The nurse is caring for a patient with left-sided heart failure and expects what assessment finding
Electrical Activity of the Heart Related to the Normal EKG, Con't.Assessment of the MI Patient Show
As a review, we remember that an MI myocardial infarct is death of the heart muscle tissue. The area of infarct can be small or large depending upon the amount of the blood supply which was cut off. The treatment for the MI patient is divided into two phases. First, the acute stage where the patient is in the ICU. The second phase of medical treatment is the rehabilitation stage. The person is placed on the nursing care until where rehabilitation starts. Assessment During the Acute Phase (Day 1 – 4)
Assessment During the Rehabilitation Phase (semi acute 4 – 10 days):
Assessment during late Rehabilitation Stage:
These are only guidelines to assessing the MI patient. Each person will progress differently and must be assess on their own merits. Their individual programs will be worked out with their cardiologist. The nurse should be familiar with each individual’s program so that it can be followed carefully. Continually asses for the above complications which can occur at any time during the rehabilitation phase of the MI patient. Complications such as arrhythmias, CHF, shock, and angina will always slow the recovery of the patient. These persons with complications will have to be assessed even more carefully to prevent life threatening further complications. Assessment of Patient with CHF Congestive heart failure, or cardiac decompensation, whatever the cause, results in lowered cardiac output. In addition to this problem, blood backs up behind the heard causing hypertension and a variety of similar conditions. In assessing this patient, first keep in mind emergency procedures in case of a crisis. CHF can lead to pulmonary edema very quickly so be prepared to act quickly. Assessment of CHF:
Drugs for treating CHF:
The above guide assumes that the patient is stable. If the patient is in a crisis situation, such as pulmonary edema, they will need emergency care in the form of intravenous digoxin and/or diuretics. In addition, the patient will require supplemental oxygen (1-3 L/min), sometimes needs oxygen via ventilator and endotracheal tube, under pressure, and in high concentrations. In this acute state of emergency it is important to continually monitor the vital signs and lab test values. The patient must be maintained with adequate oxygen and blood supply until the heart can begin again to pump sufficient supplies of blood into circulation, and the lungs can clear of the excess fluid. Digoxin is a cardiotonic drug that increased the force of the contraction of the heart, increasing cardiac output. With most vasodilators, the blood pressure will be lowered and the pulse rate will be increased as will the respiratory rate be increased. The nurse must relax the patient as much as possible and make them comfortable as possible so as to reduce the work load of the heart. Pulmonary assessment in these emergencies is also important as cardiovascular assessment. Artificial Pacemakers There are many different types of cardiac pacemakers. They can be external or internal artificial pacemakers. Earlier in the text, it was mentioned that pacemakers can be used to treat many of the Brady (slow) arrhythmias. The EKG tracing illustrated, shows a normally functioning pacemaker. The pacemaker can be the demand type, where the pacemaker will automatically start again if the patient’s rate falls below a certain preset rate. There are also pacemakers which are preset to give a constant pulse, no matter what the patient’s heart rate is. Note the pacemaker “spikes” on the sample EKG. Each of these spikes represents an electrical stimulation of the heart. Cardiovascular Disease and the EKG
Interpretation of the EKG This is perhaps the most important section of this course. Interpretation of the EKG must be performed in a logical sequence in order to best serve the patient. There are many different approaches to the interpretation of the EKG, but in this section we will present a “common sense” approach. If you are responsible for a patient who is being monitored, you want to be able to recognize any arrhythmia which may be life-threatening. You want to be able to do that as fast as possible; it may save the life of your patient. As you read through these steps, remember that they may not apply to every patient in every situation, but always be deliberate and methodical when you interpret the EKG. Step I: Assessment
In this phase, the nurse must quickly note any adverse symptoms. The symptoms will determine if the arrhythmia is severe or not. The vital signs are important. At the same time, you are assessing the patient, look at the EKG to determine if there are any gross arrhythmias, such as no rhythm, or grossly irregular rhythm. After these are determined, the nurse can then take the appropriate action. If the patient needs immediate resuscitation or if they can wait for treatment. Step II: EKG Components
Examine each of the waves of the EKG. Make sure that there is a P wave, QRS complex, etc. if all of the components are present, are they normal in configuration. They should all be identical in shape, and in timing. Step III: Determine the Arrhythmia
Once you have identified the abnormal component on the EKG, you then name the arrhythmia. If the abnormality is in the atria (P wave), then identify the arrhythmia. If the abnormality is in the ventricle, then identify the arrhythmia. Step IV: Action
As we stated above, if the arrhythmia is immediately life-threatening, then immediate action must be taken. However, in the most nursing situations, the action will involve notifying the physician and then treating the arrhythmia with the appropriate drug. As you proceed through each of the above steps, you must continually be aware of the changes in the patient’s condition and of possible intervention. Each hospital will have a different protocol for dealing with arrhythmias. Always consider your hospital’s policy and procedure and use your common sense when dealing with these potentially fatal arrhythmias. Next: Cocaine Use and Nursing Assessment Which finding would you expect to see in a patient with leftLeft-sided Heart Failure Symptoms
Shortness of breath. Difficulty breathing when lying down. Weight gain with swelling in the feet, legs, ankles. Fluid collection in the abdomen.
Which assessment finding is an indication of leftLeft-sided heart failure symptoms include: Awakening at night with shortness of breath. Shortness of breath during exercise or when lying flat. Chronic coughing or wheezing.
Which assessment finding would the nurse expect when assessing a patient with right sided heart failure?Systemic edema reflected by jugular venous distention, peripheral edema, and hepatosplenomegaly are signs of right sided heart failure.
What clinical manifestation would the nurse anticipate in a patient with left ventricular hypertrophy?Shortness of breath. Feeling tired or dizzy. Angina symptoms, such as chest pain or pressure, which may be worse when you're active. Feeling like your heart is fluttering, racing, or pounding (palpitations).
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