Question

I. Read Chapters 34 and 35 from your Text Book and PP

II. NCLEX Review Question Chapters 34 and 35 from Evolve Resources

III. Case Study: Atrial Fibrillation

Patient Profile

E.W., a 76-year-old white man, comes to the emergency department after a syncopal episode at a local restaurant. He is accompanied by two friends.

Subjective Data

Has been feeling weak for a few days

Became dizzy and fainted while awaiting his dinner

Takes one medication, a “water pill” for high blood pressure

Objective Data

Physical Examination

Blood pressure 92/50, pulse 125 and irregular, respirations 24, temperature 97° F

Alert and oriented

Lung sounds clear in all fields

Diagnostic Studies

ECG monitor shows atrial fibrillation

Discussion Questions

What is atrial fibrillation?

What are your priority actions at this time?

What additional history should you obtain from E.W.?

Describe the risks associated with atrial fibrillation.

W. is placed on diltiazem, warfarin, and dronedarone. What is the purpose of each of these medications in treating E.W.’s atrial fibrillation?

Case Study Progress

E.W. is admitted with a diagnosis of new onset of atrial fibrillation. Despite medical therapy, 12 hours later, he is still experiencing dizziness, and his systolic blood pressure remains below 100. A transesophageal echocardiogram is done, showing E.W. does not have any blood clots, so the provider elects to perform a cardioversion.

6. What instructions should you give E.W. to prepare for a cardioversion? What do you tell him to expect during the procedure and what nursing assessments will you be performing?

  

Answer 1

Atrial fibrillation is the most common cause of sustained tachyarrhythmia. The incidence and prevalence of atrial fibrillation increases with a age, with the prevalence of 0.4 %to 1 %in general population. AF is classified as lone, idiopathic, first detected, recurrent, paroxysmal, persistent and permanent AF. The clinical symptoms include palpitation, fatigue dyspnea, dizziness and diaphoresis..

Ecg shows absent p waves. Atrial activity is chaotic and fibrillatory (F) waves are present. The atrial rate is generally between 400 to 700 beats /min.

Priority action.

The choice of therapy in any unstable patient is direct current cardioversion. General management of AF centers around.

1.control of ventricular response

2.minimization of thromboembolic risk.

3.restoration and maintenance of sinus rhytm.

CONTROL OF VENTRICULAR RESPONSE.

Beta blocker (metaprolol, esmolol and propanalol) , calcium channel blocker(diltiazem and verapamil). Digitalis is used for rate control in patients with decreased lv function.

THROMBOEMBOLIC RISK MANAGEMENT.

CHAD'S SCORE is used to evaluate risk of thromboembolism. Warfarin should be continued until sinus rhythm has been maintained foe atleast 4 weeks to allow recovery of the atrial transport mechanism. If cardioversion cannot be postponed for 3 weeks patients should be anticoagulated with intravenous heparin and should undergo trans Esophageal echocardiography.

RESTORATION OF SINUS RHYTHM.

class 1 a agents.

Procainamidequinidine and disopyramide.

Class 1 c agents.

Flecainide,

propafenone.

Class 3.

Sotalol, dofetilide, amiodarone and azimilide.

Additional history.

Any history valvular diseases, previous history of AF. Other comorbidities and medical illnesses.

Complications of AF include.

Pulmonary vein stenosis presents with dyspnea following weeks of catcher based ablation.

Systems thrombo emboli events.

Atrial Esophageal fistula.

Question 2.if it is decided to perform a cardioversion the procedure to be explained to the patient. In case of a planned cardioversion we can use external pacing paddles to deliver the shock. The patient need to be started on oxygen preprocedure and to be given sedative agents. The environment should be free of noise and extra lighting. The patient should be asked to sleep and close the eyes. The shock is delivered.