Generally, minor dysrhythmias are monitored and treated in the community setting; however, potential life- threatening situations (including heart rates above 150 beats per minute) may require a short inpatient stay.
RELATED CONCERNS
Acute coronary syndrome, page 54 Angina, chronic/stable, page 64 Heart failure: chronic, page 38 Myo car dial infarction, page 72 Psychosocial aspects of care, page 835
CHAPTER 2 Cardiovascular: Dysrhythmias
D I A G N O S T I C D I V I S I O N
M A Y R E P O R T M A Y E X H I B I T
Activity/Rest
• Generalized weakness
• Exertional fatigue
• Changes in heart rate/blood pressure (BP) with activity or exercise
Circulation
• History of previous or acute MI (90% to 95% experience dysrhythmias), cardiac surgery, cardiomyopathy, rheumatic heart disease and heart failure (HF), valvular heart disease, long- standing hypertension, use of pacemaker
• BP changes (hypertension or hypotension) during episodes of dysrhythmia
• Pulse: Fast, slow, or irregular; palpitations, skipped beats • Pulses may be irregular, for example, skipped beats, pulsus alternans, bigeminal pulse
• Pulse defi cit
• Heart sounds: Irregular rhythm, extra sounds, dropped beats
• Skin color and moisture changes, such as pallor, cyanosis, diaphoresis (HF, shock)
• Edema dependent, generalized, jugular vein distention (JVD) (in presence of HF)
• Urine output decreased if cardiac output is severely diminished
Ego Integrity
• Feeling ner vous (certain tachydysrhythmias), sense of impend- ing doom
• Anxiety, fear, withdrawal, anger, irritability, crying
• Denial of health prob lems
• Stressors related to current medical prob lems
Food/Fluid
• Loss of appetite, anorexia • Weight gain or loss
• Food intolerance (with certain medi cations) • Edema
• Nausea or vomiting • Changes in skin moisture or turgor
• Changes in weight • Lung sounds have crackles
Neurosensory
• Dizzy spells, sudden fainting
• Headaches
• Numbness or tingling of fi n gers or toes
• Mental status or sensorium changes, such as disorientation, confusion, loss of memory; changes in usual speech pattern and consciousness, stupor, coma
• Behavioral changes, such as combativeness, lethargy, hallucinations
• Pupil changes (equality and reaction to light)
• Loss of deep tendon refl exes with life- threatening dysrhyth- mias (VT, severe bradycardia)
Pain/Discomfort
• Chest pain (mild to severe) that may or may not be relieved by antianginal medi cation
• Distraction be hav iors, such as restlessness
Respiration
• Shortness of breath
• Chronic lung disease
• History of or current tobacco use
• Changes in respiratory rate and depth during dysrhythmia episode
• Breath sounds: Adventitious sounds such as crackles, rhonchi, or wheezing, indicating respiratory complications, such as left- sided heart failure (pulmonary edema) or pulmonary thromboembolic phenomena
• Coughing with or without sputum production
• Abnormal pulse oximetry or blood gases C L I E N T A S S E S S M E N T D A T A B A S E
T E S T
W H Y I T I S D O N E W H A T I T T E L L S M E
• Electrocardiogram (ECG): Rec ords electrical activity of the heart (snapshot view of one point in time).
Mea sures how long it takes for impulses to travel through the atria, the conduction system, and the ventricles. Identifi es when hypoxia (e.g., due to coronary artery obstruction or myo car dial muscle damage) and imbalance of electrolytes (e.g., potassium, magnesium, and calcium) are affecting cardiac rhythm and contractility. Note: Exercise ECG reveals dysrhythmias occurring only when client is not at rest (can be diagnostic for cardiac cause of syncope).
• Holter monitor: Extended ECG tracing (24 hours to weeks). May be used to determine which dysrhythmias occur intermit- tently or may be causing specifi c symptoms (e.g., sudden fainting [syncope] or bradycardia only when client is at rest).
May also be used to evaluate pacemaker function, antidys- rhythmic drug effect, or effectiveness of cardiac rehabilitation.
• Trans- telephonic event monitor: (may be either implantable [loop memory] or external [transient symptoms event]
recorder).
Helps diagnose why a person may be having palpitations or fainting spells, especially if these symptoms don’t happen often. Results are transmitted telephonically or downloaded to a remote computer for rapid interpretation.
• Signal- averaged ECG (SAECG): Multiple ECG tracings are obtained over a period of approximately 20 minutes evaluating several hundred cardiac cycles.
May be done to detect subtle cardiac abnormalities that increase risk for dysrhythmias or for further evaluation of dysrhythmias noted on resting ECG.
M A Y R E P O R T (continued) M A Y E X H I B I T (continued)
Safety
• Fever
• Skin: Rashes (medi cation reaction)
• Loss of muscle tone and strength
Teaching/Learning
• Familial risk factors, such as heart disease, stroke
• Use or misuse of prescribed medi cations, such as heart medi cations, anticoagulants, or over- the- counter (OTC) medi cations, for example, cough syrup, analgesics containing aspirin (ASA), and decongestants
• Use of vitamins and herbal supplements for heart rhythm, such as belladonna, camphor, dong quai, ginseng, goldenseal
• Stimulant abuse, including caffeine and nicotine; street drugs, including cocaine derivatives, methamphetamines, ecstasy, inhalants
• Lack of understanding about disease pro cess and therapeutic regimen
• Evidence of failure to improve, such as recurrent or intractable dysrhythmias that are life- threatening
Discharge Plan Considerations
• Alteration of medi cation use and therapy
• Anticoagulant or digitalis toxicity precautions
• Teaching regarding pacemaker or other device
➧ Refer to section at end of plan for postdischarge considerations.
D I A G N O S T I C S T U D I E S ( A M E R I C A N H E A R T A S S O C I A T I O N [ A H A ] , 2 0 1 6 B )
(continues on page 90)
CHAPTER 2 Cardiovascular: Dysrhythmias
DISCHARGE GOALS
1. Free of life- threatening dysrhythmias and complications of impaired cardiac output and tissue perfusion.
2. Anxiety reduced and managed.
3. Disease pro cess, therapy needs, and prevention of com- plications understood.
4. Plan in place to meet needs after discharge.
NURSING PRIORITIES
1. Prevent or treat life- threatening dysrhythmias.
2. Support client and signifi cant other (SO) in dealing with anxiety and fear of potentially life- threatening situation.
3. Assist in identifi cation of cause or precipitating factors.
4. Review information regarding condition, prognosis, and treatment regimen.
W H Y I T I S D O N E (continued) W H A T I T T E L L S M E (continued)
Can help identify irregularities that can lead to sudden cardiac death in patients at risk, such as those with hypertrophic cardiomyopathy.
• Transthoracic echocardiography (TTE): Employs ultrasound waves to show heart’s size, structure, and motion.
Can rapidly provide visual information about dysrhythmia’s location and effect on cardiac function.