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.


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.


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.

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.


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.


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.


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.

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.)


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.


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.


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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Apr 13, 2020 | Posted by in NURSING | Comments Off on C

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