MYOCARDIAL INFARCTION ➔ Percutaneous Coronary Intervention (PCI), or balloon

➔ Diagnosis angioplasty
◆ ECG ◆ To open artery – 90 mins,
● NSTEMI: (+) chest pain + ø ST elevation ● (+) cardiac catheterization lab
○ Transient thrombosis ◆ Minimally invasive – ambulate within 24º
● STEMI: (+) chest pain + ST elevation ● WOF: bleeding
○ Complete occlusion ◆ (+) balloon stents
◆ Cardiac Markers: ◆ Antiplatelet d/t risk of clot formation d/t existence of
● CK-MB: ↑ 18º (peak hour, definitive of foreigh body (stent)
myocardial problem) ● Aspirin & Clopidogrel (lifetime)
○ N: 24-36º (decreases) ◆ Minimally invasive = less risk; more expensive
○ Muscle releases creatinine kinase during ➔ Coronary Artery Bypass Graft (CABG)
injury ◆ Open heart surgery (sternotomy) – to create
○ Cardiac specific isoenzyme another passage way w/ graft
● Troponin T: ↑ 10-24º (peak, point or time of ● Indications:
injury) ○ Ø medical management
○ N: 10-14 days (normalizes) ○ affects great vessels, particularly left
○ Troponin-P – definitive; most specific anterior descending artery (LADA) or 3 or
○ Most specific, present longer in blood more occluded vessels (the greater the
○ Protein found in myocardial cells vessel, the higher risk of infraction)
● Myoglobin: ↑ 3-15º ○ Ø PCI
○ N: 24º ○ Diabetes Mellitus
○ Fastest ● Graft Sites:
○ Heme protein that helps transport oxygen ○ Subclavian artery
◆ Electrolytes: PT/PTT, CBC ○ Internal mammary
● Supportive diagnostic measure ◆ Radial artery
● Hyperkalemia d/t injury of cells ◆ Saphenous vein
● PT/PTT – defines type of medical treatment, ● Post-Operative:
particularly pharmacologic intervention ○ CBR
◆ Coronary Angiography ○ Splinting – coughing/DBE
● Visualize! ○ Wound care
○ (+) femoral ➔ Fibrinolytic Therapy
○ Allergies (dye contains iodine) ◆ to dissolve clots
○ WOF: bleeding (pack the site well) ◆ Administered within 30 mins. of admission, if
○ Angiogram: result of the angiography requirements are met
○ Assess renal function before d/t contrast ◆ When PCI is not available
agent being excreted thru kidneys ◆ CI: bleeding disorders
◆ Treadmill Stress Test ◆ NC:
● (+) wear running attire/shoes ● Check pt. status
● While pt. is running, ECG is being assessed ● Check lab values: PT/PTT
● WOF: (+) chest pain → stop → NTG ○ N: 25-35 secs
● Test is terminated when target heart rate is ● ø invasive procedure: may cause bleeding
achieved or if pt. experiences signs of MI ○ Minimize number of skin puncturing
● NPO 3 hrs before ○ ø intramuscular injections
● ø tobacco & caffeine (stimulants) ● Monitor V/S, O2sat
● ø cardiac medications (beta blockers, etc) ➔ Pharmacologic Interventions
➔ Medical Management ◆ Nitrates – ISMN/ISDN
◆ Prompt diagnosis! ◆ Antiplatelets
◆ Complete Assessment! ◆ Anticoagulants – LMW Heparin (Clexane), Warfarin
◆ (+) pain (PQRST) ● WOF: heparin-induced thrombocytopenia (<
● P: exertion 150,000 platelet)
● Q: ↑ pressure/excruciating on chest ◆ Antihypertensive – beta blockers, ACE inhibitors,
● R: neck, shoulder, back CCB
● S: severe (8-10); Varies; possibly moderate pain ● ACE inhibitors cause nagging cough
● T: ø rest ◆ Antidysrhythmics
➔ Emergency Interventions ◆ “Statins” – Atorvastatin
◆ CBR s BRP – provide bedpan/diaper ◆ Stool softeners - Lactulose; ø straining
◆ Moderate HBR – semi to high ➔ Nursing Interventions:
◆ IV Line – PNSS (to increase cardiac circulation); KVO ◆ NPO → LSLF
or increase every 12 hrs ◆ Telemetry/ICU
◆ Strict NPO – d/t risk of blood flow displacement from ◆ V/S, I&O
eating d/t blood flow going to the GI ● ↓ urinary output = ↓ cardiac output
◆ O2 therapy – 2-4 lpm; first action ◆ Pain Assessment – continue
◆ Cardiac monitor/ECG within 10 minutes ◆ CBR → offer commode
◆ V/S c O2sat Q1 ◆ ECG Q8
◆ Pharmacology: ◆ Cardiac rehabilitation – (+) pain → stop immediately
● NTG Q5 mins x 3 doses (15 mins) → nitroglycerin
○ NC:
◆ do NOT expose to air d/t sensitivity to
moisture
◆ do NOT change bottle d/t photosensitivity HEART FAILURE
◆ make sure area is clean & free from hair ➔ Syndrome; from structural or functional cardiac disorders
when applying patch that impair ability of the ventricles to fill or eject blood
◆ wear gloves d/t risk of accidental touch ➔ Often referred to as Congestive Heart Failure (CHF)
◆ WOF: hypotension; hold if ↓ BP ➔ Systolic Dysfunction – impaired contraction of the heart
● Aspirin – prevents further clots from developing ➔ Diastolic Dysfunction – impaired filling of the heart
○ NC: ask pt. to chew aspirin d/t strict NPO ➔ Ø pumping ability of heart & filling
(sublingually absorbed) ➔ Preload – amount of stretching of myocardium; ability to
● Morphine – to treat pain & decrease cardiac stretch is directly related to filling capacity
workload ➔ Afterload – pressure exerted by chambers of heart;
○ via IV contraction; force against which ventricle must expel
◆ MONA – Morphine, Oxygen, Nitroglycerin, Aspirin blood
➔ In HF, there is decrease in preload & afterload. ◆ Emergent
➔ Risk Factors: ● Position: high-fowler’s w/ feet horizontal to the
◆ CAD → MI d/t necrosis of the myocardium bed or dangling to decrease venous return
◆ Hypertension d/t high pressure causing hypertrophy ● O2 therapy – BIPAP, ET to MV
leading to cardiomyopathy ● Monitor Q1 – VS, I&O, ECG, O2Sat
◆ Rheumatic Heart Disease d/t inflamm ● Hemodynamic monitoring – pulmonary
◆ ation catheter to monitor pulmonary artery wedge
◆ Congenital defects pressure (PAWP)
◆ Cardiomyopathy (thickening of myocardium) ● Ultrafiltration (hemoperfusion) – submit pt.
◆ Valvular disorder to hemodialysis to remove excess fluids; for pts.
◆ Hyperthyroidism d/t ↑ T3T4 → ↑ BMR → ↑ oxygen resistant to diuretic therapy
demand → ↑ cardiac contractility → cardiomyopathy ◆ Pharmacologic
◆ Pulmonary Hypertension ● Diuretics – Loop or Thiazide
➔ Risk factors lead to pump failure. ● Vasodilators – IV NTG, nitroprusside (to reduce
➔ Left-Sided Heart Failure: preload)
◆ Manifestations are usually pulmonary in origin. ○ Check BP 5-10 mins d/t risk of hypotension
◆ S/Sx: ● Morphine – to decrease pre & afterload, to
● (+) pink, frothy sputum decrease O2 demand
● DOB; orthopnea ● Inotropes – to increase heart contractility
● Hypoxia ○ Dopamine, dobutamine, norepinephrine
● ↑ HR ○ IV inotropes (emergency)
● Cyanosis d/t ↓ SV ○ Check BP d/t risk of hypertension
● (+) crackles ○ (+) titrated (flow rate relies on pt’s BP)
● Coughing ○
𝑑𝑜𝑠𝑒 × 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑘𝑔 × 60 𝑚𝑖𝑛𝑠
𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛 𝑐𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛
● (+) paroxysmal nocturnal dyspnea (DOB while
sleeping)
● (+) pleural effusion
● S3 (ventricular gallop) d/t abnormal ventricular
filling
● oliguria d/t ↓ CO and ↓ SV → stimulate SNS to
release catecholamines → ↓ blood flow to the
kidneys
➔ Right-Sided Heart Failure:
◆ L-sided HF → R-sided HF
◆ Manifestations are in systemic circulation
◆ S/Sx:
● (+) ascites
● RUQ pain → N&V
● Hepatomegaly
● Jugular vein distension d/t ↑ venous pressure
● Edema → weight gain d/t fluid retention
● Anasarca
● Nocturia d/t ↓ cardiac workload when asleep →
improved renal perfusion
➔ Diagnosis
◆ History & Physical Examination
● Pulse (strong, bounding pulse)
● ↓ tactile fremitus
● Check for jugular vein distention (protruding); > 4
cm
◆ Check serum chemistry, cardiac enzymes
◆ CXR to check for pulmonary congestion
◆ 2D Echocardiography to check for cardiomegaly &
◆ Therapies
confirm diagnosis of HF
● Cardiac Resynchronization Therapy (CRT)
◆ Venous doppler to check for status of leg veins
○ (+) pacemaker
◆ 12-lead ECG
● Intra Aortic Balloon Pump
◆ Cardiac Catheterization to visualize or check for
○ VAD
valvular impairment
○ WOF: infection & vascular problems d/t
◆ B-Type NAT Peptides (usually elevated) – key
foreign body inserted
diagnostic indicator of HF
➔ Nursing Interventions
● N: < 100 pg/mL
◆ Rest-activity periods
➔ Management: treat the cause!
● Limit emotional stress; ↓ anxiety
◆ Diet
● ↓ salt (500-1000 mg)
● Fluid restriction (<1000 ml)
◆ Monitor daily weight
◆ Thirst management
● Wet pt’s lips
● Sips of water
● Ice chips
◆ Cardiac rehabilitation

ELECTROCARDIOGRAPHY
➔ Also electrocardiogram
➔ Graph of electrical impulses and
activity of the heart
➔ (+) waveforms = movement of ions
➔ N: sinoatrial (SA) node →
atrioventricular (AV) node → bundle of
 his → bundle branches → left & right branch → purkinje
fibers
➔ Most common: 12 lead ECG
◆ (6) limb leads/frontal place (positively charged)
◆ (6) horizontal plane
● V1: 4th ICS, R sternal border WAVE CHARACTERISTICS DURATION ABNORMALITY
● V2: 4th ICS, L sternal border FORM
● V3: between V2 & V4 P-wave SA node → AV node 0.06–0.12 ø atria
● V4: 5th ICS, midclavicular (+) atrial depolarization sec
● V5: 5th ICS, L anterior axillary upright
● V6: 5th ICS, L midaxillary PR Atria → Purkinje 0.12–0.20 ø AV–purkinje
➔ ECG PAPER interval P to beginning QRS sec
(+) wave to ventricle
◆ Small box: 0.1 mv, 1 mm = 0.04 secs
◆ Big box: 5 x 5 mm, 0.5 mv, 0.2 secs QRS (+) ventricular < 0.12 sec ø bundle
◆ Actual heart rate of patient = 300 small boxes (1 min) complex depolarization branch/ventricles
or 5 big boxes ST S to beginning T-wave 0.12 sec ø ischemia,
◆ HR segment Between depolarization injury, MI
& repolarization
● # of QRS flat
● 3 sec mark (# of R–R in 6 secs x 10)
T-wave (+) ventricular 0.16 sec Ø electrolyte
● # of small boxes in R–R divided by 1500 repolarization imbalance,
● # of big boxes in R–R divided by 300 upright ischemia,
● 5 big boxes = 1 sec infarction
● 30 big boxes = 6 secs QT QRS to T-wave 0.34–0.43
● (+) compass interval Depolarization + sec
● Distance of R to another R = ventricular HR repolarization
○ N: 40-60 BPM
● Distance of P to another P = atrial HR

➔ ARTIFACTS – distortions d/t…

◆ Muscle tremors
◆ Loose electrodes
○ N: 60-100 BPM ➔ NORMAL SINUS RHYTHM
◆ N: P, QRS, T
➔ WAVE FORMS ◆ Regular rhythm
◆ P-wave: transmission of electrical impulse from SA ◆ Complete waves
→ AV (atrial contraction)
● (+) atrial depolarization
● N: upright, 0.06–0.12 secs
● P-wave abnormality = ø atria
◆ PR interval: transmission of electrical impulse from
atria → purkinje
● denotes P to beginning QRS ➔ DYSRHYTHMIAS – abnormal conduction & rhythm of
● (+) wave to ventricle heart
● ø contraction, only movement ◆ Risk Factors:
● N: 0.12–0.20 secs ● Cardiac conditions (HF, MI, valve disorder,
● PR interval abnormality = ø AV → purkinje cardiomyopathy)
◆ QRS complex: ● Acid-base imbalance, F&E abnormality, drugs
● (+) ventricular depolarization ● Hypoxia, hypermetabolism
● (+) contraction ➔ FIRST PACEMAKER – SINUS
● N: < 0.12 secs ◆ Rate becomes abnormal
● QRS complex abnormality = ø bundle ◆ SINUS BRADYCARDIA
branch/ventricles ● N: P, QRS, T
◆ ST segment: S to beginning of T wave ● Originates in SA node
● Between depolarization & repolarization ● < 60 BPM
● N: flat (isoelectric line), 0.12 secs ● Regular rhythm
● ST segment abnormality = ø ischemia, ● Management:
myocardial infarction or injury ○ anticholinergics (Atropine Sulfate IV);
● ↓ ST segment = ↓ impulse; hypoxia Atropine 1 mg IV push, 3-5 mins, max dose
● ↑ ST segment = (+) hyperexcitation of impulse; of 3 mg
infarction ◆ Atropine is not given in pts. w/ heart
◆ T-wave: transplant d/t denervation of heart
● (+) ventricular repolarization ○ Pacemaker
● N: upright, 0.16 secs ○ Inotropes (Dopamine, Epinephrine)
● T-wave abnormality = ø electrolyte imbalance,
ischemia, or infarction
◆ QT interval: QRS complex up to T-wave
● denotes ventricular depolarization + ventricular
repolarization (entire contraction & relaxation)
● N: 0.34-0.43 secs ◆ SINUS TACHYCARDIA
◆ Isoelectric Line: flat line ● N: P, QRS, T
● Originates in SA node
 ●> 100 BPM ● (+) fibrillatory waves
●Regular rhythm ● Highly irregular
●Management: ● Fluctuating heart rate
○ Pain management d/t pain ● 300–600 BPM
○ Diuretics d/t hypervolemia ● Management:
○ Beta-blockers d/t hypertension ○ Goal: <100 BPM
➔ SECOND PACEMAKER – ATRIA ○ Beta-blockers
◆ no definite P-wave ○ Calcium-channel blockers
◆ > 150 BPM ○ Digoxin to increase contractility
◆ PREMATURE ATRIAL CONTRACTIONS ○ Antidysrhythmics (Amiodarone)
● N: QRS ○ Anticoagulants d/t risk of blood coagulation
● ø P-wave ○ Cardioversion
● (+) ectopic focus – SA node not working well, AV
node becomes first pacemaker instead
● Abnormal pathway
● Abnormal shape P-wave
● Short PR interval
● S/Sx: “skip beat”
➔ THIRD PACEMAKER – AV NODE or HEART
● Management:
JUNCTION (connection between atrium & ventricle)
○ Beta-blockers to relax muscles of
◆ Absent or flat P-wave
myocardium
◆ Narrow QRS
○ Ø caffeine & sympathomimetics (epinephrine,
◆ Failure of atrium to contract completely
inotropes, cholinergics, bronchodilators)
◆ 40–60 BPM
◆ JUNCTIONAL RHYTHM or DYSRHYTHMIA
● Total SA failure
● AV node becomes primary pacemaker
● N: QRS
● Abnormal or inverted P-wave (hidden in QRS)
◆ PAROXYSMAL SUPRAVENTRICULAR ● Management:
TACHYCARDIA (PSVT) ○ Escape (<60 BPM)
● N: QRS ◆ Atropine sulfate
● (+) ectopic focus – Bundle of His becomes first ◆ Beta-blockers
pacemaker ◆ Calcium channel blockers
○ Re-excitation of atria ◆ Cardioversion
● Absent or abnormal P-wave ○ Accelerated (60-100 BPM)
● Short PR ○ Tachycardic (>100 BPM)
● Regular–Irregular
● Ventricles have no resting phase
● 180–220 BPM
● S/Sx:
○ Palpitations
○ ↓ BP
● Management: ◆ AV BLOCKS
○ (+) vagal stimulation ● Also “branch blocks”
◆ Valsalva maneuver – straining, bearing ● Clear manifestation of post-MI d/t presence of
down necrotic tissue blocking electrical impulses in AV
◆ Coughing node/junction
○ Beta-blockers ● 1st Degree –
○ Adenosine via SIVP (approx. 10 secs) ○ Abnormality in transmission between AV
○ Calcium-channel blockers (Amiodarone, node to purkinje fibers
Diltiazem) ○ Prolonged AV conduction
○ Cardioversion ○ N to flat P-wave
○ Prolonged PR interval (> 0.20 secs)
○ No management

◆ ATRIAL FLUTTER
● “saw tooth” ● 2nd Degree –
● N: QRS ○ Type 1: Mobitz 1
● (+) single ectopic focus ◆ Prolonged AV conduction
● (+) flutter waves ◆ N to flat P-wave
● Absent P-wave ◆ Long PR Interval
● Indefinite T-wave ◆ N: QRS (with 1 blocked)
● Risk: necrosis of atrium ◆ Management: Atropine Sulfate
● Management: ○ Type 2: Mobitz 2
○ Eliminate thrombus if d/t blood clots → ◆ Absent P w/o PR lengthening
Warfarin ◆ P > QRS (widened)
○ Beta-blockers ◆ More severe than type 1
○ Calcium-channel blockers ◆ N: PR interval
○ Antidysrhythmic (Amiodarone) ◆ Management: pacemakers
○ Cardioversion ● 3rd Degree – “Complete Heart Block”
○ Radiofrequency catheter ablation (surgically; ○ No impulses
to locate site of abnormality) ○ N to flat P wave
◆ ATRIAL FIBRILLATION ○ Variable PR interval
● N: QRS ○ N to prolonged QRS
● Disorganized electrical activity ○ Management:
● Ineffective atrial contraction ◆ Pacemaker
● Quivering of atrium ◆ Drugs: ↑ HR & BP
● (+) multiple ectopic focus
● Absent P-wave & T-wave (chaotic)
 ➔ LAST PACEMAKER – BoH or VENTRICLES ST segment NORMAL NORMAL
◆ Most dangerous or lethal T-wave NORMAL NORMAL
◆ ø QRS
Other <60 BPM >100 BPM
◆ PREMATURE VENTRICULAR CONTRACTIONS
(PVC)
SECOND PACEMAKER
● Wide or distorted QRS
● Characteristic: PAC PSVT ATRIAL A-FIB
○ (1) Unifocal – identical PVCs FLUTTER
○ (2) Multifocal – different PVCs P-wave ABNORMAL ABSENT/AB ABSENT ABSENT/
● Frequency: NORMAL CHAOTIC
○ (1) Bigeminy – every other PR interval SHORT SHORT
○ (2) Trigeminy – every 3rd QRS NORMAL NORMAL NORMAL NORMAL
○ (3) Couplet – 2 consecutive PVCs complex
● (+) ectopic beat ST segment
● Large T-wave
● Management: T-wave INDEFINITE ABSENT/
CHAOTIC
○ Check hemodynamic status
○ Beta-blockers Other (+) skip beat, re-excitation saw tooth, (+) (+) quivering,
AV node as of atria flutter waves chaotic, (+)
○ Procainamide or Lidocaine IV (stops PVCs) pacemaker fibrillatory
waves,
300-600 BPM

THIRD PACEMAKER
JUNCTIONAL AV BLOCKS, “branch blocks”
RHYTHM
1º 2º 3º
◆ VENTRICULAR TACHYCARDIA MOBITZ 1 MOBITZ 2
● Monomorphic (same QRS) P-wave ABNORMAL/ N to FLAT N to FLAT ABSENT N to FLAT
● Polymorphic (changes or differences in QRS) INVERTED
● Abnormal or hidden P-wave (hidden in
● Distorted QRS; vertical projections (does not QRS)
descend) PR LONG LONG NORMAL VARIABL
● No resting phase (pumps continuously) interval E
● Regular–Irregular QRS NORMAL NORMAL LONG N to
● 150–250 BPM complex with 1 LONG
● (+) high amplitude BLOCK
● Management: ST
○ Procainamide or Lidocaine segment
○ Amiodarone T-wave
○ Check hemodynamic status Other ø mgmt, P>QRS; no “Complete
○ Cardioversion PR interval PR heart
(>20 secs) lengthening block”
compared
to Mobitz 1

LAST PACEMAKER
◆ VENTRICULAR FIBRILLATION PVC V-TACH V-FIB ASYSTOLE
● Derangement, purely fibrillation
● ø P, QRS,T
● Quivering (bigger than atrial quivering d/t bigger P-wave ABNORMAL/ ABNORMAL ABSENT
size of ventricles) HIDDEN
● also, Pulseless V-Tach PR interval DISTORTED
● Distorted QRS & PR interval
QRS complex WIDE/ DISTORTED ABNORMAL ABSENT
● ø rate (chaotic) DISTORTED
● Irregular
ST segment ABNORMAL ABSENT
● (+) low amplitude
● Management: T-wave LARGE ABNORMAL ABSENT
○ CBR Other (+) ectopic vertical (+) quivering, flat, no
○ ACLS beat projections, derangement electrical
high chaotic rate, activity
○ Defibrillation
amplitude, low
150-250 amplitude,
BPM, no also
resting phase Pulseless
V-Tach

◆ ASYSTOLE
● Ø electrical activity
CARDIOVASCULAR MANAGEMENT
● Flat
DEFIBRILLATION
● ø P, QRS, T
➔ Delivery of electrical shock to the heart
● Management:
➔ Purely manual
○ Epinephrine (1 amp. Q3 mins)
➔ Direct current = joules/watts per second
○ BLS/ACLS
➔ (+) momentary asystole (stops & restarts to normal
○ Intubation
rhythm) → (+) depolarization
➔ To provide uniform current
➔ Indications:
◆ Pulseless Ventricular Tachycardia
◆ Ventricular Fibrillation
FIRST PACEMAKER
➔ Pad Placement:
SINUS BRADYCARDIA SINUS TACHYCARDIA ◆ R = 2nd ICS below clavicle (base of the heart)
P-wave NORMAL NORMAL ◆ L = 5th ICS mid-axillary line (apex of the heart)
➔ Types of Delivery:
PR interval
◆ Monophasic – delivered one-way, right to left
QRS complex NORMAL NORMAL ● ↑ current (↑ joules)
 ● N: 360 J PACEMAKERS
◆ Biphasic – right to left, then left to right ➔ To pace the heart to normalize conduction
● (+) reverse flow ➔ Surgically installed
● N: 120-200 J ➔ To detect abnormality & correct automatically
➔ NC:
◆ Educate the patient
◆ Avoid exposure to electricity or anything that conduct
heat or flame
◆ Aseptic technique d/t risk for infection
◆ Monitoring & follow-up

BASIC LIFE SUPPORT

➔ (+) sudden cardiac arrest
➔ (+) asystole
➔ Automated External Defibrillator (AED)
➔ Performed in clinical area or community
◆ Portable
➔ ABC – If (+) emergency, shift to CAB.
◆ (+) detects & analyzes rhythm
➔ CARDIOPULMONARY RESUSCITATION –
◆ (+) voice command process
administration of manual contractions
➔ NC:
◆ Indications:
◆ Analyze ECG
● (+) asystole
◆ Provide electrical safety
● (+) pulselessness
● Do NOT touch patient or bed
● ø ventilation
● Floor must NOT be wet during defib d/t risk of
● Adult/children/infants
transmitting impulses
◆ (1) Check the scene to ensure safety, esp. in
● Remove metal objects
community
● Detach patient from O2 d/t risk of fire
◆ (2) Check the consciousness– ”Hey, hey, are you
◆ (+) pads/gels/paste for paddles
okay?” & tap x 3
● Machine usually has sono gels pre-applied
◆ (3) Activate emergency medical service (EMS), call
● Gels protect skin of client d/t risk for burns
117, and get automated external defibrillator (AED)
◆ Charge as desired
◆ (4) Check pulse & breathing:
◆ Make sure machine is always available &
● Community – carotid pulse
ready-to-use
● Hospital – apical pulse
◆ All CLEAR! → announce SHOCK DELIVERED
● Adult – observe rise & fall of chest
◆ Verify the rhythm
● Child – observe rise & fall of abdomen
◆ (5) If pulseless, immediately start chest
CARDIOVERSION
compression.
➔ Timed & direct shocks
● Site: (+) sternum, between nipples
➔ (+) synchronizer
● Hands: one on top of the other, interlocked
➔ Targets a specific part of the ECG– R-wave (gives
○ Using heel of the hand
automatic shock if abnormality is detected)
● Depth: 1 ½ – 2 inches
➔ Lower electrical impulse compared to defibrillation
● Rate: 100-120 compression/min.
➔ Indications:
● Ratio: 30:2 (30 compressions to 2 rescue
◆ (+) Pulse Ventricular Tachycardia (100 J)
breaths) x 5 cycles
◆ Supraventricular Tachycardia (50-100 J)
● NC:
◆ Atrial Flutter (50-100 J)
○ Allow chest to recoil
◆ Atrial Fibrillation (120-200 J)
○ Ensure cardiac board
➔ NC:
○ Arms straight, parallel to the shoulders
◆ Check if synchronizer is working
○ Rescue breaths/ventilation
◆ Analyze ECG
◆ Open airway
◆ Provide electrical safety
● Head tilt, chin lift
● Do NOT touch patient or bed
● Jaw-thrust maneuver – (+) spinal
● Floor must NOT be wet during defib d/t risk of
cord injury
transmitting impulses
◆ Rate: Q1-2 secs/breath
● Remove metal objects
◆ Modalities:
● Detach patient from O2 d/t risk of fire
● Mouth-to-mouth
◆ (+) pads/gels/paste for paddles
● Bag valve mask (BVM)
● Machine usually has sono gels pre-applied
● (+) intubated + BVM + O2 source
● Gels protect skin of client d/t risk for burns
(100%) Q6
◆ Charge as desired
◆ (+) cycles
◆ Make sure machine is always available &
◆ (6) Check pulse
ready-to-use
● (+) pulse, (+) breathing → recovery position
◆ All CLEAR! → announce SHOCK DELIVERED
(side-lying)
◆ Verify the rhythm
○ (+) AED
◆ Pre-Medications:
○ Wait for EMS
● Sedatives – Diazepam, Midazolam (to limit pain
● (+) pulse, ø breathing → rescue breaths Q1-2
as pt. may still be awake)
secs
● Analgesics – Fentanyl, Demerol, Morphine (to
● ø pulse, ø breathing → resume CPR
reduce pain perception)

GASTROINTESTINAL BLEEDING
➔ Characterized by blood loss
➔ Hemorrhage: > 1,500 ml
➔ Overt/Covert
➔ UGIT BLEEDING
◆ Peptic ulcers
◆ Intake of NSAIDs or aspirin
◆ Esophageal varices
◆ Stress ulcers
◆ Infection
◆ Trauma
➔ LGIT BLEEDING
◆ Duodenal ulcers
◆ Colon cancers
◆ NSAIDs or aspirin
◆ Ruptured diverticulum (outpouching)
◆ Trauma
◆ Inflammatory diseases (Crohn’s)
➔ UGIT/LGIT bleeding → ↓ O2 →
◆ ↑ RAAS
◆ Kidney failure
◆ ↓ BV → shock
➔ S/Sx:
◆ UGIT
● Hematemesis
● Melena, or black, tarry stools d/t RBC rupture
causing release of iron
● Pain
● Heartburn
● Indigestion
● Coffee-ground residue
◆ LGIT
● Melena
● Hematochezia
● Indigestion
● Diarrhea
● Pain
◆ Collective Signs: associated w/ anemia
● Pallor
● Cold, clammy skin
● Dizziness
● Fatigue
● SOB/DOB
● ↓ capillary refill (>3 secs)
● Syncope
➔ Diagnosis:
◆ Endoscopy to visualize UGIT
● Rigid – neck extended
● Fiber-optic – R, side-lying
● (+) sedatives – Opioids, Benzodiazepines
● NC:
○ Safety – do NOT stand after administration
○ NPO 6-8 hrs
◆ Colonoscopy to visualize LGIT
● Position: L side-lying, or sims position
● NC:
○ NPO 6-8 hrs
○ Bowel preparation
○ Phosphosoda – monophasic/biphasic sodium
phosphate (NaPo4)
● Expect ↑ BM = (+) clear!
● WOF: dehydration
● Protect skin integrity – dry appropriately
◆ CBC
● ↓ Hct
● ↓ Hgb
● ↓ RBC
● (+) infection: ↑ WBC
◆ Fecal Occult Blood Test (FOBT), or Guaiac Test –
to check for presence of RBC in stool
● ø iron intake for 3 days
➔ Medical Management:
◆ Pharmacological:
● Proton-pump Inhibitors (PPIs)
● Hemostan – Tranexamic acid
◆ Endoscopic surgery
● (+) epinephrine flush – 1:10,000 solution
◆ Gastrectomy – Billroth 1 & 2
◆ Blood transfusion
➔ Nursing Management:
◆ Check VS for signs of shock (hypotachytachy)
◆ Diet: bland diet (ø gastric irritants – caffeine, citrus,
spicy, sour, dairy)
● ø dark colored food d/t stool darkening
◆ NGT connected to BSB to provide decompression
◆ Gastric lavage
◆ ADLs
● ø fatigue
● Schedule rest-activities