DYSRHYTHMIAS

 Disorders of formation/conduction (both) of the

electrical impulse w/in the heart.
 It can cause disturbances of HR, the heart Rhythm, or
both.
 Dx by analysing the ECG waveform.
 They are named according to:
1. The site of origin of the impulse and the
mechanism of function or conduction involved.
ELECTROPHYSIOLOGY
ECTOPIC FOCI
 When the electrical impulse arises anywhere other
than SA NODE, It is an AB or ectopic focus.
 If the ectopic focus depolarizes at a rate FASTER than
the SA NODE, the ectopic focus becomes the
dominant pacemaker.
 Ectopic pacemaker may arise in the atria , AV NODE,
PURKINJE FIBERS or VENTRICULAR MUSCLE.
 They may be characterized by hypoxia, ischemia or
hypokalemia.
 Ectopic foci may indicate myocardial irritability (↑
responsiveness to stimuli) and potential serious
impairment to cardiac FXN.
REENTRY EXCITATION
 Impulse continue to enter an area of the heart rather
than becoming distinguished.
 The impulse must encounter an obstacle in the N
conducting pathway.

Excitability/ irritability
NORMAL SINUS RHYTHM
 Ability of cardiac muscle to respond to an electrical
stimulus.
Automaticity
 Ability to generate an electrical impulse.
Contractility

Conductivity
 Ability of the cardiac tissue to transmit electrical
impulses.
REFRACTORY PERIOD  60-100 BPM
 Rhythm: Regular.
 Absolute Refractory Period  P Waves: Normal (Upright and Uniform)
1. Period of ↓ excitability during w/c the cell cannot  PR Interval: N (0.12-0.20 sec)
respond to a new stimuli.  QRS: N (0.6-0.10 sec)

 Relative Refractory Period. COMMON DYSRHYTHMIAS

1. Period before resting membrane potential is  Sinus
reached. 1. Sinus Tachycardia
2. A stimulus greater than N can evoke a response in 2. Sinus Bradycardia
a cell. 3. Sinus Arrythmia
4. Sick Sinus Syndrome
5. Sinus Pause/Arrest
 6. Sino Atrial Block  If HR is very rapid = reduction of CO (Cardiac
Output) will be evident. – due to shorter time for atrial
 Atria contraction and ventricular filling.
1. Premature Atrial Contraction (PAC)  CHF – cannot tolerate Sinus Tachy – hpn & chest
2. Paroxysmal Atrial Tachycardia pain.
3. Atrial Flutter
TX:
4. Atrial Fibrillation
 Correction of underlying cause.
 Ventricular  Elimination of stimulants.
1. Premature ventricular Contraction (PVC)  Admin. Of sedatives as prescribed for anxiety-
2. Ventricular Bigeminy Diazepam.
3. Ventricular Fibrillation  Admin of β -blokers such as propranolol/Indural-
4. Ventriculat Tachycardia WOF w/ respi. Disorders.

 Conduction defect 2. SINUS BRADYCARDIA

1. 1st degree AV Block
2. 2nd degree AV Block
3. 3rd degree AV Block
SINUS DYSRHYTHMIAS
1. SINUS TACHYCARDIA
General Info:

 Slowed HR by SA NODE
 Caused by Parasympathetic response …

 < 60 bpm

Etiology:

 A HR that is over 100 bpm  Excessive bagal or ↓ sympathetic …

 Originating in the SA NODE  Myocardial infarction
 Gen the result of ↑ stimulation of the SNS and the  Meningitis
resulting release of catecholamines  Myxedema – severe form of ypothyroidism
 Cardiac fibrosis
Etiology:  N variation of the HR in well trained athetes.
 Medications such as Digoxin or Verapamil.
 Fever
 Anemia Assessment:
 Apprehension Rate: < 60 bpm
 Hyperthyroidism – T3 hormone Rhythm: Regular
 Physical Activity – exercise P Wave
 Myocardial Ischemia QRS: Normal
 Caffeine
 Drugs- Epinephrine, Theophylline S/S of ↓ CO
 Weakness
S/S:
 Altered LOC
 Occasional palpitations  ↓ BP
 Dizziness  The vagal effect of some medications ( β -blokers)
 Syncope  Cond. That affect vagal tone.
 Pulmonary congestion – heart failure 1. Vomitting
2. Suctioning
Slowed rate of SA NODE discharge may allow junctional 3. Extreme emotions
or Ventricular pacemaker to take over, thereby producing 4. Severe pain.
ectopic beats sensed as palpitations.

TX:
1. Identify underlying cause. Assessment
2. Asymptomatic bradycardia, usually does not need
tx. Rhythm: Irreg
3. But if CO is inadequate ( S/Sx: dizziness, P Waves: N (Upright & Uniform)
weakness, altered LOC and ↓ BP ) PR Interval: N
a. Atropine 0.5mg-1mg IV
4. If S/SX is severe: consider catecholamines
infusion: TX:
a. Dopamine 5-20ug/kg/min  Do not usually req. tx unless BP is affected w/
b. Isoprotenerole 2-10ug/min orthostatic hpn.
WOF UO – 30 mL / UO –fluid infused.  If Dizziness, Presyncope or Syncope occurs the ff
interventions might help:
3. SINUS ARRYTHMIA 1. Apply elastic support stocking
2. Na retaining drugs – to expand the vascular vol.

4. SICK SINUS SYNDROME

 A variable rate of impulse d/c from SA NODE, occurs

when the rhythm is irregular and usually corresponds
to the respiratory pattern.
 The rhythm ↑ w/ inspiration and slows w/ expiration.
 Sinus arrhythmia can be a N variation in children.
 A N phenomenon of mild acceleration anfd slowing of
the heart rate that occurs w/ breathing in and out.
Etiology:
 Caused by diseased sinus node
 Sinus node dysfunction
 Umbrella term for a group of AB heart rhythms by
SINUS NODE malfunction.
 Sinus node conduct slow at rate / fail to conduct at all
 “bradycardia-tachycardia syndrome” – alternating
slow and fast heart rhythm.

 In response to delayed atrial filling with inspiration . S/S:

1. During inspiration venous return to RA is delayed  Few – no S/S.
bec. Of ↑ Intrathoracic pressure.  Bradycardia/Tachycardia alternating
 Quiet respiration = HR ↓ 5%  Fatigue
 Deep respiration = HR ↓ 30%  Dizziness/lightheadedness/fainting
 SOB
 Chest pain

Etiology:

 SA block – electrical signals move too slowly through

the sinus node = AB slow HR
 Sinus arrest – Sinus node activity pauses.
 Tachy-Brady syndrome – HR alternates bet AB fast
and slow w/ long pause (asystole) bet heartbeats.
 Acute MI
 Hypokal/hypomag

 myocarditis
 The block occurs in some multiple P-P interval.
 SA node initiates the impulse, but the propagation
TX:
over the atrial tissue is bloked. = NO P WAVE and
 If ischemia is due to arteriosclerotic heart disease
subsequent QRS COMPLEX.
1. Pacemaker
1. After the dropped beat, cycles continues on time.
2. .
 Underlying rhythm resumes on time following the
pause.
5. SINUS PAUSE / ARREST
1. The length of the pause being a multiple of the
underlying P-P interval/R-R interval.
 R-R interval returns to the same pattern as if nothing
happens.

ATRIAL DYSRHYTHMIAS

PREMATURE ATRIAL CONTRACTION

Etiology:

 Hyperkal.
 Hypoxia
 Myocardial ischemia
 Sinus node degeneration

S/S:
 Dizziness
 Amaurosis  An ectopic beat that originates in the atrial tissue and
 Syncope is d/c at a rate faster than Sinus Node.
 Rapid repetitive complexes, occurs earlier than the
Tx: next sinus complex.
 Pacemaker  Ectopic FOCI is Atrium and not SA Node.
 Isuprel  P waves may look peaked.
 Atropine  Usually require no medical care.
6. SINOATRIAL BLOCK  Pt. feel their heart “stop”/”misses a beat”.
 Like PVC, PAC are called “heart palpitation” but not
as serious as PVC.
Etiology:
 Idiopathic
 Diseased tissues.
 Inflammatory / infectious process.
 Post cardioversion.
Prognosis:
 In some cases, it can trigger more serious arrhythmia
such as atrial flutter or atrial fibrillation.
 Generally do not compromise the hemodynamic
system.
1. Bec. the conduction throughout is via AV NODE
and the ventricles of the heart are activated in a N
sequence.
 Ectopic atrial focus captures the heart rhythm and d/c
impulses at a rate bet. 200 – 400 bpm.
 Continuous “saw tooth” rapid sequence of atrial
complexes from a single rapid firing atrial focus.
TX:  Impulse travel in circular course in atria
 Generally does not require tx.  P waves are absent.
 If ↑ in freq. = use Quinidine or Ca-channel blocker.  Flutter waves represents AB depolarization of the
 Healthy lifestyle. atria.
ATRIAL FIBRILLATION

ATRIAL TACHYCARDIA

 MC cardiac arrhythmias involves the artria.

 Paroxysmal Artial Tachycardia = type of arrhythmia  Name comes from fibrillating(quivering) of the heart
1. Paroxysmal = episode of arrhythmia begins and muscles of the atria.
ends abruptly.  Chaotic random pathways in the atria.
2. Atrial = starts in Atria  Produces an irreg. ventricular rhythm.
3. Tachycardia = AB fast Heartbeat.  Indicator of A-Fib = Absence of P wave.
 Atrial Tachycardia= very rapid repetitive complexes  Asymptomatic / not life threatening.
originating in the atrial tissue. Not in SA node.  May result in;
 HR is rapid approx. 150 bpm w/ atrial impulse 1. Palpitations
generation. 2. Fainting
 Ventricular rate also ↑ driven by atrial impulses. 3. Angina/chest pain
 P waves may look peaked. 4. CHF
 SOB, Anasarca
ATRIAL FLUTTER ATRIAL FLUTTER & ATRIAL FIBRILLATION
Etiology:
 ACS → CAD, CHF  Assess indicators of CO, Oxygenation and LOC.
 Acquired Valvular defects/diseases  PA:
 Hypoxia; pulmonary embolism 1. Rate and rhythm , apical and peripheral pulses
 Drug induced → Digoxin/Quinidine Toxicity 2. Heart sounds
 Hyperthyroidism. 3. BP and Pulse Pressure (difference bet. Systolic
and diastolic pressure)
Clinical Manifestations: 4. Signs of fluid retension.
 DOB & SOB → s/x of Acute pulmonary edema.  Health Hx:
 Palpitations 1. Presence of coexisting cond.
 ↓ CO → s/sx of ↓ Arterial vol. 2. Indications of previous occurrence
 Medications
TX:
Nursing Dx
 Prevent circulatory instability.
1. Rhythm cntrl  ↓ CO / Anxiety
2. Rate cntrl
Nurisng Management: ↓ CO
 Cardioselective β -blokers
 METOPROLOL  Monitoring
 ATENOLOL 1. ECG monitoring
 BISOPROLOL 2. Assessment of s/sx
 NEBIVOLOL  Administration of medications WOF effects.
 Ca Channel blockers  Adjunct Therapy: Cardioversion, defibrillation,
 DILTIAZEM pacemakers.
 VERAPAMIL
 Cardiac Glycosides
 DIGOXIN PACEMAKERS
 AMIODARONE  Electronic device that provides electrical stimuli to the
 AV node blocking effects when admin. IV heart muscle.
 Can be used when other agents are  Types
contraindicated or ineffective. 1. Permanent
 DILTIAZEM 2. Temporary
 More effective than DIGOXIN or  Implanted transvenous pacemaker
AMIODARONE.  Transcutaneous pacemaker
 Prevent circulatory stroke.  NASPE-BPEG code for pacemaker FXN
1. Anticoagulation , WOF bleeding.  Complications of pacemaker use:
 Drugs : WARFARIN, HEPARIN, ASPIRIN 1. Infection
2. Prevent Thromboembolism → stroke 2. Bleeding or hematoma formation
 If cardiovascularly unstable due to uncontrld 3. Dislocation of the elad
tachycardia 4. Skeletal muscle/ phrenic nerve stimulation
1. Immediate cardioversion. 5. Cardiac tamponade
 Electrical cardioversion 6. Pacemaker malfunction
 Restoration of N heart rhythm by electric  Implantable Cardioverter Defibrillator (ICD)
shock. 1. A device that detects and terminates life-
 Chemical cardioversion threatening episodes of tachycardia or fibrillation
 Performed w/ drugs 2. NASPE-BPEG code
o AMIODARONE 3. Antitachycardia pacing.
o DRONEDARONE
o PROCAINAMIDE

NURSING PROCESS
The care of the patient with a Dysrhythmia:
Assessment