4. What are the symptoms of Beck’s Triad in Cardiac Tamponade and what is the treatment?
Cardiac Tamponade is an emergent medical condition where there is an excess of fluid or blood in the pericardial sac. This causes the heart to lose its ability to expand and contract properly resulting in insufficient blood flow to the body. Cardiac Tamponade can be a complication from a number of conditions such as a thoracic dissecting aortic aneurysm, end-stage lung cancer, acute myocardial infarction, heart surgery, pericarditis, wounds to the heart, etc. Early recognition of this syndrome is important. Cardiac Tamponade can be identified by Beck’s Triad which describes the three main clinical manifestations seen. These symptoms include jugular vein distention, muffled heart sounds, and hypotension. Other signs and symptoms include unstable angina, dyspnea, tachycardia, syncope, pallor, tachypnea, absent or weak peripheral pulses and edema. Treatment includes immediate pericardiocentesis which is a procedure where the excess fluid or blood in aspirated using a needle from the pericardial sac. The patient also may receive oxygen to decrease the workload of the heart, fluids to maintain a normal blood pressure, and vasopressors to increase blood pressure until pericardiocentesis can be performed. A surgical pericardiectomy or pericardial window may also be performed which includes removing part of the pericardium in order to drain the excess fluid or blood in the pericardial sac.
5. List the American Heart Association 2050 guidelines for CPR in an Adult in Established order. What is the CPR sequence? How many compressions to breaths, how many compressions per minute, depth? What is the management for a client in Asystole utilizing these guidelines?
A client in Asystole would be unresponsive and not breathing with a flat line on the ECG monitor if one was applied. One member of the health care team should get the AED/defibrillator while another member checks the clients pulse and defines whether one is present or not within 10 seconds. If no breathing, pulse or it is irregular, the health care member should begin cycles of 30 compressions at a rate of at least 100/min and at a depth of 2 inches (5 cm). They should allow for complete chest recoil after each compression. The airway should then be opened by tilting the clients head back slightly and two breaths should then be delivered while avoiding excessive ventilation. The acronym to use for this sequence is C-A-B (chest compressions, airway, and breathing). This sequence should be performed, alternating between health care providers in order to deliver maximum quality chest compressions for two minutes and until the AED/defibrillator arrives. The health care provider should then place the pads on the client’s bare, hairless chest. The client’s chest should be dry. One pad should be placed on the right center of the client’s chest above the nipple. The other pad should be placed slightly below the client’s other nipple to the left of their ribcage. The pads should be placed at least inch away from any metal piercings or devices implanted in the client’s body. Allow the machine to analyze the client’s rhythm and see if there is a shock-able rhythm. If there is a shock-able rhythm deliver 1 shock and resume CPR immediately for 2 minutes. If the rhythm is not shock-able the health member should immediately resume CPR for two minutes. The client’s rhythm should be assessed every two minutes. This should be continued until ALS providers take over or the client begins to move. * Name the appropriate treatment in sequence for each of the following rhythms V-Tach * With a pulse Treatment- Cardiologist (consultation), Synchronized cardioversion (sedation, sync mode, 50-100 joules on the r wave) * Without a pulse Treatment- CPR, Defibrillation, Epinephrine or Vasopressin, Amiodarone * V-Fib * Treatment: CPR, Defibrillation, Epinephrine 1mg or Vasopressin 40units, Amiodarone 300mg followed by 150mg (followed by continuous infusion if client converts) * 1st degree HB * Occurs when? – PR interval is >5 boxes, but regular * Treatment- Nothing, just watch it * 2nd degree HB I 2nd degree HBII * Occurs when? – Either QRS gets wider, wider, wider then drops OR there are more P waves than QRS * Treatment- If patient is asymptomatic then no treatment is necessary; If patient is symptomatic than drugs that may be contributing to this are discontinued, pacemakers may also be considered * 3rd degree HB * Occurs when? – The atria’s and ventricles are not communicating * Treatment- Pacemaker * Pulseless Electrical Activity (PEA): This is a rhythm on the monitor and no pulse * Cause: Hypoxia, Hypervolemia, Hypothermia, Acidosis (H ions), Hypo/Hyperkalemia, Tablets (overdose), Tamponade (cardiac), Tension pneumothorax, Thrombosis (coronary or pulmonary) * Treatment- Treat the cause, CPR, Epinephrine or Vasopressin 6. Describe the mechanism of action, half-life, contraindications and dosing for the following medications:
A) Amiodarone- * Mechanism of Action: Slows the sinus rate; Increases PR and QT intervals; Decreases peripheral vascular resistance (Vasodilator) * Half-life: 13-107 days * Contraindications: Cardiogenic shock, severe sinus node dysfunction resulting in sinus bradycardia, second or third degree atrioventricular block, or symptomatic sinus bradycardia in the absence of an adequately functioning pacemaker. * Dosing: For pulseless V Fib/V Tach 300mg IV push, may repeat once after 3-5min with 150mg IV push
B) Epinephrine- * Mechanism of Action: Bronchodilation; Maintenance of blood pressure and heart rate; Localization/prolongation of local/spinal anesthetic * Half-life: Unknown * Contraindications: Hypersensitivity to adrenergic amines, Cardiac arrhythmias, Some products may contain bisulfites or fluorocarbons and should be avoided in patients with known hypersensitivity or intolerance * Dosing: 2-2.5mg
C) Vasopressin- * Mechanism of Action: Alters the permeability of the renal collecting ducts, allowing reabsorption of water. * Half-life: 10-20 minutes * Contraindications: Chronic renal failure with increased BUN, Hypersensitivity to beef or pork proteins * Dosing: Pulseless V Tach/V Fib, Asystole, or PEA 40units as a single dose
D) Adenosine- * Mechanism of Action: Restores natural sinus rhythm by interrupting re-entrant pathways in the AV node; Slows conduction time through the AV node; Coronary artery vasodilation * Half-life: < 10sec * Contraindications: Hypersensitivity; 2nd or 3rd degree AV block or sick sinus rhythm * Dosing: 6mg by rapid IV bolus; if no results, repeat 1-2 min later with 12mg rapid bolus. This dose may be repeated (single dose not to exceed 12mg)
E) Atropine- * Mechanism of Action: Inhibits action of acetylcholine at postganglionic sites located in smooth muscle, secretory glands, CNS; Increased heart rate; Decreased GI and respiratory secretions; Reversal of muscarinic effects * Half-life: 4-5 hours * Contraindications: Hypersensitivity, Angle-closure glaucoma, Acute hemorrhage, Tachycardia secondary to cardiac insufficiency or thyrotoxicosis, Obstructive disease of the GI tract * Dosing: Bradycardia- 0.5-1mg, may repeat as needed every 5 minutes, not to exceed a total of 2mg.
F) Norepinephrine- * Mechanism of Action: Peripheral vasoconstrictor and as an inotropic stimulator of the heart and dilator of coronary arteries; Constricting the blood vessels and increasing blood pressure and blood glucose levels * Half-life: 1-2 minutes * Contraindications: Hypotension due to blood volume deficit * Dosing: 8 to 12 mcg/min -titrate to BP (Usual target: SB: 80-100 or MAP=80). Usual maintenance: 2 to 4 mcg/min 7. The nurse is caring for a client that presented to the emergency room in symptomatic bradycardia. The client was placed on a transcutaneous pacer and sent to the cardiovascular interventional lab for a pacemaker. How will the nurse know when receiving the patient in recovery if the pacemaker is working?
A nurse is caring for a client coming to recovery after being placed on a pacemaker. The nurse would be able to tell that the pacemaker is working when the patient’s heart rate is equal to or greater than 60 beats per minute, the client denies any chest pains or shortness of breath, and the clients vital signs are within normal limits. The client 's LOC and pulses will be within normal limits. The nurse would also be able to monitor the ECG. Atrial and ventricular pacing can be seen on the electrocardiogram (ECG) as a pacing stimulus (spike) followed by a P wave or QRS complex, respectively. The ECG has the ability to show normal and abnormal pacemaker function. Other issues the nurse needs to be aware of are failure to capture and failure to sense.
Define the following elements:
Failure to Capture- Failure to capture (Noncapture) happens when the pacemaker fires, but the chamber (atria, ventricles, or both) in which is being paced do not depolarize. It can been seen on the ECG strip as a pacer spike that is not followed by a P-wave or QRS complex. Common reasons failure to capture happens is because of displacement of the pacing wires or the energy level is set too low. This patient may become hypotensive and bradycardic.
Failure to Sense- Failure to sense (Under sensing) happens when the pacer does not recognize or sense the hearts natural electrical activity. This can be seen by the pacer spike on the ECG occurring too closely behind the client 's QRS complex.
References:
ECG images retrieved from http://www.ambulancetechnicianstudy.co.uk/rhythms.html#.Ud8WFkHVAhw
Essman, A. (2012, Fall). Mega Code Guide. Retrieved from http://nursingonline.chamberlain.edu/re/DotNextLaunch.asp?courseid=8382524&userid=11040766&sessionid=7d97bd0e17&tabid=DcX0wcta9SUjH/BmfLeA9retkFdr9XxU+nENBbF6s3tsYaYnvUtTcd3Qjgu+pdDr&sessionFirstAuthStore=true&macid=yO/8SaRJiin9JQ3Ofaw4gP25aMCjUCzTGSMopN51xXADwjTaiLn+E0ARP1TPvnd/OxS8r18Co3cLP+QhjymCoaz/aeIKYKjJFXjxNAlXLaM13zXN18mgjUYNjjfzUn8nw0fDW3gXozzLCOnXQu7owA7c/54TO10JuArs4650UKUwjMcCX1lMD0k8RmizZ6bUVuRqDu83IUcc2BRHOeYCPbg9B+/TDEEtC4dQBLMKn8w=
Hazard, A., & Hopfer, J. (2009). Davis 's drug guide for nurses. (11th ed.). Philladelphia: F. A. Davis Company.
Hazinski, M. F. (n.d.). Retrieved from http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf
Perrin, K. (2009). "Chapter 7." understanding the essentials of critical care nursing. Upper Saddle River, NJ: Pearson Prentice Hall
Zieve, D., & Eltz, D. (n.d.). Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/000194.htm