MANAGEMENT OF PATIENTS WITH DYSRHYTHMIAS & CONDUCTION

PROBLEMS

Introduction:

Have you imagined living without any electricity at home? How do you think you would
feel? Do you think you can still enjoy your favorite shows or message your friends or play your
favorite online games, and etc? You wouldn’t be living a normal life, right?

How about in our body? Are there any electrical impulses in it? What if there will also be
an electrical problem? Do you think you could still function? Like the electricity at home,
whereas we maintain our lines, our switches, plugs, bulbs, and even pay our bills to
continuously enjoy life, our hearts when electrical sources and poor conduction happens,
disorders may start.

In this sub unit you will understand how our heart conducts electricity and learn the
management of patients with dysrhythmias and conduction problems. Like our electric bills,
our heart’s electrical impulses and conduction can also be read through an ECG. In order to
learn more about this first disorder, understand your lessons and visit the sites that are
attached here for you to enjoy the wonders of the “Socoteco” of our heart.

Learning Outcomes:

On completion of this unit, I will be able to learn to:

1. Correlated the components of the normal electrocardiogram (ECG) with physiologic
events of the heart.
2. Familiarize with the elements of the ECG rhythm strip.
3. Identify the ECG criteria, causes, and management of several dysrhythmias, including
conduction disturbances.
4. Compare the different types of pacemakers, their uses, possible complications, and
nursing implications.
5. Describe invasive methods to diagnose and treat recurrent dysrythmias and discuss the
nursing implications.
DYSRHYTHMIAS
⚫ Disorders of the formation or conduction (or both)
of the electrical impulse within the heart
⚫ Disturbance in heart rate, rhythm, or both
⚫ Analyzing ECG wavelength
⚫ Named according to site of origin of the impulse &
mechanism of formation or conduction involved
◼ Example: sinus bradycardia – impulse form SA
node and has slow rate

Normal Electrical Conduction

⚫ Sinus node
⚫ Atria
⚫ AV node
⚫ Bundle of His
⚫ Purkinje fibers
⚫ Depolarization, systole
⚫ Repolarization, diastole

Influences of heart rate and contractility

⚫ Influenced by the autonomic nervous system
which consist of:
◼ Sympathetic & parasympathetic fibers
◆ Sympathetic nerve fibers (adrenergic fibers)
◼ Attached to the heart and arteries & other areas of the body
◼ Increases heart rate (positive chronotropy)
◼ Conduction thru the AV node (positive dromotropy)
◆ Force of myocardial contraction (positive inotropy)
◆ Constricts peripheral blood vessels
⚫ Increase BP
◆ Decreased stimulation - dilation of arteries – lowering
BP
◆ Parasympathetic nerve fibers
◼ attached to heart and arteries
◼ Reduces heart rate (negative chronotropy)
◼ AV conduction (negative dromotropy)
◼ Force of atrial myocardial contraction
Manipulation of autonomic nervous system may increase or decrease dysrhytmias

The Electrocardiogram
⚫ The end product of electrical impulse
that travels through the heart and can
be viewed by means of
electrocardiography
⚫ Obtaining an ECG
⚫ Interpreting the ECG
◼ ECG waveform – heart’s
conduction system (initiates &
conducts electrical activity in
relation to the lead)
◆ Printed on graph paper that is
divided by light and dark vertical and horizontal lines at standard intervals
OBTAINING AN ECG (The pictures will guide you on how an ECG is taken):

⚫ ECG waveform – heart’s conduction system

(initiates & conducts electrical activity in relation to the
lead)
◼ Time & rate are measured on the horizontal axis
of the graph
◼ Amplitude or voltage is measured on the
vertical axis
◼ If moves toward on the top of paper, called
positive deflection
◼ If moves toward the bottom of the paper, called negative deflection
INTERPRETING THE ECG:

The Electrocardiogram
⚫ Waves, complexes, and intervals
◼ ECG is composed of:
◆ waveforms – P wave, QRS complex, T wave, U wave
◆ Segments or intervals – PR interval, ST
segment, QT interval
◆ P wave – electrical impulse starting in
the sinus node and spreading
through the atria
◼ Represents atrial depolarization
◼ 2.5 mm or less in height & 0.11 seconds or less in duration
◆ QRS complex
⚫ Ventricular depolarization
⚫ With 3 wave forms
⚫ Q wave – 1st negative
deflection after P wave
◼ Less than 25% of the
R – wave amplitude
⚫ R wave – 1st + deflection
after P wave
⚫ S wave – 1st – deflection
after the R wave
◆ If wave is <5mm in height (qrs);
if taller than 5mm (QRS)
◆ Less than 0.12 seconds in a
duration
◆ T wave – ventricular
repolarization (when the cells regain a negative charge, also called
resting state)
⚫ Follows and with the same direction with the QRS complex
◆ U wave – repolarization of the Purkinje fibers
⚫ Also seen in patients with hypokalemia, hypertension or heart
disease
⚫ Follows the T wave and usually smaller than the P wave.
⚫ If tall, can be mistaken for an extra P wave
◆ PR interval is measured from the beginning of the P wave to the
beginning of the QRS complex
⚫ Represents time needed for sinus node stimulation, atrial
depolarization conduction through the AV node before
ventricular depolarization.
⚫ In adults, 0.12 to 0.220 seconds in duration
◆ ST segment – early ventricular repolarization
⚫ Last from the end of the QRS complex to the beginning of the T
wave
⚫ Identified thru change in the thickness or angle of the terminal
portion of the QRS complex
◆ QT interval – total time for ventricular depolarization and repolarization
⚫ Measured from the beginning of the QRS complex to the end of
the T wave
⚫ Varies with heart rate, gender and age
⚫ .032 to .04 seconds in duration if the HR is 65 – 95 bpm
⚫ If prolonged, risk for torsades de pointes – lethal ventricular
dysrhythmia
◆ TP interval – measured from the end of the T wave to the beginning of
the next P wave, an isoelectric period
⚫ Isoelectric line
◆ P interval – measured from the beginning of one P wave to the
beginning of the next
 ⚫ Used to determine atrial rhythm and atrial rate
⚫ RR interval is measured from one QRS complex to the next QRS
complex
⚫ Used to determine ventricular rate and rhythm

Determining ventricular HR from the ECG

Methods:
⚫ 1 minute strip – 300 large boxes
and 1500 small boxes
⚫ 3 second interval – 15 large
boxes horizontaly

Analyzing the ECG rhythm strip

⚫ Normal sinus rhythm
◼ Types of dysrhythmias
◆ Sinus node dysrhythmias
⚫ Sinus bradycardia
⚫ Sinus tachycardia
⚫ Sinus arrhyt

SINUS NODE DYSRHYTHMIAS

◆ Atrial dysrhythmias
⚫ Premature atrial complex (PAC)
⚫ Atrial flutter
⚫ Atrial fibrillation
 ◆Atrial flutter
⚫ Occurs in
the atrium,
creates impulses at a regular rate bet. 250 – 400x/min
⚫ Because atrial rate is faster than the AV node can conduct – not all atrial
impulses are conducted to ventricles causing therapeutic block at the
AV node, important feature of dysrhythmia
⚫ If all are conducted, ventricular rate is 250 – 400 & results to ventricular
fibrillation
⚫ Can cause chest
pain, DOB, low BP
⚫ If patient is
unstable electrical
cardioverson is
indicated
⚫ If patient is stable,
narrow QRS, RR
interval is regular
◼ 6 mg
adenosine
rapid IV then 20 ml saline flush, elevate arm for rapid circulation
◼ If rhythm did not convert to sinus rhythm within 1 – 2 minutes,
12mg bolus & repeated prn within 1 – 2 minutes
◼ If not relieved, magnesium, diltiazem, beta blockers slow IV to
slow ventricular rate
◼ If unsuccessful, electrical cardioversion
◆ Atrial fibrillation
⚫ Causes rapid,
uncoordinated
twitching of
atrial
musculature
⚫ Linked to
stroke, HF,
dementia,
premature
death
⚫ Transient,
starting &
stopping suddenly & occurring in a very short time (paroxysmal) or
⚫ Persistent requiring
treatment
⚫ Associated with advanced
age
⚫ Valvular heart disease
⚫ CAD
⚫ Hypertension, DM,
pulmonary disease,
moderate to heavy
ingestion of alcohol
(holiday heart syndrome)
⚫ After coronary bypass,
valvular replacement,
heart transplant
⚫ Sometimes after discharge w/o symptoms, w/o underlying
pathophysiology (lone atrial fibrillation
⚫ Rapid ventricular response reduces the time for ventricular filling – smaller
stroke volume
⚫ Atrial fib causes atria & ventricles to contract at different times, the atrial kick
(last part of diastole & ventricular filling is also lost thus s/s
⚫ Irregular palpitations, fatigue, malaise, pulse deficit, myocardial ischemia
(shorter time in diastole reduces the time available for coronary artery
perfusion)
⚫ Thrombus within the atria due to erratic atrial contraction increasing risk for
embolic event – stroke
⚫ Treatment depends on cause, duration, age, comorbidity
⚫ In many converts to sinus rhytym within 24h – no treatment
⚫ Cardioversion of atrial fibrillation that has lasted 48h should be
avoided unless with anticoagulants
⚫ For acute onset (w/in 48h) IV give adenosine to achieve cardioversion to
sinus rhythm & to assist in dx
⚫ Warfarin – if at risk for stroke
⚫ Pacemaker if unresponsive to meds
◆ Junctional dysrhythmias
⚫ Premature junctional complex
◼ Impulse that
starts in the AV
nodal area
before the next
normal sinus
impulse reaches
the AV node
◼ Digitalis toxicity
(treatment for
HF), HF, CAD
◼ ECG is the same
with PAC,
except for the P
wave (absent,
may follow QRS, or may occur before the QRS) & PR interval (<0.12
seconds)
◼ Rarely produce significant symptoms
◼ Treatment is the same for frequent PACs
⚫ Junctional rhythm
◼ Also called
idionodal rhythm
◼ AV node, instead
of the SA
becomes the
pacemaker of the
heart
◼ s/s reduced
cardiac output
◼ Treatment same
with sinus
bradycardia.
◼ Emergency pacing may be needed
⚫ Nonparoxysmal junctional tachycardia
◼ Junctional tachycardia is caused by enhanced automaticity in the
junctional area, resulting to same rhythm except rate @70 – 120
◼ Though not detrimental, indicates serious underlying conditions like
digitalis toxicity, myocardial ischemia, hypokalemia, COPD
◼ Cardioversion may increase ventricular rate – not indicated

⚫ Atrioventricular nodal reentry tachycardia (AVNRT)

◼ Factors like caffeine, nicotine, hypoxemia, stress
◼ Uderlying pathologies CAD, cardiomyopathy
◼ s/s vary with rate & duration of tachycardia & underlying
condition
◼ Tachycardia of short duration resulting in palpitations
◼ Fast rate may reduce cardiac output – result to restlessness, chest
pain, shortness of breath, pallor, hypotension and loss of
consciousness
◼ Treatment’s aim – break the reentry of the impulse
◼ Vagal maneuvers (carotid sinus massage, gag reflex, breath holding,
immersing the face in ice water – increases parasympathetic
stimulation –
slower conduction
through the AV
node & blocking
the reentry of the
rerouted impulse
◼ If not effective,
bolus of adenosine
or beta blockers
◆ Ventricular
dysrhythmias
⚫ Premature
ventricular
complex
(PVC)
⚫ Ventricular
tachycardia
⚫ Ventricular
fibrillation

⚫ Idioventricular rhythm
⚫ Ventricular asystole

⚫ Premature ventricular
complex (PVC)
◼ Impulse that
starts in a
ventricle & is
conducted
through the
ventricles before
the next normal
sinus impulse
◼ Can occur in
healthy
people
especially
with intake
of caffeine,
nicotine or
alcoho
◼ Also by
cardiac
ischemia or
infarction,
increased
workload in
the heart,
digitalis
 toxicity, hypoxia, electrolyte imbalance
◼ In the absence of disease, not serious
◼ Feel nothing except saying the “heart skipped a beat”
◼ Initial treatment – correcting the cause
◼ No indicated treatment if only PVC

Ventricular tachycardia
◼ 3 or more PVCs
in a row,
occurring at a
rate exceeding
100 bpm
◼ Similar cause
with PVC
◼ Usually
associated with
CAD & may
precede
ventricular
fibrillation
◼ An emergency,
usually unresponsive & pulseless

⚫ Ventricular fibrillation
◼ Rapid, disorganized ventricular rhythm that causes ineffective
quivering of the ventricles
◼ No atrial activity on the ECG
◼ Causes is the same with VT
◼ May from
untreated or

unsuccessfully treated VT
◼ Dysrhythmias has absence of audible heartbeat, palpable pulse &
respiration
◼ If not corrected – cardiac arrest & death
◼ Treatment, CPR, defibrillation, activation of emergency services
◼ Vasoactive meds like epinephrine, vasopressin or both ASAP before
or after 2nd defib
◼ Antidysrhythmic (amiodarone, lidocaine, or possibly magnesium)
before or after the 3rd defib
⚫ Idioventricular rhythm
◼ Or ventricular
escape rhythm
impulse starts
in the
conduction
system below
the AV node
◼ Sinus fail to
create an
impulse or is
created but
can’t be
conducted
through the AV
node, the Purkinje fibers automatically discharge an impulse
◼ Causes lose of consciousness & s/s of less cardiac output
◼ Identify cause, administer IV atropine & vasopressor meds, initiate
emergency transcutaneous pacing
◼ Bed rest to increase cardiac workload

⚫ Ventricular asystole
◼ Commonly called flatline
◼ Absent QRS complexes
◼ No hearbeat, no palpable pulse, no respiration
◼ Fatal without immediate treatment
◼ Rapid assessment – identify cause(hypoxia, acidosis, severe
electrolyte imbalance, cardiac tamponade, drug overdose,
hypovolemia, tension pneumothorax, coronary pulmonary
thrombosis, trauma, hypothermia)
◼ Initiate CPR then intubate, establish IV access, no or minimal
interruptions in chest compressions
◼ After 2 minutes of 5 cycles CPR, bolus of epi & repeated at 3 – 5
minutes interval
 ◼ 1 dose of vasopressine (1 mg bolus of atropine) for the 1st 2nd
dose of epi
◼ poor prognosis –resuscitation efforts are usually ended if did not
respond

◆ Conduction abnormalities
⚫ s/s of heart block vary with the:
◼ Resulting ventricular rate & severity of underlying disease processes
⚫ Health care providers to treat ailment not the rhythm
⚫ Treatment is based on the hemodynamic effect of the rhythm

CONDUCTION PROBLEMS

Conduction abnormalities:
⚫ First – degree atrioventricular block
⚫ Second – degree atrioventricular block, type I
⚫ Second – degree atrioventricular block, type II
⚫ Third – degree atrioventricular block

Nursing Process (assessment)

⚫ Causes
⚫ Contributing factors
⚫ Heath history
⚫ Coexisting conditions
⚫ Medications
⚫ Lab results

Nursing Process (Diagnosis)

⚫ Decreased cardiac output
⚫ Anxiety related to fear of the unknown
⚫ Deficient knowledge about the dysrhytmia & its treatment

Nursing Process (potential complications)

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

Nursing Process (planning and goals)

⚫ Eliminate or decrease the occurrence of the dysrhythmia
⚫ Maintain cardiac output
⚫ Minimize anxiety
⚫ Acquire knowledge

Nursing Process (nursing interventions)

⚫ Monitoring & managing the dysrhythmia
⚫ Minimizing anxiety
⚫ Promoting home & community – based care

Nursing Process (evaluation)

⚫ Maintains cardiac output
⚫ Experiences reduced anxiety
⚫ Expresses understanding of the dysrhythmia & its treatment

Adjunctive modalities & management

⚫ Acute or chronic
⚫ Cause & actual or potential hemodynamic effects
◼ Meds or external electrical therapy (emergency defibrillation, cardioversion, or
pacing)
◆ Nurse to monitor & document response to meds
⚫ Ensure knowledge & ability to manage
⚫ Cardioversion & defibrillation
◼ Use to treat tachydysrhythmias – deliver electrical current that depolarizes a critical
mass of myocardial cells
◼ Difference between the 2 is the timing of the delivery of electrical current.
◼ Nurse must observe 2 safety methods: good contact & no one to be in contact
 ⚫Pacemaker
therapy
◼ Provides electrical stimuli to the heart muscle
◼ Use when a patient has a slower than normal impulse formation or a
symptomatic AV or ventricular conduction disturbances
◼ Control tachydysrhytmias that do not respond to medication
◼ Permanent or temporary
◼ Design and type
◆ Electronic pulse generator
◆ Pacemaker electrodes
◼ Complications of pacemaker use
◆ Local infection at the entry site
◆ Bleeding and
hematoma
◆ Hemothorax
◆ Ventricular
atrophy
◆ Movement or
dislocation of the lead
◆ Phrenic nerve,
diaphragmatic or
skeletal muscle
stimulation
◆ Cardiac
tamponade
◼ Pacemaker
surveillance
◆ Pacemaker clinics
◆ Computerized device
◼ Implantable cardioverter defibrillator
 ◆ Detects and terminates life
threatening episodes of
tachycardia or fibrillation
◆ With generator and at least 1 lead
that can sense intrinsic electrical
activity & deliver an electrical
impulse
◆ Implanted like a pacemaker
◆ Antiarrhythmic medication is
usually administer

Nursing process on patient with an implantable cardiac device

Assessment
⚫ HR and rhythm are monitored by ECG
⚫ Devises settings are noted to check for function
⚫ Cardiac output & hemodynamic stability
⚫ Appearance or increasing frequency of dysrhythmias
⚫ Incision site
⚫ Anxiety, depression, anger
⚫ Knowledge level

Diagnosis
Nursing diagnosis
⚫ Risk for infection related to lead or generator insertion
⚫ Risk for ineffective coping
⚫ Deficient knowledge regarding self – care program
Collaborative problems/potential complications
⚫ Decreased cardiac output

Planning and goals

⚫ Absence of infection
⚫ Adherence to self – care program
⚫ Effective coping
⚫ Maintenance of device function

Nursing interventions
⚫ Preventing infection
⚫ Promoting effective coping
⚫ Promoting home and community based care

Expected patient outcomes

⚫ Remains free of infection
⚫ Adheres to a self care program
 ⚫ Maintains device function
⚫ Demonstrates and /or describes an effective coping strategy

Home care checklist:

⚫ Monitor pacemaker function
⚫ Promote safety and avoid infection
⚫ Electromagnetic interference: understand the importance of:
◼ Large magnetic fields
◼ Electrical & small motor devices, as well as products that contain magnet
◼ Household items
◼ Security gates
◼ Hospitalization

Electrophysiologic studies
⚫ Invasive procedure use to evaluate and treat various dysrhythmias that have caused
cardiac arrest or significant symptoms
⚫ With symptoms that suggest a dysrhythmia that has gone undetected & undiagnosed by
other methods
⚫ Do the following:
◼ Identify the impulse information & propagation through the cardiac electrical
conduction system
◼ Assess the function or dysfunction of the SA and AV nodal areas
◼ Identify the location & mechanism of dysrhythmogenic foci
◼ Assess the effectiveness of antiarrhythmic medications and devices of patients with
dysrhythmia and mechanism
◼ Treat certain dysrhythmias through the destruction of the causative cells (ablation)
⚫ A cardiac catheterization that is performed in a specially equipped cardiac catheter lab
by an electrophysiologist
⚫ Conscious and slightly sedated
⚫ # & placement of electrodes allow the electrical signal to be recorded from within the
heart
Cardiac conduction surgery
⚫ Atrial tachycardias and ventricular tachycardias that do not respond to medications
⚫ Maze procedure
◼ Open heart surgery procedure for refractory atrial fibrillation
◼ 95% effective
◼ Some patients need permanent pacemaker after the surgery

⚫ Catheter ablation therapy

◼ Destroys specific cells that are the cause or central conduction route of a
tachydysrhythmia
◼ Perform with or after an EP study
◼ Indicated to eliminate accessory AV pathways or bypass tracts that exist in the
hearts of patients with reexcitation syndromes
◼ Most often accomplished by using radio frequency, especial catheter near origin of
the dysrhythmia
◼ Defib pads, automatic BP cuff, pulse oximeter are used plus indwelling catheter
◼ Monitored more closely
END