After completing the chapter, you will be able to accomplish the following:

1. Perform cardiopulmonary resuscitation.
2. Perform emergency automated external defibrillation.
3. Perform emergency manual external defibrillation (asynchronous).
4. Obtain a 12-lead electrocardiogram.
5. Apply a cardiac monitor.
6. Apply and monitor a transcutaneous (external) pacemaker.
7. Remove a peripheral arterial catheter.

• Assessment
• Clinical Decision Making/Clinical Judgment
• Perfusion
• Safety
• Tissue Integrity

• biventricular pacemakers
• cardiac arrest
• cardiac monitoring
• cardiopulmonary resuscitation (CPR)
• cardioversion
• circulation
• defibrillation
• dysrhythmia
• electrocardiogram (ECG)
• electrocardiography
• fibrillation
• implantable cardioverter-defibrillator (ICD)
• pacemakers
• synchronized cardioversion

Life depends on a constant supply of oxygen. This demand for oxygen is met by the function of the respiratory and cardiovascular systems, together known as the cardiopulmonary system. Gas exchange, the intake of oxygen and the release of carbon dioxide, is made possible by the respiratory system (refer to Chapter 14). The cardiovascular system (Fig. 14-2 in Chapter 14) delivers oxygen to the cells. Perfusion of body tissues depends on essentially three factors:

• Integrity of the airway system to transport air to and from the lungs
• A properly functioning alveolar system in the lungs to oxygenate venous blood and to remove carbon dioxide from the blood
• A properly functioning cardiovascular system and blood supply to carry nutrients and wastes to and from body cells

The cardiovascular system is composed of the heart and the blood vessels. The heart is the main organ of circulation, which is the continuous one-way circuit of blood through the blood vessels (Norris, 2020). The heart is the circulatory pump, squeezing through the heart and out into the body. This is accomplished by contractions starting in the atria, followed by contraction of the ventricles, with a subsequent resting of the heart. Figure 15-1 provides an overview of cardiac anatomy. Deoxygenated blood (low in oxygen; high in carbon dioxide) is carried from the right side of the heart to the lungs, where oxygen is picked up and carbon dioxide is released, and then returned to the left side of the heart. This oxygenated blood (high in oxygen; low in carbon dioxide) is pumped out to all other parts of the body and back again (refer to Fig. 14-2 in Chapter 14). The contraction of the muscles of the heart is controlled by electrical impulses produced in and carried over specialized tissue within the heart. These tissues make up the heart's conduction system. Figure 15-2 provides a review of the cardiac conduction system.

Assessment of cardiovascular function commonly involves noninvasive techniques such as inspection, auscultation, and palpation. Additional basic and important indicators of the heart's effectiveness are pulse rate, strength, and rhythm; blood pressure; skin color and temperature; and level of consciousness. Refer to Chapters 2 and 3 for additional information related to these assessments. Chapter 14 provides additional information related to oxygenation and cardiopulmonary function.

This chapter covers select skills necessary for the nurse to promote perfusion and provide cardiovascular care. While performing skills related to perfusion, keep in mind factors that affect cardiopulmonary function, leading to impaired perfusion, and how these factors might affect a particular patient (see Fundamentals Review 14-1 in Chapter 14). Chapter 14 presents skills related to oxygenation, which assist nurses in providing cardiovascular care. Should the heart stop pumping, it can be manually pumped via cardiopulmonary resuscitation (CPR) until electrical defibrillation and additional health care support arrives. Noninvasive heart monitoring involves electrocardiography and cardiac monitoring. Figure 15-3 highlights cardiac landmark reference lines that are used in assessment and for placing devices related to perfusion and cardiovascular care, such as a transcutaneous (external) pacemaker. Other electrical therapy devices are discussed in Fundamentals Review 15-1.

Invasive techniques, such as pulmonary artery pressure monitoring, Swan-Ganz catheterization, cardiac output determination, and cardiac support via an intra-aortic balloon pump (IABP) typically are used by trained critical care personnel to provide additional monitoring and support. These techniques are beyond the scope of this text.

1. Explain the steps involved in obtaining an ECG. Tell Mr. Pruder that the test records the heart's electrical activity, and it may be repeated at certain intervals. Emphasize that no electrical current will enter their body and that the ECG will provide important information to help guide their health care. Tell them the test typically takes about 5 minutes.
2. Call for help, pull call bell, and call the facility emergency response number. Call for emergency equipment and the automated external defibrillator (AED) or defibrillator. Put on gloves, if available. Position Mr. Stebbings supine on their back on a firm, flat surface, with arms alongside the body. If they are in bed, place a backboard or other rigid surface under them (often the footboard of the patient's bed). Initiate CPR. Provide defibrillation as soon as an AED becomes available.
3. Check the cardiac monitor alarm settings to ensure the upper and lower limits of the heart rate alarm and other alarm settings are based on the patient's condition and goals of patient care. If the alarms are set for parameters that are not relevant to this patient, the alarms may be triggering at inappropriate times. Check that the electrodes are securely adhered to the patient's skin. Change the electrodes; clean excess oil or other substances from the skin. Use a gauze pad to vigorously rub and dry the skin. Oils and excess hair interfere with electrode contact and function. Rubbing with gauze abrades and dries the skin. Poor contact with the skin may result in an inaccurate signal. Proper skin preparation is essential to reduce artifacts in and increase the quality of the ECG tracing. When you open the electrode package, check the gel for moistness before applying the new electrode. Dried electrodes do not conduct the signal well or accurately. Apply the electrode to the skin by pressing firmly to ensure a tight seal. Poor contact with the skin may result in an inaccurate signal.