Polish up on client care

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

TREATMENT
Atrial fibrillation
Antiarrhythmics (if client is stable): amiodarone (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) protocol 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 (Cordarone), epinephrine, lidocaine (Xylocaine),
magnesium sulfate, procainamide, vasopressin per ACLS protocol
Implantable cardiac defibrillator
Buffering agent: sodium bicarbonate

Ventricular tachycardia
CPR, if pulseless
Defibrillation
Antiarrhythmics: amiodarone (Cordarone), 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 lifethreatening arrhythmias.

313419NCLEX-RN_Chap03.indd 39

If the clients pulse is abnormally rapid,

slow, or irregular, watch for signs of hypoperfusion, 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 defibrillation 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 maintaining 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 pacemaker insertion or transcutaneous pacing, if
necessary, to treat arrythmia.
Restrict the clients activity after temporary 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.

39

Fluid and
electrolyte
imbalances
can increase the risk
of arrhythmias.

4/8/2010 7:01:41 PM