NCP Dysrhytmias (Including Digitalis Toxicity)

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).


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.



Heart failure: chronic

Myocardial infarction

Psychosocial aspects of care

Patient Assessment Database


May report: Generalized weakness and exertional fatigue

May exhibit: Changes in heart rate/BP with activity/exercise


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


May report: Feeling nervous (certain tachydysrhythmias), sense of impending doom

Stressors related to current medical problems

May exhibit: Anxiety, fear, withdrawal, anger, irritability, crying


May report: Loss of appetite, anorexia

Food intolerance (with certain medications)


Changes in weight

May exhibit: Weight gain or loss


Changes in skin moisture/turgor

Respiratory crackles


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)


May report: Chest pain, mild to severe, which may or may not be relieved by antianginal medication

May exhibit: Distraction behaviors, e.g., restlessness


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


May exhibit: Fever

Skin: Rashes (medication reaction)

Loss of muscle tone/strength


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.


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.


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.


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.