Minggu, 02 September 2012

Nuring care for arrhythmias

A. Definition
http://1.bp.blogspot.com/-703cqpQeNmY/Tbxf73kvT7I/AAAAAAAAAFM/-6dlt6an12Y/s400/KeSimpulan+Laporan+Penelitian+Mutasi+Gen+KCNQ+Pemicu+Epilepsi+dan+Serangan+Jantung+Aritmia+%2528arrhythmia%2529.jpgHeart rhythm disturbances or arrhythmias are a frequent complication of myocardial infarction. Arrhythmias or dysrhythmias is the change in frequency and heart rhythm caused by abnormal or automatic electrolytic conduction (Doenges, 1999). Dysrhythmias are abnormal heart rate or rhythm include frequency interference or both. Dysrhythmias are conducting system disorders of the heart and not the heart strruktur. (Medical Surgical Nursing, Brunner & Suddarth, 1997)
B. EtiologyThe cause of cardiac arrhythmias usually one or a combination of these abnormalities in the cardiac conduction system of rhythm:a. Abnormal rhythm of the pacemaker.b. Shifting pacemaker from the sinus node to another part of the heart.c. Blocks at different places sewktu conduct impulses through the heart.d. Abnormal impulse conducting pathways through the heart.e. The spontaneous formation of abnormal impulses in almost all parts of the heart.
The etiology of cardiac arrhythmias in the outline can be caused by:a. Inflammation of the heart, such as rheumatic fever, myocardial inflammation (myocarditis due to infection)b. Impaired coronary circulation (coronary atherosclerosis or coronary artery spasm), such as myocardial ischemia, myocardial infarction.c. Because the drug (intoxication), among others by digitalis, quinidine and anti-arrhythmia drugs otherd. Electrolyte balance disorders (hyperkalemia, hypokalemia)e. Disturbances in the regulation of autonomic nervous system that affects the heart rhythm of work andf. Psikoneurotik disruption and central nervous system.g. Metabolic disorders (acidosis, alkalosis)h. Endocrine disorders (hyperthyroidism, hypothyroidism)i. Heart rhythm disturbances due to cardiomyopathy or cardiac tumorj. Heart rhythm disturbances due to degeneration disease (cardiac conduction system fibrosis).
C. Pathophysiology1. Sinus node dysrhythmiasa. Sinus bradycardiaSinus bradycardia may occur due to vagal stimulation, digitalis intoxication, increased intracranial pressure, or myocardial infarction. Sinus bradycardia was also observed in olahraghawan weight, people who are very ill, or those who received medication (propranolol, reserpine, methyldopa), the state hipoendokrin (myxoedema, Adison disease, panhipopituitarisme), in anorexia nervosa, the hypothermia, and after surgical damage to the lymph SA.Characteristics:• Frequency: 40 to 60 beats per minute• P wave: precede each QRS complex; normal PR interval• QRS complex: usually normal• delivery: usually normsl• Rhythm: regularb. Sinus tachycardiaSinus tachycardia (rapid heart rate) may disebablkan by fever, acute blood loss, anemia, shock, exercise, congestive heart failure, pain, state hipermetabolisme, anxiety, or treatment simpatomimetika parasimpatolitik.Characteristics:• Frequency: 100 to 180 beats per minute• P wave: precede each QRS complex, can be lost in the preceding T wave; normal PR interval• QRS complex: usually have a normal duration• delivery: usually normsl• Rhythm: regular2. Dysrhythmias ATRIUMa. Premature Contractions AtriumAtrium Premature Contractions (PAC = premature atrial contraction) can are due to atrial muscle irritability kerana caffeine, alcohol, nicotine, which stretched as Atrium myocardium in congestive heart failure, stress or in anxiety, hypokalemia (low potassium levels), injury, infarct, or state hypermetabolic.Characteristics:• Frequency: 60 to 100 beats per minute• P wave: usually have different configurations with P waves originating from the SA node. Nowhere else in the atrium has become irritable (increased automation) and release the SA node impulse before releasing impulses normally. PR interval may vary with PR interval impulses from the SA node.• QRS complex: may be normal, distorted or absent. When the ventricles have completed phase rep [olarisasi, they can respond to stimulus from the atria awal.Hantaran: usually normsl• Rhythm: regular, except in the event of PAC. P waves will occur earlier in the cycle and usually will not have lag compensation is complete.b. Paroxysmal tachycardia AtriumAtrium Paoksismal tachycardia (PAT = paroxysmal atrial tachychardia) atrial tachycardia is characterized by sudden onset and sudden termination. Can be triggered by emotions, tobacco, caffeine, fatigue, sympathomimetic medication, or alcohol. PAT is usually not associated with organic heart disease. Frequency is very tinggfi can cause angina due to coronary artei pebnurunan charging. Will decrease cardiac output and heart failure can occur.Characteristics:• Frequency: 150 to 250 beats per minute• P wave: ectopic and distorted than the normal P wave; may be found at the beginning of the T wave; shortened PR interval (less than 0.12 seconds)• Complex QR: usually normal, but can be distorted if there are deviations delivery• delivery: usually normal• Rhythm: regularc. Flutter AtriumFluter atrium occurs when there is a point of focus in the atrium that captures the rhythm of the heart and make impulse between 250 to 400 times per minute. Important character is the dysrhythmias sealing therapy in the AV node, which prevents the delivery of several impulses. Sebenartnya delivery of impulses through the heart is normal, so the comp; Leks QRS unaffected. This is the dysrhythmias important sign of this type, because hantran 1: 1 atrial impulses given off 250 to 400 times per minute will lead to ventricular fibrillation, a life-threatening dysrhythmias.Characteristics:• Frequency: atrial frequency between 250 to 400 beats per minute• P wave: No, it was replaced by a sawtooth pattern generated by a release focused on atrial impulse quickly. The wave is called a wave of F.• QRS complex: normal configuration and time hantarannya also normal.• T wave: No, but can be covered by a wave fluter• Rhythm: regular or irregular, depending on the type of insulation (eg, 2:1, 3:1, or a combination thereof)d. Atrial AtriumAtrial fibrillation (atrial muscle contraction in disorganized and uncoordinated) is usually associated with atherosclerotic heart disease, heart valve disease, congestive heart failure, thyrotoxicosis, cor pulmonale, or congenital heart disease.3. Ventricular dysrhythmiasa. Premature Ventricular ContractionsPremature ventricular contraction (PVC = premature ventricular contraction) occurs due to increased automation ventricular muscle cells. PVC commonly caused by digitalis toxicity, hypoxia, hypokalemia, fever, acidosis, exercise, or an increase in circulating catecholamines.b. Bigemini ventricleBigemini ventricle is usually caused by digitalis intoxication, coronary artery disease, acute MI, and CHF. Bigemini term refers to the condition in which each beat is premature.c. Ventricular tachycardiaDysrhythmias is caused by an increase in myocardial irritability, such as PVC. The disease is usually associated with coronary artery disease and occurs before ventricular fibrillation. Ventricular tachycardia is dangerous and should be regarded as an emergency. Patients are usually aware of the rhythm is fast and very anxious.d. Ventricular FibrillationIs a rapid ventricular beats and ineffective. In these dysrhythmias heartbeat audible and palpable, and no respiration. The pattern is very irregular and can be distinguished from other types of dysrhythmias. Since there is no coordination of activity of the heart, they can lead to cardiac arrest and death if not promptly corrected ventricular fibrillation.4. Abnormalities deliverya. Insulation degree AV-OneUsually associated with organic heart disease or may be due to the effects of digitalis pleh. It is usually seen in patients with inferior wall myocardial infarction heart.b. Insulation AV-Two DegreesAlso be caused by organic heart disease, IM, or digitalis intoxication. This baffle shape resulting in a reduction of heart frequency and usually decrease in cardiac output (cardiac output = heart rate x volume sekuncup).c. Insulation AV-Three DegreesAlso associated with organic heart disease, digitalis intoxication, and MI. heart rate decreases dramatically, resulting in decreased perfusion to vital organs. Such as the brain, heart, lungs, and skin.5. ASISTOLE ventricularIt will not happen QRS complex. No heart rate, pulse and respiration. Without management immediately, fatal ventricular asistole.
D. Clinical Manifestations1. Changes in BP (hypertension or hypotension), the pulse may be irregular; deficit pulse; rhythm irregular heart sounds, extra sounds, beats down; pale skin, cyanosis, sweating; edema; output of urine decreases as cardiac output decreased weight.2. Syncope, dizziness, throbbing, headache, disorientation, confusion, lethargy, pupillary changes.3. Mild to severe chest pain, may be lost or not with drugs antiangina, anxiety4. Shortness of breath, cough, change in velocity / depth of breathing; additional breath sounds (krekels, crackles, wheezing) may be demonstrated respiratory complications such as left heart failure (pulmonary edema) or pulmonary tromboembolitik phenomenon; hemoptysis.5. fever; redness of the skin (drug reaction), inflammation, erythema, edema (siperfisial thrombosis), loss of muscle tone / strength.
E. Examination Supporta. ECG: shows the pattern of ischemic injury and conduction disturbances. Declare the type / source dysrhythmia and effect electrolyte imbalance and cardiac drugs.b. Holter Monitor: Overview of ECG (24 hours) may be required to determine where the dysrhythmia caused by specific symptoms when the patient is active (at home / work). It can also be used to evaluate the function of a pacemaker / drug effects antidisritmia.c. Photo Chest: Can menunjukkanpembesaran heart shadow in relation to ventricular dysfunction or valved. Miokardia imaging scan: may show aea ischemic / myocardial damage that could affect or disturb the normal conduction wall motion and the ability to pump.e. Exercise stress test: do utnnuk demonstrate exercises that cause dysrhythmias.f. Electrolytes: An increase or decrease in potassium, calcium and magnesium can mnenyebabkan dysrhythmias.g. Examination medicine: Can be expressed cardiac drug toxicity, the presence of street drugs or suspected instances of drug interactions digitalis, quinidine.h. Examination of the thyroid: increased or penururnan serum thyroid levels can menyebabkan.meningkatkan dysrhythmias.i. Sedimentation rate: Penignggian can menunukkan acute inflammatory process as an example of endocarditis trigger dysrhythmias.j. GDA / pulse oximetry: Hypoxaemia can cause / exacerbate dysrhythmias.

F. Medical Management Medical TherapyAntiarrhythmic medications are divided into 4 classes: Anti-arrhythmia Class 1: sodium channel blockers1) Class 1 A• quinidine is a drug used in maintenance therapy to prevent recurrence of atrial fibrillation or flutter.• procainamide for ventricular fibrillation and atrial systole extra aritmi accompanying anesthesia.• Dysopiramide for acute and recurrent SVT
2) Class 1 B• Lignocain for ventricular arrhythmias due to myocardial ischemia, ventricular tachycardia.• Mexiletine for entrikel arrhythmias and VT3) Class 1 CFlecainide for ventricular tachycardia and ectopic Anti-arrhythmia Class 2 (Beta-adrenergic blockade)Atenolol, Metoprolol, Propranolol: aritmi indication of heart disease, angina pectoris and hypertension Anti-arrhythmia grade 3 (Prolong repolarisation)Amiodarone, an indication VT, SVT repeated Anti-arrhythmia grade 4 (calcium channel blocker)Verapamil, supraventricular arrhythmia indication mechanical therapy1. Cardioversion: includes use of electric current to stop with complex dysrhythmias GRS, usually an elective procedure. Cardioversion include use of electric current to stop dysrhythmias with the QRS complex is usually an elective procedure. The patient was conscious and asked to consent.2. Defibrillation: cardioversion asinkronis used in an emergency. Asinkronis cardioversion defibrillation is used in an emergency. Usually limited to the management of ventricular fibrillation in the absence of an organized cardiac rhythm. Defibrillation will mendepolarisasi complete all myocardial cells at once, allowing the sinus node to recover its function as a pacemaker.3. Implantabel cardioverter defibrillator: a tool to detect and terminate ventricular tachycardia episodes of life-threatening risk or in patients experiencing ventricular fibrillation. It is a tool to detect and terminate episodes of life-threatening ventricular takiakrdia or in patients who have a high risk of ventricular fibrillation.4. Pacemaker therapy: electrical appliance that can produce repeatable electrical stimulus to the heart muscle to control the heart rate. Pacemaker is a power tool that is able to produce repeatable electrical stimulus to the heart muscle to control the frequency of the heart. This tool is started and memeprtahankan heart frequency kerika natural pacemaker heart no longer able to fulfill its function. Pacemaker is normally used when the patient has impaired delivery or delivery disruption resulting stepping cardiac failure.

1. ASSESSMENT DATA BASE ACTIVITY / RESTSymptoms:• weakness, general fatigue and because of work.Signs:• Changes in the frequency of heart / TD with activity / exercise. CIRCULATIONSymptoms:• Riwatar previous IM / acute 90% -95% had dysrhythmias), cardiomyopathy, GJK, heart valve disease, hypertension.Signs:• Changes TD, for example hypertension or hypotension during the period dysrhythmias.• Nadi: may be irregular, eg strong pulse, pulsus altenan (irregular pulse strong / weak pulse), pulse bigeminal (irregular pulse strong / weak pulse).• pulse deficit (difference between the apical pulse and the radial pulse).• The sound of the heart: irregular rhythm, extra sounds, beats down.• Skin: color and humidity changes, eg pallor, cyanosis, sweating (heart failure, shock).• Edema: dependent, general, DVJ (in the presence of heart failure).• Urine output: cardiac output decreases as weight decreases. EGO INTEGRITYSymptoms:• Feeling nervous (with tachyarrhythmia), feeling threatened.• Stressor relation to medical issues.Signs:• Anxiety, fear, rejected, angry, agitated, crying.

 FOOD / FLUIDSymptoms:• Loss of appetite, anorexia.• Not tolerant of food (due to drugs).• Nausea / vomiting.• Changes in weight.Signs:• Changes in weight.• Edema• Changes in skin moisture / turgor.• Breathing krekels.NEURO  SENSORSymptoms:• Dizziness, throbbing, headache.Signs:• Mental status / sensory changes, eg disorientation, confusion, memory loss, changes in speech patterns / consciousness, seizures, coma.• Changes in behavior, examples of attacks, lethargy, hallucinations.• Changes in pupil (equality and reaction to light).• Loss of deep tendon reflexes with life-threatening dysrhythmias (ventricular tachycardia, bradycardia weight). PAIN / INCONVENIENCESymptoms:• Chest pain, mild to severe, which may or may not disappear by biased anti-angina drugs.Signs:• Behavior distraction, anxious sample. RESPIRATORYSymptoms:• Chronic lung disease.• History of recurrent or tobacco use.• Shortness of breath.• Cough (with / without sputum production).Signs:• Change the speed / depth of breathing during episodes of dysrhythmias.• The sound of breathing: additional sounds (krekels, crackles, wheezing) may be demonstrated respiratory complications, such as left heart failure (pulmonary edema) or pulmonary tromboembolitik phenomenon. SAFETYSigns:• Fever.• Redness of skin (drug reaction).• Inflammation, erythema, edema (superficial thrombosis).• Loss of muscle tone / strength. EXTENSIONSymptoms:• Risk factors for example family, heart disease, stroke.• The use / not use drugs disresepkan, eg cardiac drugs (digitalis), anti-coagulants (Coumadin) or other drugs are sold freely, eg cough syrup and analgesics containing ASA.• A failure to memeprbaiki, recurrent dysrhythmias examples / can not heal life-threatening.Considerations:• DRG showed the average time in care: 3.2 days.Repatriation plan:• Changes in drug use
2. Nursing Diagnosisa. Rissiko height to decreased cardiac conduction disturbances eliktrikal associated with a reduction in myocardial contractility.b. Lack of knowledge about the causes / treatment of conditions related to lack of information / misinterpretation of medical conditions / needs therapy; does not know the source of information; less mengungatc. Pain related to tissue ischemiad. Intolerans activity associated with weakness / fatiguee. Risks related to changes in tissue perfusion with oxygen to tissues inadekuat suply.
3. PLANNING AND RATIONAL1. Diagnosis: High risk for decreased cardiac conduction disturbances eliktrikal associated with a reduction in myocardial contractility. Purpose: Expected outcomes:1) Maintain / increase cardiac output adequately evidenced by the TD / pulse in the normal range, adequate output of urine, the same palpable pulse, normal mental status2) Shows the reduction in the frequency / absence of dysrhythmias3) Participate in activities that lower miokardia work. Planning and rational:a) Feel the pulse (radial, carotid, femoral, dorsalis pedis) record the frequency, regularity, amplitude (full / powerful) and symmetrical. Note the presence of pulsus alternan, bigeminal pulse, or pulse deficit.Rational: frequency difference, similarity and regularity of the pulse shows the effect of cardiac disorders in systemic circulation / peripheral.b) heart sound auscultation, record the frequency, rhythm. Note Adaiah extra heartbeat, decreased pulse.Rationale: Special dysrhythmias more clearly detected with auditory than with palpation. Pendenganaran for extra heart sounds or pulse reduction help identify dysrhythmias in patients uncontrolled.c) Monitor vital signs and examine the adequacy of cardiac output / tissue perfusion. Report significant variation in the TD / pulse frequency, similarity, breathing, changes in skin color / temperature, level of consciousness / sensory, and hakuaran urine during episodes of dysrhythmias.Rationale: Although not all life-threatening dysrhythmias, respond quickly to end the disruption dysrhythmias required on cardiac output and tissue perfusion.d) Provide quiet environment. Assess the reasons for limiting activity during the acute phaseRational: the decline and disappearance of excitatory stress due to catecholamines, which cause / increase dysrhythmias and vasoconstriction and increase miokardia work.e) Demonstrate / encourage pemnggunaan pengbaturan behavioral stress, eg relaxation techniques, counseling imagination, breath slowly / inRational: to increase patient participation in several flavors mengekluarkan control in stressful situations.f) Prepare / do CPR if indicatedRational: the threatening dysrhythmias, life requires an intervention to prevent ischemic damage / death.g) Provide supplemental oxygen as indicated.Rational: increase the amount of oxygen to myocardial preparations, which decreases irritability caused by hypoxia.h) Prepare for / Help planting automatic cardioverter or defibrillator (AICD) when indicatedRationale: This device surgically implanted in patients with recurrent life-threatening dysrhythmias despite drug therapy given carefully.2. Pain related to tissue ischemia Purpose: Expected outcomes:1) Report from reduction in pain immediately2) Looks comfortable and pain free Planning and rational:a) Investigate complaints of chest pain, note the onset and factor weights and nonverbal clues inconvenience penurun.PerhatikanRationale: Pain is typically located subternal and can spread keleher and back. But this is different from ischemia myocardial infarction. At this pain can worsen the inspiration, movement or lie down and disappear by sitting upright / bentb) Provide a quiet environment and comfort measures eg: change in position, masasage backs, warm compresses cold, emotional supportRational: to lower the patient's physical and emotional discomfort.c) Provide appropriate entertainment activitiesRational: directing attention, provide distraction in individual activity levelsd) Give the medication as an indication of painRational: to relieve pain and inflammatory response3. Intolerans activity associated with weakness / fatigue Purpose: Planning and rational:a) Assess the patient's response to activityRational: It can affect the activity of the cardiac outputb) Monitor heart rate, blood pressure, breathing after activityRationale: Helps to determine the degree of cardiac and pulmonary compensation, decreased blood pressure, tachycardia, dysrhythmias and takipneu is indicative of damage tolerance for activityc) Maintain bed rest during periods of fever, and as an indicationRationale: Increasing the resolution of inflammation during faseakut of pericarditis / endocarditis.d) Assist patients in an exercise program activityRationale: When the inflammatory / basic condition is resolved, the patient may be able to perform the desired activity4. Lack of knowledge about the causes / treatment of conditions related to lack of information / misinterpretation of medical conditions / needs therapy; does not know the source of information; less given Purpose: Expected outcomes:1) expressed an understanding of the condition, treatment programs2) Declare the necessary precautions and possible side effects of drugs Planning and rational:a) Review the normal cardiac function / conduction eliktrikalRational: memeberikan basic knowledge to understand individual variation and understand the reasons for therapeutic interventionb) Explain / stress issues specific dysrhythmias and therapeutic measures for patients / significant otherRational: terus-menerus/baru information can reduce anxiety related circuitry ignorance and prepare patient / significant other. Education at the closest possible important when elderly patients, impaired vision or hearing, or unable or interest in learning / follow instructions. Repeated explanations may be necessary, because of anxiety and / or new information barriers to prevent / limit learning.c) Help installing / maintaining a functioning pacemakerRational: temporary pacemaker may need to neningkatkan impulse formation or inhibit takidisritmia and ectopic activity in order to maintain cardiovascular function until repaired or spontaneous spur permanent grandstand stiffened.d) Encourage routine, avoid excessive exercise.  Identify training development signs / symptoms that require rapid activity, eg dizziness, glare, dyspnea, chest pain.Rationale: if the dysrhythmia is handled appropriately, normal activities should be carried out. The exercise program is useful in improving cardiovascular health.5. Risks related to changes in tissue perfusion with oxygen to tissues inadekuat suply. Purpose: Planning and rational:a) Investigate chest pain, sudden dyspnea accompanied by tachypnea, pleuritic pain, pale cyanosisRational: arterial embolism. Affect the heart can occur as a result of chronic valvular disease and dysrhythmias.b) Observations of the limb edema, eroitemaRationale: Inactivity / prolonged bed rest trigger venous stasis, increasing the risk of venous thrombosis formationc) Observation hematuriRationale: Indicates renal embolid) Consider the left upper abdominal painRational: indicates embolism splenik
REFERENCESDoengoes, Marylin E. 2000. Nursing Care Plans and Documentation. Edition 3. Jakarta: EGC.Carpenito J.L. 1997. Nursing Diagnosis. Philadelphia: Lippincott J.B.Carpenito J.L. , 1998. Handbook of Nursing Diagnosis. Edition 8. Jakarta: EGC.Smeltzer, Suzanne & Brenda G. Bare, 2001. Textbook of Medical Surgical Nursing Brunner & Suddarth. Vol 8 issue 1. Jakarta: EGC

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