NUR3111 Care of People with Non-

Communicable Disease (I)

Dysrhythmias
Objectives
1. Define dysrhythmias
2. Identify causes of dysrhythmias
3. Discuss various types of dysrhythmias
4. Understanding the pathophysiology of
dysrhythmias
5. Describe clinical manifestations of dysrhythmias
6. Identify diagnostic tests for dysrhythmias
7. Discuss medical care for dysrhythmias
8. Discuss nursing care plan for dysrhythmias
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H.
(2016). Brunner and Suddarth’s Textbook of Medical
Surgical Nursing. (14th Ed.). Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins.
Chapter 26, p. 692-713
 Important Concept:

◆ The electrical stimulation of the muscle cells

contraction DEPOLARIZATION.

◆ Atrial contraction (“atrial kick”) 25-30% of the

ejected blood volume during ventricular contraction
(Cardiac output).

◆ Relaxation REPOLARIZATION.

◆ Stimulation of the sympathetic system increased

heart rate and the force of myocardial contraction
increased heart workload 5
 Disorders of the conduction of electrical impulse within the heart

Definition
•Overstimulation
•Block
•Unknown
•Heredity
•Cardiac problems Causes Dysrhythmias Types
•Atrial
•Nodal
Consequences •Ventricular

Hemodynamics Rhythm or rate Other cardiac

problems
Reduced CO
Too fast Too slow •AMI
•Shock
 Diagnostic Tests and Treatments

➢ Physical /health assessment

➢ Continuous ECG monitoring
➢ 12-Lead ECG
➢ Holter ECG
➢ Echocardiogram
➢ Electrophysiology Studies (EPS)
 Diagnostic Tests and Treatments
➢ Holter ECG
 Diagnostic Tests and Treatments

➢ Echocardiogram
 Diagnostic Tests and Treatments

Electrophysiology Study (EPS)

 Important Concepts
• All dysrhythmias with NO signs and symptoms
or potential complications may not need any
treatments.

• Signs and symptoms are usually related to

inadequate cardiac output.

• Treatment mainly targets on restoration of

cardiac function, treatment of underlying causes,
and prevention of complications.
 Sinus Rhythm (SR)

• Rate: PP interval: Regular

• RR interval: Regular
• P wave: normal and consistent shape
• PR: 0.12 – 0.2 sec
• QRS: narrow (normal)
• P:QRS ratio: 1:1
Sinus Bradycardia (SB)

• Rate: <60 bpm

• PP interval: Regular
• RR interval: Regular
• P wave: normal and present
• PR: 0.12 – 0.2 sec
• QRS: narrow(normal)
• P:QRS ratio: 1:1
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Causes:
• Low metabolic needs
• Medications
Definition:
• Increased ICP The automaticity is slow;
• MI heart rate is slower than
• Hypoxia 60/min.
• Hypovolemia
• Hypothermia
• Toxins
• Tension pneumothorax
• Vagal stimulation (vomiting, SB
suctioning, severe pain,
extreme emotions) Treatment:
• No treatment
• Atropine
• Vasopressor/Inotropes
(Dopamine/Dobutamine)
• Transcutaneous pacing

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 Treatments
➢ Atropine (0.5mg bolus; repeat every 3-5 mins;
max dose: 3mg)
Action: increase automatic stimulation to increase
HR

Side effect (S/E): Dryness of the mouth, blurred

vision, photophobia and tachycardia

Nursing consideration: IV access available, Normal

saline (NS) flush
 Treatments
➢ Vasopressor (Dopamine, Dobutamine, Epinephrine) (2-
10 mcg/kg/min)
Action: stimulate and increase the strength of heart muscle
contraction causing the heart rate to increase

Side effect (S/E): Hypertension, tachycardia, and chest pain

Nursing consideration:
1) IV access available;
2) must be diluted and administered through IV infusion;
3) Must check the blood pressure
4) should not be administered in the presence of
uncorrected tachyarrhythmias or ventricular fibrillation
Pacemaker/transcutaneous pacing

Temporary Permanent
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 Treatments
Transcutaneous Pacing:
Action: to regular heart beats by delivering
electrical pulses

S/E: invasive procedure; device malfunction

Nursing consideration: pre and post-operative care,

wound infection, pacing abnormalities.
Sinus Tachycardia (ST)

• Rate: >100 bpm

• PP interval: Regular
• RR interval: Regular
• P wave: normal and present
• PR: 0.12 – 0.2 sec
• QRS: narrow
• P:QRS ratio: 1:1
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 Definition:
Causes: The automaticity is fast;
• Increased metabolic the heart rate is faster
needs than 100/min.
• Psychological stress
• Medications
• Hypotension Treatment:
• No treatment
ST • Medication (ß-blockers
and Calcium blockers)
• Catheter ablation
• Treat POTS: Increased
fluid and sodium intake
and use of anti-
embolism stockings.

POTS: Postural Orthostatic Tachycardia Syndrome

-- is an abnormal increase in heart rate after sitting or
standing up 20
Arrhythmias in atrium
Atrial Flutter

• PP interval: Regular
• Atrial rate: 250 – 400 bpm
• RR interval: regular
• Ventricular rate: variable; 75-150 bpm
• P wave: Saw-toothed (F waves)
• QRS: narrow
• PR interval: cannot be measured
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• F:QRS ratio: 2:1, 3:1 or 4:1
 Definition:
A conduction defect in the atrium and
causes a rapid, regular atrial rate, usually
Causes: between 250 and 400 times per minute.
• COAD
• Valvular disease Treatment:
• Thyrotoxicosis Atrial • No treatment
• Open heart surgery Flutter • Vagal maneuvers
• Repair of congenital defects • Administration of adenosine
• Cardioversion
• Beta-/ Calcium blockers
• Digitalis
**Impaired ventricular function: Verapamil, • *Catheter ablation
Bronchospasm: beta-blockers • Anti-arrhythmic medications
AV block: Verapamil and beta-blockers and anticoagulants
 Atrial Fibrillation

• RR interval: irregular
• Ventricular rate: variable
• P wave: unable to identify or absent
(fibrillation waves), or f waves
• QRS: narrow
• PR interval: cannot be measured
• f:QRS ratio: x:1
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Causes:
Definition:
• Valvular disease An uncoordinated atrial electrical activation that causes a rapid,
• Inflammatory cardiac diseases disorganized, and uncoordinated twitching of atrial musculature
• CAD
• HT
• HF
• DM Treatment:
• Obesity • No treatment
• Vagal maneuvers
• Hyperthyroidism AF • Administration of adenosine
• Pheochromocytoma
• Pulmonary HT • Cardioversion+/- Beta-blockers
• Warfarin for preventing
embolism
• Amiodarone
• Digoxin
• Procainamide
• *Catheter ablation

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• Aims to increase
parasympathetic
stimulation
causing slower
conduction
through AV node
and blocking
reentry of the
rerouted impulse.
• Vagal maneuver:
Carotid sinus
massage, gagging,
breath holding

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 Antiarrhythmic agent (tachycardia)
Name Adenosine (1st dose: 6mg rapid IV
push and followed with NS flush;
2nd dose: 12mg if needed)

Action Normalize heartbeat by slowing the

electrical conduction in the heart
Side effect Dizziness; flushing; headache; light-
headedness; stomach pain
Nursing Very short action
consideration IV access must be available

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 Antiarrhythmic medications
Class Drug name
IA Quinidine, Procainamide
IB Lidocaine

IC Flecainide
II Atenolol, Labetalol, Metoprolol, Propanolol,
Sotalol
III Amiodarone

IV Verapamil, Diltiazem
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 Antiarrhythmic medications
II Atenolol, Labetalol, Metoprolol, Propanolol, Sotalol
Action Decreases automaticity and conduction
Treats atrial and ventricular dysrhythmias
Side effect Bradycardia, AV block
Decreased contractility; Bronchospasm
Nausea
Asymptomatic and symptomatic hypotension
Masks hypoglycemia and thyrotoxicosis
CNS disturbances (eg, confusion, dizziness, fatigue,
depression)
Nursing Monitor heart rate, BP, PR interval, signs and symptoms of
consideration HF, especially in those also taking calcium channel blockers
Monitor blood glucose level in patients with type 2
diabetes mellitus
Caution the patient about abrupt withdrawal to avoid
tachycardia, hypertension, and myocardial ischemia
29
 Antiarrhythmic medications
III Amiodarone

Action Prolongs repolarization

Amiodarone treats and prevents ventricular and atrial
dysrhythmias, especially in patients with ventricular
dysfunction
Side effect **Pulmonary toxicity …..Lung function test
Corneal microdeposits
Photosensitivity
Bradycardia, Hypotension, especially with IV administration
Nausea and vomiting
Potentiates digoxin
Nursing Make sure patient is sent for baseline pulmonary function
consideration tests
Fall precaution if IV administration
Assess for digoxin toxicity prior to administration
Monitor QT duration
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 Antiarrhythmic agent (tachycardia)
Name Digoxin

Action Improves contractility, increasing left

ventricular output, which also enhances
diuresis.
Side effect Digoxin toxicity
Nursing i) check digoxin level, ii) S/S of digoxin
consideration toxicity; iii) HR before
administration; withhold if HR <60/min;
iv) Vital signs especially bradycardia

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32
Cardioversion

Because of the high risk of

embolization of atrial thrombi,
cardioversion of atrial fibrillation
that has lasted longer than 48
hours should be avoided unless
the patient has received warfarin
for at least 3 to 4 weeks prior to
cardioversion.
 Cardioversion Defibrillation
Patients Need to be sedated In coma or unconsciousness
Aim • Convert fast arrhythmia • Stimulate normal electrical
to normal rhythm conduction
• Therapeutic use • Life-saving support or
resuscitation
Energy use Low dosage / 50-200J High dosage /200-360J
Synchronization Yes No
to be used
Rhythm Fast arrhythmias such as Life-threatening arrhythmias
atrial flutter, atrial such as ventricular tachycardia,
fibrillation ventricular fibrillation

Application May or may not be a Emergency treatment

scheduled treatment

Informed Consent Yes No

 EPS & Catheter ablation

• Aim to
eliminate the
area of
rerouting
 Atrial Arrhythmias
• Premature atrial contraction (PAC)

• Atrial Flutter

• Atrial fibrillation (AF)

Arrhythmias in nodal /AV
 Junctional Rhythm

• RR interval: regular
• Ventricular rate: 40 to 60
• P wave: absent or inverted
• QRS: narrow
• PR interval: < 0.12 secs
• P:QRS ratio: 1:1

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Causes: Definition:
• Unknown An impulse occurs at the AV node,
• Digitalis toxicity instead of the sinus node.
• HF Treatment:
• CAD
JR • No treatment
• Medication
• Pacemaker

39
 Atrioventricular Nodal Reentry
Tachycardia (AVNRT)

• PP interval: should be regular

• Atrial rate: should be 150 to 250
• RR interval: regular
• Ventricular rate: 120 to 200
• P wave: difficult to discern
• QRS: usually normal, but may be narrow
• PR interval: if present, <0.12 sec
• P:QRS ratio: 1:1, 2:1
• Remarks: Sudden onset and termination
40
Causes: Definition:
• Caffeine An impulse is conducted to an area in the AV node that
• Nicotine causes the impulse to be rerouted back into the same area
• Hypoxemia over and over again at a very fast rate.
• Stress Treatment:
• CAD • Catheter ablation
• HF AVNRT • Vagal maneuver
• Structural heart diseases • Adenosine
• Cardioversion
For recurrent cases:
• Verapamil , diltiazem
• Procainamide
• Amiodarone
• Propranolol

41
Management of Tachycardia
• Stable
• Vagal Maneuver (i.e. Valsalva Maneuver)
• Adenosine triphosphate (ATP)
- Short effect
• Beta blocker
• Calcium Blocker
• Unstable
• Synchronized Cardioversion
• https://www.youtube.com/watch?v=d7ymmR8WuYE

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Arrhythmias in Ventricle
Premature Ventricular Contraction
(PVC)

• Beware R on T phenomenon
• Atrial rate: depends on the number of PVCs
• RR interval: irregular
• Ventricular rate: depends on the number of PVCs
• P wave: Depends on the timing of PVCs; may be
absent
• QRS: usually normal or longer; shape can be
bizzare and abnormal especially if not following
normal P waves
• PR interval: if present, <0.12 sec
44
• P:QRS ratio: 0:1, 1:1
Causes:
• Unknown
• Caffeine Definition:
• Nicotine An impulse starts in a ventricle and is conducted through the
• Alcohol ventricles before the next normal sinus impulse.
• MI
• HF Treatment:
• Digitalis toxicity • Untreated
• Hypoxia PVC • Treat underlying causes
• Hypovolemia
• Acidosis
• Electrolytes imbalance

45
 Ventricular Tachycardia (VT)

• Ventricular rate: 100 to 200

• Ventricular rhythm: regular
• QRS: > 0.12 sec, bizarre
• P wave: obscured
• P:QRS ratio: fusion
complexes

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Causes: (more serious)
• Unknown
• Caffeine
Definition:
• Nicotine Three or more PVCs in a row (short run VT), occurring at a
• Alcohol rate exceeding 100/min.
• MI Treatment:
• HF • Antiarrhythmic medications
• Digitalis toxicity VT • Treat underlying causes
• Hypoxia • Cardioversion
• Hypovolemia • Defibrillation
• Acidosis • ICD
• Electrolytes imbalance

47
Ventricular Fibrillation (VF)

• Ventricular rate: > 300

bpm
• Ventricular rhythm:
irregular
• QRS: irregular shape
without pattern
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Causes: (more serious) Definition:
• Unknown A rapid, disorganized ventricular rhythm that causes
• Caffeine ineffective quivering of the ventricles.
• Nicotine
• Alcohol
Treatment:
• MI • Antiarrhythmic medications
• HF
VF • Treat underlying causes
• Digitalis toxicity • Cardioversion
• Hypoxia • Defibrillation
• Hypovolemia • ICD
• Acidosis
• Electrolytes imbalance

49
 Idioventricular Rhythm (IVR)

Ventricular rate: 20-40

Ventricular rhythm: regular
QRS shape and duration: Bizarre, abnormal shape; duration is 0.12 seconds
or more

50
 Definition:
An impulse starts in the conduction system below the AV node.
Treatment:
IVR • Resuscitation
• IV epinephrine
• Atropine
• Vasopressor
• Emergency pacing

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Asystole

Flat line

52
Causes:
• Hypoxia
Definition:
• Acidosis
• Severe electrolytes
Absent QRS complexes confirmed in two
imbalance different leads, although P waves may be
• Drug overdose apparent for a short duration.
• Hypovolemia Treatment: (no use)
• Cardiac tamponade • Resuscitation
• Tension pneumothorax Asystole • Atropine
• Coronary or pulmonary • Epinephrine
thrombosis
• Trauma
• Hypothermia

53
Management of Pulseless Arrest
CPR

• Chest compression
• +/ - Defibrillation
Post-resuscitation Care
• Hypothermic Therapy

• Mechanical respiratory support

• Circulatory/hemodynamic support

• If VT/VF-caused- ICD implantation

 Ventricular Arrhythmias

• Premature Ventricular Contraction (PVC)

• Ventricular Tachycardia (VT)

• Ventricular Fibrillation (VF)

• Idioventricular Rhythm (IVR)

 • No treatment
Tachycardia • Medication
(fast: ß blockers;
Sinus Rhythm slow: atropine)
(SA node) • Too slow: pacing
Bradycardia
• No treatment
Too fast:
• vagal maneuver Atrium
Flutter • IV Adenosine (ATP)
• Cardioversion
Atrial • EPS + catheter ablation
• Antiarrhythmic drugs/ ß
Fibrillation or calcium blockers
• Warfarin (AF and atrial
flutter only)
• No treatment
JR Too slow
Junctional • Medication AV node/bundle of His
• Pacing
AVNRT Too fast: same as above

Depending on the frequency

PVC and signs and symptoms
(S/S)
Tachycardia (VT) • Resuscitation
Ventricular • Atropine Ventricle
Fibrillation (VF) • Antiarrhythmic drugs
• Epinephrine
IVR • Vasopressor
• ICD
Asystole/Flat line
Common hemodynamic responses/ consequences due to dysrhythmia

1) Cardiac output (CO) = Stroke volume (SV) X Heart rate (HR)

2) Bradycardia decreases CO due to slow HR
3) Tachycardia decreases CO due to inadequate filling time within ventricles

Inadequate CO

Stimulation of sympathetic Inadequate blood

nervous system supply to vital organs

Increased BP, P, RR Ischemia

Serious health problems

 Nursing Management
• Provide life support if necessary
• Provide comprehensive assessment and assist investigations such
as Echocardiogram, Stress exercise
• Basic assessment: Continuous ECG monitoring and 12 Lead ECG
• Psychological support : anxiety
• Complete Bedrest: reduce cardiac workload
• Reduce/remove underlying causes
• Symptoms relief, esp. chest pain and reduced cardiac output
• Medication administration as ordered
• Other medical adjuncts such as cardioversion, defibrillation,
Pacemaker, ICD, or
• Surgical treatment such as EPS and catheter ablation
• Prevent complications and deterioration such as cardiogenic
shock, sudden cardiac death
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 First degree heart block

• Ventricular and atrial rate: Depends on the underlying rhythm

• Ventricular and atrial rhythm: Depends on the underlying
rhythm
• QRS shape and duration: Usually normal, but may be abnormal
• P wave: In front of the QRS complex; shows sinus rhythm,
regular shape
• PR interval: Consistently greater than 0.20 seconds
• P:QRS ratio:1:1.

60
Second degree heart block Type 1

• Progressively lengthening PR interval until a missed

QRS

61
 Second degree heart block Type 2

• Normal PR interval, Regular P

• Unpredicted absence of QRS

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Third degree heart block/ Complete heart block

•NO Association between P and QRS (Atrial and ventricular contraction)

•Ventricular and atrial rate: Depends on the escape rhythm and underlying atrial rhythm
•Ventricular and atrial rhythm: The PP interval is regular and the RR interval is regular, but the PP
interval is not equal to the RR interval
•QRS shape and duration: Depends on the escape rhythm; with junctional rhythm, QRS shape and
duration are usually normal; with idioventricular rhythm, QRS shape and duration are usually
abnormal
•P wave: Depends on underlying rhythm
•PR interval: Very irregular
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•P:QRS ratio: More P waves than QRS complexes
Management of Bradycardia

• Atropine IV
• Pacemaker (temporary /permanent)

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 Heart /AV Blocks

• First degree heart block

• Second degree heart block Type I

• Second degree heart block Type II

• Third heart block/ Complete heart block

A patient is admitted due to chest discomfort
and shortness of breath. ECG is performed and
bradycardia (~40bpm) is found. He appears very
anxious.

Illustrate a care plan with 2 ACTUAL problems.