Reference no: EM133496118

Assignment: Current Complaint and History of Present Illness Essay

Patient Parker is a woman, 74 years of age, who presents to her physician's office with complaints of dizziness and recent unexpected falls. She reports that she experiences symptoms once every week or so. When questioned about her falls, she states that she thinks she "blacks out for a second" but "comes to fast" and "knows where she is." She denies any injury from the falls. On admission, her blood pressure is 154/86 mm Hg, her heart rate is 68 bpm and irregular, and her respiratory rate is 14. Patient Parker is alert and oriented, and does not appear to be in any distress. A 12-lead ECG shows that the patient is in atrial fibrillation at a controlled rate. A review of Patient Parker's medical record shows that she has persistent atrial fibrillation. Past attempts at pharmacologic and electrical cardioversion have failed, and Patient Parker remains on low dose antiarrhythmic therapy for rate control and on warfarin for anticoagulation. She has a history of hypertension, coronary artery disease, and percutaneous transluminal angioplasty (PTCA) for placement of two stents. She also has a history of a mitral valve replacement with an artificial valve. Patient Parker lives alone in a senior citizen apartment complex; she participates in the social life of the community and takes frequent walks outside in good weather. Her favorite hobby is window-shopping at the mall.

Question A. What complaints are signs and symptoms or bradycardia?
Question B. What labs does the nurse anticipate the physician to order and what are the rationales?
Question C. What is the treatment of choice for a symptomatic bradycardia and the rationales?
Question D. This patient is on Coumadin and any surgical intervention is required what does the nurse anticipate; provide rationales

Initial Medical Management

The physician orders AECG monitoring for Patient Parker. A continuous loop event recorder is selected, and the patient is instructed on its use. She is also instructed to contact the physician when she has experienced one of her symptomatic episodes.

Question A. What is a loop recorder and why is this required?

Diagnostic Test Results

Approximately 10 days after Patient Parker begins wearing the AECG, she experiences another symptomatic episode. Following instructions, she depresses the switch on the recorder. When the episode has ended, she contacts her physician and follows instructions to transmit the data from the AECG via telephone. Analysis of the transmitted data shows that Patient Parker is experiencing episodes of severe bradycardia; her ECG tracing shows that she has pauses that last several seconds without an effective heartbeat; during these episodes, her heart rate drops to well less than 60 bpm

A diagnosis of symptomatic bradycardia caused by atrial fibrillation with a slow ventricular response is established. Patient Parker is referred for pacemaker implantation. Based on a thorough assessment, the physician chooses to implant a VVIR pacemaker.

Question A. Why would this patient require a pacemaker?
Question B. Provide patient teaching to pt and family prior to hospitalization and provide rationales?

Hospital Stay

The physician instructs Patient Parker to discontinue taking her warfarin two days in advance of her admission to the hospital. When the patient is admitted to the hospital, her INR remains elevated. A continuous heparin drip is initiated and partial thromboplastin times (PTTs) are monitored; the heparin drip is adjusted to maintain the PTT in the desired range. Preoperative lab work, ECG, and chest x-ray are completed. Preoperative education is begun. Two days after admission, Patient Parker's INR has dropped to the desired level, and pacemaker implantation is scheduled for the next day. Preoperative preparation is completed; Patient Parker is made NPO overnight, and her heparin drip is discontinued. The following morning, Patient Parker is taken to the cardiac catheterization lab. Under sedation and local anesthesia, the pacemaker is implanted. The low rate setting is programmed at 60 bpm, and the upper rate limit for rate adaptation is set at 120 bpm.

Question A. Patient and family are hesitant to stop the medication. Provide rationale to patient and family.
Question B. What post-operative teaching should be provided to patient and family (provide rationale).

Following Patient Parker's return to her room, she is placed on continuous telemetry monitoring. Her vital signs are monitored periodically, and the pacemaker pocket site is inspected for signs of excessive swelling or bleeding. She is instructed to limit use of the arm on the same side as the pacemaker generator, and she receives analgesic medications as prescribed for pain management. A chest x-ray is done, and a 12-lead ECG (with and without magnet) is completed. Patient Parker's vital signs remain stable; the pacemaker generator site shows no signs of excessive bleeding or swelling.

Question A. What nursing intervention should the nurse anticipate when the patient returns to the room? Please provide rationales?
Question B. What are some complications that can occur after pacemaker placement?
Question C. Why is a chest x ray required?

Discharge Education

Prior to Patient Parker's discharge, she receives information on incision line care and precautions to consider. She receives her temporary pacemaker identification card and is instructed to carry the identification card at all times. She is taught how and when to count her pulse and when to notify the physician. The nurse provides the patient with additional written materials, including the patient education handbook supplied by the pacemaker manufacturer. Patient Parker expresses concerns about using cellular phones and flying; the nurse provides specific information about the use of cellular phones and how to manage airport security. Patient Parker is discharged home; she has a follow-up appointment one week following discharge.

Question A. What patient and family teaching should the nurse provide (please provide rationales)
Question B. What patient and family teaching regarding pacemakers the nurse should provide?