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Chapter 27 Management of Patients With Dysrhythmias and Conduction Problems

Christie M. Candelaria, MA, RN, CCRN

Learning Outcomes/Objectives:
• Identify clinical characteristics and ECG patterns of normal sinus rhythm and common dysrhythmias as follows:
– sinus bradycardia – sinus tachycardia – atrial fibrillation

– atrial flutter
– – ventricular tachycardia ventricular fibrillation

• Describe the nursing and collaborative management of patients with common dysrhythmias mentioned above.

Cardiac conduction
• SA Node • AV node • Bundle of HIS • Right & Left Bundle Branches • Purkinje Fibers d3rJCLCE&feature=related

Cardiac Cycle
Refers to the a repetitive pumping process that includes all of the events associated with blood flow through the heart Depolarization- electrical stimulation Systole—period during which ventricles mechanically contract and blood is being ejected Repolarization – electrical relaxation Diastole—period of mechanical relaxation in which ventricles are filling

EKG Paper .

EKG Paper .


11 seconds (less than 3 small squares) • Amplitude (height) is no more than 3 mm • Normally no notching or peaking .Components of EKG Waveform P WAVE • Indicates atrial depolarization. contraction of the atrium • Normal duration is not longer than 0.

20 seconds .12 to 0.Components of EKG Waveforms PR Interval • Indicates AV conduction time • Duration time is 0.

08-0. the ventricles contract • Normal duration is 0. or contraction of the ventricles • Shortly after depolarization begins.Components of EKG Waveform QRS Complex • Indicates ventricular depolarization.12 .

QRS complex Q Wave– 1st downward deflection in the depolarization of the ventricle (many times may be absent) .

QRS Complex R Wave– 1st upward deflection of the QRS (may follow a Q wave or be present by itself) .

QRS complex ST Segment • terminal portion of QRS. represents the delay time after depolarization and waiting for repolarization • Normally not depressed more than 0.5mm • May be elevated slightly in some leads (no more than 1 mm) (this is EXTREMELY important in diagnosing MI) .

V-Tach can occur • Also useful in diagnosing ischemia or MI .Components of EKG Waveform T Wave (ahhh rest) • Indicates ventricular repolarization • Not more than 5mm in amplitude in standard leads and 10mm in precordial leads • Rounded and asymmetrical • Last 1/3 of vulnerable area of time—if a ventricular response is initiated here. such as a PVC.

Components of EKG Waveform QT Interval • Indicates repolarization time • General Rule: duration is less than half the preceding R-R interval • Will lengthen and shorten as the rate changes .

hypokalemia.U Wave • Represents repolarization of His-Purkinje system • Not present on every strip • A prominent U wave may be due to hypercalcemia. or digoxin toxicity .

Putting it all together: .

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



• Apply tincture of benzoin if keeping electrodes is difficult. • Avoid applying electrodes over these areas: – Bony areas – Scar tissue – Muscle mass (significant) skin folds breast tissue heart apex .Tips for applying electrodes • Make sure skin is thoroughly dry. • Make sure the center of the electrode disc is moist. • Clip chest hair. • Remove any excess skin oil with alcohol. • Connect each lead wire to a disc before applying it to the chest.

Mosby. All Rights Reserved. .Assessment of Cardiac Rhythm Fig. 2004.. Inc. 365 Copyright © 2007. 2000. an affiliate of Elsevier Inc.

. . Inc. Mosby. All Rights Reserved. 2000. 369 Copyright © 2007.Assessment of Cardiac Rhythm Fig. 2004. an affiliate of Elsevier Inc.

an affiliate of Elsevier Inc. . 2000. Inc. All Rights Reserved. Mosby.. 2004.Assessment of Cardiac Rhythm Copyright © 2007.

Heart Rate Determination .


Evaluation of Dysrhythmias • Holter monitoring • Event recorder monitoring • Exercise treadmill testing • Signal-averaged ECG • Electrophysiologic study .

Normal Sinus Rhythm

 Originates in the sinoatrial node (SA)  Rhythm: atrial/ventricular regular  Rate: atrial/ventricular rates 60 to 100 bpm  P waves: present, consistent configuration  One P wave before each QRS  PR interval: 0.12 to 0.20 second and constant  QRS duration: 0.04 to 0.10 second and constant

Normal Sinus Rhythm
• Sinus node fires 60 to 100 bpm
• Follows normal conduction pattern

Fig. 368
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Normal Sinus Rhythm

Sinus Bradycardia

Sinus Bradycardia • Clinical associations – Occurs in response to •Carotid sinus massage •Hypothermia •Increased vagal tone •Administration of parasympathomimetic drugs .

Sinus Bradycardia • Clinical associations – Occurs in disease states • Hypothyroidism • Increased intracranial pressure • Obstructive jaundice • Inferior wall MI .

Sinus Bradycardia • Clinical significance – Dependent on symptoms • Hypotension • Pale. cool skin • Weakness • Angina • Dizziness or syncope • Confusion or disorientation • Shortness of breath .

Sinus Bradycardia • Treatment – Atropine – Pacemaker may be required .


36-27 Copyright © 2007. All Rights Reserved. . an affiliate of Elsevier Inc.. 2000. Mosby. 2004. Inc.Pacemakers Fig.

36-25 Fig.Pacemakers Fig. 36-26 .

36-24 B Copyright © 2007.Pacemakers Fig. 2000. All Rights Reserved. 36-24 A Fig. . Inc. Mosby. an affiliate of Elsevier Inc.. 2004.

Pacer spikes .

Sinus Tachycardia .

Tachycardia  Heart rate greater than 100 bpm  Shorten diastolic time =  perfusion time  Initial  CO and B/P  Ventricular filling =  stroke volume =  aortic pressure  Eventually =  CO and B/P  Increases the work of the heart. increasing myocardial O2 demand .

Mosby. . All Rights Reserved. 2000.html • Discharge rate from the sinus node is increased as a result of vagal inhibition and is >100 bpm Copyright © an affiliate of Elsevier Inc.Sinus Tachycardia http://ems-ed. 2004. Inc.

Sinus Tachycardia • Clinical associations – Associated with physiologic stressors • Exercise • Pain • Hypovolemia • Myocardial ischemia • Heart failure (HF) • Fever .

Sinus Tachycardia • Clinical significance – Dizziness and hypotension due to decreased CO – Increased myocardial oxygen consumption may lead to angina .

Sinus Tachycardia • Treatment – Determined by underlying cause •-Adrenergic blockers to reduce HR and myocardial oxygen consumption •Antipyretics to treat fever •Analgesics to treat pain .

Atrial Flutter .

quinidine. epinephrine .Atrial Flutter • Clinical associations – Usually occurs with • CAD • Hypertension • Mitral valve disorders • Pulmonary embolus • Chronic lung disease • Cardiomyopathy • Hyperthyroidism • Drugs: Digoxin.

Atrial Flutter • Clinical significance – High ventricular rates (>100) and loss of the atrial ―kick‖ can decrease CO and precipitate HF. angina – Risk for stroke due to risk of thrombus formation in the atria .

-adrenergic blockers • Electrical cardioversion may be used to convert the atrial flutter to sinus rhythm emergently and electively .Atrial Flutter • Treatment – Primary goal is to slow ventricular response by increasing AV block • Drugs to slow HR: Calcium channel blockers.

.Atrial Flutter • Treatment – Primary goal is to slow ventricular response by increasing AV block • Antidysrhythmia drugs to convert atrial flutter to sinus rhythm or to maintain sinus rhythm (e. propafenone) • Radiofrequency catheter ablation can be curative therapy for atrial flutter . amiodarone.g.

Atrial Fibrillation .

such as rheumatic heart disease.Atrial Fibrillation • Clinical associations – Usually occurs with •Underlying heart disease. CAD •Cardiomyopathy •HF •Pericarditis .

Atrial Fibrillation • Clinical associations – Often acutely caused by •Thyrotoxicosis •Alcohol intoxication •Caffeine use •Electrolyte disturbance •Cardiac surgery .

Atrial Fibrillation • Clinical significance – Can result in decrease in CO due to ineffective atrial contractions (loss of atrial kick) and rapid ventricular response – Thrombi may form in the atria as a result of blood stasis – Embolus may develop and travel to the brain. causing a stroke .

calcium channel blockers – Long-tern anticoagulation: Coumadin . adrenergic blockers.Atrial Fibrillation • Treatment – Goals • Decrease ventricular response • Prevent embolic stroke – Drugs for rate control: digoxin.

conversion to sinus rhythm may be considered • Antidysrhythmic drugs used for conversion: Amiodarone.Atrial Fibrillation • Treatment – For some patients. propafenone • cardioversion may be used to convert atrial fibrillation to normal sinus rhythm .

anticoagulation therapy with warfarin is recommended for 3 to 4 weeks before cardioversion and for 4 to 6 weeks after successful cardioversion .Atrial Fibrillation • Treatment – If patient has been in atrial fibrillation for >48 hours.

Atrial Fibrillation • Treatment – Radiofrequency catheter ablation – Maze procedure – Modifications to the Maze procedure •Use of cold (cryoablation) •Use of heat (highintensity ultrasound) .


Ventricular Tachycardia .

Ventricular Fibrillation .

Asystole .

Nursing Process: Care of the Patient with a Dysrhythmia . rhythm of apical. peripheral pulses – Heart sounds – Blood pressure. especially changes in level of consciousness • Physical assessment include – Rate.Assessment • Assess indicators of cardiac output and oxygenation. pulse pressure – Signs of fluid retention .

indications of previous occurrence • Medications .Nursing Process: Care of the Patient with a Dysrhythmia – Assessment (cont’d) • Health history: include presence of coexisting conditions.

Nursing Process: Care of the Patient with a Dysrhythmia .Diagnoses • Decrease cardiac output • Anxiety • Deficient knowledge .

Collaborative Problems/Potential Complications • Cardiac arrest • Heart failure • Thromboembolic event. especially with atrial fibrillation .

its treatment .Nursing Process: Care of the Patient with a Dysrhythmia .Planning • Goals – Eradicating or decreasing occurrence of dysrhythmia to maintain cardiac output – Minimizing anxiety – Acquiring knowledge about dysrhythmia.

symptoms • Administration of medications.Decreased Cardiac Output • Monitoring – ECG monitoring – Assessment of signs. assessment of medication effects • Adjunct therapy: cardioversion. pacemakers . defibrillation.

reassuring manner – Measures to maximize patient control to make episodes less threatening – Communication.Other Interventions • Anxiety – Use calm. teaching • Teaching self-care – Include family in teaching .

Cardioversion and Defibrillation • Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial ceils – When cells repolarize. current delivery synchronized with patient’s ECG • In defibrillation. sinus node usually able to recapture role as heart pacemaker • In cardioversion. current delivery is unsynchronized .

. 2004. Inc. 3621 Copyright © 2007. Mosby. All Rights Reserved. an affiliate of Elsevier Inc. . 2000.Defibrillation Fig.

. Mosby. an affiliate of Elsevier Inc. All Rights Reserved. 2004. 36-20 A and B Copyright © 2007. 2000.Defibrillation Fig. Inc. .

Paddle Placement for Defibrillation .

Implantable Cardioverter Defibrillator (ICD) • Device that detects. terminates life-threatening episodes of tachycardia or fibrillation • NASPE-BPEG code • Antitachycardia pacing .

2000.Implantable CardioverterDefibrillator (ICD) Fig. 2004. an affiliate of Elsevier Inc. 22 . 36Copyright © 2007. Inc. Mosby. All Rights Reserved..

Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias • Electrophysiologic studies • Cardiac conduction surgery – Maze procedure – Catheter ablation therapy .

hyperkalemia .

hypocalcemia .

ST elevation or flag .

not the rhythm .“How will I know what to do?” you ask • Treat the a good place to start • Anticipate the problem • Know your drugs • Know CPR .