Complete Heart Block
Complete Heart Block
Complete Heart Block
In Partial Fulfilment
of the Requirements
for NCM364L
Curative and Rehabilitative Nursing Care Management 2 – Part A (RLE)
Submitted by
Cantong, Rinolucy
Dela Cruz, Katrina Paola
Dela Peňa, Marco
Fadrigo, Kevin
Haidar, Nahida
Leonardo, Roddy Levin
Lim, Carmina Bianca
Nicolas, Katherine Anne
Sison, Francis
Tan, Joan Rae
Tomines, Guthrie
Villaos, Donna Pia
September 7, 2007
TABLE OF CONTENTS
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I. OVERVIEW OF THE STUDY
Third-degree heart block: Also called complete heart block, each sinus node
impulse is completely interrupted in the A-V node or beyond, and the ventricles must
generate their own impulse to contract. Depending on its cause, third-degree block
may be transient (temporary) or permanent.
II. PROFILE OF THE PATIENT
Patient Profile:
Registration #: 1P087363
Age: 29 years old Sex: Women
Date of Birth: 08-07-1978 Place of Birth: Quezon City
Civil Status: Single Religion: Mormon (LDS)
Ethnicity: Asian
Home Address: #21 Lakandula st. Parang, Marikina City, 1800
Educational Attainment: College undergraduate
Occupation: Government employee
Client Complaint:
Admitting Diagnosis:
Final Diagnosis
Patient History:
Patient is apparently well until 10 years prior to admission when she had her
second pregnancy. She experienced episodes of dizziness and near syncopal
attack. Also, she had a syncopal attack twice when she was still a child. The
first incident was when she was 8 years old and the other was when she was
12 years old. The doctor advised her to consult a cardiologist but she did not
comply. 8 years prior to admission, she had another episode of syncopal
attack. She sought for medical help and it was found out that her heart rate is
slow. According to her 2D-echo was done but the result was unrecalled. She
was given Bricanyl as a maintenance medication. 3 years prior to admission,
the patient had frequent episodes of dizziness, near syncopal attack and easy
fatigability. No consultation was done. She just continued her maintenance
medication. 6 hours prior to admission, patient had continuous episodes of
dizziness, DOB, and near syncopal attack thus she was immediately brought
to PHC-ER.
At the ER, patient is drowsy and confused. BP then was 90/60, cardiac rate
30, clear breath sounds. Atropine was given and BP went up but after 10
minutes patient had another episode of syncope. Thus, emergency TPI was
done. Patient was then admitted to the ward.
The patient has no family background on cancer from her uncle and
hypertension from her mother. She is a heavy alcohol drinker and cigarette
smoker. For the past 10 years, she has used amphetamine occasionally.
Narrative Summary:
Elimination pattern
The client has normal urinary output but abnormal bowel movement (twice a
week). She urinates without discomfort.
Activity/Exercise Pattern
The client has a sufficient energy for completing her desired required
activities. She has the ability to do full self-care She doesn’t have any
musculoskeletal problems.
Value-belief Pattern
The patient is a mormon (LDS) and handles things by talking to God. She
believes in the wonders of herbal medicine. She is not against blood
transfusion. She’s looking forward to go home.
IV. PHYSICAL EXAMINATION
General Information
Client is female,29 years old,currently residing at 21 Lakandula St. Marikina
City. She is presently confined in Female ward at Bed “L”.
General Survey
Client is conscious, coherent and not in distress. Client is oriented to person,
time and place. Client’s body is mesomorph and well-developed. Her looks is
appropriate to her age. She’s is well nourished. She is calm and happy so far.
Skin
Client’s skin is pallor and smooth with good skin turgor. The client’s skin is
warm to touch. Edema or lesions are not present.
Head
Client’s head is normocephalic. Closed fontanelles were noted. Hair is evenly
distributed. Scalp is clean and intact.
Eyes
Client’s eyelids are symmetrical. Conjunctiva is pale. Client’s sclera is
anicteric. Her cornea is smooth and clear. Pupil size is equal (R=3mm; L=
3mm). Client’s visual acuity is normal.
Ears
Client has 2 ear piercings (1 Right and 1 Left). External pinnae are normoset
and symmetrical. External canal is clean. Tympanic membrane is intact.
Gross hearing is symmetrical
Nose
Nasolabial fold is symmetrical. External nose is not tender and there’s no
presence of lesions. There is no discharge or nasal flaring. Air moves freely as
the client breathes through the nares. Mucosa is pinkish with clear, water
discharge. There are no lesions. Nasal septum is intact and in midline. The
maxillary and frontal sinuses are not tender. Client’s gross smell is
symmetrical
Mouth
Client’s outer lips are pale and dry. Client’s gums are pale and with a moist
and firm texture. The tongue is on central position. It moves freely and there
is no presence of tenderness. It is smooth with no palpable nodules. Client’s
speech is intact.
Pharynx
The uvula is positioned in midline of soft palate. Client’s mucosa is pale.
Tonsils are not inflamed.
Neck
Client’s neck is head centered. Lymph nodes are not palpable. Trachea is
placed in midline of the neck.
Heart
Heart sounds are distinct. She has an adynamic precordium, normal rate
regular rhythm, no murmurs.
Abdomen
Client’s abdomen is uniform in color. Abdomen is symmetrical.Umbilicus is
sunken. Bowel sounds are audible.
Genito-urinary System
Not Performed.
Interpretation:
Electrocardiogram
*The ECG in the case of Ms. Margarita Villareal the rhythm of the Atrial and
Ventricular are usually regular. The Atrial rate is 86 beats per minute while
the ventricular rate is 53 beats per minute. The Atrial conduction produced
normal P waves but occur more frequently than the QRS complex. The P-R
intervals are inconsistent to each other. The QRS complex produced are
normal with a 0.10 per seconds. Since there is a complete dissociation
between the SA and the AV node, the ventricular depolarization is slowed
because the ventricles use its intrinsic ability to contract without the aid of
impulse conduction.
Normal ECG:
P wave – represent the normal electrical impulse starting in the sinus node
and spreading through the atria. It is normally 2.5 mm or less in height and
0.11 sec in duration.
PR interval – measures from the start of the P wave to the beginning of the
QRS complex and represent the time needed for sinus node stimulation, atrial
depolarization and conduction through the AV node before ventricular
depolarization. Normal ranges from 0.12 to 0.20 seconds.
ECG Post Temporary Pacemaker as of August 24, 2007
The heart’s electrical system controls all the events that occur when your
heart pumps blood. The electrical system also is called the cardiac
conduction system. The EKG/ECG (electrocardiogram), is a graphical picture
of the electrical activity of the heart.
Each heartbeat has two basic parts: diastole, and atrial and ventricular
systole. During diastole, the atria and ventricles of the heart relax and begin
to fill with blood. At the end of diastole, the heart’s atria contract (atrial
systole), pumping blood into the ventricles, and then begin to relax. The
heart’s ventricles then contract (ventricular systole), pumping blood out of
your heart.
Each beat of the heart is set in motion by an electrical signal from within your
heart muscle. In a normal, healthy heart, each beat begins with a signal from
the SA node. This is why the SA node is sometimes called the heart’s natural
pacemaker. The pulse, or heart rate, is the number of signals the SA node
produces per minute.
The signal is generated as the two vena cava fill your heart’s right atrium
with blood from other parts of the body. The signal spreads across the cells of
the heart’s right and left atria. This signal causes the atria to contract. This
action pushes blood through the open valves from the atria into both
ventricles.
The signal arrives at the AV node near the ventricles, where it slows for an
instant to allow the heart’s right and left ventricles to fill with blood. The
signal is released and moves to the His bundle located in the walls of the
heart’s ventricles.
From the His bundle, the signal fibers divide into left and right bundle
branches through the Purkinje fibers that connect directly to the cells in the
walls of the heart’s left and right ventricles. As the signal spreads across the
cells of the heart’s ventricle walls, both ventricles contract, but not at exactly
the same moment. The left ventricle contracts an instant before the right
ventricle. This pushes blood through the pulmonary valve (for the right
ventricle) to your lungs, and through the aortic valve (for the left ventricle) to
the rest of the body.
As the signal passes, the walls of the ventricles relax and await the next
signal. This process continues over and over as the atria refill with blood and
other electrical signals come from the SA node.
PHYSIOLOGY OF THE ELECTRICAL CONDUCTION SYSTEM
Coronary Arteries supply blood to the
myocardium
Atrial Contraction occurs and stimulus is further sent towards the Atrio-
Ventricular Nodes
Bundle of His
separates into the
Ischemia
Decreased rate at SA
node
Decrease excitability of
Exacerbation AV junction fibers
Deterioration of Progresses to a
cardiac nodal conduction block at the
fibers level of AV
Absence of impulse
conduction
Legend:
•••••• Etiology/Predisposing
factors
•••••• Mechanism
VIII. TREATMENT AND MANAGEMENT
Medical Intervention/s
Intervention Rationale
Administration of Atropine 1mg The administration of Atropine
every 3-5 mins. for 3 doses sulfate is indicated to the patient’s
case to be used as a treatment of
bradycardia (an extremely low heart
rate), asystole and pulseless
electrical activity (PEA) in cardiac
arrest.
Surgical Intervention/s
Intervention Rationale
“E” Temporary Pacemaker Insertion Temporary pacing may be used in
via femoral vein (transvenous) emergency or elective situations
that require limited, short-term
pacing. In this form of pacing, the
pulse generator is external.
PACEMAKERS
The heart has an electrical system that controls how fast or slow it beats. The
natural pacemaker sends electrical impulses from the top of the heart (the
atria), towards the bottom of the heart (the ventricles). When electrical
signals reach these chambers, the heart contracts and then relaxes. The
heart pumps blood to all parts of the body. This pumping makes waves of
pressure that are felt as our pulse.
When the electrical signal is intermittent or slow, you may need an artificial
pacemaker. You may have had one of the following symptoms:
• Dizziness – when the heart rate drops, even for a few seconds, you
may feel dizzy or faint. You may fall down;
• Blackouts or fainting spells;
• Blurred vision;
• Shortness of breath; and
• Chest pain
The heartbeat is usually 50 to 110 beats per minute. However, it may be as
low as 30 to 40 beats per minute if you have a condition called “heart block”.
There are different types of heart block.
Types of Pacing
Modes of Pacing
PACEMAKER THERAPY
Electronic Pacemakers
• Pulse Generator – contains the circuitry and battery that generate the
electrical signal. The battery can last from 6 to 15 years, depending on
the type of pacemaker and how much you use it.
• Leads – the wires that carry the electrical signal from the pulse
generator to the heart. An electrode is located at the end of the lead.
Through this, the pacemaker monitors (senses) the heart’s electrical
activity and sends out electrical impulses (paces) only when needed.
Leads
Pulse
Generator
Procedure
BRAND NAME/
GENERIC MECHANISM OF ADVERSE NURSING
CHEMICAL NAME/ INDICATION CONTRAINDICATION
NAME ACTION EFFECTS CONSIDERATIONS
AVAILABILITY
NUBAIN GN: NALBUPHINE An opiate Management of Patients with a history CNS Effects: Advise patient or
HDROCHLORIDE analgesic with moderate-to- of hypersensitivity to Nervousness, caregiver that
medication will
Dose: 5mg both narcotic severe pain; any ingredients of the depression, usually be prepared
and administered by
IM AVAILABILITY: 10 agonist and preoperative drug restlessness, a health care
mg/mL, 10 mL antagonist and crying, provider in a health
care setting.
multiple dose vials actions. Analgesic postoperative euphoria,
(box of 1) IM, SQ potency is about analgesia; floating,
Caution patient or
equal to that of supplement to hostility, caregiver that
morphine, and balanced unusual medication may be
habit forming and, if
antagonist anesthesia; dreams, used at home, to
potency is about obstetrical confusion, use exactly as
prescribed and not
1/ 25 that of analgesia during faintness, to change the dose
or discontinue
naloxone. May labor and hallucinations, therapy unless
cause sphincter delivery. dysphoria, advised by health
care provider.
of Oddi spasm. feeling of Advise patient or
Does not increase heaviness, caregiver to notify
health care provider
pulmonary artery numbness, if medication does
pressure, tingling, not adequately
control pain.
systemic vascular unreality.
resistance, or Advise patient or
myocardial work Cardiovascular: caregiver that if
medication needs to
load. Hypertension, be discontinued
hypotension, after prolonged use
that it will usually
bradycardia, slowly be withdrawn
tachycardia. unless safety
concerns (eg, rash)
require a more rapid
Gastrointestina withdrawal.
l: Cramps,
dyspepsia, Advise patient or
caregiver to notify
bitter taste. health care provider
if any of the
Respiratory: following occur:
Depression, excessive sedation
or drowsiness; slow
dyspnea, or shallow
asthma. breathing; low BP;
slow heart rate;
severe constipation.
Dermatologic:
Itching, Instruct patient to
burning, get up slowly from
lying or sitting
urticaria. position and to
avoid sudden
position changes to
prevent postural
hypotension.
Advise patient to
report dizziness with
position changes to
health care
provider.
Genitourinary:
Hematu
ria;
proteinu
ria;
dysuria;
renal
failure.
Hematologic:
Decreas
ed
hemato
crit;
bleedin
g;
neutrop
enia;
leukope
nia;
pancyto
penia;
eosinop
hilia;
thrombo
cytopen
ia.
Hepatic: Mild
elevatio
ns in
LFT
results.
Respiratory:
Broncho
spasm;
larynge
al
edema;
rhinitis;
dyspnea
;
pharyng
itis;
hemopt
ysis;
shortne
ss of
breath.
Miscellaneous:
Autoimmune
hemolytic
anemia may
occur if used
long term.
DIAZEPAM GN: Diazepam The skeletal Management of Hypersensitivity to Somnolence, Document
Intensol effect of anxiety benzodiazepines; Suppression of indications for
Dose: 10 diazepam may be disorders; relief psychoses; acute REM sleep or therapy and time for
mg IV AVAILABILITY: due to of acute alcohol narrow-angle dreaming, anticipated results.
Injection: 5 enhancement of withdrawal glaucoma; use in Addiction,
mg/ml, GABA-mediated symptoms; relief children younger than Impaired motor Determine any
Oral Solution: 1 presynaptic of preoperative 6 mo of age; lactation. function, depression or drug
mg/ml inhibition at the apprehension Depression, abuse. Avoid
Tablet: 2 mg, 5 spinal level as and anxiety and Anterograde simultaneous use of
mg, 10 mg well as in the reduction of amnesia CNS depressants.
brain stem memory recall; (especially
reticular treatment of pronounced in Reduce Drug
formation. muscle spasms, higher doses), gradually to avoid
convulsive Reflex withdrawal
disorders (used tachycardia symptoms such ad
adjunctively), anxiety, tremors,
and status anorexia, insomnia,
epilepticus. weakness,
headache and N&V.
Smoking may
increase drug
metabolism; thus
requiring higher
dose than the
nonsmoker. Do not
stop drug abruptly.
Hematologic:
Eosinop
hilia;
neutrop
enia;
lymphoc
ytosis;
leukocyt
osis;
thrombo
cytopen
ia;
decreas
ed
platelet
function
;
anemia;
aplastic
anemia;
hemorr
hage.
Hepatic:
Hepatic
dysfunc
tion;
abnorm
al LFT
results.
Miscellaneous:
Hyperse
nsitivity,
,
erythem
a
multifor
me,
toxic
epiderm
al
necrolys
is;
candidal
overgro
wth;
serum
sickness
–like
reaction
s (eg,
skin
rashes,
polyarth
ritis,
arthralgi
a,
fever);
phlebitis
,
thrombo
phlebitis
, and
pain at
injection
site.
X. NURSING CARE PLAN
MEDICATIONS
Mefenamic Acid
• One (1) tablet 500mg to be taken orally/by mouth
• May return to doing normal activities within six (6) weeks after
the surgery.
• Any exercise is fine after 4-5 weeks
• No heavy lifting (usually five pounds[5lbs.] or more) or strenuous
arm exercise for about 2 to 3 weeks.
• May still be able to drive or at least travel unless the physician
has instructed you not to do so.
• May still go to work unless the physician has instructed you
not to do so.
• May still do almost all the household activities.
• May still participate in sports and other recreational activities
except contact sports that may increase the chance of
receiving a blow on the chest or the pacemaker device.
TREATMENT
A. Wound Care
• Proper hand washing should be carried and observe
cleanliness at all times.
• Observe wound daily, instruct patient to report any signs of
inflammation to your doctor.
• Clean the wound daily using prescribed antiseptic solution
(Betadine).
• Avoid wearing constrictive clothing like tight bra straps which
puts excessive pressure in the wound and the pulse
generator.
• Advise the patient to avoid getting the incision wet until the
sutures have been removed (1 week). If on a shower, cover
the incision with plastic wrap.
• If the patient sees a suture sticking out of his/her incision,
have the doctor remove it.
B. Pacemaker Management
• Regularly ensure that the pacemaker is properly placed by:
i. Taking the pulse daily either radial or carotid. The
pulse can be found on the side of the lower neck, on
the inside of the elbow, or at the wrist.); notify the
doctor if pulse is slower than the set rate. Also, report
for excessive palpations, vertigo or fainting.
• Using the first and second fingertips, press firmly but gently
on the arteries until you feel a pulse.
• Begin counting the pulse when the clock's second hand is on
the 12
• Count your pulse for 60 seconds (or for 15 seconds and then
multiply by four to calculate beats per minute).
• When counting, do not watch the clock continuously, but
concentrate on the beats of the pulse.
• If unsure about your results, ask another person to count for
you.
ii. Check your "pacing lead" (the lead which sends
information from the heart to the pacemaker) with an
electrocardiogram (ECG) at your physician's office. In
addition, you may participate in a telephonic check up
for your pacemaker on a periodic basis. Your physician
will provide special instructions.
iii. The table below lists various electrical and magnetic
sources that are safe and sources that you should
avoid.
• Dental procedures
iv. Ensure the patient to carry a pacemaker identity card
at all times because equipment used by doctors and
dentists can affect the pacemaker.
v. Airport security systems will not affect the pacemaker,
but the pacemaker may set off the alarm. Inform the
patient to tell the guard regarding the use of a
pacemaker.
HYGIENE
• Before leaving the hospital, the patient will usually have a full
evaluation, including a chest X-ray, electrocardiography (EKG, ECG),
and a pacemaker check. One week to 10 days after discharge, the
incision will be checked.
• In 6 to 8 weeks after placement of the pacemaker, a full evaluation,
including an EKG, and a pacemaker will be checked.
• About every 1 to 3 months, the patient will be asked to have the
pacemaker checked over the phone.
• In 3 to 6 months after placement, the patient should either visit the
doctor or clinic in person or have the pacemaker checked over the
phone. Information can be sent directly over the phone to a
computer on the other end of the line. This computer prints the
information, and it can be reviewed by your doctor.
• Once or twice per year, the patient will be asked to visit his/her
doctor to have a full evaluation of the pacemaker.
• If the battery life is low, the battery will need to be replaced his
involves a surgical procedure similar to the initial implantation,
except that the battery change is often a more simple procedure
since the leads are already in place.
DIET (Nutrition)
BACKGROUND
The use of methamphetamine is widespread and, in many countries,
is a major drug of abuse. As such, it is important to identify and
understand the adverse health effects associated with
methamphetamine use and consider the risk of such consequences
for users. Although methamphetamine has effects on multiple organ
systems, this report will focus on the cardiovascular effects of
methamphetamine. Specifically, the aim of this report is to review
the evidence for methamphetamine-related cardiovascular
pathology and discuss the implications for methamphetamine users.
Methamphetamine cardiotoxicity
Methamphetamine increases catecholamine activity in the branch of
the peripheral nervous system responsible for modulating heart rate
and blood pressure. Excessive catecholamine activity is thought to
be the primary mechanism underlying the cardiotoxic effects of
methamphetamine. High catecholamine levels are known to be
cardiotoxic, causing narrowing and spasm of the blood vessels,
rapid heart rate (tachycardia), high blood pressure (hypertension),
and possible death of the heart muscle. Other features of
catecholamine toxicity include the formation of fibrous tissue and an
increase in the size of heart muscle cells.