Because it allows continuous observation of the heart’s electrical activity, cardiac monitoring is useful not only for assessing cardiac rhythm but also for gauging a patient’s response to drug therapy and for preventing complications associated with diagnostic and therapeutic procedures. Like other forms of electrocardiography, cardiac monitoring uses electrodes placed on the patient’s chest to transmit electrical signals that are converted into a tracing of cardiac rhythm on an oscilloscope. Cardiac monitoring may be hardwired monitoring, in which the patient is connected to a monitor at the bedside, or telemetry, in which a small transmitter connected to the patient sends an electrical signal to a monitor screen for display.
Essential Documentation
In the nurse’s notes, the nurse should document the date and time that monitoring began and the monitoring leads used.
CARDIAC TAMPONADE
With cardiac tamponade, a rapid, unchecked rise in intrapericardial pressure impairs diastolic filling of the heart. The rise in pressure usually results from accumulation blood or fluid in the pericardial sac. If fluid accumulates rapidly, the patient requires emergency lifesaving measures.
Cardiac tamponade may be idiopathic or may result from effusion, hemorrhage trauma or nontraumatic causes, pericarditis, acute myocardial infarction, chronic renal failure, drug reaction, or connective tissue disorders.
If the nurse suspects cardiac tamponade in a patient, the nurse should notify the health care provider immediately and prepare for pericardiocentesis (needle aspiration of the pericardial cavity), emergency surgery (usually a pericardial window), or both. Anticipate intravenous (IV) fluids, inotropic drugs, and blood products to maintain blood pressure until treatment is performed.
Essential Documentation
Include the assessment findings, such as jugular vein distention, decreased arterial blood pressure, pulsus paradoxus, narrow pulse pressure, muffled heart sounds, acute chest pain, dyspnea, diaphoresis, anxiety, restlessness, pallor or cyanosis, rapid and weak pulses, and hepatomegaly. Record the name of the health care provider notified and the time of notification. Make a note of diagnostic tests ordered by the health care provider, such as an electrocardiogram (ECG) or chest x-ray, and the findings. Document treatments and procedures and the patient’s response. Note any patient teaching provided. The frequency of vital signs, titration of drugs, and patient responses may be documented on the appropriate flow sheets.
Cardiac Tamponade
6/5/2019
1320
NURSING ASSESSMENT: BP at 1300 90/40 via cuff on right arm. Last BP at 1200 was 120/60. Drop of 17 mm Hg in systolic BP noted during inspiration. P 132 and regular, RR 34, oral T 97.2°F. See frequent vital sign sheet for q15min VS. Neck veins distended with pt. in semi-Fowler’s at 45-degrees, heart sounds muffled, peripheral pulses weak. Pt. anxious and dyspneic, skin pale and diaphoretic. Pt. c/o chest pain. Pt. awake, alert, and oriented X3. ______________________________________
6/5/2019
1400
NURSING INTERVENTION: Dr. H. Hoffman notified at 1305. Stat portable CXR done. ECG shows sinus tachycardia with rate of 130. 200-mL bolus of NSS given. Dopamine 400 mg in 250 D5W started at 4” mcg/kg/min. Results of CXR called to Dr. Hoffmann. Awaiting Dr. M. May’s arrival for pericardiocentesis. ________________________________
PATIENT TEACHING: Explained the procedure to pt. and wife and answered their questions. _________________________________________________Cindy Rogers, RN
CARDIOPULMONARY ARREST AND RESUSCITATION
Guidelines established by the American Heart Association direct the nurse to keep a written, chronological account of a patient’s condition throughout cardiopulmonary resuscitation (CPR). If the nurse is the designated recorder, the nurse should document therapeutic interventions and the patient’s responses as they occur. The nurse should not rely on memory to record these details later. Writing “recorder” after the nurse’s name indicates that the nurse documented the event but did not participate in the code.
The form used to chart a code is the code record. It incorporates detailed information about the nurse’s observations and interventions as well as drugs given to the patient. Remember, the code response should follow Advanced Cardiac Life Support guidelines.
Some facilities use a resuscitation critique form to identify actual or potential problems with the resuscitation process. This form tracks personnel responses and response times.
Essential Documentation
The code record is a precise, quick, and chronological recording of the events of the code. (See The code record, page 62.) The nurse should document the date and time the code was called. The nurse also needs to record the patient’s name, the location of the code, the person who discovered the patient, the patient’s condition, and whether the arrest was witnessed or unwitnessed. Document the name of the health care provider running the code, and list other members who participated in the code. Record the exact time for each code intervention, and include vital signs, heart rhythm, laboratory results (e.g., arterial blood gas or electrolyte levels), type of treatment (e.g., CPR, defibrillation, or cardioversion), drugs (name, dosage, and route), procedures (e.g., intubation, temporary or transvenous pacemaker, and central line insertion), and patient response. Record the time that the family was notified. At the end of the code, indicate the patient’s status and the time that the code ended. Some facilities require that the health care provider leading the code and the nurse recording the code review the code sheet and sign it.
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THE CODE RECORD
Here is an example of the completed resuscitation record for inclusion in the patient’s chart.
In the nurse’s notes, the nurse should record the events leading up to the code, the assessment findings prompting the decision to call a code, who initiated CPR, and other interventions performed before the code team arrived. Include the patient’s response to interventions. Document notification of the family and attending physician.
Cardiopulmonary Arrest
11/9/2019
0650
NURSING ASSESSMENT: Summoned to pt.’s room at 0630 by a shout from roommate. Found pt. unresponsive in bed without respirations or pulse. ____________________
NURSING INTERVENTION: Code called at 0630. Initiated CPR with Ann Barrow, RN. Code team arrived at 0632 and continued resuscitative efforts. (See code record.) Pt. transported to CCU, RM 201. Family notified. Dr. R. Stout notified. ________________________________________________________________________Connie Brown, RN
CARDIOVERSION, SYNCHRONIZED
Used to treat tachyarrhythmias, cardioversion delivers an electric charge to the myocardium at the peak of the R wave. This causes immediate depolarization, interrupting reentry circuits and allowing the sinoatrial node to resume control. Synchronizing the electric charge with the R wave ensures that the current won’t be delivered on the vulnerable T wave and thus disrupt repolarization.
Indications for cardioversion include stable paroxysmal atrial tachycardia, unstable paroxysmal supraventricular tachycardia, atrial fibrillation, atrial flutter, and ventricular tachycardia. Cardioversion may be an elective or urgent procedure, depending on how well the patient tolerates the arrhythmia.
Essential Documentation
The nurse should document the date and time of the cardioversion. Record the signing of a consent form and any patient teaching. Include any preprocedure activities, such as withholding food and fluids, withholding drugs, removing dentures, administering a sedative, and obtaining a 12-lead ECG. Document vital signs, and obtain an ECG before starting. Note that the cardioverter was on the synchronized setting, how many times the patient was cardioverted, and the voltage used each time. After the procedure, obtain vital signs, and record that a 12-lead ECG was obtained. Assess and document the patient’s level of consciousness, airway patency, respiratory rate and depth, and use of supplemental oxygen until the patient is awake. Indicate the specific time of each assessment, and avoid block charting.
Cardioversion Synchronized
6/18/2019
1800
PATIENT TEACHING: Explained procedure to pt. and answered his questions. Pt. states, “I’m very anxious about this cardioversion but I” understand why it’s necessary.”_______________________
NURSING INTERVENTION: Consent form signed and placed in chart. Pt. has been NPO for 6 hr. Dentures removed. Started O2 at 2 L/min via NC. O2 sat. 94%. _______________________________________
NURSING ASSESMENT: 12-lead ECG shows atrial fibrillation at rate of 130. BP 92/54, RR 28, oral T 96.8°F. Midazolam given I.V. by anesthesiologist, Mark Goodman. Cardioverter set to synchronized setting. Cardioverted X2 with 50 J, followed by 100 J with conversion to NSR at rate of 80. NSR confirmed by 12-lead ECG. BP 102/60, RR 24. Postprocedure rhythm strip attached below. ____________________
NURSING ASSESSMENT: Pt. responds with eye opening when name called. O2 sat. 96% via pulse oximetry. Respirations regular and shallow. Skin color pink, warm, capillary refill less than 3 sec. Breath sounds clear and heard in all lobes. ___________________________________________________________________________Susan Banks, RN
CAREGIVER STRAIN
Illness in a family member commonly takes a toll on other family members and caregivers. In fact, family members under great stress from trying to carry out their own roles while also caring for a sick person are at risk for burnout. If the patient has a long-term illness such as Alzheimer disease, the caregiver could be facing years of hard work. Signs of stress in a caregiver include muscular aches, headache, insomnia, illness, unexplained pain or gastrointestinal complaints, fatigue, weight loss, grinding of the teeth, inability to concentrate, mood swings, use of tranquilizers or alcohol, decreased socialization, depression, forgetfulness, feelings of despair, and thoughts of suicide.
Refer caregivers at risk for or showing signs of strain to social services. Educate caregivers about signs and symptoms of stress to report to their health care provider or nurse. Help them identify support systems and community services that are available.
Essential Documentation
The nurse should record the date and time of the entry. Identify the individual at risk for or experiencing caregiver strain. Describe subjective and objective signs of caregiver strain. Use the caregiver’s own words in quotes, when possible. Include education and support given and the caregiver’s response. Identify referrals made to services, such as social services, chaplain, support groups, meals-on-wheels, and respite care.
Family education may be documented on a patient education flow sheet, depending on facility policy. Appropriate notes should also be recorded on discharge-planning forms.
Caregiver Strain
6/2/2019
1830
NURSING ASSESSMENT: Pt’s. daughter stated concern regarding caring for her father at home. States, “I don’t think I can do it myself.”
NURSING INTERVENTION: Social services consulted. Daughter given brochures regarding home care. _____________________________________________Mary Albright, RN
CARE PLAN, TRADITIONAL
The nursing care plan serves as a written guide to facilitate continuity of care for individual patients. The care plan provides an avenue for communication among health care providers who interact to deliver comprehensive care. Nursing care plans are mainly used in extended care, long-term care, or nursing homes and are not used in acute care facilities.
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USING A TRADITIONAL CARE PLAN
Here’s an example of a traditional care plan. It shows how these forms are typically organized. Remember that a traditional care plan is written specifically for each patient.
The traditional care plan is initiated when the patient is admitted and continues throughout the hospitalization. The patient’s problem, expected outcomes, specific interventions, and evaluations, along with the date that the problem was resolved, are typical components of the traditional care plan. The traditional care plan is written from scratch and is rarely used today, except in nursing homes, because of the time required to write one for each patient. It is, however, specific to the patient so that all health care workers understand the precise patient problem, expected outcomes, and individualized interventions.
Essential Documentation
The traditional care plan includes dates for problem identification and resolution, the problem (written as a nursing diagnosis), the expected patient outcomes, individualized nursing interventions, and evaluation of the expected outcome. (See Using a traditional care plan, page 66.)
CAST CARE
A cast is a hard mold that encloses a body part, usually an extremity, to provide immobilization without discomfort. It can be used to treat injuries, correct orthopedic conditions, or promote healing after general or plastic surgery, amputation, or neurovascular repair. Care of the cast involves assessment of the limb for neurovascular function, prevention of complications, and patient and family education. Complications include compartment syndrome, palsy, paresthesia, ischemia, ischemic myosis, pressure necrosis, and misalignment or nonunion of fractured bones.
Essential Documentation
Record the date and time of, and the reason for, cast application and the skin condition of the extremity before the cast was applied. Document diagnostic tests performed and the results. Note any contusions, redness, or open wounds. Assess and document the results of neurovascular checks, before and after application, bilaterally. Include the location of special devices, such as felt pads or plaster splints. Document patient education and whether written instructions were given.
Cast Care
6/5/2019
1400
NURSING ASSESSMENT: X-ray shows simple left radial fracture. Fiberglass cast applied to left forearm by Dr. A. Brown at 1330. Before cast application, 5 cm × 10 cm area of bruising at fracture site, no open wounds noted. Radial pulses strong, capillary refill less than 3 sec, hands warm, no finger edema bilaterally. Patient c/o pain at fracture site. No numbness or tingling, able to move fingers and feel light touch in both hands equally. _____________________
NURSING INTERVENTION: After cast application, left forearm elevated on 2 pillows. Neurovascular status remains unchanged. ___________
PATIENT TEACHING: Patient and family told to keep left forearm elevated on pillows. Instructed them to call the doctor if pt. is unable to move fingers, if numbness or tingling develops in fingers of left hand, or if pain increases despite taking pain medication as ordered. Explained S/S of infection to report. Advised them not to insert anything into cast. Written discharge instructions for cast care given to pt. and family. All questions answered. Pt. to follow up with orthopedist in 1” week. __________________________________________________________________________________Joyce Chow, RN
CENTRAL VENOUS ACCESS DEVICE INSERTION
A central venous access device (CVAD) is a sterile catheter that is inserted through a major vein, such as the subclavian vein, jugular vein, or femoral vein. CVAD therapy allows for the monitoring of central venous pressure (CVP), which indicates blood volume or pump efficiency. It also permits aspiration of blood samples for diagnostic tests and administration of IV fluids (in large amounts, if necessary) in emergencies or when decreased peripheral circulation causes peripheral veins to collapse. A CVAD helps when prolonged IV therapy reduces the number of accessible peripheral veins, when solutions must be diluted (for large volumes or for irritating or hypertonic fluids such as total parenteral nutrition solutions), and when long-term access is needed to the patient’s venous system. A peripherally inserted central catheter (PICC) is inserted in a peripheral vein, such as the basilic vein, and used for infusion and blood sampling only.
Essential Documentation
When assisting the health care provider who inserts a CVAD, the nurse should document the time and date of insertion; type, length, and location of the catheter; solution infused; the health care provider’s name; and the patient’s response to the procedure. If the ports are not being used, document that they have needle-free injection caps, and include any orders related to maintaining patency. The nurse also needs to document the time and results of the x-ray performed to confirm placement. Note whether the catheter is sutured in place and the type of dressing applied. For a PICC, record the length of the external catheter.
Central Venous Cather Insertion
2/24/2019
1100
PATIENT TEACHING: Procedure explained to pt. and consent obtained by Dr. S. Chavez. TLC placed by Dr. Chavez on first attempt in right subclavian vein. Cath sutured in place with 3-0 silk, and sterile dressing applied per protocol. Needle-free injection caps placed on all lines. Lines flushed with 100 units heparin. Portable CXR obtained to confirm line placement. Results pending. ____________________
NURSING ASSESSMENT: P 110, BP 90/58, RR 24, oral T 97.9° F. Pt. sitting in semi-Fowler’s position and breathing easily, lungs clear bilaterally. ___________________________________________Louise Flynn, RN
2/24/2019
1150
RN received telephone report from Dr. Turner in radiology confirming proper placement of CV line in superior vena cava. ______________________________________________________Joyce Williams, RN
CENTRAL VENOUS ACCESS DEVICE OCCLUSION
A central venous access device (CVAD) may become occluded because of kinks in the tubing, the presence of a blood clot or fibrin sheath, or crystalline adherence. Signs of occlusion include the inability to draw blood, infuse a solution, or flush the catheter. If CVAD occlusion is suspected, the nurse should check the tubing for kinks. The dressing may need to be removed to check for kinks under it. Ask the patient to cough or change position. Attempt to withdraw blood, or gently flush with normal saline solution. A specialized vascular team should be called to remedy occlusion of a CVAD.
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