Chapter 27 Management of Patients With Dysrhythmias and Conduction Problems

OVERVIEW y Electrical stimulation of the normal heart causes depolarization of the myocardium; this depolarization produces a synchronized, rhythmic contraction of the myocardium producing a beat; propelling the blood through the arteries and capillaries. y Cardiac dysrhythmias are defined as alterations in this stimulation, which can affect the synchronized pattern of contractions and affect the efficiency of the heart. Dysrhythmias y Disorders of formation or conduction (or both) of electrical impulses within heart y Can cause disturbances of: -Rate -Rhythm -Both rate, rhythm y y Potentially can alter blood flow, cause hemodynamic changes Diagnosed by analysis of electrographic waveform

NORMAL SINUS RHYTHM Cardiac Dysrhythmias y May be benign or lethal. y Caused by many factors. y Any dysrhythmia can affect cardiac function, regardless of cause. y Client s response to the rhythm determines urgency of treatment. Cardiac dysrhythmias y Originate as: -Sinus -Atrial -Junctional -Ventricular -Heart blocks Pathophysiology y Altered electrical activity may cause alterations in cardiac function. y Dysrhythmias may result from internal or external forces. Internal forces: External forces: -Hypoxia - Stress -Electrolyte disturbances - Exercise -Acidosis - Pain -Diseases of the myocardium - Anemia -Atherosclerotic processes - Hypovolemia y y Cardiac muscle cells have the capability of automaticity (ability to fire without stimulation), allowing the cell to serve as a pacemaker or cause premature beats. Each heartbeat creates distinctive wave forms: P, QRS, and T. Each QRS should correspond to the pulse.

Action Potential y The electrical activity that occurs in a cell by the movement of ions across cell membranes. 1. During the resting state, the cell is polarized, with positive and negative ions equal on either side of the membrane; maintained by the sodium (Na)-potassium (K) pump. 2. Depolarization (contraction) requires a change from a negative to positive state; Na ions enter rapidly, opening the Na channels; Calcium (Ca) is allowed in, K is not allowed to cross. 3. A threshold potential is reached when the cell becomes less negative, creating an action potential; which depolarizes cardiac muscle cells; Ca enters the cell and causes contraction of the cardiac muscle. 4. A repolarization then occurs in order to return the cell to a polarized state, Na channels close, the cell begins to gain negative charge; the Na-K pump restores the ions to proper concentration. 5. The sequence is repeated for each heartbeat. Refractory Period y A certain stage in the conduction cycle where there is to stimulation. A. Absolute refractory period: from beginning of Q to midle of T wave; no stimulus of any size can cause another impulse to occur. B. Relative refractory period: from middle of T to end of T wave; a stimulus that is larger than the usual stimulus to create an impulse can stimulate the muscle cells to contract; an example is when a PVC occurs directly at the same time as a T wave, resulting in ventricular tachycardia or ventricular fibrillation. Two Major Categories of Dysrhythmias y Alteration in impulse formation. -Rate: tachycardia or bradycardia. -Rhythm: regular or irregular. -Ectopic beats (extra impulse) y Premature atrial contractions (PAC) y Premature junctional contractions (PJC) y Junctional escape beats y Premature ventricular contractions (PVC) Alteration in conductivity. -Heart blocks. -Reentry phenomena is the blockage of an impulse through one of the bundle branches, causing the impulse to retrograde backwards, reentering the other bundle branch and causing a premature beat. Normal sinus rhythm (NSR) y impulse originates at the SA node, travels normal pathway; no delays; wave forms are uniform; all waveforms are of a fixed duration; P wave present representing atrial depolarization and the waveform is normal, smooth, and upright. Mx: -None; normal heart rhythm. y Rate: 60 to 100 bpm Rhythm: Regular P:QRS: 1:1 PR interval: 0.12 to 0.20 sec QRS complex: 0.06 to 0.10 sec

SINUS BRADYCARDIA (SB) y Same configuration as normal sinus rhythm except rate is less than 60 bpm. y Clients may be asymptomatic; if not tolerating the bradycardia, may experience decreased level of consciousness, syncope, hypotension. Mx: -Treated only if the client is experiencing symptoms. -IV atropine and/or pacemaker therapy may be used. Rate: < 60 bpm Rhythm: Regular P:QRS: 1:1 PR interval: 0.12 to 0.20 sec QRS complex: 0.06 to 0.10 sec SINUS TACHYCARDIA (ST) y Same configuration as normal sinus rhythm except rate is greater than 100 bpm. y Can be an early warning sign of cardiac dysfunction, such as heart failure. y Client may be asymptomatic; symptoms experienced may be racing feeling, syncope, dyspnea. Mx: -Treated only if the client is experiencing symptoms or is at risk for myocardial damage. -Treat underlying cause (e.g., hypovolemia, fever, pain) -Beta blockers or verapamil may be used. Rate: 101 to 150 bpm Rhythm: Regular P:QRS: 1:1 (With very fast rates, P wave may be hidden in preceding T wave) PR interval: 0.12 to 0.20 sec QRS complex: 0.06 to 0.10 sec SINUS ARRHYTHMIA y Sinus rhythm that varies in rate during inspiration (faster) and during expiration (slower) y Common in very young and the very old. Mx: -Generally none. -Considered a normal rhythm in the very young and the very old. Rate: 60 to 100 bpm Rhythm: Irregular, varying with respirations P:QRS: 1:1 PR interval: 0.12 to 0.20 sec QRS complex: 0.06 to 0.10 sec PREMATURE ATRIAL CONTRACTIONS (PAC) y Ectopic beat that comes early in the cycle with the same configuration as normal beats. y Usually asymptomatic and benign. Mx: -Usually requires no treatment. -Advise client to reduce alcohol and caffeine intake, to reduce stress, and to stop smoking.

Rate: Variable Rhythm: irregular, with normal rhythm interrupted by early beats arising in the atria. P:QRS: 1:1 PR interval: 0.12 to 0.20 sec, but may be prolonged QRS complex: 0.6 to 0.10 sec ATRIAL FLUTTER y Usually regular rhythm (but may be irregular) with saw-toothed waves instead of P waves. y Thought to be result of intra-atrial reentry mechanism. Signs and symptoms: may be asymptomatic, palpitations or fluttering in chest, if rapid ventricular response is present, signs of decreased cardiac output are present because of the loss of atrial kick and decreased ventricular filling time. Mx: -Synchronized cardioversion; medications to slow ventricular response such as a beta blocker or calcium channe-blocker (verapamil), followed by quinidine, procainamide, flecainide, or amiodarone. Rate: Atrial 240 to 360 bpm; ventricular rate depends on degree of AV block and usually is < 150 bpm Rhythm: Atrial regular, ventricular usually regular P:QRS: 2:1, 4:1, 6:1; may vary PR interval: Not measured QRS complex: 0.06 to 0.10 sec ATRIAL FIBRILLATION (A-fib) y Chaotic atrial activity causing the atria to quiver instead of contract normally. y Rapid impulse firing from atrial wall bombards the AV node, resulting in a wavy baseline between R-R, no visible consistent P waves, and an irregular ventricular response pattern. y May be intermittent or a chronic rhythm disturbance. y Clinical signs and symptoms depends on ventricular response: signs and symptoms of decreased CO, hypotension, SOB, fatigue, angina, syncope, HF, peripheral pulses will be irregular and variable in quality. y High risk for thromboemboli formation due to pooling of blood in atria and absence of atrial kick. Mx: -Sychronized cardioversion. -Medications to reduce ventricular response rate: verapamil, propranolol, digoxin, anticoagulant -therapy to reduce risk of clot formation and stroke. Atrial 300 to 600 bpm (too rapid to count); ventricular 100 to 180 bpm in untreated clients Rhythm: Irregularly irregular P:QRS: Variable PR interval: Not measured QRS complex: 0.06 to 0.10 sec Rate: PREMATURE VENTRICULAR CONTRACTION (PVC) y Most common dysrhythmia. y Comes early in the cycle. y Frequent, recurrent, or multifocal PVCs indicate myocardial irritability; may precipitate lethal dysrhythmias.

y y y y y Mx:

Incidence greatest following myocardial ischemia, infarction, hypertrophy, or infection. Common and usually clinically insignificant in older adults. May be unifocal (coming from site); multifocal (coming from different sites in the ventricular wall). May come in patterns: bigeminy every other beat is a PVC; trigeminy every third beat is PVC; couplets two beats together; triplets three beats together; salvo three to six beats in a row. Signs and symptoms: may be asymptomatic; feeling skipped beats, chest discomfort, dyspnea, hypotension, dizziness. -Treat if client is experiencing symptoms. Advise against stimulant use (caffeine, nicotine). -Drug therapy includes IV lidocaine, procainamide, quinidine, propranolol, phenytoin, bretylium.

Rate: Variable Rhythm: Irregular, with PVC interrupting underlying rhythm and followed by a compensatory pause P:QRS: No P wave noted before PVC PR interval: Absent with PVC QRS complex: Wide (>0.12 sec) and bizarre in appearance; differs from normal QRS complex VENTRICULAR TACHYCARDIA (V-tach or VT) y Rapid ventricular rhythm disturbance defined as three or more consecutive PVCs; can be short burst or sustained rhythm; usually regular with a rate greater than 100 bpm. y Reentry mechanism usual cause. y Signs and symptoms: fluttering in chest , palpitations, SOB, signs of decreased CO, hypotension, loss of consciousness, no palpable pulses, may soon deteriorate into lethal rhythm. Mx: Treat if VT is sustained or if the client is experiencing symptoms. Treatment includes IV procainamide or lidocaine and/or immediate defibrillation if the client is unconscious or unstable. Rate: 100 to 250 bpm Rhythm: Regular P:QRS: P waves usually not identifiable PR interval: Not measured QRS complex: 0.12 sec or greater; bizarre shape VENTRICULAR FIBRILLATION (V-fib or VF) y Rapid chaotic ventricular rhythm causing the ventricles to quiver, heart does not pump; cardiac arrest occurs. y Without effective treatment death occurs. y Effective treatment: defibrillation and CPR. y ECG show chaotic irregular bizarre complexes with no discernable rate or rhythm. Mx: Immediate defibrillation. Rate: Too rapid to count Rhythm: Grossly irregular P:QRS: No identifiable P waves PR interval: None QRS complex: Bizarre, varying in shape and direction y Asystole

ATRIOVENTRICULAR CONDUCTION BLOCKS (HEART BLOCKS) y Conduction defects that delay or block transmission of the sinus impulse through the AV node. -May be from injured or diseased SA node or AV node area. -May be from increased vagal tone. -May be benign or severe. -Should be monitored for progression to a more severe level of block. FIRST-DEGREE AV BLOCK y Benign condition and is not considered a true block. y Prolonged but constant PR interval (greater than 0.2 sec) in duration, otherwise normal sinus rhythm. y Usually asymptomatic; can progress to a higher level block. Mx: None required. Rate: Usually 60 to 100 bpm Rhythm: Regular P:QRS: 1:1 PR interval: > 0.20 sec QRS complex: 0.06 to 0.10 sec SECOND-DEGREE AV BLOCK: TYPE I y Also called Mobitz I or Wenckebach. y Cyclic pattern of complexes with a progressively prolonging PR interval until one QRS is totally blocked or dropped. y Signs and symptoms: asymptomatic; if rate drops, then signs and symptoms of decreased CO would be observed. Mx: -Monitoring and observation. -Atropine or isoproterenol if client is experiencing symptoms. Rate: 60 to 100 bpm Rhythm: Atrial regular; ventricular irregular P:QRS: 1:1 until P wave blocked with no subsequent QRS complex PR interval: Progressively lengthens in a regular pattern. QRS complex: 0.06 to 0.10 sec; sudden absence of QRS complex SECOND-DEGREE AV BLOCK: TYPE II y Also called Mobitz II or Classical. y Usually seen in CAD and anterior wall MI. y Nonconducted impulses usually occurring in a regular manner. y Must have more than one P wave to every QRS complex (can have several Ps to each QRS). y PR interval is constant. y Signs and symptoms depend on ventricular rate. Mx: -Atropine or isoproterenol; pacemaker therapy. Rate: Atrial 60 to 100 bpm; ventricular <60 bpm Rhythm: Atrial regular; ventricular irregular P:QRS: Typically 2:1; may vary PR interval: Constant PR interval for each conducted QRS complex QRS complex: 0.06 to 0.10 sec

THIRD-DEGREE AV BLOCK y Also called COMPLETE HEART BLOCK. y SA node fires, P waves are regular but do not conduct through to AV node; ventricular rhythm (QRS) will be regular but in no way related to P wave. y No relationship between P waves and QRS complexes; may or may not have more Ps than QRS complexes. y PR interval constantly varies. y Signs and symptoms associated with bradycardia and decreased CO: lightheadedness, confusion, syncope. y Requires intervention, can be life-threatening. Mx: - Immediate pacemaker therapy. Rate: Atrial 60 to 100 bpm; ventricular 15 to 60 bpm Rhythm: Atrial regular; ventricular regular P:QRS: No relationship between P waves and QRS complexes; independent rhythms PR interval: Not measured QRS complex: 0.06 to 0.10 sec if junctional escape rhythm; >0.12 sec if ventricular escape rhythm Nursing Process: Care of the Patient with a Dysrhythmia Assessment y Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness y Physical assessment include -Rate, rhythm of apical, peripheral pulses -Heart sounds -Blood pressure, pulse pressure -Signs of fluid retention y Health history: include presence of coexisting conditions, indications of previous occurrence y Medications Diagnoses y Decrease cardiac output y Anxiety y Deficient knowledge y Collaborative Problems/Potential Complications y Cardiac arrest y Heart failure y Thromboembolic event, especially with atrial fibrillation Planning y Goals -Eradicating or decreasing occurrence of dysrhythmia to maintain cardiac output -Minimizing anxiety -Acquiring knowledge about dysrhythmia, its treatment Decreased Cardiac Output y Monitoring -ECG monitoring -Assessment of signs, symptoms y Administration of medications, assessment of medication effects y Adjunct therapy: cardioversion, defibrillation, pacemakers Anxiety y Use calm, reassuring manner y Measures to maximize patient control to make episodes less threatening

y Communication, teaching Teaching self-care y Include family in teaching Cardioversion and Defibrillation y Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial cells y When cells repolarize, sinus node usually able to recapture role as heart pacemaker y In cardioversion, current delivery synchronized with patient s ECG y In defibrillation, current delivery is unsynchronized Safety Measures y Assure good contact between skin, pads or paddles -Use conductive medium, 20 to 25 pounds of pressure y Place paddles so they do not touch bedding or clothing, are not near medication patches or oxygen flow y If cardioverting, turn synchronizer on y If defibrillating, turn synchronizer off y Do not charge device until ready to shock y Call clear three times; follow checks required for clear Assure no one is in contact with patient, bed, or equipment y Paddle Placement for Defibrillation