care of patient with conduction problems

2. NURSING CARE OF PATIENTS
WITH CONDUCTION DISORDERS
PRINCY FRANCIS M
II year MSc(N)
JMCON

3. DYSRHYTHMIA
Dysrhythmia are disorders of the formation or conduction (or both ) of
the electrical impulse within the heart.

4. CONDUCTION SYSTEM

5. NORMAL ECG

7. CONDUCTION ABNORMALITIES
• FIRST DEGREE HEART BLOCK
• SECOND DEGREE HEART BLOCK
• THIRD DEGREE HEART BLOCK

8. FIRST DEGREE HEART BLOCK
It occurs when all the atrial impulses are conducted through AV node
into the ventricles at a rate slower than normal.
PR interval is lengthened beyond 0.20 seconds.

9. RATE RHYTHM P wave PR interval QRS
Normal Regular In front of each QRS > 0.2 sec ,
constant
<0.12 sec
P:QRS = 1:1

10. • Causes : Acute MI, Myocarditis, electrolyte imbalance
, drugs.
• Treatment : None

11. Second degree heart block
It fails to conduct atrial impulse to ventricle resulting in intermittently
dropped QRS complexes.
Mobitz Type I wenkeback phenomeneon
Type II second degree AV block / Mobitz type 2

12. Mobitz TYPE I heart block
• Prolonged AV conduction time until an atrial impulse is nonconducted
and a QRS is missing.
• Commonly occurs in the AV node
• Gradual lengthening of the PR Interval.

13. • pp
RATE RHYTHM P wave PR interval QRS
Normal,
can be
slow
Irregular Present but some
not followed by
QRS
Progressively
longer
<0.12 sec

14. treatment
Symptomatic,
Administer atropine
Temporary pacing

15. Mobitz type 2 heart block
• Sudden failure of an atrial impulse to the ventricles without
progressive increases in conduction time of consecutive P waves.
• Occurs below the AV node

16. • Conduction through the AV node is constant.
• PR interval is normal and constant.
• Occasionally a dropped beat is seen

17. • Pp
P: QRS = 2:1, 3:1, 4:1
RATE RHYTHM P wave PR interval QRS
Usually
slow
Regular/
irregular
2, 3, 4 before each
QRS, identical
0.12 – 0.2
sec ,
constant
<0.12 sec

18. Treatment
• Temporary pacemaker
• Permanent pacemaker

19. Third degree AV block / Complete Heart block
• No impulses from the atria are conducted to the ventricle
• Atrioventricular dissociation

20. • Ppp
RATE RHYTHM P wave PR interval QRS
30 – 60 Regular Normal but
dissociated with QRS
complex
Varies <0.12 sec

21. treatment
Symptomatic,
Emergency temporary transvenous pacemaker
Drugs: atropine, epinephrine and dopamine
Permanent pacemaker.

23. ASSESSMENT
• Signs and symptoms of heart block such as syncope, lightheadedness,
dizziness, fatigue, chest discomfort and palpitation.
• Any coexisting condition that could be a possible cause of the
dysrhythmia (Heart disease - MI, COPD).
• Medication and over the counter drugs

24. ASSESSMENT cont…
• Level of consciousness
• Skin colour, temperature
• Signs of fluid retention such as neck vein distention and crackle,
wheeze in lung.
• Rate and rhythm of pulses

25. Interventions
1. Monitoring and managing heart block
• Continuously monitor the patient.
• Obtain 12 lead ECG
• Regularly evaluate the patient’s blood pressure, pulse rate and rhythm, rate
and depth of respiration and breath sounds.
• Frequently assess the episodes of lightheadedness, dizziness or fainting
• Administer medications

26. 2. Minimizing anxiety
• Fosters a trusting relationship with the patient
• Maintain calm and reassuring attitude

27. 3. Caring of patient with pacemaker
• Check the proper functioning of pacemaker
• Avoid close/ prolonged contact with electrical devices and devices that
have strong magnetic field
• Certain procedures may disrupt pacemaker like MRI, electrocauterization
during surgery.

28. • Status of the pacemaker should be regularly checked to provide
information regarding the rhythm, functioning of pacemaker leads,
frequency of utilization of pacemaker, battery life and presence of
abnormal rhythm.

29. Caring of patient with a temporary
pacemaker
• Assess the patient’s tolerance of the heart rhythm
• Monitor ECG continuously
• Assess patient’s mental status, BP, HR, heart sounds, lung sounds, skin
colour and urinary output
• Check the system for proper functioning. Secure all connection.

30. Pacing rhythm
• Atrial pacing
• Ventricular pacing

31. • Maintain electrical safety – verify that wires are connected and secured to
the correct connector ports
• Prevent liquids from coming in contact with generator cables or insertion
site.
• Monitor for complications at insertion site- assess the site daily and change
dressing every 48hrs.
• Assess the patient safety and comfort.
• Restrict the movement of insertion site of the extremity.

32. Initiating temporary pacing
Transvenous
1. Connect the negative terminal of the Pulse generator to the distal end of
pacing lead
2. Connect the positive terminal to proximal end of pacing lead
3. Set the rate at 70 - 80 beats/mt or as per physician order.
4. Set the output at 5mA
5. Set the sensitivity at 2mV

33. Epicardial pacing
Unipolar atrial or ventricular pacing
1. Connect the negative terminal of the PG to the lead on the chamber to
be paced.
2. Connect the positive terminal to ground lead.
3. Set the rate at 70 - 80 beats/mt or as per physician order.
4. Set the output at 5mA for ventricular pacing and 10 mA for atrial pacing
5. Set the sensitivity at 2mV
In bipolar atrial or ventricular pacing negative terminal is connected to 1
lead and positive terminal to another lead to chambers to be paced.

34. Caring of a patient with permanent pacemaker
Pre operative nursing care
• Assess baseline vital signs, peripheral pulses and heart and lung sounds.
• Get 12 lead ECG, chest Xray, blood test.
• NPO 8hrs before procedure
• IV access for fluids, sedation and emergency medication
• Skin preparation
• Remove all ornaments, garments and sterile dress should be weared
• Remove dentures, contact glasses.

35. During procedure
• Keep cardiac monitor on at all times during procedure
• Scrub the access site where generator will be implanted
• Maintain sterile field
• Keep emergency medication ready- adrenaline, xylocard, Hydrocortisone,
NTG, Dopamine, Dobutamine, Noradrenaline, Cordarone.

37. Pacing codes
1. VVI :
Electrode is in the ventricle and paces the ventricle, senses ventricular
activity and inhibits its output when it senses intrinsic ventricular
depolarization.
2. DDD:
Both atrial and ventricular electrodes are present and both are paced,
both chambers are sensed and the device either inhibit or trigger an
output in response to sensed intrinsic activity.

38. Post operative nursing care
• Monitor for complications of insertion such as pneumothorax,
hemothorax , perforation from pacemaker lead, cardiac tamponade.
- Shortness of breath, low BP, chest pain or a rapid HR.
• Monitor for lead dislodgement
– ECG changes, Hiccups

39. • Assess insertion site for bleeding and infection
• Maintain bedrest for 12 hrs.
• Monitor ECG
- Loss of sensing
- Loss of capture
- Failure to pace

40. Sensing
• Undersensing results in a device that doesn’t know when to turn off. It
fails to detect spontaneous myocardial depolarisation
• Oversensing occurs when the device interprets non-cardiac sources of
energy as being cardiac. This results in the device not turning on when it
should.

41. Loss of sensing
• F

42. Loss of capture
• A pacemaker loses its ability to cause depolarization (capture)
• The generator is unable to deliver a sufficient amount of energy to
cause depolarization

43. Failure to pace
• Gg

44. • Restrict movement of the affected arm for 12 – 24hrs.
• After 24hrs, assist with gentle limited ROM exercises 3 times daily, to
restore normal movement and prevent stiffness.
• Don’t give aspirin or heparin for 48hrs.

45. INSTRUCTIONS
• Minimize arm or shoulder activity of affected arm and wear loose
covering over incision for 1- 2 weeks
• Avoid contact sports and heavy lifting for 2 months after surgery
• Carry pacemaker information card.

46. Can use defibrillation on pacemaker
patient?
• It can be safely cardioverted or defibrillated with precautions to protect the
pacemaker from high energy electrical forces.
• Paddles not to be placed over directly over the pulse generator
• Use of low energy shock is preferred.
• The pacemaker should be interrogated after cardioversion/ Defibrillator to
make sure that it is still programmed and function as it is intended.

47. 1. Identify the type of pacing rhythm
• Atrial pacing rhythm

48. 2. Identify the type of pacing rhythm
• Atrioventricular pacing rhythm

49. REFERENCES
• Woods LS, Froelicher SSE, Motzer US, Bridges EJ. Cardiac Nursing. 6th
edition. Baltimore: Wolters Kluwer Publication; 2010
• Smeltzer CS, Bare GB, Hinkle LJ, Cheever HK. Brunner & Suddarth’s
textbook of Medical-surgical nursing. Volume I. Twelvth edition.
NewDelhi:Wolters Kluwer (India) ; 2011.
• Lewis LS, Dirksen RS, Heitkemper MM, Bucher L. Lewis’s Medical
Surgical Nursing Assessment and management of clinical problems.
Second edition. Volume 1.India: Reed Elsevier; 2015.