Medical-surgical Nursing Demystified

(Michael S) #1

CHAPTER 1 Cardiovascular System^55



  • Install a pacemaker.

  • If atrial fibrillation is the ongoing rhythm, warfarin therapy will be initiated
    to reduce the risk of emboli.


NURSING DIAGNOSES



  • Impaired gas exchange

  • Decreased cardiac output

  • Ineffective tissue perfusion


NURSING INTERVENTION



  • Monitor for signs of decreased blood flow to tissues or organs (hypoperfusion)
    because decreased cardiac output, as indicated by these symptoms, can occur
    as a result of atrial fibrillation:

    • Decreased pulse pressure.

    • Cool extremities.

    • Altered mental state.

    • Rapid resting heart rate.

    • Alternating breathing between deep and shallow.

    • Increased BUN.



  • Prepare for synchronized cardioversion, if patient is unstable.

  • Assess for life-threatening arrhythmias.

  • Assess for signs of drug toxicity and withhold if the patient is toxic—i.e.,
    seizures, respiratory arrest, arrhythmias.

  • Limit patient’s activities to reduce cardiac workload.

  • Explain to the patient:

    • The need for warfarin therapy, as well as monitoring of INR, diet modifi-
      cations, use of NSAIDs, and aspirin.

    • The importance of regular examinations to ascertain for any changes in
      rhythm.

    • Call the physician if the patient feels light-headed or dizzy, as this can be
      a symptom of a change in rhythm.

    • Avoid ethanol, caffeine, nicotine as they can trigger an arrhythmia.



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