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HOSPITALS
During The Presentation PLEASE:
Put cell-phones on silent/vibrate mode. Take emergency calls outside. Maintain silence.

CARDIAC DYSRHYTHMIAS Mrs. Akhila Sailesh

Learning Outcomes
Describe the normal electrical conduction of the heart. Discuss the characteristics of various types of sinus node and ventricular dysrhythmias. Describe the nursing management of a patient with dysrhythmias.

Introduction
For the heart to perform efficiently as a pump, it should have a regular rate and rhythm. Without this, the heart is considered dys-rhythmic, which could be a dangerous condition. Dysrhythmias are disorders of the formation or conduction (or both) of the electrical impulse within the heart that can cause disturbances of the heart rate, rhythm, or both.
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Dysrhythmias may initially usually cause decreased blood pressure. Dysrhythmias are diagnosed by analyzing the ECG waveform. They are named according to the site of origin of the impulse and the mechanism of formation or conduction involved. e.g.: an impulse that originates in the sino-atrial (SA) node and that has a slow rate is called sinus bradycardia.

REVIEW OF CONDUCTION

Normal Sinus Rhythm in Lead II

To make an accurate assessment of the hearts electrical activity, the ECG needs to be evaluated from every lead. Here the different areas of electrical activity are identified by color.
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ELECTRICAL CONDUCTION
Sinoatrial node (SA) Intra-atrial fiber Intranodal tracts Atrioventricular (AV) Node Bundle of his (Common bundle) Bundle branches Purkinje fibers

PR INTERVAL
Time from the beginning of atrial depolarization to the beginning of ventricular depolarization Measured from the beginning of the P wave to the beginning of the QRS complex (0.12-0.20 sec)

QRS INTERVAL
Length of time for depolarization of the ventricular muscle and is measured from the beginning of the QRS complex to the end of the s wave, Should measure between 0.06-0.10 secs in duration

ST INTERVAL
Total length of time for ventricular muscle to be depolarized and repolarized, measured from the beginning of the QRS complex to the end of the T wave Normal 0.32-0.42 sec

To Summarize
P wave 0.04 0.12 secs T wave 0.16 secs

QRS Complex 0.06-0.10 sec

ST segment 0.12 secs

PR interval 0.12-0.2 sec

QT interval 0.34 -0.43 secs

Normal ECG

INHERENT RATES
SA
AV JUNCTION VENTRICULAR

60-100
40-60 20-40

Types of Dysrhythmias
Dysrhythmias include sinus node, atrial, junctional, and ventricular dysrhythmias and their various subcategories.
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SINUS DYSRHYTHMIA
Occurs if the P-P interval vary by more than 0.16 sec Less than 0.16 is considered normal because of the fluctuation of the sympathetic/ parasympathetic stimulation Associated with respiration in children and elderly

SINUS BRADYCARDIA
HR < 60/min arising from the SA node Impulses follow the normal pathway through the conduction system P & QRS complexes normal duration and pattern

ETIOLOGY
Increased vagal stimulation May be a normal variation in athletes and healthy young adults Medical conditions:

Anorexia nervosa Atherosclerotic heart disease Hypo-endocrine states Hypothermia Increased intracranial pressure Myocardial infarction Anti-hypertensives Beta blockers Calcium channel blockers CNS depressants Digoxin

Medications:

SINUS TACHYCARDIA
HR of 100-160/ min Normal response to sympathetic nervous system stimulation Any condition that produces an increase in metabolic rate

ETIOLOGY
Diet caffeine Life-style smoking / nicotine Medical conditions anemia, hemorrhage, fever, hypotension, pain, shock Medications Central Nervous System stimulants Myocardial damage

ATRIAL DYSRHYTHMIAS
Impulse arises outside the Sino Atrial node P waves differ in configuration Types

Wandering atrial pacemaker Premature atrial contractions Paroxysmal atrial tachycardia Atrial flutter Atrial fibrillation

ETIOLOGY
Cardiac disease
Ischemia Coronary artery disease Congestive heart failure Myocardial infarction

Increased vagal stimulation Medications

ATRIAL FLUTTER
Atrial ectopic pacer fires at a rate of 250-400/ min Occurs in a variety of heart diseases- rheumatic, coronary, hypertensive, also cardiomyopathy, hypoxia, heart failure, May be asymptomatic or have palpitations Management- digitalis, beta blockers, calcium channel blockers, may use cardioversion

ATRIAL FIBRILLATION
Several ectopic foci causing the atria to quiver rather than contract Rate >400 Ventricular rate depends on the number of impulses conducted thru the av node Management- Digoxin, Beta blockers, calcium channel blockers, counter-shock

AV HEART BLOCKS
Abnormal delay in conduction of impulse from the atrium to the ventricles
Usually asymptomatic

FIRST DEGREE
Delay occurs at the AV node producing a prolonged PR interval > 0.20 sec

ETIOLOGY
Common occurrence in normal hearts Cardiac disease including:

Arteriosclerotic heart disease, myocarditis, organic heart disease, myocardial infarction Beta blockers Calcium channel blockers Digitalis toxicity

Medications:

SECOND DEGREE HEART BLOCK

Type I- Mobitz I or Wenckebach- progressive lengthening of the PR interval until a QRS complex is dropped or not conducted Usually asymptomatic Tx- maybe none, atropine, Temporary Pacing

SECOND DEGREE - TYPE II

Every second third or fourth sinus impulse is blocked may have 2,3,4 Ps to each QRS More serious- aggressive management to prevent progression to complete heart block Treatment:

Pacer Atropine Dopamine for severe hypotension

THIRD DEGREE HEART BLOCK

Total disassociation of atria to ventricles. Ventricles are stimulated by a secondary or escape beat. The ventricular rate will be 40-60 depending upon the location of the ventricular pacemaker Both the sinus P wave and the escape rhythm will be obvious on the electrocardiogram Etiology

Cardiac disease Medications beta blockers, calcium channel blockers, digitalis toxicity

Manifestations- fatigue, hypotension, syncope, heart failure Tx.- Atropine, dopamine, pacer.

THIRD DEGREE HEART BLOCK

JUNCTIONAL RHYTHMS
Rate 40- 60 The dominant pacer of the heart fails , retrograde or backward stimulation of the atria- producing a characteristic P wave - may be a negative deflection before or after the QRS complex or no P wave at all

VENTRICULAR DYSRHYTHMIAS
Impulse originates in the ventricles CausesDrug toxicity Hypoxia Hypothermia Electrolyte imbalances

Occur early- noted compensatory pause, qrs complex wide May be multifocal or unifocal Bigeminy, trigeminy or couplets Three or more = ventricular tach. R on T phenomenon Tx- 6 or > /min, couplets , R on T , or multifocal Lidocaine most commonly used for immediate short term therapy

PREMATURE VENTRICULAR CONTRACTIONS

VENTRICULAR TACHYCARDIA
Three or more premature ventricular contractions in a row Rate of ventricular discharge is 100-250/min Etiology- increased myocardial irritability associated with coronary artery disease, myocardial infarction, electrolyte imbalance, cardiomyopathy

VENTRICULAR FIBRILLATION
Rapid, disorganized ventricular rhythm that results in ineffective quivering of the ventricles No atrial activity seen on ECG Absence of audible heartbeat, palpable pulse, and respiration

ETIOLOGY
Same as ventricular tachycardia Untreated ventricular tachycardia Electrical shock

VENTRICULAR ASYSTOLE
Absence of:
QRS Heartbeat Palpable pulse Respiration

ETIOLOGY
Hypoxia Acidosis Electrolyte imbalance Drug overdose Hypothermia

NURSING PROCESS DYSRHYTHMIA

Assessment

History

Causes of dysrhythmia

Physical exam Effect on cardiac output

NURSING PROCESS
DIAGNOSES:
Decreased cardiac output Anxiety related to fear of the unknown Deficient knowledge about the dysrhythmia and treatment

NURSING PROCESS
PLANNING AND GOALS
Eradicating or decreasing the incidence of the dysrhythmia Acquire knowledge about the dysrhythmia and treatment

NURSING PROCESS
INTERVENTIONS

Monitor :

Blood pressure, pulse rate and rhythm, rate and rhythm of respirations, breath sounds Episodes of lightheadedness, dizziness, faintness Rhythm strips

Medication administration Assist in developing a plan to modify lifestyle Minimize anxiety Teach self care

NURSING PROCESS
EVALUATION

EXPECTED OUCOMES
Maintains cardiac output Experiences reduced anxiety Expresses understanding of the dysrhythmia and its treatment.

Nursing Interventions: Arrhythmias in summary

Document any arrhythmias in a monitored patient. Notify the doctor if a change in pulse pattern or rate occurs in an unmonitored patient. As ordered, obtain an ECG tracing in an unmonitored patient to confirm and identify the type of arrhythmia present. Be prepared to initiate cardiopulmonary resuscitation, if indicated, when a life threatening arrhythmia occurs.

Nursing Interventions: Arrhythmias.contd

Administer medication as ordered, monitor for adverse effect, and perform nursing interventions related to monitoring vital signs, hemodynamic monitoring, and appropriate laboratory work. Provide adequate oxygen and reduce heart workload while carefully maintaining metabolic, neurologic, respiratory, and hemodynamic status. Evaluate the monitored patients ECG regularly for arrhythmia. Monitor for predisposing factors, such as fluid and electrolyte imbalance, and signs of drug toxicity, especially with digoxin. Teach the patient how to take his pulse and recognize an irregular rhythm and instruct him to report alterations from his baseline to the doctor. Emphasize the importance of keeping laboratory and physicians appointments.

Thanks