UNIVERSITY OF THE BAHAMAS

School of Nursing and Allied Health Professions

NURS228 Adult Nursing I Lecture

CHAPTER 27
MANAGEMENT OF PATIENTS WITH
DYSRHYTHMIAS AND
CONDUCTION PROBLEMS

Shamel Y. Sands RN, MSN, CM

Assistant Professor, SNAHP, UB
OBJECTIVES
REVIEW CONDUCTION SYSTEM OF THE HEART.
DEFINE DYSRHYTHMIA.
OUTLINE THE RELATIONSHIP BETWEEN THE ECG COMPLEX,
ELECTRICAL IMPULSE AND THE LEAD SYSTEM.
DISCUSS THE NORMAL CARDIAC RHYTHMS.
DISCUSS ABNORMAL CARIAC RHYTHMS.
UTILIZE THE NURSING PROCESS TO FORMULATE A PLAN OF CARE
FOR A PATIENT WITH A DYSRHYTHMIA.
DYSRHYTHMIAS
Disorders of formation or conduction (or both) of electrical impulses
within heart
Can cause disturbances of
 Rate
 Rhythm
 Both rate, rhythm

Potentially can alter blood flow, cause hemodynamic changes

Diagnosed by analysis of electrographic waveform
RELATIONSHIP OF ECG COMPLEX, LEAD
SYSTEM, AND ELECTRICAL IMPULSE
ECG GRAPH AND COMMONLY MEASURED
COMPONENTS
HEART RATE DETERMINATION
NORMAL SINUS RHYTHM
SINUS BRADYCARDIA
SINUS TACHYCARDIA
SINUS ARRHYTHMIA
PREMATURE ATRIAL COMPLEXES
ATRIAL FLUTTER
ATRIAL FIBRILLATION
MULTIFOCAL PVCS-QUADRIGEMINY
VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILLATION
ASYSTOLE
FIRST DEGREE AV BLOCK
SECOND DEGREE AV BLOCK, TYPE I
SECOND DEGREE AV BLOCK, TYPE II
THIRD DEGREE AV BLOCK
NURSING PROCESS: CARE OF THE PATIENT
WITH A DYSRHYTHMIA - ASSESSMENT
Assess indicators of cardiac output and oxygenation, especially
changes in level of consciousness
Physical assessment include
 Rate, rhythm of apical, peripheral pulses
 Heart sounds
 Blood pressure, pulse pressure
 Signs of fluid retention
NURSING PROCESS: CARE OF THE PATIENT
WITH A DYSRHYTHMIA – ASSESSMENT
(CONT’D)
Health history: include presence of coexisting conditions, indications of
previous occurrence
Medications
NURSING PROCESS: CARE OF THE PATIENT
WITH A DYSRHYTHMIA - DIAGNOSES
Decrease cardiac output
Anxiety
Deficient knowledge
COLLABORATIVE PROBLEMS/POTENTIAL
COMPLICATIONS
Cardiac arrest
Heart failure
Thromboembolic event, especially with atrial fibrillation
NURSING PROCESS: CARE OF THE PATIENT
WITH A DYSRHYTHMIA - PLANNING
Goals
 Eradicating or decreasing occurrence of dysrhythmia to maintain cardiac output
 Minimizing anxiety
 Acquiring knowledge about dysrhythmia, its treatment
DECREASED CARDIAC OUTPUT
Monitoring
 ECG monitoring
 Assessment of signs, symptoms

Administration of medications, assessment of medication effects

Adjunct therapy: cardioversion, defibrillation, pacemakers
OTHER INTERVENTIONS
Anxiety
 Use calm, reassuring manner
 Measures to maximize patient control to make episodes less threatening
 Communication, teaching

Teaching self-care
 Include family in teaching
PACEMAKERS
Electronic device that provides electrical stimuli to heart muscle
Types
 Permanent
 Temporary

NASPE-BPEG code for pacemaker function

ECG-ON DEMAND PACING
 COMPLICATIONS OF PACEMAKER USE

Infection
Bleeding or hematoma formation
Dislocation of lead
Skeletal muscle or phrenic nerve stimulation
Cardiac tamponade
Pacemaker malfunction
NURSING PROCESS: CARE OF THE PATIENT WITH AN
IMPLANTED CARDIAC DEVICE - ASSESSMENT
Device function: ECG
Cardiac output, hemodynamic stability
Incision site
Coping
Patient, family knowledge
 NURSING PROCESS: CARE OF THE PATIENT
WITH AN IMPLANTED CARDIAC DEVICE -
DIAGNOSES
Risk for infection
Risk for ineffective coping
Knowledge deficient
 NURSING PROCESS: CARE OF THE PATIENT
WITH AN IMPLANTED CARDIAC DEVICE -
PLANNING
Goals
 Absence of infection
 Adherence to self-care program
 Effective coping
 Maintenance of device function
 INTERVENTIONS
Risk for ineffective coping
 Support of patient, family coping
 Setting of realistic goals
 Allow patient to talk, share feelings, experiences
 Support groups or referral
 Stress-reduction techniques

Knowledge deficient
 Patient, family teaching
CARDIOVERSION AND DEFIBRILLATION
Treat tachydysrhythmias by delivering electrical current that
depolarizes critical mass of myocardial ceils
 When cells repolarize, sinus node usually able to recapture role as heart pacemaker

In cardioversion, current delivery synchronized with patient’s ECG

In defibrillation, current delivery is unsynchronized
SAFETY MEASURES
Assure good contact between skin, pads or paddles
 Use conductive medium, 20 to 25 pounds of pressure

Place paddles so they do not touch bedding or clothing, are not near
medication patches or oxygen flow
If cardioverting, turn synchronizer on
If defibrillating, turn synchronizer off
SAFETY MEASURES (CONT’D)
Do not charge device until ready to shock
Call “clear” three times; follow checks required for clear
 Assure no one is in contact with patient, bed, or equipment
 IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR (ICD)
Device that detects, terminates life-threatening episodes of tachycardia or
fibrillation
NASPE-BPEG code
Antitachycardia pacing
INVASIVE METHODS TO DIAGNOSE AND
TREAT RECURRENT DYSRHYTHMIAS
Electrophysiologic studies
Cardiac conduction surgery
 Maze procedure
 Catheter ablation therapy
REFERENCE
Smelter, S. C., Bare, B. G., Hinkle, J. L. & Cheever, K. H.
(2014). Brunner & Suddarth's textbook of medical-surgical
nursing (Edition 13.). Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.