CHART 293 NANDA, NIC, AND NOC LINKAGES

The Client with a Dysrhythmia

NURSING DIAGNOSIS NURSING INTERVENTIONS NURSING OUTCOMES Activity Intolerance Energy Management Activity Tolerance Self-Care Assistance Self-Care: ADL Anxiety Anxiety Reduction Anxiety Control Decreased Cardiac Output Cardiac Care: Acute Cardiac Pump Effectiveness Cardiac Precautions Circulation Status Deficient Knowledge Teaching: Disease Process Knowledge: Disease Process Teaching: Procedure/Treatment Knowledge:Treatment Procedure(s) Ineffective Tissue Perfusion Dysrhythmia Management Cardiac Pump Effectiveness Vital Signs Monitoring Vital Signs Status
Note. Data from Nursing Outcomes Classification (NOC) by M.Johnson & M.Maas (Eds.),1997, St.Louis:Mosby;Nursing Diagnoses: Definitions & Classification 20012002 by North American Nursing Diagnosis Association,2001,Philadelphia:NANDA; Nursing Interventions Classification (NIC) by J.C. McCloskey & G. M.Bulechek (Eds.),2000,St.Louis:

effort focuses onpermission.strategies and lifestyle changes, as Mosby.Reprinted by coping well as specific management of prescribed therapies. Include the following topics as appropriate when teaching the client and family for home care. Function, maintenance, precautions, and signs of malfunc-

Specific instructions related to planned diagnostic tests or procedures The importance of follow-up visits with the cardiologist The importance of and where to obtain CPR training for c the lient and family members

tion or complications of any implanted device such as a pace- In addition, discuss fears related to treatment or maker or ICD devices, such as that of shocking a significant other during implanted Monitoring pulse rate and rhythm close contact or sexual activity. Explain that if a shock Activity or dietary restrictions, and any potential effects of occurs, the dysrhythmia or its treatment on lifestyle the partner may feel a slight buzz or tingling but should not Medication management to reduce the risk of dysrhythmias, be including the desired and potential adverse effects of anti- harmed. Refer to and encourage the client and family to dysrhythmic drugs attend a peer support group for the specific condition.

Nursing Care Plan A Client with Supraventricular Tachycardia

Elisa Vasquez, 53 years old, is admitted to the cardiac unit with complaints of palpitations, lightheadedness, and shortness of breath. Her histor y reveals rheumatic fever at age 12 with subsequent rheumatic heart disease and mitral stenosis. An intravenous line is in place and she is receiving oxygen. Marcia Lewin, RN, is assigned to Ms. Vasquez.

DIAGNOSIS
Ms. Lewin formulates the following nursing diagnoses for Ms. Vasquez. Decreased cardiac output related to inadequate ventricular filling associated with rapid tachycardia Ineffective tissue perfusion: cerebral/cardiopulmonary/peripheral related to decreased cardiac output Anxiety related to unknown outcome of altered health state

ASSESSMENT

Ms. Lewins assessment reveals that Ms. Vasquez is moderately anxious. Her ECG shows supraventricular tachycardia (SVT ) with EXPECTED OUTCOMES a The rate of 154.Vital signs: T 98.8 F (37.1 C), R 26, BP 95/60. Peripheral expected outcomes for the plan of care specify that Ms. Vasquez will: pulses weak but equal, mucous membranes pale pink, skin cool and dry. Fine crackles noted in both lung bases. A loud S3 gallop Maintain adequate cardiac output and tissue perfusion. and a diastolic murmur are noted. Ms. Vasquez is still complaining Demonstrate a ventricular rate within normal limits and stable vital signs. of palpitations and tells Ms. Lewin, feel so nervous and weak and Verbalize reduced anxiety. dizzy.s.Vasquezs cardiologist orders 2.5 mg of verapamil to be Verbalize an understanding of the rationale for the treatment given slowly via intravenous push and tells Ms. Lewin to prepare measures to control the hear t rate. to assist with synchronized cardioversion if drug therapy does not control the ventricular rate.

CHAPTER 29 / Nursing Care of Clients with Coronar y Hear t Disease 863

Nursing Care Plan

A Client with Supraventricular Tachycardia (continued)
PLANNING AND IMPLEMENTATION
Ms. Lewin plans and implements the following nursing interventions for Ms. Vasquez. Provide oxygen per nasal cannula at 4 L/min. Continuously monitor ECG for rate, rhythm, and conduction. Assess vital signs and associated symptoms with changes in ECG. Report findings to physician. Explain the importance of rapidly reducing the hear t rate. Explain the cardioversion procedure and encourage questions. Encourage verbalization of fears and concerns. Answer questions honestly, correcting misconceptions about the disease process, treatment, or prognosis. Administer intravenous diazepam as ordered before cardioversion. Document pretreatment vital signs, level of consciousness, and peripheral pulses. Place emergency cart with drugs and airway management supplies in client unit. Assist with cardioversion as indicated. Assess LOC, level of sedation, cardiovascular, and respiratory status, and skin condition following cardioversion. Document procedure and postcardioversion rhythm, and response to intervention. cardiologist, Dr. Mullins, performs carotid sinus massage. The ventricular rate slows to 126 for 2 minutes, revealing atrial flutter waves, and then returns to a rate of 150. Dr. Mullins explains the treatment options, including synchronized cardioversion. Ms.Vasquez agrees to the procedure. Ms. Vasquez is lightly sedated and synchronized cardioversion is performed. One countershock conver ts Ms. Vasquez to regular sinus rhythm at 96 BPM with BP 112/60. Ms. Vasquez is sleepy from the sedation but recovers without incident. She states that she feels uch better,and her vital signs return to her normal levels. She remains in NSR with a rate of 86 to 92 for the remainder of her hospital stay. Dr. Mullins places Ms.Vasquez on furosemide to treat manifestations of mild heart failure.

Critical Thinking in the Nursing Process

1. What is the scientific basis for using carotid massage to treat supraventricular tachycardias? Was this an appropriate maneuver in the case of Ms. Vasquez? 2. What other treatment options might the physician have used to treat Ms. Vasquezs supraventricular tachycardia if she had been asymptomatic with stable vital signs? 3. Develop a teaching plan for Ms. Vasquez related to her prescription for furosemide.

EVALUATION

Intravenous verapamil lowers Ms.Vasquez s heart rate to 138 for aSee Critical Thinking in the Nursing Process in Appendix C. short time, after which it increases to 164 with BP of 82/64. Her

sudden Risk factors for SCD are those associated with coronary cardiac death are listed in Box 296. heart disease (see the next section of this chapter). Sudden cardiac death (SCD) is defined as unexpected death Advancing occurring within 1 hour of the onset of cardiovascular sympage and toms. It usually is caused by ventricular fibrillation and cardiac male gender are powerful risk factors. After age 65, the arrest. Cardiac arrest is the sudden collapse, loss of consciousgap ness, and cessation of effective circulation that precedes bio- between male and female incidence of SCD narrows (Braunwald et al., 2001). Clients with dysrhythmias such as logic death. Nearly half of all cardiac arrest victims die before PATHOPHYSIOLOGY rereaching the hospital; only 25% to 30% of out-of-hospital carEvidence may have a higher risk of SCD. diac arrest victims survive to be discharged (Woods et al., current VT of coronary heart disease with significant atheroscle2000). Almost 50% of all deaths due to coronary heart disease are rosis and narrowing of two or more major coronary arteries attributed to SCD. Coronary heart disease (CHD) causes up to is 80% of all sudden cardiac deaths in the United States. Other found in 75% of SCD victims. Although most have had cardiac pathologies such as cardiomyopathy and valvular dis- prior orders also may lead to SCD. Noncardiac causes of sudden myocardial infarction, only 20% to 30% have recent acute death include electrocution, pulmonary embolism, and rapid myblood loss from a ruptured aortic aneurysm. ocardial infarction. An acute change in cardiovascular status Ventricular fibrillation is the most common dysrhythmia asprecedes cardiac arrest by up to 1 hour; however, often the sociated with sudden cardiac death, accounting for 65% to 80% Abnormalities of myocardial structure or function also onof cardiac arrests. Sustained severe bradydysrhythmias, tribute. Structural abnormalities include infarction, hypertrosetconis instantaneous or abrupt. Tachycardia develops, and the asystole or cardiac standstill, and pulseless electrical activity phy, myopathy, and electricalThis is followed by adevia-of number of PVCs increase. anomalies. Functional run (organized cardiac electrical activity without a mechanical re-tions are caused by such factors as ischemia followed by ventricsponse) are responsible for most remaining SCDs (Braunwaldreperfusion, altered homeostasis, into ventricular fibrillation ular tachycardia that deteriorates autonomic nervous system (Braunwald et al., 2001).

et THE CLIENT WITH SUDDEN CARDIAC DEATH al., 2001). Selected cardiac and noncardiac causes of