Patients with atrial fibrillation are at increased risk of heart failure Quizlet

Severe dyspnea and blood-streaked, frothy sputum

(Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased.)

old age, hypertension, ischemic stroke, TIA, thromboembolic events, coronary heart disease, diabetes mellitus, heart failure, obesity, hyperthyroidism, chronic kidney disease, excess alcohol use, mitral valve disease

· ___________________ is characterized by a disorganized, very rapid (atrial impulses at a rate of 350 to 600 times/min), and irregular atrial rhythm, resulting in an irregular ventricular rhythm (ventricular response is 120-200 beats per minute)
§ The result is a chaotic rhythm with no clear P waves, no atrial contractions, loss of atrial kick, and irregular ventricular response (QRS rhythm). (irregularly irregular).
§ The atrial merely quivery in fibrillation. The ventricles often beat with a rapid, irregular rate (decreases filling and reduces cardiac output -> allows blood to pool -> increased risk for clotting, DVT, PE)
· Atrial fibrillation (AF) causes a lot of SA node pacemaker dominance, decreased cardiac output, and increased myocardial oxygen consumption
· Individuals with AF are at high risk for a cerebrovascular accident (CVA) and/or pulmonary emboli (BECAUSE OF INEFFECTIVE BLOOD FLOW = BLOOD STASIS)
· Significant ECG features of AF include ________________________
· Research shows a number of genetic associations for AF.

New Onset Atrial Fibrillation Causes:
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Other Etiologies of Atrial Fibrillation
· Cardiac Causes:
§ Hypertensive heart disease
§ Hypertension
§ Coronary Artery Disease
§ Valvular heart disease, LA stretch
§ Ischemic heart disease, MI
§ Cardiomyopathy, heart failure
§ Pericarditis
§ Congenital heart disease, genetic mutations
§ Post cardiac surgery
· Non-Cardiac Causes
§ Pulmonary: Pneumonia, COPD, PE
§ Hyperthyroidism
§ Excess catecholamine/sympathetic activity
§ Drugs and alcohol
§ Digitalis toxicity
§ Significant electrolyte imbalance
· What is reversible? Alcoholism (difficult long term due to addiction), Digoxin toxicity, Anemia, Sepsis, Pericarditis/Endocarditis, sleep apnea (CPAP), HTN (beta blockers, CCB), hyperthyroidism (thyroid surgeries)

Management of Acute Atrial Fibrillation (less than 48 hours)
· For Hemodynamically unstable patients with Atrial Fibrillation
§ Hypotension
§ Heart failure
§ Chest pain
§ Syncope
§ Patient shoes up to ED, in Supraventricular tachycardia (SVT), LOC changes, BP changes, tachycardia, hypotensive, chest pain, shortness of breath, anxiety = UNSTABLE (not perfusing the brain)
§ Treatment: Cardioversion!!!!!!!
· Digoxin to prevent reoccurrence
· Anticoagulants to prevent clotting
· For Hemodynamically stable patients with Atrial Fibrillation:
§ Rate Control (significant tachycardia)
§ Rhythm control: Flecainide, Propafenone (class IC antiarrhythmic); Amiodarone, Sotalol (class-III antiarrhythmic) Digoxin; beta-blockers (propranolol); calcium channel blockers (verapamil, diltiazem) work the fastest and are the drug of choice when patient is medically unstable.
· Why do we take a calcium channel blocker? these drugs slow conduction and DECREASE IRRITABILITY of SA node (prevents it from over-firing)
§ ALWAYS Anticoagulant (we don't want them to develop a clot in the atrium!): LMWH
§ BEST: DIGOXIN and BETA BLOCKERS! They decrease HR, but increase cardiac contractility!!!!! Thus, they improve CO!
· REGARDLESS OF HEMODYNAMICALLY STABLE OR UNSTABLE,________________________
· Class I antiarrhythmics are also known as sodium channel blockers
· Class III antiarrhythmics

Anticoagulants
· Heparin, (usually on LMWH (enoxaparin) until INR gets to 2-3 with warfarin!)::
§ Side effects:
· Toxicity
· Hemorrhage secondary to toxicity
· Epidural or spinal hematoma
· Heparin induced thrombocytopenia (HIT): low platelets, increased thrombi
§ Caution: low platelet counts, uncontrollable bleeding, after brain/eye/spinal surgeries, PUD, hypertension
§ Interactions: aspirin, NSAIDs, saw palmetto, garlic, ginger, gingko biloba
§ Nursing Actions
· Monitor H/H, and aPTT (q4-6h) and keep it at 1.5-2 times the baseline
· If started on heparin, but needing to take warfarin, understand that it takes a few days for warfarin levels to reach a steady state. Older persons are usually maintained on heparin until that occurs.
· For toxicity, __________________
· Monitor vitals and observe for increased HR, decreased BP, bruising, petechiae, hematomas, black stools
· Monitor platelet count, stop treatment if less than 100,000
· Monitor rate of infusion every 30-60 minutes
· Use a soft toothbrush and electric razor

Anticoagulants
Warfarin:
§ Side Effects:
· Bleeding
· Hepatitis
· Toxicity
§ Contraindications: active bleeding, peptic ulcer disease, CVA, recent trauma, pregnancy (catX), recent surgery, alcohol use disorder, severe HTN, thrombocytopenia
§ Interactions: heparin, aspirin, acetaminophen, glucocorticoids, phenobarbital, carbamazepine, phenytoin, oral contraceptives, vitamin K, saw palmetto, garglic, ginger, ginkgo biloba
§ Nursing Actions
!!!! Patients need ________________________________________
!!!! The Bridge from heparin to warfarin is important to prevent clots in between treatment!!!!
· Antidote: vitamin K
· Avoid foods high in vitamin K and herbs (ginger, ginseng, garlic, gingko biloba, St. John's wort)
· Teach older adults that vitamin K is the antidote to warfarin, so they need to maintain a stable intake or limit intake of foods containing vitamin K
· DO NOT take aspirin, NSAIDs
· Report any change in diet or medications when having INR tested
· Monitor for bleeding: bruising, black stools, petechiae, high HR, low BP
Monitor LFT and assess for jaundice

Older Adults and Atrial Fibrillation
· Atrial fibrillation is characterized by rapid and disorganize atrial activity. ECG show NO P WAVE. Incidence increases with age. Common causes include stretching of atria, ischemic heart disease, or hyperthyroidism
§ The random impulses to the AV node cause irregular heart rate. When it first begins, the ventricular response can be as high as 160 beats per minute (Afib with long-duration can show HR in normal range)
§ There is a loss of cardiac output due to fast HR and short ventricular filling times
· When assessing older adults for Atrial Fibrillation, count beats for a full minute to avoid over-underestimated true pulse rate
· Complications: embolic cerebrovascular accident (result of atria failing to empty, clots form in blood that stagnates in atria, then they break off, and flow to any part of the body)
§ !!! Older adults are at risk for ejecting clots from the heart when they are converting from atrial fibrillation to regular sinus rhythm
§ Warfarin therapy and INR of about 3 are needed to prevent stroke or thrombus ejection
· Goals of Treatment: correct hemodynamic instability, control ventricular rate, restore sinus rhythm if possible.
§ Ventricular response can be controlled with beta-blockers, calcium channel blockers, and digoxin
§ Monitor for _________________________________. If it occurs, older adults will need a pacemaker. Nurses monitor functioning by checking pulse rates and looking for pacemaker activity on the ECG.

Etiology of _________________________
· Coronary artery disease
· Drugs: cardiac glycoside(digoxin TOXICITY!), antihypertensive agents, calcium channel blockers, beta-blockers, and antiarrhythmics
· Myocardial infarction (large, extensive heart attacks that cause significant damage)
· Inflammatory or degenerative processes like amyloidosis, sarcoidosis, Chagas disease, and cardiomyopathies
· Frequently intermittent and unpredictable, may occur in the absence of heart disease
· SSS is relatively uncommon.

Physical Assessment of _________________________
· Pulse : bradycardia that alternates with tachycardia, referred to as brady-tachy syndrome
· BP: may decrease due to decreased cardiac output
· If cardiac output is decreased, the following clinical manifestations may occur:
§ Fatigue, generalized weakness, dizziness or lightheadedness, shortness of breath syncope or near syncope, chest pains, insomnia, confusion, palpitations, and altered LOC (HEART FAILURE SYMPTOMS)

· Electrocardiogram (ECG) provides a graphic representation of cardiac electrical activity that provides information about cardiac dysrhythmias, myocardial ischemia, the site and extent of MI, cardiac hypertrophy, electrolyte imbalances, and the effectiveness of cardiac drugs.
§ Electrodes are placed on specific sites of the body and attached to an ECG machine
§ A lead provides one view of the heart's electrical activity
· A standard 12-lead ECG consists of 12 leads (views) of the heart's electrical activity. 6 leads are placed on the limbs, and 6 leads are placed on the chest.
· 18-lead ECG consists of 6 leads placed on the horizontal plane on the right side of the chest (views right side of heart). The extra leads are sometimes placed on the back
· Continuous ECG Monitoring: with this ECG, electrodes are not placed on the limbs because motion alters readings. It requires the client to be in close proximity to the monitoring system. Electrodes are placed:
§ Right arm electrode just below the right clavicle
§ Left arm electrode just below the left clavicle
§ Right leg electrode on the lowest palpable rib, right clavicular line
§ Left leg electrode on the lowest palpable rib, left midclavicular line
§ Fifth electrode is placed to obtain one of six chest leads
§ To ensure best signal transmission, ____________________________________
· Telemetry allows the client to ambulate while maintaining proximity to the monitoring system
· Instruct clients that monitoring will not detect shortness of breath, chest pain, or other symptoms of acute coronary syndrome and they need to report these symptoms.

· Electrocardiogram (ECG) provides a graphic representation of cardiac electrical activity that provides information about cardiac dysrhythmias, myocardial ischemia, the site and extent of MI, cardiac hypertrophy, electrolyte imbalances, and the effectiveness of cardiac drugs.
· Preprocedure: position the client supine with the chest exposed, and wash the skin. CLIP the hair on the chest (do not shave), attach one electrode to each of the client's extremities and attach 6 to the chest
· Intraprocedure: monitor for chest pain and dysrhythmias, decreased LOC, dyspnea, hypoxia; instruct the client to _________________________________
· Post-procedure: remove leads from the client, print the ECG report, and notify the provider. Apply a Holter monitor if the client is on telemetry. Continue to monitor for dysrhythmias

Class IA Medications: slows impulse conductions in atria, ventricles, to treat SVT, atrial flutter, and atrial fibrillation
· Procainamide, others: Quinidine, Disopyramide
· Side effects:
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· Caution: AV block, ventricular tachycardia, SLE, liver/kidney problems, HF
· Interactions: antidysrhythmics, beta blockers, cimetidine, ranitidine, antihypertensives
· Nursing Actions:
§ Lupus syndrome resolves with discontinuation. Control with NSAIDs. Monitor ANA
§ Monitor CBC for 12 weeks, then periodically
§ Monitor for infection and bleeding
§ Monitor therapeutic level: 4-10mcg/mL
§ Monitor ECG and vitals

Class IB Medications: decreases conduction, automaticity for short-term treatment of ventricular dysrhythmias
· Lidocaine, Mexiletine, Phenytoin
· Side Effects:
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· Caution: Stokes-Adams syndrome, heart block, kidney problems, sinus brady, HF
· Interactions: beta blockers, cimetidine, phenytoin
· Nursing Actions:
§ Monitor for CNS symptoms.
§ Monitor ECG and vitals. Ensure resuscitation equipment at bedside
§ IV admin at 1-4 mg/min for maintenance dose
§ Used for no more than 24 hours
§ Never administer lidocaine that contains epinephrine because hypertension and dysrhythmias can occur
§ Monitor BP, cardiac rhythm, and CNS effects

Class IC Medications: decreases conduction velocity in atria, ventricles to treat SVT
· _________________
· Side Effects:
§ Bradycardia, heart failure, dizziness, weakness, hypotension, bronchospasm
· Caution: AV block, HF, hypotension, liver/kidney problems, asthma
· Interactions: digoxin, oral anticoagulants, propranolol, amiodarone, grapefruit
· Nursing Actions
§ Monitor HR, BP, ECG; monitor for chest pain, dyspnea, crackles, weight gain, edema
§ Monitor for bradycardia, hypotension, drowsiness, weakness, dizziness
§ Take with food

Class II Medications: decreases HR, automaticity, and contractility to treat atrial fibrillation, atrial flutter, SVT, HTN, angina, PVCs, ventricular tachycardia
· Propranolol, esmolol, acebutolol
· Side effects: hypotension, bradycardia, heart failure, AV block, sinus arrest, fatigue, bronchospasm (with asthma)
· Caution: AV block, diabetes, HF, bradycardia, liver/thyroid/respiratory dysfunction
· Interactions: __________________________
· Nursing actions:
§ Monitor HR, BP; monitor for chest pain, dyspnea, crackles, weight gain, edema
§ Monitor for bronchospasm
§ Notify provider of pulse below 50
§ Give IV no faster than 1mg/min

Class III Medications: used for conversion of atrial fibrillation, ventricular fibrillation, ventricular tachycardia
· Amiodarone, sotalol, ibutilide
· Side Effects:
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· Caution: pregnancy, infants, newborns, AV block, liver/thyroid/respiratory dysfunction, HF
· Interactions: quinidine, procainamide, digoxin, diltiazem, warfarin, cholestyramine, St. John's wort, rifampin, diuretics, antidysrhythmics, antibiotics, beta blockers, verapamil, grapefruit
· Nursing actions:
§ Obtain chest x-ray and PFT and monitor during therapy
§ Monitor BP and ECG, eye exams, chest x-ray, potassium, thyroid/liver/respiratory function
§ Monitor for indications of HF (dyspnea, cough, weight gain)
§ Obtain LFT and thyroid function tests
§ Wear sunscreen and avoid sun lamps
§ Use central venous catheter for IV admin
§ This drug is highly toxic, so monitor closely for adverse effects (lung injury, visual impairment)

Class IV Medications: decreases HR and force of contraction to treat atrial fibrillation and flutter, SVT, HTN, and angina
· Verapamil, diltiazem
· Side Effects:
§ Bradycardia, hypotension, heart failure, AV block, constipation, peripheral edema
· Caution: AV block, atrial fibrillation/flutter, HF, hypotension, beta blockers, liver/kidney problems
· Interactions: atenolol, esmolol, propranolol, carbamazepine, digoxin, beta blockers, grapefruit
· Nursing actions:
§ monitor ECG and BP. Treat hypotension with IV fluids, Trendelenburg, IV _______________
§ Monitor for HF
§ Notify provider of pulse below 50
§ Change positions slowly and avoid hazardous activities

A nurse is reviewing the medical record of a client who is to undergo a scheduled electrical cardioversion. For which of the following findings should the nurse report to the provider?
MAR: Ferrous sulfate, Diazepam, Isosorbide; Vitals: T 99, BP 142/86, HR 88 irregular, RR 20; history: bariatric surgery 10 years ago, dyspnea with exertion for 3 years, atrial fibrillation started 3 years ago. Client reports taking iron supplement, multivitamin, antilipemic, and nitroglycerin in the past 6 weeks.
A. Respiratory history
B. Vital signs
C. Medication history
D. Medications to be administered