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Atrial Fibrillation: A Case Study Approach

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by

Anna Christine

on 21 November 2013

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Transcript of Atrial Fibrillation: A Case Study Approach


Atrial Fibrillation:
A Case Study Approach

Patient
Initials: JG
Age: 62
Sex: Male
Resident of Grand Junction, CO. Often travels abroad for extended periods to work.
Married, wife is often present and very supportive.
Adult children live elsewhere and are not present.
Both are religious (Christian) and very involved in church functions.
JP and his wife like to travel together and separately, especially interested in hisorical sites.
JP strives for healthy lifestyle, which has been recently limited by the onset of atrial fibrillation.
Health History
Mitral Stenosis

HTN

Rheumatic fever (childhood)

CAD (RCA complete occlusion)

Mild congestive heart failure (EF = 45%)

Chronic lung disease

Situation
-In mid-September JG's a. fib was electrically cardioverted to sinus rhythm (SR).

-Upon returning home, his a. fib recurred.

-JG reports discomfort in abdomen after eating and dyspnea

-On 10/5 the patient was readmitted to begin Sotalol loading and another direct current cardioversion (DCCV) in a couple of days.

-Physician anticipates the addition of Sotalol will maintain SR for a longer period after DCCV.
AF Common Causes

- Binge drinking
-CAD***
-MI
-CABG
-HTN***
-Mitral valve disease ***
-Medicines
-Hyperthyroidism
- Pericarditis
- Sick sinus syndrome
NIH, 2013
Common Symptoms of AF
- None or transient
- Rapid, irregular or slow pulse
- Palpitations
- Confusion
- Chest pain
- Dizziness/ syncope
- Fatigue***
- SOB***

NIH, 2013
Potential Complications
- Thrombus formation/ embolism to brain (ischemic stroke)

- Rapid Ventricular Response (A. Fib with RVR)

- Heart failure***

- Recurrence despite treatment***

What is A. Fib?
Healthy Conduction

- Signal originates in SA node
- Travels to AV node
- Causing a single, regular atrial contraction
- Followed by a single, regular ventricular contraction

A. Fib

- Electric signals originate from ectopic foci in both atria and pulmonic vein
- AV node becomes irritable with excessive stimuli
- Ventricular response may be slow, normal, irregular or rapid.
Image: Hamilton Cardiology Associates, 2013
Treatment of A. Fib
Pharmaceutical

- Anticoagulants
- Rate Control
- Rhythm Control
- Treat underlying cause

Electrical Cardioversion***

Catheter Ablation

Direct Current Cardioversion
(DCCV)
- Sedation

- Pain prophylaxis

-Informed consent

- 75% success rate (NLM, 2013)
Ackley, B. & Ladwig, G. (2011) Nursing diagnosis handbook; An evidence-based guide to planning care.

Banner, D. & Lauck, S. (2013). Overview and management of AF.
British Journal of Cardiac Nursing (8)
5, 241-248.

Hamilton Cardiology Associates. (2013). Atrial fibrillation. Retreived from http://www.hcahamilton.com/?page_id=1019

National Heart, Lung and Blood Instite (NIH). What is cardioversion? Retreived from http://www.nhlbi.nih.gov/health/health-topics/topics/crv/

Banner, D. & Lauck, S. (2013). Overview and management of AF.
British Journal of Cardiac Nursing (8)
5, 241-248.
Physical Assessment
Vitals: T-98.2, HR- 76, BP- 93/69, O2- 93% on RA
General: Well- nourished male in no apparent distress
HEENT: Pink, dry mucous membranes, no lumps, bumps tenderness at neck.
CV: Distant heart sounds. Rate irregular. No edema. Capillary refill <2 sec all extremities.
Respiratory: Diminished breath sounds bilat. Easy work of breathing.
GI: Abd soft and nontender. BS present all 4 quadrants.
Neuro: A&Ox4, awake.
Notable test results: lengthened QT interval, elevated CR at 1.4


Discharge Planning:
Medication
-Digoxin
-Cardizem
-Sotalol***new med
-Coumadin
-Lipitor
-Pulmicort inhaler
PRN
-Combivent inhaler
- Albuterol inhaler
-Tums
-Prilosec
Discharge Planning
Follow-up
- Contact primary care physician

- Appointment at Coumadin clinic

- Appointment at Lung and Sleep Center
Seek Immediate Medical Attention
- Chest pain, abd. pain, sweating, weakness, nausea.
- Change in rate, rhythm, strength of pulse
- SOB
- Pedal or lower extremity edema
- Dizziness, numbness, weakness of face or extremities.
-Change in vision or speech
Discharge Planning

Discharge Planning
Home instructions: A. Fib
- NO caffeine
- NO alcohol
- NO smoking
- Maintain healthy weight
- Take medication as prescribed (especially Coumadin)
- Low fat, low salt diet (with HF)
- Stay active
- Attend follow-up appointments and blood testing appointments
Priority Nursing Diagnosis #1
Decreased cardiac output

r/t altered electrical conduction, impaired cardiac function, abnormal flow through valve

AEB decreased ejection fraction (45%), dyspnea, ECG changes and fatigue.
Priority Nursing Dx #1
Independent interventions
- Monitor for symptoms of worsening decreased CO
- Regularly assess pulse oximetry
- Position for comfort (Fowlers/Semi-Fowlers)
- Observe for signs of chest pain
- Observe for effects of sleep disordered breathing
- Monitor I's & O's/ daily weight
- Gradually increase activity
- Teach patient about signs and symptoms of decreased CO
(Ackley & Ladwig, 2011)
(Ackley & Ladwig, 2011)
Priority Nursing Diagnosis #2
Risk for ineffective cerebral tissue perfusion.

Risk factor: Stasis of blood in atria, thrombus formation, emboli, ischemia



A. Fib carries 500% increased risk of stroke. (Bannar & Lauck, 2013)
Priority Nursing Diagnosis #2
Independent Interventions
- Monitor for changes in mental status or behavior

- Teach patient/family warning signs of stroke.

- Emphasize the importance of taking anticoagulant medications as directed and following up on blood work.

- Notify physician immediately for any sign of new cerebrovascular incident.
Priority Nursing Diagnosis #3
Ineffective breathing pattern

r/t compromised cardiac and pulmonary function

AEB dyspnea, orthopnea, paroxysmal nocturnal dyspnea.
(Ackley & Ladwig, 2011)
Priority Nursing Dx #3
Interventions
- Monitor rate, depth and ease of respirations

- Assess for patterns of dyspnea

-Ensure pt has received prescribed medications during a dyspneic episode

- Regularly monitor oxygen saturation

- Observe for cyanosis

-Elevate HOB

Priority Nursing Dx #4
Anxiety

r/t change in health status

AEB report of apprehension, increased tension.
(Ackley & Ladwig, 2011)
Priority Nursing Dx #4
Interventions
- Assess and discuss sources of anxiety

- Use empathy to encourage pt to interpret symptoms of anxiety as normal

- Explain activities, procedures and issues involving the pt in non-medical terms

- Help client to define anxiety levels and determine appropriate interventions
Atrial Fibrillation ECG
Irregular rhythm
No discernible P waves
References
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