Chapter 26

Management of Patients With

Dysrhythmias and
Conduction Problems

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Dysrhythmias
Disorders of formation or conduction (or both) of
electrical impulses within heart
Can cause disturbances of
Rate
Rhythm
Both rate and rhythm
Potentially can alter blood flow and cause hemodynamic
changes
Diagnosed by analysis of electrographic waveform
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Normal Electrical Conduction

SA node (sinus node)
AV node
Conduction
Bundle of His
Right and left bundle branches
Purkinje fibers
Depolarization = stimulation = systole
Repolarization = relaxation = diastole
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Relationship of ECG Complex,

Lead System, and Electrical Impulse

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The Electrocardiogram (ECG)

Electrode placement
Electrode adhesion

P wave
QRS complex
T wave

Types of ECG
ECG Interpretation

U wave
PR interval
ST segment
QT interval
TP interval
PP interval

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ECG Electrode Placement

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ECG Graph and Commonly Measured

Components

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Heart Rate Determination

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Normal Sinus Rhythm

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Sinus Bradycardia

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Sinus Tachycardia

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Sinus Arrhythmia

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Question
The nurse is preparing a male patient to have a 12-lead
ECG performed. When prepping the skin the nurse notices
that the patient has abundant chest hair. What is the most
appropriate nursing intervention to improve adhesion of the
ECG leads?
A.Use alcohol swabs to cleans the skin before applying the
leads.
B.Clip the chest hair with the patients permission before
applying the leads.
C.Apply the leads to the arms and legs only.
D.Reschedule the ECG.
Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
B. Clip the chest hair with the patients permission before
applying the leads.
Rationale: Alcohol should not be used to prep the skin
because it increases the skins electrical impedance,
thereby hindering the detection of the cardiac electrical
signal. Clipping the hair would provide access to the
skin to assist with adhesion. The ECG would not be
performed correctly if the leads were only placed on the
extremities, and there is no need to reschedule the ECG
at this time.

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Nursing Process: Care of the Patient with

a DysrhythmiaAssessment
Causes of dysrhythmia, contributing factors
Assess indicators of cardiac output and oxygenation
Health history: include presence of coexisting conditions,
indications of previous occurrence
All medications (prescribed and OTC)
Psychosocial assessment: patients perception of
dysrhythmia

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Nursing Process: Care of the Patient with

a DysrhythmiaAssessment (contd)
Physical assessment include
Skin (pale and cool)
Signs of fluid retention (JVD, lung auscultation)
Signs of decreased CO (altered LOC)
Rate, rhythm of apical, peripheral pulses
Heart sounds
Blood pressure, pulse pressure

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Nursing Process: Care of the Patient With

a DysrhythmiaDiagnoses
Decrease cardiac output
Anxiety
Deficient knowledge

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Collaborative Problems and Potential

Complications
Cardiac arrest
Heart failure
Thromboembolic event, especially with atrial fibrillation

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Nursing Process: Care of the Patient With

a DysrhythmiaPlanning
Goals
Eradicating or decreasing occurrence of dysrhythmia
to maintain cardiac output
Minimizing anxiety
Acquiring knowledge about dysrhythmia and its
treatment

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Nursing Process: Care of the Patient With

a DysrhythmiaNursing Interventions
Monitor and manage the dysrhythmia
Minimize anxiety
Promote home- and community-based cared
Educate the patient
Continuing care

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Nursing Intervention: Monitor and

Manage the Dysrhythmia
Assess vital signs on an ongoing basis
Assess for lightheadedness, dizziness, fainting
If hospitalized
Obtain 12-lead ECG
Continuous monitoring
Monitor rhythm strips periodically
Antiarrhythmic medications
6-minute walk test
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Nursing Intervention: Minimize Anxiety

Stay with patient
Maintain safety and security
Discuss emotional response to dysrhythmia
Help patient develop a system to identify factors that
contribute to episodes of the dysrhythmia
Maximize the patients control

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Nursing Intervention: Promote Home and

Community-Based Cared
Educate the patient
Treatment options
Therapeutic medication levels
How to take pulse before medication administration
How to recognize symptoms of the dysrhythmia
Measures to decrease recurrence
Plan of action in case of an emergency
CPR (family)
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Nursing Intervention: Continuing Care

Referral for home care
Hemodynamically unstable with signs of decreased
CO
Significant comorbidities
Socioeconomic issues
Limited self-management skills
Electronic device recently implanted

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Nursing Process: Care of the Patient With

a DysrhythmiaEvaluation
Maintain cardiac output
Stable VS, no signs of dysrhythmia
Experience decreased anxiety
Positive attitude, confidence in ability to act if an
emergency occurs
Express understanding of dysrhythmia and treatment

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Adjunctive Modalities and Management

Used when medications alone are ineffective against
dysrhythmia
Pacemakers
Cardioversion
Defibrillation
Nurse responsible for assessment of the patients
understanding regarding the mechanical therapy

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Pacemakers
Electronic device that provides electrical stimuli to heart
muscle
Types
Permanent
Temporary
NASPE-BPEG code for pacemaker function

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Implanted Transvenous Pacemaker

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Transcutaneous Pacemaker

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Complications of Pacemaker Use

Infection
Bleeding or hematoma formation
Dislocation of lead
Skeletal muscle or phrenic nerve stimulation
Cardiac tamponade (pressure on the heart when fluid builds up
between muscle and sac)
Pacemaker malfunction

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Implantable Cardioverter Defibrillator

(ICD)
Device that detects and terminates life-threatening
episodes of tachycardia and fibrillation
NASPE-BPEG code
Antitachycardia pacing

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ICD (contd)

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Nursing Management (After Permanent

Electronic Device Insertion)
ECG assessment
CXR
Nursing assessment
CO and hemodynamic stability
Incision site
Signs of ineffective coping
Level of knowledge and education needs of family
and patient
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Cardioversion and Defibrillation

Treat tachydysrhythmias by delivering electrical current
that depolarizes critical mass of myocardial cells
When cells repolarize, sinus node usually able to
recapture role as heart pacemaker
In cardioversion, current delivery synchronized with
patients ECG
In defibrillation, current delivery is unsynchronized

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Safety Measures
Ensure good contact between skin, pads, and paddles
Use conductive medium, 20 to 25 pounds of pressure
Place paddles so they do not touch bedding or clothing
and are not near medication patches or oxygen flow
If cardioverting, turn synchronizer on
If defibrillating, turn synchronizer off

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Safety Measures (contd)

Do not charge device until ready to shock
Call clear three times; follow checks required for clear
Ensure no one is in contact with patient, bed, or
equipment

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Paddle Placement for Defibrillation

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Question
What must a patient with an automatic ICD do?
A.Continue to go through metal-detection devices at the
airport
B.Call for assistance when blood pressure increases
C.Document events that trigger a shock sensation
D.Be compliant with all of the above-listed interventions

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer
C. Document events that trigger a shock sensation
Rationale: The patient with an automatic ICD must
document events that trigger a shock sensation. The
patient must avoid magnetic fields such as metaldetection devices at the airport and should call for
emergency assistance when feeling dizzy.

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Invasive Methods to Diagnose and Treat

Recurrent Dysrhythmias
Electrophysiologic studies
Ablation
Cardiac conduction surgery
Maze procedure ("Maze" refers to the series of
incisions arranged in a maze-like pattern in the atria)
Catheter ablation therapy

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