NCLEX REVIEW
PART THREE
3- CARE OF THE CLIENT UNDERGOING
CARDIAC SURGERY
CARE OF THE CLIENT UNDERGOING CARDIAC
SURGERY WITH CARDIOPULMONARY BYPASS
surgical treatments
intra-aortic balloon counterpulsation
heart transplant
antihistamines
aminophylline (Truphylline)
neurogenic
treat according to cause
septic shock
antiinfective agents based on culture results
fluid replacement
Dysrhythmias
Definition: disturbance in heart rate or
rhythm
Types of dysrhythmia
supraventricular: sinus, atrial, and
junctional
sinus tachycardia
sinus bradycardia
sinus arrhythmia
premature atrial complexes
atrial tachycardia
atrial flutter
atrial fibrillation
premature junctional complex
junctional tachycardia
ventricular
ventricular fibrillation*
asystole*
atrioventricular block
first degree A-V block
second degree A-V block
third degree A-V block
* dysrhythmias associated with death
Nursing interventions
PHARMACOLOGIC INTERVENTIONS
FOR DYSRHYTHMIAS
A. Adenosine Narrow complex paroxysmal supravenntricular tachycardia; Wolff-
Parkinson-White Syndrome
B. Amiodarone hydrochloride Ventricular & supraventricular tachycardia; atrial
fibrillation & flutter
C. Atropine sulfate Symptomatic bradycardia (hypotension, ventricular ectopy,
chest pain, change in mentation)
D. Beta-Adrenergic blocking agent Wolff-Parkinson-White and digitalis toxic
rhythms; Ventricular rhythms refractory to other drugs
E. Bretylium tosylate Ventricular fibrillation resistant to defibrillation and
Lidocaine; ventricular tachycardia resistant to lidocaine and procainamide
(Pronestyl)
F. Digoxin Congestive heart failure; Atrial flutter or fibrillation; supraventricular
tachycardias
G. Diltiazem Atrial fibrillation or flutter with rapid ventricular response; Narrow-
complex PSVT refractory to other medications
H. Disopyramide Premature ventricular contractions; ventricular tachycardia not
requiring cardioversion; Atrial fibrillation or flutter
PHARMACOLOGIC INTERVENTIONS
FOR DYSRHYTHMIAS
I. Epinephrine Ventricular fibrillation; pulseless ventricular
tachycardia; Asystole
J. Lidocaine hydrochloride Frequent, multifocal, paired, or R-
on-T premature ventricular contractions; Ventricular tachycardia;
Ventricular fibrillation
K. Magnesium sulfate Torsade de pointes; Refractory
ventricular fibrillation; Cardiac arrest or ventricular dysrhythmias
due to digitalis toxicity, tricyclic overdose, or hypomagnesemia
L. Procainamide hydrochloride Symptomatic ventricular
ectopy when lidocaine is ineffective or contraindicated; in
ventricular fibrillation/pulseless VT when lidocaine and bretylium
are ineffective
M. Quinidine Atrial fibrillation and flutter; PSVT
N. Tocainide Symptomatic ventricular dysrhythmias when
lidocaine not effective
O. Verapamil Supraventricular tachyarrhythmias with heart rate
>120
EKG MEASURES ELECTRICAL ACTIVITY
OF HEART
Electrocardiogram = (ECG) = (EKG)
Do not confuse with Echocardiogram (Echo)
An EKG is a graphic recording of the electrical currents of the heart. It may be a one-lead,
which is used for continuous monitoring, or a 12-lead, which is used for diagnostic
purposes.
The EKG records two basic events - depolarization and repolarization as a series of waves:
P-wave: associate with atrial contraction
P-R Interval
QRS complex: associate with ventricular contraction
T wave
S- T interval
U wave
PVCs: premature ventricular contractions
An EKG can show these conditions:
Sinus tachycardia
Ventricular tachycardia*
Sinus bradycardia
Atrial fibrillation
Ventricular fibrillation*
Asystole*
*death producing
EKG MEASURES ELECTRICAL ACTIVITY
OF HEART
monitor hemodynamic indicators as
ordered
administer oxygen as ordered
provide a restful environment
prepare the client for cardioversion, as
indicated
initiate cardiopulmonary resuscitation as
indicated
provide emotional support to client/family
reinforce client teaching regarding
medications and side effects
importance of dysrhythmia identification
jewelry
atrio-ventricular (AV) conduction
disturbances
asymptomatic: no nursing interventions
indicated
symptomatic
administer medications as ordered
PACEMAKERS
surgical treatment
embolectomy
bypass of affected artery (
illustration )
amputation of limb
percutaneous transluminal
coronary angioplasty
Chronic Arterial Occlusive Disease
Etiology
arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use
slow, progressive arteriosclerotic changes give collateral circulation a chance
to form
collateral circulation cannot give tissues enough oxygen; result is
hypoperfusion
hypoperfusion leads to ischemia
usually affects legs
Findings
intermittent claudication indicates mild to moderate obstruction
pain at rest indicates severe obstruction
affected limb will show
edema
paresthesia
in men, impotence
Diagnostics - arteriography
Medical management
pharmacologic
Both Acute and Chronic Arterial
Occlusive Disease
Nursing interventions
administer medications as ordered
monitor peripheral pulses and blanch test for capillary refill <
five seconds
provide comfort measures such as placing legs in dependent
position can improve blood flow and reduce pain
help client develop an exercise program
provide care for the client undergoing surgery
provide regular foot care
reinforce for client to
change positions frequently
Diagnostics - venography
Management
goal is to reduce pain and halt underlying condition
medical: sclerotherapy (injection of sclerosing agent that causes
vein thrombosis)
surgical: vein ligation (vein stripping)
Nursing interventions
provide care to the client undergoing surgery
post-operative care includes:
application of elastic stocking or bandages
elevation of legs
Diagnostics
history and physical
ultrasonography
plethysmography
Management
bed rest with elastic stockings
elevation of affected extremity
anticoagulants - to prevent clot formation
analgesics - to control discomfort
Nursing interventions
keep affected extremity elevated
monitor
for signs of pulmonary embolism (sudden pain, cyanosis, hemoptysis,
shock)
vital signs, including bilateral peripheral pulses
Nursing interventions
maintain bed rest
follow guidelines for anticoagulation
monitor coagulation lab studies (APTT for heparin, PT/INR
for warfarin)
observe for evidences of bleeding (bruises, nosebleeds,
toothbrushes
skin grafting
Nursing interventions
keep client's legs elevated, with feet above level of heart as
much as possible
apply elastic bandages as ordered, usually bilateral
cleanse and dress ulcer as ordered
administer drugs as ordered
reinforce client teaching regarding: