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Chapter 27
Management of Patients With
Dysrhythmias and
Conduction Problems
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Dysrhythmias (See Chart 27-1)
• Dysrhythmias: disorders of the formation or conduction
(or both) of the electrical impulses in the heart
• These disorders can cause disturbances of:
– Rate
– Rhythm
– Both rate and rhythm
• Potentially can alter blood flow & cause hemodynamic
changes
• Diagnosed by analysis of ECG waveform
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Relationship of ECG Complex, Lead
System, and Electrical Impulse
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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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Premature Atrial Complexes
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Atrial Flutter
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Atrial Fibrillation
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Multifocal PVCs-Quadrigeminy
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Ventricular Tachycardia
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Ventricular Fibrillation
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Asystole
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First-Degree AV Block
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Second-Degree AV Block, Type 1
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Second-Degree AV Block, Type 2
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Third-Degree AV Block
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Nursing Process: The Care of the Patient
with a Dysrhythmia: Assessment
• Assess indicators of cardiac output and oxygenation,
especially changes in level of consciousness.
• Physical assessment includes:
– Rate and rhythm of apical and peripheral pulses
– Assess heart sounds
– Blood pressure and pulse pressure
– Signs of fluid retention
• Health history: include presence of coexisting conditions
and indications of previous occurrence
• Medications
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Nursing Process: The Care of the Patient
with a Dysrhythmia: Diagnosis
• Decreased cardiac output
• Anxiety
• Deficient knowledge
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Collaborative Problems/Potential
Complications
• Cardiac arrest
• Heart failure
• Thromboembolic event, especially with atrial fibrillation
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Nursing Process: The Care of the Patient
with a Dysrhythmia: Planning
• Goals may include eradicating or decreasing the
occurrence of the dysrhythmia to maintain cardiac
output, minimizing anxiety, and acquiring knowledge
about the dysrhythmia and its treatment.
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Decreased Cardiac Output
• Monitoring
– ECG monitoring
– Assessment of signs and symptoms
• Administration of medications and assessment of
medication effects
• Adjunct therapy: cardioversion, defibrillation,
pacemakers
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Other Interventions
• Anxiety
– Use a calm, reassuring manner.
– Measures to maximize patient control to make
episodes less threatening
– Communication and teaching
• Teaching self-care
– Include family in teaching
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Pacemakers
• An electronic device that provides electrical stimuli to the
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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ECG On-Demand Pacing
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Complications of Pacemaker Use
• Infection
• Bleeding or hematoma formation
• Dislocation of the lead
• Skeletal muscle or phrenic nerve stimulation
• Cardiac tamponade
• Pacemaker malfunction
See Table 27-2
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Nursing Process: The Care of the Patient
with an Implanted Cardiac Device:
Assessment
• Device function; ECG
• Cardiac output and hemodynamic stability
• Incision site
• Coping
• Patient and family knowledge
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Nursing Process: The Care of the Patient
with an Implanted Cardiac Device:
Diagnosis
• Risk for infection
• Risk for ineffective coping
• Knowledge deficiency
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Nursing Process: The Care of the Patient
with an Implanted Cardiac DevicePlanning
• Goals include absence of infection, adherence to self-care
program, effective coping, and maintenance of device
function.
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Interventions
• Risk for ineffective coping
– Support of patient and family coping
– Setting of realistic goals
– Allow patient to talk, share feeling and experiences
– Support groups or referral
– Stress reduction techniques
• Knowledge deficiency
– Patient and family teaching
See Chart 27-3
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Cardioversion and Defibrillation
• Treat tachydysrhythmias by delivering an electrical
current that depolarizes a critical mass of myocardial
ceils. When cells repolarize, the sinus node is usually able
to recapture its role as heart pacemaker.
• In cardioversion, the current delivery is synchronized
with the patient’s ECG.
• In defibrillation, the current delivery is unsynchronized.
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Safety Measures
• Ensure good contact between skin and pads or paddles.
Use a conductive medium and 20-25 pounds of
pressure.
• Place paddles so that they do not touch bedding or
clothing and are not near medication patches or oxygen
flow.
• If cardioverting, turn the synchronizer on.
• If defibrillating, turn the synchronizer off.
• Do not charge the device until ready to shock.
• Call “clear” three times; follow checks required for
clear and ensure that no one is in contact with the
patient, bed, or equipment.
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Paddle Placement for Defibrillation
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Implantable Cardioverter Defibrillator
(ICD)
• A device that detects and terminates life-threatening
episodes of tachycardia or fibrillation
• NASPE-BPEG code
• Antitachycardia pacing
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ICD
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Invasive Methods to Diagnose and Treat
Recurrent Dysrhythmias
• Electrophysiologic studies
• Cardiac conduction surgery
– Maze procedure
– Catheter ablation therapy
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