Management of Patients With Dysrhythmias and
Conduction Problems o Same with normal sinus rhythm except
Definition of Terms:
 Depolarization - Electrical Stimulation
 Systole - Mechanical Contraction
 Repolarization - Electrical Relaxation
 Diastole - Mechanical Relaxation
Normal Sinus Rhythm
 electrical impulse starts at a regular rate and
rhythm in the SA node and travels through the
normal conduction pathway
Characteristics of Normal Sinus Rhythm
 Ventricular and atrial rate: 60 to 100 bpm
 Ventricular and atrial rhythm: Regular
 QRS shape and duration: Usually normal
 P wave: Normal and consistent shape; always in
front of the QRS
 PR interval: Consistent interval between 0.12
and 0.20 seconds
 P:QRS ratio: 1:1
Dysrhythmias
 disorders of the formation or conduction (or
both) of the electrical impulse within the heart
 diagnosed by analyzing the ECG waveform
 treatment is based on the frequency and
severity of symptoms produced
 named according to the site of origin of the
electrical impulse and the mechanism of
formation or conduction involved
Types of Dysrhythmias:
 Sinus
 Atrial
 Junctional
 Ventricular
Sinus Dysrhythmias
A. Sinus Bradycardia
 SA node creates an impulse at a slower-than-
normal rate
Characteristics:
Ventricular and atrial rate which is Less than 60
Management:
o depends on the cause and symptoms
o If there are signs and symptoms of clinical
instability (acute alteration in mental status,
chest discomfort, hypotension)
Rapid IV bolus of 0.5 mg of atropine
Repeated every 3 to 5 minutes
Until maximum dosage of 3 mg
Administer O2 as prescribed for
symptomatic
 If unresponsive to atropine
o Emergency transcutaneous pacing
o Catecholamines (dopamine or
epinephrine)
B. Sinus Tachycardia
 sinus node creates an impulse at a faster-than-
normal rate
Characteristics:
o Same with normal sinus rhythm except
Ventricular and atrial rate which is greater than
100, but usually lesser than 120
Heart rate increases
Diastolic filling time decreases
Reduced cardiac output
Syncope and low blood pressure
Management:
o determined by the severity of symptoms
o directed at identifying and abolishing its cause
o Synchronized cardioversion - treatment of
choice if persistent and causing hemodynamic
instability
o Vagal maneuvers
Carotid sinus massage
Gagging
Bearing down against a closed glottis
Forceful and sustained coughing
Applying a cold stimulus to the face
o Beta-blockers and calcium channel blockers
 o Adenosine (Adenocard)
o Procainamide (Pronestyl), amiodarone, and
sotalol (Betapace)
C. Sinus Arrhythmia
 sinus node creates an impulse at an irregular
rhythm
 rate usually increases with inspiration and
decreases with expiration
Characteristics:
 Same with normal sinus rhythm except
Ventricular and atrial rhythm: Irregular
Management:
 Sinus arrhythmia does not cause any significant
hemodynamic effect and therefore is not
typically treated.
Atrial Dysrhythmias
A. Atrial Fibrillation
 most common sustained dysrhythmia
 rapid, disorganized, and uncoordinated twitching
of the atrial musculature causing the atria to
quiver or fibrillate instead of fully squeezing. As a
result, blood is collected in atria increasing the
risk for clot formation
 Rapid and irregular ventricular response reduces
the time for ventricular filling, resulting in a
smaller stroke volume
 Risk of heart failure, myocardial ischemia, and
embolic events such as stroke
Characteristics:
 Ventricular and atrial rate: Atrial rate is 300 to
600 bpm; ventricular rate is usually 120 to 200
bpm in untreated atrial fibrillation
 Ventricular and atrial rhythm: Highly irregular
 P wave: No discernible P waves; irregular
undulating waves that vary in amplitude and
shape are seen and referred to as fibrillatory or
f waves
 PR interval: Cannot be measured
 P:QRS ratio: Many:1
Management:
 Antithrombotic Medications
o Anticoagulants and antiplatelet drugs -
to reduce risk of embolic stroke
o Patients with low stroke risk – Aspirin
o Patients with at least moderate risk -
warfarin (Coumadin)
 Administer O2 as prescribed
 Medications That Control the Heart Rate
o Beta-blocker
o Calcium channel blocker
 Medications That Convert the Heart Rhythm or
Prevent Atrial Fibrillation
o Flecainide, propafenone, amiodarone,
dofetilide, or sotalol
 Cardioversion
B. Atrial Flutter
 conduction defect in the atrium and causes a
rapid, regular atrial impulse at a rate between
250 and 400 bpm
 Atrial rate is faster than the AV node can
conduct, not all atrial impulses are conducted
into the ventricle, causing a therapeutic block
at the AV node
Characteristics:
 Ventricular and atrial rate: Atrial rate ranges
between 250 and 400 bpm; ventricular rate
usually ranges between 75 and 150 bpm.
 P wave: Saw-toothed shape; these waves are
referred to as F waves.
 PR interval: Multiple F waves may make it difficult
to determine thePR interval.
 P:QRS ratio: 2:1, 3:1, or 4:1
Management:
 Can cause chest pain, shortness of breath, and
low blood pressure
 Adenosine
o causes sympathetic block and slowing
of conduction through the AV node
o IV rapid administration, followed by a
20-mL saline flush, elevation of the arm
with the IV line
 Antithrombotic therapy
  Electrical cardioversion
 Vagal maneuvers
Ventricular Dysrhythmias
A. Premature Ventricular Complex
 impulse that starts in a ventricle and is
conducted through the ventricles before the
next normal sinus impulse
 PVCs can occur in healthy people, especially with
intake of caffeine, nicotine, or alcohol.
 The patient may feel nothing or may say that the
heart “skipped a beat.”
Management:
 If asymptomatic - usually is not serious
 Frequent and persistent may be treated with
amiodarone or sotalol (short term)
B. Ventricular Tachycardia
 three or more PVCs in a row, occurring at a rate
exceeding 100 bpm
 emergency because the patient is nearly always
unresponsive and pulseless
Management:
 Procainamide – pt’s who do not have acute MI
or severe HF
 IV amiodarone - medication of choice for a
patient with impaired cardiac function or acute
MI
 Lidocaine - medication most commonly used for
immediate, short-term therapy, especially for
patients with impaired cardiac function
 Cardioversion or defibrillation
C. Ventricular Fibrillation
 most common dysrhythmia in patients with
cardiac arrest
 rapid, disorganized ventricular rhythm that
causes ineffective quivering of the ventricles
 No atrial activity is seen on the ECG
 most common cause of ventricular fibrillation is
coronary artery disease and resulting acute MI
Management:
 Always characterized by the absence of an
audible heartbeat, a palpable pulse, and
respirations
 no coordinated cardiac activity, cardiac arrest
and death are imminent if the dysrhythmia is
not corrected
 Early defibrillation
 Cardiopulmonary resuscitation (CPR) until
defibrillation is available
 Administration of amiodarone and epinephrine
may facilitate the return of a spontaneous pulse
after defibrillation
D. Ventricular Asystole
 Commonly called flatline
 Characterized by absent QRS complexes
 no heartbeat, no palpable pulse, and no
respiration
Management:
 CPR
 Hs and Ts: hypoxia, hypovolemia, hydrogen ion
(acid–base imbalance), hypo- or hyperglycemia,
hypo- or hyperkalemia, hyperthermia, trauma,
toxins, tamponade (cardiac), tension
pneumothorax, or thrombus (coronary or
pulmonary)
 intubation and establishment of IV access

Adjunctive Modalities and Management Of
Dysrhythmias
Cardioversion and Defibrillation
 used to treat tachydysrhythmias by delivering
an electrical current that depolarizes a critical
mass of myocardial cells
 When the cells repolarize, the SA node is usually
able to recapture its role as the heart’s
pacemaker
 Defibrillator, is used for both cardioversion and
defibrillation
 Electrical voltage required to defibrillate the
heart is usually greater than that required for
cardioversion
 One major difference between is the timing of
the delivery of electrical current
 In cardioversion, the delivery of the electrical
current is synchronized with the patient’s
electrical events; in defibrillation, the delivery
of the current is immediate and
unsynchronized.
Cardioversion
 Synchronized countershock to convert an
undesirable rhythm to a stable rhythm
 Elective or emergency
 set to synchronize with the ECG on a cardiac
monitor so that the electrical impulse
discharges during ventricular depolarization
(QRS complex)
o prevents the discharge during the
vulnerable period of repolarization (T
wave), which could result in VT or
ventricular fibrillation
 Lower amount of energy is used than
defibrillation
 50 to 360 joules, depending on the
defibrillator’s technology, the type and duration
of the dysrhythmia, and the size and
hemodynamic status of the patient
Nursing Interventions
 Pre-procedure
 If elective – consent
 NPO at least 4 hours if elective
 Sedation as ordered
 If elective, hold digoxin for 48 hours
preprocedure as prescribed to prevent
postcardioversion ventricular irritability
 If elective for atrial fibrillation or atrial
flutter, client should receive anticoagulant
therapy for 4-6 weeks prior to the
procedure and TEE should be performed
 Respiration is then supported with
supplemental oxygen delivered by a bag-
valve mask device with suction equipment
readily available
 Although patients rarely require intubation,
equipment is nearby in case it is needed
 During the Procedure
 Ensure that the skin is clean and dry in the
area where the electrode pads/hands-off
pads will be placed
 Be sure that no one is touching the bed of
the client when delivering the countershock
 Gels or pastes with poor electrical
conductivity (e.g., ultrasound gel) should
not be used
 Paddles or pads should be placed so that
they do not touch the patient’s clothing or
bed linen and are not near medication
patches or in the direct flow of oxygen
 Women with large breasts should have the
left pad or paddle placed underneath or
lateral to the left breast
 Monitor leads must be attached to the
patient in order to set the defibrillator to
the synchronized mode (“in sync”)
 When it is time to defibrillate, whomever is
delivering the charge should announce,
“charging to (number of joules)” prior to
discharging.
 “Clear!” must be called three times before
discharging
o 1st: discharger must visually check
that he or she is not touching the
patient, bed, or equipment
o 2nd: discharger must visually check
that no one else is touching the
bed, the patient, or equipment
o 3rd: discharger must perform a final
visual check to ensure that
everyone is clear of the patient and
anything touching the patient
 The delivered energy and resulting rhythm
are recorded
  Post Procedure
o Priority assessment includes ability of the A. First-Degree Atrioventricular Block
client to maintain the airway and breathing  all the atrial impulses are conducted through
o Resume O2 administration as ordered the AV node into the ventricles at a rate slower
o Assess v/s than normal
o Assess LOC  PR interval: Greater than 0.20 seconds; PR
o Monitor cardiac rhythm interval measurement is constant
o Monitor for indications of successful
response - sinus rhythm, strong peripheral
pulses, normal BP, adequate urine output
o Assess the skin on the chest for evidence of
burns

Defibrillation B. Second-Degree Atrioventricular Block, Type I

 Used in emergency situations as the treatment (Wenckebach)
of choice for ventricular fibrillation and  repeating pattern in which all but one of a
pulseless VT series of atrial impulses are conducted through
 Asynchronous countershock the AV node into the ventricles
 Not used for patients who are conscious or have  Each atrial impulse takes a longer time for
a pulse conduction than the one before, until one
 The sooner defibrillation is used, the better the impulse is fully blocked.
survival rate  PR interval: The PR interval becomes longer
 The defibrillator is charged to 120-200 joules with each succeeding ECG complex until there
(biphasic) or 360 joules (monophasic) for one is a P wave not followed by a QRS. The changes
countershock from the defibrillator, CPR is in the PR interval are repeated between each
resumed immediately and continued for 5 “dropped” QRS, creating a pattern in the
cycles or about 2 minutes irregular PR interval measurements.
 Epinephrine is given after initial unsuccessful
defibrillation to make it easier to convert the
dysrhythmia to a normal rhythm with the next
defibrillation
o Epinephrine increases cerebral and
coronary artery blood flow
 Antiarrhythmic medications such as
amiodarone, lidocaine, or magnesium may be
given if ventricular dysrhythmia persists
C. Second-Degree Atrioventricular Block, Type II
Conduction Abnormalities  occurs when only some of the atrial impulses
 PR interval is assessed for the possibility of an are conducted through the AV node into the
AV block ventricles.
 AV blocks occur when the conduction of the
impulse through the AV nodal or bundle of His
area is decreased or stopped
 AV block may be temporary and resolve on its
own, or it may be permanent and require
permanent pacing

D. Third-Degree Atrioventricular Block
 occurs when no atrial impulse is conducted
through the AV node into the ventricles
 two impulses stimulate the heart: one
stimulates the ventricles and one stimulates
the atria
 P waves may be seen, but the atrial electrical
activity is not conducted down into the
ventricles to cause the QRS complex
Medical Management of Conduction Abnormalities
 treatment is directed toward increasing the
heart rate to maintain a normal cardiac output
 No symptoms, no treatment may be indicated
or it may simply consist of decreasing or
eliminating the cause (e.g., withholding the
medication or treatment).
 initial treatment of choice is an IV bolus of
atropine
o not effective in second-degree AV block,
type II, or third-degree AV block
 Temporary transcutaneous pacing
 Permanent Pacemaker
Pacemakers
 Temporary or permanent device that provides
electrical stimulation and maintains the heart
rate when the clint’s intrinsic pacemaker fails to
provide perfusing rhythm.
A. Noninvasive Transcutaneous Pacing
 Used as temporary emergency measure in
profoundly bradycardic or asystolic client until
invasive pacing can be initiated
 Large electrode pads are placed on the client’s
chest and back and connected to an external
pulse generator
Nursing Considerations:
 Wash the skin with soap and water before
applying electrodes
 It is not necessary to shave the hair or apply
alcohol or tinctures to the skin
 Do not take BP and pulse on the left side
 Electrodes should be in good contact with
the skin
 If loss of capture occurs, assess the skin
contact of the electrodes
 Evaluate client for discomfort
B. Invasive Transvenous Pacing
 Pacing lead wire is place through the vein into
the right atrium or right ventricle
Nursing Considerations:
 Monitor the pacemaker insertion site
 Restrict client movement to prevent wire
displacement
 Monitor v/s and cardiac monitor
C. Permanent Pacemakers
 Pulse generator is internal and surgically
implanted in a subcutaneous pocket below the
clavicle
 The leads are passed transvenously via the
cephalic or subclavian vein to the endocardium
on the right side of the heart
Client Education:
 Instruct the client about the pacemaker
 Instruct the client in the signs of battery
failure and when to notify the HCP
o Fainting, losing consciousness
o Chest pain with weakness,
dizziness, nausea and vomiting
o Palpitations
o Bradycardia
o Frequent hiccups
 Instruct the client to report any fever,
redness, swelling or drainage from the
insertion site
 Report signs of dizziness, weakness or
fatigue, swelling of the ankle, chest pain or
SOB
 Always wear a MedicAlert Bracelet
 Loose fitting clothes
 No contact sports
 Inform all HCP’s that pacemaker has been
inserted
 Most electrical appliances can be used
without any interference with the
functioning of the pacemaker; however, do
 not operate electrical appliances directly
over the pacemaker site
 Avoid transmitter towers and antitheft
devices in store
 Instruct the client to inform airport security
that he/she has a pacemaker because the
pacemaker may set off the security detector
 If any unusual feelings occur when near
electrical devices, move 5-10 feet away and
check the pulse
 Emphasize the importance of follow up
 Use cellphones on the opposite side of the
pacemaker