Cardiac/Vascular Nurse Exam Secrets Study Guide (32 page)

Junctional tachycardia: Regular rhythm with a rate of 100–200 beats per minute. P wave is inverted and occurs after the QRS complex.

Ventricular

Premature ventricular contraction (PVC): Underlying regular rate and rhythm, with occasional early, wide and bizarre-looking QRS complex.

Ventricular tachycardia: No P wave, wide and bizarre QRS complex with rapid rate of 100–200 beats per minute.

Ventricular fibrillation: No identifiable rhythm, no identifiable wave forms. ECG shows only a fine or coarse chaotic wavy line. Patient is unresponsive and pulseless.

Idioventricular rhythms: Ventricular rate of 20–40 beats per minute, independent or no P wave (PR interval unmeasurable) with bizarre-looking QRS complex longer than 0.12 seconds.

Asystole: No electrical conduction, displayed as an almost flat line only disturbed by medical interventions such as CPR. Patient is unconscious and pulseless.

Types of heart block as seen on ECG

First-degree AV block: Rhythm is regular and appears very similar to a normal sinus rhythm. The only difference is a PR interval longer than 0.20 seconds.

Type I second-degree AV block: Regular atrial rhythm with a repeating pattern of progressively longer PR intervals until a QRS complex no longer appears behind the P wave.

Type II second-degree AV block: Atrial rhythm is regular, ventricular rhythm maybe either regular or irregular. Look for missing QRS complexes.

Third-degree AV block: Atrial and ventricular rates are regular, but independent of each other. PR interval will vary.

Left bundle-branch block: QRS complex is wider than 0.12 seconds, R wave may not be detected or may be “slurred.”

Right bundle-branch block: QRS complex is wider than 0.12 seconds and has an unusual appearance (may look like rabbit ears or the letter M). T wave is inverted.

Ventricular assist devices (VAD)

A ventricular assist device is a 1–2 pound pump, usually placed internally by the left ventricle. It is electrically controlled from outside the body. It reroutes the blood flow from the ineffective or damaged ventricle through a series of tubes that will pump the blood more efficiently than the body is able to do on its own. This treatment is not without significant risk, but the patient with chronic heart failure that can no longer be controlled with medication or pacemaker may be assessed for eligibility. The most likely candidate is a younger, healthy patient who is awaiting transplant.

Enhanced external counterpulsation (EECP)

Enhanced external counterpulsation (EECP) is a pain control method that may be effective for patients with recurring stable angina. Treatment involves sequential compression of the patient’s entire leg length to promote blood flow and increase cardiac output. The patients who might receive the most benefit from this type of treatment are those who refuse invasive treatment measures, have not responded to medication and revascularization efforts or are not candidates for such treatments. EECP should be used cautiously in the patient with preexisting decreased left ventricular ejection fraction or heart failure.

Outcome evaluation

Outcome evaluation is a necessary step taken by practicing clinicians to assess a patient’s recovery from cardiovascular procedures. The process is used to evaluate the patient’s status, evaluate effectiveness of interventions, and identify areas of improvement.

Commonly used patient outcomes include morbidity, mortality, hemodynamic parameters, laboratory values such as blood sugar, lipid levels, and prothrombin time, symptoms such as nausea, vomiting, pain, fatigue, angina, anxiety and depression, and functional status. Commonly used practicing clinician parameters include change in knowledge or skill level and compliance with patient standards. Commonly used system outcomes include service utilization, length of hospital stay, and cost of care or services. Outcome evaluation is often used to identify factors associated with complications post cardiovascular intervention.

Stages of Prochaska’s transtheoretical model of motivation and change

Prochaska states there are five stages a person must go through in order to accept the value of change and take action accordingly:

• Precontemplation: The patient is resistant to change. This stage can last up to 6 months after a need for change has been initially identified.
  
• Contemplation: For the next 6 months to a year, the patient begins to visualize what changing would actually be like.
  
• Preparation: The patient begins taking tentative steps, such as option exploration, toward change. This stage’s timeframe can vary greatly.
  
• Action: For approximately the next 6 months the patient begins taking active steps toward change; relapse and setbacks may occur, but overall the patient remains resolved toward change.
  
• Maintenance: For at least 6 months following completion of the change goal, the patient works to maintain the changes achieved. Setbacks may still occur but become less frequent.
  

The nurse must meet the patient at whatever stage he/she is currently in and promote progress toward the next stage.

Benefits of cardiac rehabilitation

Endorsed by both the American Heart Association (AHA) and American College of Cardiology, cardiac rehabilitation is an individualized program designed for the patient with cardiac disease, including those recovering from myocardial infarction and treatment surgeries. Cardiac rehabilitation focuses on education, including diet and lifestyle changes, and developing an individualized exercise program that will return the cardiac patient to his/her highest functioning capacity and reduce the risk of further cardiac injury.

For the first 3–6 months, care is focused on gradual exercise progression and probable consults with cardiologists, health educators, dietitians, physical and occupational therapists and psychologists/psychiatrists.

Exercise options might include both endurance and strength training. Lifestyle education and counseling focuses on disease management, risky behavior reduction, diet and mental health.

Attending cardiac rehabilitation increases the cardiac patient’s chances of survival and effective healing.

Subacute care facilities

General: Patients discharged to this level of care are stable and healing well, but still require skilled care for such things as long-term intravenous treatments.

Chronic: Chronic care facilities are for terminal and end-of-life patients who cannot be cared for in an at-home setting because of choice or complexity of care such as ventilator dependency.

Transitional: At this level the patient still needs complex medical and nursing care, such as deep wound management.

Long-term transitional: Identifies a need for continued complex medical care that is expected to have an extended treatment time.

End-of-life care related to heart failure

If treatments fail to control the patient’s heart failure, it is possible for the disease to progress to a point where even heart transplant is no longer an option. At this point, it is time to educate the patient and family regarding his/her end-of-life care options. Many patients choose the support of hospice. This option allows for care at home surrounded by family and friends. Those involved in the care might include nurses, nursing aides, social workers and even trained volunteers to help ease the passage from life to death by giving support to all facets of a person’s life: health, social, mental, emotional and spiritual. Other options might be continued care within the hospital or transfer to a chronic care facility. Discussions must be held regarding end-of-life care parameters and wishes and these decisions documented and expressed to family and friends.

Cardiac/Vascular Education for Patients, Families, or Groups

Qualities of an excellent nurse-teacher

Confidence: An excellent teacher provides a comfortable and appropriate learning environment and is prepared ahead of time regarding what and how to teach the individual or group according to their needs.

Competence: Prioritize learning goals and material, focusing on the most critical first. Care should be taken to ensure patient safety and confidentiality during teaching exercises.

Communication: Speak clearly and concisely on a level that is comfortable for the patient. Provide for an interpreter or any available resources in the patient’s native language. Materials should be presented in a variety of ways to accommodate different learning styles.

Caring: The most effective teacher is able to show empathy toward the patient and his/her emotions and concerns. He/she is unhurried and willing to address any questions the patient might have while encouraging and providing positive feedback in the patient’s efforts to learn.

Standards established by JCAHO for evaluating the effectiveness of education efforts

· Did the effort promote open and honest communication between the nurse and the participants?

· Was patient understanding of the concept improved after the experience?

· Was the patient actively involved in the learning and decision-making processes?

· Was the information provided pertinent to the patient’s individual needs, values, abilities and concerns at the time of the teaching event?

· Can the patient easily demonstrate the needed skills being taught?

· Is the patient aware of his/her responsibility related to any treatments and goals that will be employed toward a healthy lifestyle?

· Does the knowledge gained improve the patient’s ability to cope with circumstances and to participate in his/her care?

· Will the patient be able to follow and accomplish any care goals that have been set?

Kleinman model

The Kleinman model relies on a series of questions to help a nurse prepare to teach a patient from an unfamiliar cultural background. These questions allow the patient to define his/her own healthcare beliefs and problems. The questions include:

• The patient’s name for a problem or condition.
  
• The patient’s perception of the problem’s cause and initiating events, as well as their timing.
  
• How the problem is affecting the patient—what problems result from the illness or variance in health.
  
• The patient’s beliefs regarding the severity of the problem and its anticipated progression.
  
• The patient’s confidence in various treatments.
  
• What the patient hopes intervention will accomplish for him/her.
  
• What fears the patient possesses regarding the illness and the proposed treatments.
  

Adult learning

Adult learning is defined as a consistent change in behavior due to life experiences. The characteristics of adult learning include motivation to know more information, self-direction, life experiences that positively or negatively impact the learning process and ability to enhance an already established knowledge base. Adult learning is most effective when an individual can relate to an immediate need, problem, or deficit. These individuals are self-directed by a need to know more information based on their current situation. They will take a proactive approach to gain more insight due to a current situation or based on a need to build on past experience.

Three conditions for adult learning

The 3 conditions necessary for adult learning include motivation to learn, ability to learn and the learning environment. Motivation is a condition that is defined as the effect of internal and external factors that drive an individual’s need to learn, change, and maintain behavior. It is a willingness of an individual to want to acquire knowledge or insight. Motivation can be driven by different factors including reinforced or rewarded behavior, need for survival, ability to recognize a previous behavior that caused a negative outcome, personality, perceived ability to achieve a specific goal, and coping style.

Three domains of adult learning

The domains of adult learning include cognitive learning, affective learning, and psychomotor learning. Each type of learning impacts how an individual addresses adult learning and affects the knowledge the individual can acquire. Cognitive learning is defined as the ability to acquire knowledge or intellectual information through acquisition of facts, data, making decisions or drawing conclusions. Affective learning is defined as the ability of an individual to change their attitude, feeling, emotions, or interests toward a particular event or idea. Psychomotor learning is defined as an individual’s ability to master physical or motor skills and/or activities.

Impact of environment on adult learning

External factors and the environment may affect an individual’s ability to learn. Many external factors may need to be addressed in order for an individual to have the ability to learn, as these external factors may pose barriers to learning. Understanding how individuals learn most effectively is key to addressing environmental factors. Some individuals learn better on a one-on-one basis, while others learn more effectively in small groups, where others learn better in large groups. Understanding the environmental factors that impact learning can positively or negatively influence an individual’s learning process. Providing a comfortable learning environment that includes a moderate temperature, sufficient lighting, minimal noise, adequate ventilation, and comfortable furniture will facilitate the learning process.