A cardiac dysrhythmia is any disturbance in the normal rhythm of the electrical excitation of the heart. It can be the result of a primary cardiac disorder, a response to a systemic condition, the result of electrolyte imbalance or drug toxicity. Dysrhythmias vary in severity and in their effects on cardiac function, which are partially influenced by the site of origin (ventricular or supraventricular).
CARE SETTING
Generally, minor dysrhythmias are monitored and treated in the community setting; however, potential life-threatening situations (including heart rates above 150 beats/min) usually require a short inpatient stay.
RELATED CONCERNS
Angina
Heart failure: chronic
Myocardial infarction
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Generalized weakness and exertional fatigue
May exhibit: Changes in heart rate/BP with activity/exercise
CIRCULATION
May report: History of previous/acute MI (90%–95% experience dysrhythmias), cardiac surgery, cardiomyopathy, rheumatic/HF, valvular heart disease, long-standing hypertension, use of pacemaker
Pulse: Fast, slow, or irregular; palpitations, skipped beats
May exhibit: BP changes (hypertension or hypotension) during episodes of dysrhythmia
Pulses may be irregular, e.g., skipped beats; pulsus alternans (regular strong beat/weak beat); bigeminal pulse (irregular strong beat/weak beat)
Pulse deficit (difference between apical pulse and radial pulse)
Heart sounds: irregular rhythm, extra sounds, dropped beats
Skin color and moisture changes, e.g., pallor, cyanosis, diaphoresis (heart failure, shock)
Edema dependent, generalized, JVD (in presence of heart failure)
Urine output decreased if cardiac output is severely diminished
EGO INTEGRITY
May report: Feeling nervous (certain tachydysrhythmias), sense of impending doom
Stressors related to current medical problems
May exhibit: Anxiety, fear, withdrawal, anger, irritability, crying
FOOD/FLUID
May report: Loss of appetite, anorexia
Food intolerance (with certain medications)
Nausea/vomiting
Changes in weight
May exhibit: Weight gain or loss
Edema
Changes in skin moisture/turgor
Respiratory crackles
NEUROSENSORY
May report: Dizzy spells, fainting, headaches
May exhibit: Mental status/sensorium changes, e.g., disorientation, confusion, loss of memory; changes in usual speech pattern/consciousness, stupor, coma
Behavioral changes, e.g., combativeness, lethargy, hallucinations
Pupil changes (equality and reaction to light)
Loss of deep tendon reflexes with life-threatening dysrhythmias (ventricular tachycardia, severe bradycardia)
PAIN/DISCOMFORT
May report: Chest pain, mild to severe, which may or may not be relieved by antianginal medication
May exhibit: Distraction behaviors, e.g., restlessness
RESPIRATION
May report: Chronic lung disease
History of or current tobacco use
Shortness of breath
Coughing (with/without sputum production)
May exhibit: Changes in respiratory rate/depth during dysrhythmia episode
Breath sounds: Adventitious sounds (crackles, rhonchi, wheezing) may be present,
indicating respiratory complications, such as left-sided heart failure (pulmonary edema) or pulmonary thromboembolic phenomena Hemoptysis
SAFETY
May exhibit: Fever
Skin: Rashes (medication reaction)
Loss of muscle tone/strength
TEACHING/LEARNING
May report: Familial risk factors, e.g., heart disease, stroke
Use/misuse of prescribed medications, such as heart medications (e.g., digitalis), anticoagulants (e.g., warfarin [Coumadin]), benzodiazepines (e.g., diazepam [Valium]), tricyclic antidepressants (e.g., amitriptyline [Elavil]), or antipsychotic agents (e.g., fluphenazine [Prolixin], chlorpromazine [Thorazine]), or OTC medications (e.g., cough syrup and analgesics containing ASA)
Stimulant abuse, including caffeine/nicotine
Lack of understanding about disease process/therapeutic regimen
Evidence of failure to improve, e.g., recurrent/intractable dysrhythmias that are lifethreatening
Discharge plan
DRG projected mean length of inpatient stay: 3.9 days
Alteration of medication use/therapy
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
ECG: Reveals type/source of dysrhythmia and effects of electrolyte imbalances and cardiac medications. Demonstrates patterns of ischemic injury and conduction aberrance. Note: Exercise ECG can reveal dysrhythmias occurring only when patient is not at rest (can be diagnostic for cardiac cause of syncope).
Extended or event monitoring (e.g., Holter monitor): Extended ECG tracing (24 hr to weeks) may be desired to determine which dysrhythmias may be causing specific symptoms when patient is active (home/work) or at rest.
May also be used to evaluate pacemaker function, antidysrhythmia drug effect, or effectiveness of cardiac rehabilitation.
Signal-averaged ECG (SAE): May be used to screen high-risk patients (especially post-MI or unexplained syncope) for ventricular dysrhythmias, presence of delayed conduction, and late potentials (as occurs with sustained ventricular tachycardia).
Chest x-ray: May show enlarged cardiac shadow due to ventricular or valvular dysfunction.
Myocardial imaging scans: May demonstrate ischemic/damaged myocardial areas that could impede normal conduction or impair wall motion and pumping capabilities.
Electrophysiological (EP) studies: Provides cardiac mapping of entire conduction system to evaluate normal and abnormal pathways of electrical conduction. Used to diagnose dysrhythmias and evaluate effectiveness of medication or pacemaker therapies.
Electrolytes: Elevated or decreased levels of potassium, calcium, and magnesium can cause dysrhythmias.
Drug screen: May reveal toxicity of cardiac drugs, presence of street drugs, or suggest interaction of drugs, e.g., digitalis and quinidine.
Thyroid studies: Elevated or depressed serum thyroid levels can cause/aggravate dysrhythmias.
ESR: Elevation may indicate acute/active inflammatory process, e.g., endocarditis, as a precipitating factor for dysrhythmias.
ABGs/pulse oximetry: Hypoxemia can cause/exacerbate dysrhythmias.
NURSING PRIORITIES
1. Prevent/treat life-threatening dysrhythmias.
2. Support patient/SO in dealing with anxiety/fear of potentially life-threatening situation.
3. Assist in identification of cause/precipitating factors.
4. Review information regarding condition/prognosis/treatment regimen.
DISCHARGE GOALS
1. Free of life-threatening dysrhythmias and complications of impaired cardiac output/tissue perfusion.
2. Anxiety reduced/managed.
3. Disease process, therapy needs, and prevention of complications understood.
4. Plan in place to meet needs after discharge.
CARE SETTING
Generally, minor dysrhythmias are monitored and treated in the community setting; however, potential life-threatening situations (including heart rates above 150 beats/min) usually require a short inpatient stay.
RELATED CONCERNS
Angina
Heart failure: chronic
Myocardial infarction
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Generalized weakness and exertional fatigue
May exhibit: Changes in heart rate/BP with activity/exercise
CIRCULATION
May report: History of previous/acute MI (90%–95% experience dysrhythmias), cardiac surgery, cardiomyopathy, rheumatic/HF, valvular heart disease, long-standing hypertension, use of pacemaker
Pulse: Fast, slow, or irregular; palpitations, skipped beats
May exhibit: BP changes (hypertension or hypotension) during episodes of dysrhythmia
Pulses may be irregular, e.g., skipped beats; pulsus alternans (regular strong beat/weak beat); bigeminal pulse (irregular strong beat/weak beat)
Pulse deficit (difference between apical pulse and radial pulse)
Heart sounds: irregular rhythm, extra sounds, dropped beats
Skin color and moisture changes, e.g., pallor, cyanosis, diaphoresis (heart failure, shock)
Edema dependent, generalized, JVD (in presence of heart failure)
Urine output decreased if cardiac output is severely diminished
EGO INTEGRITY
May report: Feeling nervous (certain tachydysrhythmias), sense of impending doom
Stressors related to current medical problems
May exhibit: Anxiety, fear, withdrawal, anger, irritability, crying
FOOD/FLUID
May report: Loss of appetite, anorexia
Food intolerance (with certain medications)
Nausea/vomiting
Changes in weight
May exhibit: Weight gain or loss
Edema
Changes in skin moisture/turgor
Respiratory crackles
NEUROSENSORY
May report: Dizzy spells, fainting, headaches
May exhibit: Mental status/sensorium changes, e.g., disorientation, confusion, loss of memory; changes in usual speech pattern/consciousness, stupor, coma
Behavioral changes, e.g., combativeness, lethargy, hallucinations
Pupil changes (equality and reaction to light)
Loss of deep tendon reflexes with life-threatening dysrhythmias (ventricular tachycardia, severe bradycardia)
PAIN/DISCOMFORT
May report: Chest pain, mild to severe, which may or may not be relieved by antianginal medication
May exhibit: Distraction behaviors, e.g., restlessness
RESPIRATION
May report: Chronic lung disease
History of or current tobacco use
Shortness of breath
Coughing (with/without sputum production)
May exhibit: Changes in respiratory rate/depth during dysrhythmia episode
Breath sounds: Adventitious sounds (crackles, rhonchi, wheezing) may be present,
indicating respiratory complications, such as left-sided heart failure (pulmonary edema) or pulmonary thromboembolic phenomena Hemoptysis
SAFETY
May exhibit: Fever
Skin: Rashes (medication reaction)
Loss of muscle tone/strength
TEACHING/LEARNING
May report: Familial risk factors, e.g., heart disease, stroke
Use/misuse of prescribed medications, such as heart medications (e.g., digitalis), anticoagulants (e.g., warfarin [Coumadin]), benzodiazepines (e.g., diazepam [Valium]), tricyclic antidepressants (e.g., amitriptyline [Elavil]), or antipsychotic agents (e.g., fluphenazine [Prolixin], chlorpromazine [Thorazine]), or OTC medications (e.g., cough syrup and analgesics containing ASA)
Stimulant abuse, including caffeine/nicotine
Lack of understanding about disease process/therapeutic regimen
Evidence of failure to improve, e.g., recurrent/intractable dysrhythmias that are lifethreatening
Discharge plan
DRG projected mean length of inpatient stay: 3.9 days
Alteration of medication use/therapy
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
ECG: Reveals type/source of dysrhythmia and effects of electrolyte imbalances and cardiac medications. Demonstrates patterns of ischemic injury and conduction aberrance. Note: Exercise ECG can reveal dysrhythmias occurring only when patient is not at rest (can be diagnostic for cardiac cause of syncope).
Extended or event monitoring (e.g., Holter monitor): Extended ECG tracing (24 hr to weeks) may be desired to determine which dysrhythmias may be causing specific symptoms when patient is active (home/work) or at rest.
May also be used to evaluate pacemaker function, antidysrhythmia drug effect, or effectiveness of cardiac rehabilitation.
Signal-averaged ECG (SAE): May be used to screen high-risk patients (especially post-MI or unexplained syncope) for ventricular dysrhythmias, presence of delayed conduction, and late potentials (as occurs with sustained ventricular tachycardia).
Chest x-ray: May show enlarged cardiac shadow due to ventricular or valvular dysfunction.
Myocardial imaging scans: May demonstrate ischemic/damaged myocardial areas that could impede normal conduction or impair wall motion and pumping capabilities.
Electrophysiological (EP) studies: Provides cardiac mapping of entire conduction system to evaluate normal and abnormal pathways of electrical conduction. Used to diagnose dysrhythmias and evaluate effectiveness of medication or pacemaker therapies.
Electrolytes: Elevated or decreased levels of potassium, calcium, and magnesium can cause dysrhythmias.
Drug screen: May reveal toxicity of cardiac drugs, presence of street drugs, or suggest interaction of drugs, e.g., digitalis and quinidine.
Thyroid studies: Elevated or depressed serum thyroid levels can cause/aggravate dysrhythmias.
ESR: Elevation may indicate acute/active inflammatory process, e.g., endocarditis, as a precipitating factor for dysrhythmias.
ABGs/pulse oximetry: Hypoxemia can cause/exacerbate dysrhythmias.
NURSING PRIORITIES
1. Prevent/treat life-threatening dysrhythmias.
2. Support patient/SO in dealing with anxiety/fear of potentially life-threatening situation.
3. Assist in identification of cause/precipitating factors.
4. Review information regarding condition/prognosis/treatment regimen.
DISCHARGE GOALS
1. Free of life-threatening dysrhythmias and complications of impaired cardiac output/tissue perfusion.
2. Anxiety reduced/managed.
3. Disease process, therapy needs, and prevention of complications understood.
4. Plan in place to meet needs after discharge.
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