Module 2 Advanced Concepts
Chapter 28 Concepts of Care for Patients with Dysrhythmias
Bradydysrhythmia
HR is less than 60 beats/min, these rhythms can be significant because
myocardial oxygen demands is reduced from the slow HR, which can be
beneficial, coronary perfusion time may be adequate because of prolonged
diastole which is desirable, coronary perfusion pressure may decrease if the HR is
too slow to provide adequate cardiac output and blood pressure; this is a serious
consequence.
*The patient may tolerate this dysrhythmia if the BP is adequate
If BP is not adequate, symptomatic brady dysrhythmia may lead to myocardial
ischemia or infarction, dysrhythmias hypotension, and heart failure.
Common types of bradycardia caused by irregular heart rhythms:
Sinus Bradycardia: When the sinus node discharge rate is less than 60 beats/min.
What causes it? Excessive vagal (Parasympathetic) Stimulation to the heart causes
a decreased rate of sinus node discharge , may result from carotid sinus massage,
vomiting, suctioning, Valsalva maneuvers like bearing down for a bowel
movement or gagging., ocular pressure, or pain.
Assessment: Patient may be asymptomatic except for decreased pulse rate.
Assess the EHR to determine if the patient is taking meds that slow the HR. Assess
pt for: Syncope (blackouts or fainting), Dizziness or weakness, Confusion,
Hypotension, Diaphoresis, SOB, Chest pain.
Interventions: If the pt is stable, tx includes identification and tx of the underlying
cause. If the patient has any of the above symptoms and the cause cannot be
identified, the treatment is to administer drug therapy with IV atropine, increase
intravascular volume via IV fluids, and apply oxygen if O2 is less than 94% or the
patient is short of breath. Drugs that are suspected of causing bradycardia are
discontinued. If beta-blocker overdose is suspected, administration of glucagon
may help by increasing the HR and BP. If the heart rate does not increase enough.
Prepare the pt for transcutaneous or transvenous pacing to increase the HR.
*If the tx of the underlying cause does not restore normal sinus rhythm, the
patient will require permanent pacemaker implantation.
,Tachydysrhythmia
HR greater than 100 beats/min
A major concern for pts with coronary artery disease
Tachydysrhythmias are serious because they:
*Shorten the diastolic time and therefore the coronary perfusion time (The
amount of time available for blood to flow through the coronary arteries to the
myocardium)
*Initially increase cardiac output and BP(However, a continued rise in HR
decreases the ventricular filling time because of a shortened diastole, decreasing
the stroke volume
Common types of tachycardia caused by irregular heart rhythms:
*Atrial Fibrillation (A-Fib) MOST COMMON DYSRYTHMIA SEEN
*A chaotic rhythm with No clear P waves, no atrial contractions, loss of atrial kick,
and an irregular ventricular response. The atria merely quiver in fibrillation.
*Genetic and shows most commonly ages 35-40 most common to show up with
HTN, HF, CAD
*Risk Factors: HTN, a previous stroke, TIA, obesity, hyperthyroidism, CKD,
excessive alcohol use and mitral valve disease.
*Largely related to clotting concerns such as embolic stroke, DVT, or PE
History: Assess for prior hx of AF or other dysrhythmias. Reoccurrence of AF is
common.
Physical Assessment and S/S: Take apical pulse on apex of the heart for 1 full
minute with the BELL, pulse may be irregular. Check for signs of poor perfusion
such as faigue, weakness, SOB, dizziness, anxiety, syncope, palpitations, chest
discomfort, or pain and hypotension. Slurred speech is a sign of embolus that has
traveled to the brain.
Psychosocial Assessment: These patients tend to feel very anxious especially
those with high ventricular rate. With increased heart rate, cardiac output
decreases, which ca n crease dyspnea, contributing to feelings of anxiety. Assess
pts with chronic AF for methods of coping with a long term conduction issue,
patients who on chronic may have anxiety related to anticoagulation medications
and potential for emboli development.
How to get a definitive diagnosis? By obtaining a 12 lead ECG.
AF is classified in to 5 categories based on length of time in the rhythm:
Paroxysmal: an episode within 7 days converts back to sinus rhythm; episode
lenths vary but do not lat longer than a week.
,Persistent: Longer than 7 days
long standing persistent: Longer than 12 months
Permanent: Patients who remain in AF and a decision is made not to restore or
maintain sinus rhythm by either surgical or medical intervention.
Nonvalvular: occurs in the absence of mitral valve disease or repair.
*ACTION ALERT* If a pulmonary embolism is suspected, remain with the patient
and monitor for SOB, chest pain and/or hypotension. Initiate the RR team and
notify the provider.
Traditional interventions for AF include antidysrhythmic drugs to slow the
ventricular conduction or to concert the AF to normal sinus rhythm: Examples of
drugs to slow the conduction are calcium channel blockers such as diltiazem or for
more difficult to control AF, amiodarone. Dronedarone is a medication similar to
amiodarone, yet better tolerated for maintenance of sinus rhythm after a
cardioversion. But should NOT be used in patients with HF because it can cause an
exacerbation of cardiac symptoms OR in patients with permanent AF because it
increases the risk of stroke, MI, or cardiovascular death.
Beta Blockers: Such as metoprolol and esmolol, may also be used to slow
ventricular response. Digoxin I given for patients with HF AND AF. It is useful in
controlling the rate of ventricular response HOWEVER it does NOT convert AF to
sinus rhythm, carefully monitor the pulse rate od patients that are taking these
drugs.
Medications used for rhythm control of AF: flecainide, dofetilide, propafenone,
and ibutilide. These meds are usually started in the acute care setting because the
risk of prolonged QT intervals and bradycardia. Continuous EKG monitoring are
needed. Amiodarone is also used but not rq a an acute care stay.
If permanent AF Is present rhythm control antiarrhythmic meds should NOT be
used.
Although the goal is to concert pt from AF to sinus rhythm that may not be
possible for older adults . These patients require long term anticoagulant to
prevent stroke and thrombus formation. INR is required when a patient is taking
Warfarin.
Patient teaching: Importance of avoiding foods high in vitamin K, avoiding herbs
such as ginger, ginseng, goldenseal, gingko biloba, and st johns wort. Teach
importance of reporting bleeding, nose or gums or any other signs of bleeding to
PCP immediately. Teach pts and family generic names for their medications and
their purposes. Emphasize importance of reporting any dizziness, N/V and chest
discomfort or SOB. Educate meds should not be stopped abruptly. Teach t and
, family how to take BP and HR. Remind pts to report any signs of change in heart
rhythm such as a significant decrease in pulse rate or increase more that 100BPM
Preventing Heart Failure:
Electrical Cardioversion a synchronized countershock that may be performed to
restore normal conduction in a hospitalized patient with new-onset AF, can also
be scheduled electively for stable AF that is resistant to medical therapy.When
the onset of AF is greater than 48 hours, the patient must take anticoagulants for
at least 3 weeks(Or until the INR is 2-3) before the procedure to prevent clots
from moving from the heart to the brain or lungs. Emergency equipment must be
available during the procedure. The physician, APRN, or other qualified nurse
explains the procedure to the patient and the family. Help the pt sign a consent
form unless the procedure is an emergency for a life threatening dysrhythmia.
The patient is usually conscious a short acting anesthetic agent is administered for
sedation. For safety before cardioversion turn oxygen off and remove from
patient, fire could result shout “CLEAR” before shock delivery for electrical safety.
*Sinus Tachycardia: When the rate of the SA node discharge is more than 100
beats/min. Patients may be asymptomatic except for an increased pulse rate, if
the rhythm is not well tolerated, they may have symptoms of instability.
*ACTION ALERT* Patients with sinus tachycardia assess for fatigue, weakness,
SOB, orthopnea, decreased oxygen saturation, increased pulse rate, and
decreased blood pressure, Also restlessness, anxiety from decreased cerebral
perfusion and decreased urine output from impaired renal perfusion. Patient may
also have anginal pain and palpitations. ECG pattern may show T-Wave in version
or ST segment elevation or depression in response to myocardial ischemia(when
heart doesn’t receive enough oxygen r/t reduced blood flow)
Teaching: Remind the patient to remain on bed rest id the tachycardia is causeing
hypotension or weakness. Teach the patient to avoid substances that increase
cardiac rate , including caffeine, alcohol, and nicotine. Help patients develop
stress management strategies.
*Premature Atrial Complex (contraction) (PAC): An atrial dysrhythmia, occurs
when atrial tissue becomes irritable. The premature P wave may not always be
clearly visible because it can be hidden in the preceding T wave. A PAC is usually
followed by a pause.
What causes a PAC? Stress, fatigue, anxiety, inflammation, infection, caffeine,
nicotine, alcohol, drugs such as epinephrine, sympathomimetics, amphetamines,
digoxin or anesthetic agents.
Chapter 28 Concepts of Care for Patients with Dysrhythmias
Bradydysrhythmia
HR is less than 60 beats/min, these rhythms can be significant because
myocardial oxygen demands is reduced from the slow HR, which can be
beneficial, coronary perfusion time may be adequate because of prolonged
diastole which is desirable, coronary perfusion pressure may decrease if the HR is
too slow to provide adequate cardiac output and blood pressure; this is a serious
consequence.
*The patient may tolerate this dysrhythmia if the BP is adequate
If BP is not adequate, symptomatic brady dysrhythmia may lead to myocardial
ischemia or infarction, dysrhythmias hypotension, and heart failure.
Common types of bradycardia caused by irregular heart rhythms:
Sinus Bradycardia: When the sinus node discharge rate is less than 60 beats/min.
What causes it? Excessive vagal (Parasympathetic) Stimulation to the heart causes
a decreased rate of sinus node discharge , may result from carotid sinus massage,
vomiting, suctioning, Valsalva maneuvers like bearing down for a bowel
movement or gagging., ocular pressure, or pain.
Assessment: Patient may be asymptomatic except for decreased pulse rate.
Assess the EHR to determine if the patient is taking meds that slow the HR. Assess
pt for: Syncope (blackouts or fainting), Dizziness or weakness, Confusion,
Hypotension, Diaphoresis, SOB, Chest pain.
Interventions: If the pt is stable, tx includes identification and tx of the underlying
cause. If the patient has any of the above symptoms and the cause cannot be
identified, the treatment is to administer drug therapy with IV atropine, increase
intravascular volume via IV fluids, and apply oxygen if O2 is less than 94% or the
patient is short of breath. Drugs that are suspected of causing bradycardia are
discontinued. If beta-blocker overdose is suspected, administration of glucagon
may help by increasing the HR and BP. If the heart rate does not increase enough.
Prepare the pt for transcutaneous or transvenous pacing to increase the HR.
*If the tx of the underlying cause does not restore normal sinus rhythm, the
patient will require permanent pacemaker implantation.
,Tachydysrhythmia
HR greater than 100 beats/min
A major concern for pts with coronary artery disease
Tachydysrhythmias are serious because they:
*Shorten the diastolic time and therefore the coronary perfusion time (The
amount of time available for blood to flow through the coronary arteries to the
myocardium)
*Initially increase cardiac output and BP(However, a continued rise in HR
decreases the ventricular filling time because of a shortened diastole, decreasing
the stroke volume
Common types of tachycardia caused by irregular heart rhythms:
*Atrial Fibrillation (A-Fib) MOST COMMON DYSRYTHMIA SEEN
*A chaotic rhythm with No clear P waves, no atrial contractions, loss of atrial kick,
and an irregular ventricular response. The atria merely quiver in fibrillation.
*Genetic and shows most commonly ages 35-40 most common to show up with
HTN, HF, CAD
*Risk Factors: HTN, a previous stroke, TIA, obesity, hyperthyroidism, CKD,
excessive alcohol use and mitral valve disease.
*Largely related to clotting concerns such as embolic stroke, DVT, or PE
History: Assess for prior hx of AF or other dysrhythmias. Reoccurrence of AF is
common.
Physical Assessment and S/S: Take apical pulse on apex of the heart for 1 full
minute with the BELL, pulse may be irregular. Check for signs of poor perfusion
such as faigue, weakness, SOB, dizziness, anxiety, syncope, palpitations, chest
discomfort, or pain and hypotension. Slurred speech is a sign of embolus that has
traveled to the brain.
Psychosocial Assessment: These patients tend to feel very anxious especially
those with high ventricular rate. With increased heart rate, cardiac output
decreases, which ca n crease dyspnea, contributing to feelings of anxiety. Assess
pts with chronic AF for methods of coping with a long term conduction issue,
patients who on chronic may have anxiety related to anticoagulation medications
and potential for emboli development.
How to get a definitive diagnosis? By obtaining a 12 lead ECG.
AF is classified in to 5 categories based on length of time in the rhythm:
Paroxysmal: an episode within 7 days converts back to sinus rhythm; episode
lenths vary but do not lat longer than a week.
,Persistent: Longer than 7 days
long standing persistent: Longer than 12 months
Permanent: Patients who remain in AF and a decision is made not to restore or
maintain sinus rhythm by either surgical or medical intervention.
Nonvalvular: occurs in the absence of mitral valve disease or repair.
*ACTION ALERT* If a pulmonary embolism is suspected, remain with the patient
and monitor for SOB, chest pain and/or hypotension. Initiate the RR team and
notify the provider.
Traditional interventions for AF include antidysrhythmic drugs to slow the
ventricular conduction or to concert the AF to normal sinus rhythm: Examples of
drugs to slow the conduction are calcium channel blockers such as diltiazem or for
more difficult to control AF, amiodarone. Dronedarone is a medication similar to
amiodarone, yet better tolerated for maintenance of sinus rhythm after a
cardioversion. But should NOT be used in patients with HF because it can cause an
exacerbation of cardiac symptoms OR in patients with permanent AF because it
increases the risk of stroke, MI, or cardiovascular death.
Beta Blockers: Such as metoprolol and esmolol, may also be used to slow
ventricular response. Digoxin I given for patients with HF AND AF. It is useful in
controlling the rate of ventricular response HOWEVER it does NOT convert AF to
sinus rhythm, carefully monitor the pulse rate od patients that are taking these
drugs.
Medications used for rhythm control of AF: flecainide, dofetilide, propafenone,
and ibutilide. These meds are usually started in the acute care setting because the
risk of prolonged QT intervals and bradycardia. Continuous EKG monitoring are
needed. Amiodarone is also used but not rq a an acute care stay.
If permanent AF Is present rhythm control antiarrhythmic meds should NOT be
used.
Although the goal is to concert pt from AF to sinus rhythm that may not be
possible for older adults . These patients require long term anticoagulant to
prevent stroke and thrombus formation. INR is required when a patient is taking
Warfarin.
Patient teaching: Importance of avoiding foods high in vitamin K, avoiding herbs
such as ginger, ginseng, goldenseal, gingko biloba, and st johns wort. Teach
importance of reporting bleeding, nose or gums or any other signs of bleeding to
PCP immediately. Teach pts and family generic names for their medications and
their purposes. Emphasize importance of reporting any dizziness, N/V and chest
discomfort or SOB. Educate meds should not be stopped abruptly. Teach t and
, family how to take BP and HR. Remind pts to report any signs of change in heart
rhythm such as a significant decrease in pulse rate or increase more that 100BPM
Preventing Heart Failure:
Electrical Cardioversion a synchronized countershock that may be performed to
restore normal conduction in a hospitalized patient with new-onset AF, can also
be scheduled electively for stable AF that is resistant to medical therapy.When
the onset of AF is greater than 48 hours, the patient must take anticoagulants for
at least 3 weeks(Or until the INR is 2-3) before the procedure to prevent clots
from moving from the heart to the brain or lungs. Emergency equipment must be
available during the procedure. The physician, APRN, or other qualified nurse
explains the procedure to the patient and the family. Help the pt sign a consent
form unless the procedure is an emergency for a life threatening dysrhythmia.
The patient is usually conscious a short acting anesthetic agent is administered for
sedation. For safety before cardioversion turn oxygen off and remove from
patient, fire could result shout “CLEAR” before shock delivery for electrical safety.
*Sinus Tachycardia: When the rate of the SA node discharge is more than 100
beats/min. Patients may be asymptomatic except for an increased pulse rate, if
the rhythm is not well tolerated, they may have symptoms of instability.
*ACTION ALERT* Patients with sinus tachycardia assess for fatigue, weakness,
SOB, orthopnea, decreased oxygen saturation, increased pulse rate, and
decreased blood pressure, Also restlessness, anxiety from decreased cerebral
perfusion and decreased urine output from impaired renal perfusion. Patient may
also have anginal pain and palpitations. ECG pattern may show T-Wave in version
or ST segment elevation or depression in response to myocardial ischemia(when
heart doesn’t receive enough oxygen r/t reduced blood flow)
Teaching: Remind the patient to remain on bed rest id the tachycardia is causeing
hypotension or weakness. Teach the patient to avoid substances that increase
cardiac rate , including caffeine, alcohol, and nicotine. Help patients develop
stress management strategies.
*Premature Atrial Complex (contraction) (PAC): An atrial dysrhythmia, occurs
when atrial tissue becomes irritable. The premature P wave may not always be
clearly visible because it can be hidden in the preceding T wave. A PAC is usually
followed by a pause.
What causes a PAC? Stress, fatigue, anxiety, inflammation, infection, caffeine,
nicotine, alcohol, drugs such as epinephrine, sympathomimetics, amphetamines,
digoxin or anesthetic agents.
