Chapter 10: Management of Patients with Dysrhythmias and Conduction Problems Dysrhythmias are disorders of the formation or conduction

(or both) of the elect rical impulse within the heart. These disorders can cause disturbances of the he art rate, the heart rhythm, or both. Identifying Dysrhythmias Sites of Origin Sinus (SA) node Atria Atrioventricular (AV) node or junction Ventricles Mechanisms of Formation or Conduction Normal (idio) rhythm Bradycardia Tachycardia Dysrhythmia Flutter Fibrillation Premature complexes Blocks Glossary ablation: purposeful destruction of heart muscle cells, usually in an attempt to control a dysrhythmia antiarrhythmic: a medication that suppresses or prevents a dysrhythmia automaticity: ability of the cardiac muscle to initiate an electrical impulse cardioversion: electrical current administered in synchrony with the patients own QRS to stop a dysrhythmia conductivity: ability of the cardiac muscle to transmit electrical impulses defibrillation: electrical current administered to stop a dysrhythmia, not synch ronized with the patients QRS complex depolarization: process by which cardiac muscle cells change from a more negativ ely charged to a more positively charged intracellular state dysrhythmia (also referred to as arrhythmia): disorder of the formation or condu ction (or both) of the electrical impulse within the heart, altering the heart r ate, heart rhythm, or both and potentially causing altered blood flow implantable cardioverter defibrillator (ICD): a device implanted into the chest to treat dysrhythmias inhibited: in reference to pacemakers, term used to describe the pacemaker withh olding an impulse (not firing) P wave: the part of an electrocardiogram (ECG) that reflects conduction of an el ectrical impulse through the atrium; atrial depolarization paroxysmal: a dysrhythmia that has a sudden onset and/or termination and is usua lly of short duration PR interval: the part of an ECG that reflects conduction of an electrical impuls e from the sinoatrial (SA) node through the atrioventricular (AV) node proarrhythmic: an agent (eg, a medication) that causes or exacerbates a dysrhyth mia QRS complex: the part of an ECG that reflects conduction of an electrical impuls e through the ventricles; ventricular depolarization QT interval: the part of an ECG that reflects the time from ventricular depolari zation to repolarization repolarization: process by which cardiac muscle cells return to a more negativel y charged intracellular condition, their resting state sinus rhythm: electrical activity of the heart initiated by the sinoatrial (SA) node ST segment: the part of an ECG that reflects the end of ventricular depolarizati on (end of the QRS complex) through ventricular repolarization (end of the T wav e)

 supraventricular tachycardia (SVT): a rhythm that originates in the conduction s ystem above the ventricles T wave: the part of an ECG that reflects repolarization of the ventricles triggered: in reference to pacemakers, term used to describe the release of an i mpulse in response to some stimulus U wave: the part of an ECG that may reflect Purkinje fiber repolarization; usual ly seen when a patients serum potassium level is low ventricular tachycardia (VT): a rhythm that originates in the ventricles NORMAL ELECTRICAL CONDUCTION The electrical impulse that stimulates and paces the cardiac muscle normally ori ginates in the sinus node (SA node), an area located near the superior vena cava in the right atrium. Usually, the electrical impulse occurs at a rate ranging b etween 60 and 100 times a minute in the adult. The electrical impulse quickly tr avels from the sinus node through the atria to the atrioventricular (AV) node. T he electrical stimulation of the muscle cells of the atria causes them to contra ct. The structure of the AV node slows the electrical impulse, which allows time for the atria to contract and fill the ventricles with blood before the electri cal impulse travels very quickly through the bundle of His to the right and left bundle branches and the Purkinje fibers, located in the ventricular muscle. The electrical stimulation of the muscle cells of the ventricles, in turn, causes t he mechanical contraction of the ventricles (systole). The cells repolarize and the ventricles then relax (diastole). The process from sinus node electrical imp ulse generation through ventricular repolarization completes the electromechanic al circuit, and the cycle begins again. Sinus rhythm promotes cardiovascular circulation. The electrical impulse causes (and, therefore, is followed by) the mechanical contraction of the heart muscle. The electrical stimulation is called depolarization; the mechanical contraction is called systole. Electrical relaxation is called repolarization and mechanica l relaxation is called diastole. INTERPRETATION OF THE ELECTROCARDIOGRAM Electrocardiogram (ECG) is a procedure use to view the electrical impulse that travels through the heart . is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on the body at specific areas. Electrodes come in various shapes and sizes, but all have two components: (1) An adhesive substance that attaches to the skin to secure the electrode in p lace and (2) A substance that reduces the skins electrical impedance and promotes detecti on of the electrical current Lead is an imaginary line created by the electrodes that serves as a reference point from which the electrical activity is viewed. Is like an eye of a camera; it has a narrow peripheral field of vision, looking only at the electrical activity directly in front of it. Obtaining an Electrocardiogram Electrodes are attached to cable wires, which are connected to one of the follow ing: An ECG machine placed at the patients side for an immediate recording (standard 12-lead ECG) A cardiac monitor at the patients bedside for continuous reading; this kind of mo

nitoring, usually called hardwire monitoring, is associated with intensive care units A small box that the patient carries and that continuously transmits the ECG in formation by radio waves to a central monitor located elsewhere (called telemetr y) A small, lightweight tape recorder-like machine (called a Holter monitor) that the patient wears and that continuously records the ECG on a tape, which is late r viewed and analyzed with a scanner ECG Electrode Placement The standard left precordial leads are V14th intercostal space, right sternal bor der; V24th intercostal space, left sternal border; V3diagonally between V2 and V4; V45th intercostal space, left midclavicular line; V5same level as V4, anterior ax illary line; V6 (not illustrated)same level as V4 and V5, midaxillary line. The r ight precordial leads, placed across the right side of the chest, are the mirror opposite of the left leads. WAVES, COMPLEXES, AND INTERVALS The ECG is composed of waveforms (including the P wave, the QRS complex, the T w ave, and possibly a U wave) and of segments or intervals (including the PR inter val, the ST segment, and the QT interval). P wave represents the electrical impulse starting in the sinus node and spreadin g through the atria. Therefore, the P wave represents atrial muscle depolarizati on. It is normally 2.5 mm or less in height and 0.11 second or less in duration. QRS complex represents ventricular muscle depolarization. Not all QRS complexes have all three waveforms. The first negative deflection after the P wave is the Q wave, which is normally less than 0.04 second in duration and less than 25% of the R wave amplitude; the first positive deflection after the P wave is the R w ave; and the S wave is the first negative deflection after the R wave. When a wa ve is less than 5 mm in height, small letters (q, r, s) are used; when a wave is taller than 5 mm, capital letters (Q, R, S) are used. The QRS complex is normal ly less than 0.12 seconds in duration. T wave represents ventricular muscle repolarization (when the cells regain a neg ative charge; also called the resting state). It follows the QRS complex and is usually the same direction as the QRS complex. U wave is thought to represent repolarization of the Purkinje fibers, but it som etimes is seen in patients with hypokalemia (low potassium levels), hypertension , or heart disease. If present, the U wave follows the T wave and is usually sma ller than the P wave. If tall, it may be mistaken for an extra P wave. PR interval is measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial d epolarization, and conduction through the AV node before ventricular depolarizat ion. In adults, the PR interval normally ranges from 0.12 to 0.20 seconds in dur ation. The ST segment, which represents early ventricular repolarization, lasts from the end of the QRS complex to the beginning of the T wave. The beginning of the ST segment is usually identified by a change in the thickness or angle of t he terminal portion of the QRS complex. The end of the ST segment may be more di fficult to identify because it merges into the T wave. The ST segment is normall y isoelectric (see discussion of TP interval). It is analyzed to identify whethe r it is above or below the isoelectric line, which may be, among other signs and symptoms, a sign of cardiac ischemia). QT interval, which represents the total time for ventricular depolarization and repolarization, is measured from the beginning of the QRS complex to the end of the T wave. The QT interval varies with heart rate, gender, and age, and the mea sured interval needs to be corrected for these variables through a specific calc ulation. Several ECG interpretation books contain charts of these calculations. The QT interval is usually 0.32 to 0.40 seconds in duration if the heart rate is 65 to 95 beats per minute. If the QT interval becomes prolonged, the patient ma

y be at risk for a lethal ventricular dysrhythmia called torsades de pointes. TP interval is measured from the end of the T wave to the beginning of the next P wave, an isoelectric period PP interval is measured from the beginning of one P wave to the beginning of the next. The PP interval is used to determine atrial rhythm and atrial rate. The R R interval is measured from one QRS complex to the next QRS complex. The RR inte rval is used to determine ventricular rate and rhythm DETERMINING VENTRICULAR HEART RATE FROM THE ELECTROCARDIOGRAM Heart rate can be obtained from the ECG strip by several methods. A 1-minute str ip contains 300 large boxes and 1500 small boxes. Therefore, an easy and accurat e method of determining heart rate with a regular rhythm is to count the number of small boxes within an RR interval and divide 1500 by that number. If, for exa mple, there are 10 small boxes between two R waves, the heart rate is 1500/10, o r 150; if there are 25 small boxes, the heart rate is 1500/25, or 60. An alterna tive but less accurate method for estimating heart rate, which is usually used w hen the rhythm is irregular, is to count the number of RR intervals in 6 seconds and multiply that number by 10. The top of the ECG paper is usually marked at 3 -second intervals, which is 15 large boxes horizontally. The RR intervals are co unted, rather than QRS complexes, because a computed heart rate based on the lat ter might be inaccurately high. The same methods may be used for determining atrial rate, using the PP interval instead of the RR interval. DETERMINING HEART RHYTHM FROM THE ELECTROCARDIOGRAM The RR interval is used to determine ventricular rhythm The PP interval to determine atrial rhythm Regular Rhythm intervals are the same or nearly the same throughout the strip Irregular Rhythm intervals are different Normal Sinus Rhythm Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the sinus node and travels through the normal conduction pathway. The following are the ECG criteria for normal sinus rhythm: Ventricular and atrial rate: 60 to 100 in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1:1 Interpreting Dysrhythmias: Systematic Analysis of the Electrocardiogram When examining an ECG rhythm strip to learn more about a patients dysrhythmia, th e nurse conducts the following assessment: 1. Determine the ventricular rate. 2. Determine the ventricular rhythm. 3. Determine QRS duration. 4. Determine whether the QRS duration is consistent throughout the strip. If not , identify other duration. 5. Identify QRS shape; if not consistent, and then identify other shapes. 6. Identify P waves; is there a P in front of every QRS?

7. Identify P-wave shape; identify whether it is consistent or not. 8. Determine the atrial rate. 9. Determine the atrial rhythm. 10. Determine each PR interval. 11. Determine if the PR intervals are consistent, irregular but with a pattern t o the irregularity, or just irregular. 12. Determine how many P waves for each QRS (P_QRS ratio). In many cases, the nu rse may use a checklist and document the findings next to the appropriate ECG cr iterion. Types of Dysrhythmias SINUS NODE DYSRHYTHMIAS * Sinus Bradycardia occurs when the sinus node creates an impulse at a slo wer-than-normal rate Causes ) lower metabolic needs (eg, sleep, athletic training, hypothermia, hypothyroidism vagal stimulation (eg, from vomiting, suctioning, severe pain, extreme emotions) medications (eg, calcium channel blockers, amiodarone, beta-blockers) increased intracranial pressure, myocardial infarction (MI) especially of the inferior wall

Characteristics of Sinus Bradycardia Ventricular and atrial rate: Less than 60 in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1:1 Medical Management Atropine, 0.5 to 1.0 mg given rapidly as an intravenous (IV) bolus, is the medic ation of choice in treating sinus bradycardia It blocks vagal stimulation, thus allowing a normal rate to occur Rarely, catecholamines and emergency transcutaneous pacing also may be implemen ted * Sinus tachycardia occurs when the sinus node creates an impulse at a fas ter-than-normal rate Causes acute blood loss, anemia shock Hypervolemia or hypovolemia congestive heart failure pain hypermetabolic states fever exercise anxiety or sympathomimetic medications ECG criteria for sinus tachycardia Ventricular and atrial rate: Greater than 100 in the adult Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly P wave: Normal and consistent shape; always in front of the QRS, but may be buri

ed in the preceding T wave PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1_1

Medical Management Calcium channel blockers and beta-blockers may be used to reduce the heart rate quickly * Sinus arrhythmia occurs when the sinus node creates an impulse at an irr egular rhythm; the rate usually increases with inspiration and decreases with ex piration. ECG Criteria for Sinus Arrhythmia Ventricular and atrial rate: 60 to 100 in the adult Ventricular and atrial rhythm: Irregular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent shape; always in front of the QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1:1 ATRIAL DYSRHYTHMIAS * Premature atrial complex (PAC) is single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the s inus node Causes caffeine, alcohol, nicotine, stretched atrial myocardium (as in hypervolemia), anxiety hypokalemia(low potassium level) hypermetabolic states atrial ischemia Injury or infarction PACs Characteristics Ventricular and atrial rate: Depends on the underlying rhythm (eg, sinus tachycardia) Ventricular and atrial rhythm: Irregular due to early P waves, creating a PP int erval that is shorter than the others. This is sometimes followed by a longer-th an-normal PP interval, but one that is less than twice the normal PP interval. T his type of interval is called a no compensatory pause. QRS shape and duration: The QRS that follows the early P wave is usually normal, but it may be abnormal (aberrantly conducted PAC). It may even be absent (block ed PAC). P wave: An early and different P wave may be seen or may be hidden in the T wave ; other P waves in the strip are consistent. PR interval: The early P wave has a shorter-than-normal interval, but still betw een 0.12 and 0.20 seconds. P: QRS ratio: usually 1_1 * Atrial flutter occurs in the atrium and creates impulses at an atrial ra te between 250 and 400 times per minute Characteristics of Atrial Flutter Ventricular and atrial rate: Atrial rate ranges between 250 and 400; ventricular rate usually ranges between 75 and 150. Ventricular and atrial rhythm: The atrial rhythm is regular; the ventricular rhy thm is usually regular but may be irregular because of a change in the AV conduc

tion. QRS shape and duration: Usually normal, but may be abnormal or may be absent P wave: Saw-toothed shape. These waves are referred to as F waves. PR interval: Multiple F waves may make it difficult to determine the PR interval . P: QRS ratio: 2:1, 3:1, or 4:1 Medical Management diltiazem (eg, Cardizem) verapamil (eg, Calan, Isoptin) beta-blockers, or digitalis may be administered intravenously to slow the ventri cular rate. These medications can slow conduction through the AV node Flecainide(Tambocor) Ibutilide (Corvert) Dofetilide (Tikosyn) Quinidine (eg, Cardioquin, Quinaglute) Disopyramide (Norpace) Amiodarone (Cordarone, Pacerone) may be given to promote conversion to sinus rhy thm * Atrial fibrillation causes a rapid, disorganized, and uncoordinated twit ching of atrial musculature may occur for a very short time (paroxysmal), or it may be chronic Characteristics of Atrial Fibrillation Ventricular and atrial rate: Atrial rate is 300 to 600. Ventricular rate is usua lly 120 to 200 in untreated atrial fibrillation Ventricular and atrial rhythm: Highly irregular QRS shape and duration: Usually normal, but may be abnormal P wave: No discernible P waves; irregular undulating waves are seen and are refe rred to as fibrillatory or f waves PR interval: Cannot be measured P: QRS ratio: many:1 Medical Management Acute onset: Quinidine Ibutilide Flecainide Dofetilide Propafenone Procainamide (Pronestyl) Disopyramide Amiodarone may be given to achieve conversion to sinus rhythm Intravenous adenosine (Adenocard, Adenoscan) JUNCTIONAL DYSRHYTHMIAS * Premature Junctional Complex is an impulse that starts in the AV nodal a rea before the next normal sinus impulse reaches the AV node * Junctional or Idionodal Rhythm occurs when the AV node, instead of the s inus node, becomes the pacemaker of the heart. When the sinus node slows (eg, fr om increased vagal tone) or when the impulse cannot be conducted through the AV node (eg, because of complete heart block), the AV node automatically discharges an impulse ECG criteria for Junctional Rhythm Ventricular and atrial rate: Ventricular rate 40 to 60; atrial rate also 40 to 6

0 if P waves are discernible Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be abnormal P wave: May be absent, after the QRS complex, or before the QRS; may be inverted , especially in lead II PR interval: If P wave is in front of the QRS, PR interval is less than 0.12 sec ond. P: QRS ratio: 1:1 or 0:1 * Atrioventricular Nodal Reentry Tachycardia. AV nodal reentry tachycardia occurs when an impulse is conducted to an area in the AV node that causes the i mpulse to be rerouted back into the same area over and over again at a very fast rate. Each time the impulse is conducted through this area, it is also conducte d down into the ventricles, causing a fast ventricular rate. AV nodal reentry ta chycardia that has an abrupt onset and an abrupt cessation with a QRS of normal duration had been called paroxysmal atrial tachycardia (PAT) ECG Criteria for Atrioventricular Nodal Reentry Tachycardia Ventricular and atrial rate: Atrial rate usually ranges between 150 to 250; vent ricular rate usually ranges between 75 to 250 Ventricular and atrial rhythm: Regular; sudden onset and termination of the tach ycardia QRS shape and duration: Usually normal, but may be abnormal P wave: Usually very difficult to discern PR interval: If P wave is in front of the QRS, PR interval is less than 0.12 sec onds P: QRS ratio: 1:1, 2:1 Supraventricular Tachycardia (SVT) P waves cannot be defined VENTRICULAR DYSRHYTHMIAS * Premature Ventricular Complex (PVC) is an impulse that starts in a ventr icle and is conducted through the ventricles before the next normal sinus impuls e. PVCs can occur in healthy people, especially with the use of caffeine, nicoti ne, or alcohol Characteristics of PVC Ventricular and atrial rate: Depends on the underlying rhythm (eg, sinus rhythm) Ventricular and atrial rhythm: Irregular due to early QRS, creating one RR inter val that is shorter than the others. PP interval may be regular, indicating that the PVC did not depolarize the sinus node. QRS shape and duration: Duration is 0.12 seconds or longer; shape is bizarre and abnormal P wave: Visibility of P wave depends on the timing of the PVC; may be absent (hi dden in the QRS or T wave) or in front of the QRS. If the P wave follows the QRS , the shape of the P wave may be different. PR interval: If the P wave is in front of the QRS, the PR interval is less than 0.12 seconds. P: QRS ratio: 0:1; 1:1 * Ventricular tachycardia (VT) is defined as three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute Characteristics of VT Ventricular and atrial rate: Ventricular rate is 100 to 200 beats per minute; at rial rate depends on the underlying rhythm (eg, sinus rhythm)

Ventricular and atrial rhythm: Usually regular; atrial rhythm may also be regula r. QRS shape and duration: Duration is 0.12 seconds or more; bizarre, abnormal shap e P wave: Very difficult to detect, so atrial rate and rhythm may be indeterminabl e PR interval: Very irregular, if P waves seen. P: QRS ratio: Difficult to determine, but if P waves are apparent, there are usu ally more QRS complexes than P waves. * Ventricular fibrillation is a rapid but disorganized ventricular rhythm that causes ineffective quivering of the ventricles Characteristics of Ventricular Fibrillation Ventricular rate: Greater than 300 per minute Ventricular rhythm: Extremely irregular, without specific pattern QRS shape and duration: Irregular, undulating waves without recognizable QRS com plexes * Idioventricular Rhythm also called Ventricular Escape Rhythm occurs when the impulse starts in the conduction system below the AV node. When the sinus n ode fails to create an impulse (eg, from increased vagal tone), or when the impu lse is created but cannot be conducted through the AV node (eg, due to complete AV block), the Purkinje fibers automatically discharge an impulse. Characteristics of Idioventricular Rhythm Ventricular rate: Ranges between 20 and 40; if the rate exceeds 40, the rhythm i s known as accelerated idioventricular rhythm (AIVR). Ventricular rhythm: Regular QRS shape and duration: Bizarre, abnormal shape; duration is 0.12 seconds or mor e * Ventricular Asystole. Commonly called flatline, ventricular asystole is characterized by absent QRS complexes, although P waves may be apparent for a sh ort duration in two different leads. There is no heartbeat, no palpable pulse, a nd no respiration CONDUCTION ABNORMALITIES * First-Degree Atrioventricular Block. First-degree heart block occurs whe n all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. Characteristics Conduction Disorder Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: Depends on the underlying rhythm QRS shape and duration: Usually normal, but may be abnormal P wave: In front of the QRS complex; shows sinus rhythm, regular shape PR interval: Greater than 0.20 seconds; PR interval measurement is constant. P: QRS ratio: 1:1 * Second-Degree Atrioventricular Block, Type I. Second-degree, type I hear t block occurs when all but one of the atrial impulses are conducted through the AV node into the ventricles. Each atrial impulse takes a longer time for conduc tion than the one before, until one impulse is fully blocked Characteristics of Second-Degree Atrioventricular Block, Type I Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: The PP interval is regular if the patient has an

underlying normal sinus rhythm; the RR interval characteristically reflects a pa ttern of change. Starting from the RR that is the longest, the RR interval gradu ally shortens until there is another long RR interval. QRS shape and duration: Usually normal, but may be abnormal P wave: In front of the QRS complex; shape depends on underlying rhythm PR interval: PR interval becomes longer with each succeeding ECG complex until t here is a P wave not followed by a QRS. The changes in the PR interval are repea ted between each dropped QRS, creating a pattern in the irregular PR interval meas urements. P: QRS ratio: 3:2, 4:3, 5:4 * Second-Degree Atrioventricular Block, Type II. Second-degree, type II he art block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles Characteristics of Second degree AV block, type II Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: The PP interval is regular if the patient has an underlying normal sinus rhythm. The RR interval is usually regular but may be ir regular, depending on the P_QRS ratio. QRS shape and duration: Usually abnormal, but may be normal P wave: In front of the QRS complex; shape depends on underlying rhythm. PR interval: PR interval is constant for those P waves just before QRS complexes . P: QRS ratio: 2:1, 3:1, 4:1, 5:1 * Third-Degree Atrioventricular Block. Third-degree heart block occurs whe n no atrial impulse is conducted through the AV node into the ventricles. In thi rd-degree heart block, two impulses stimulate the heart: one stimulates the vent ricles (eg, junctional or ventricular escape rhythm), represented by the QRS com plex, and one stimulates the atria (eg, sinus rhythm, atrial fibrillation), repr esented by the P wave. P waves may be seen, but the atrial electrical activity i s not conducted down into the ventricles to cause the QRS complex, the ventricul ar electrical activity. This is called AV dissociation Charateristics of Third-Degree Atrioventricular Block Ventricular and atrial rate: Depends on the escape and underlying atrial rhythm Ventricular and atrial rhythm: The PP interval is regular and the RR interval is regular; however, the PP interval is not equal to the RR interval. QRS shape and duration: Depends on the escape rhythm; in junctional escape, QRS shape and duration are usually normal, and in ventricular escape, QRS shape and duration are usually abnormal. P wave: Depends on underlying rhythm PR interval: Very irregular P: QRS ratio: More P waves than QRS complexes NURSING PROCESS: THE PATIENT WITH A DYSRHYTHMIA Assessment Major areas of assessment include possible causes of the dysrhythmia and the dys rhythmias effect on the hearts ability to pump an adequate blood volume. A health history is obtained to identify any previous occurrences of decreased cardiac ou tput, such as syncope (fainting), lightheadedness, dizziness, fatigue, chest dis comfort, and palpitations. Coexisting conditions that could be a possible cause of the dysrhythmia (eg, heart disease, chronic obstructive pulmonary disease) ma y also be identified. Diagnosis Nursing Diagnoses

Decreased cardiac output Anxiety related to fear of the unknown Deficient knowledge about the dysrhythmia and its treatment

COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS In addition to cardiac arrest, a potential complication that may develop over ti me is heart failure. Another potential complication, especially with atrial fibr illation, is a thromboembolic event. If the dysrhythmia necessitates treatment w ith medication, the beneficial and detrimental effects must be assessed. Planning and Goals The major goals for the patient may include eradicating or decreasing the incide nce of the dysrhythmia (by decreasing contributory factors) to maintain cardiac output, minimizing anxiety, and acquiring knowledg e about the dysrhythmia and its treatment. Nursing Interventions Monitoring and management of dysrhythmias Minimizing anxiety Promoting home and community-based care

Evaluation EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: 1. Maintains cardiac output a. Demonstrates heart rate, blood pressure, respiratory rate, and level of consc iousness within normal ranges b. Demonstrates no or decreased episodes of dysrhythmia 2. Experiences reduced anxiety a. Expresses a positive attitude about living with the dysrhythmia b. Expresses confidence in ability to take appropriate actions in an emergency 3. Expresses understanding of the dysrhythmia and its treatment a. Explains the dysrhythmia and its effects b. Describes the medication regimen and its rationale c. Explains the need for therapeutic serum level of the medication d. Describes a plan to eradicate or limit factors that contribute to the occurre nce of the dysrhythmia. States actions to take in the event of an emergency PACEMAKER THERAPY A pacemaker is an electronic device that provides electrical stimuli to the hear t muscle. Pacemakers are usually used when a patient has a slower-than-normal im pulse formation or a conduction disturbance that causes symptoms. They may also be used to control some tachydysrhythmias that do not respond to medication ther apy. Biventricular (both ventricles) pacing may be used to treat advanced heart failure that does not respond to medication therapy. Pacemakers can be permanent or temporary. Permanent pacemakers are used most commonly for irreversible comp lete heart block. Temporary pacemakers are used (eg, after MI, after open heart surgery) to support patients until they improve or receive a permanent pacemaker . CARDIOVERSION AND DEFIBRILLATION Cardioversion and defibrillation are treatments for tachydysrhythmias. They are used to deliver an electrical current to depolarize a critical mass of myocardia l cells. When the cells repolarize, the sinus node is usually able to recapture its role as the hearts pacemaker. One major difference between cardioversion and defibrillation current. Another m ajor difference concerns the circumstance: defibrillation is usually performed a s an emergency treatment, whereas cardioversion is usually, but not always, a pl anned procedure.

ELECTROPHYSIOLOGIC STUDIES An electrophysiology (EP) study is used to evaluate and treat various dysrhythmi as that have caused cardiac arrest or significant symptoms. It also is indicated for patients with symptoms that suggest a dysrhythmia that has gone undetected and undiagnosed by other methods CARDIAC CONDUCTION SURGERY Atrial tachycardias and ventricular tachycardias that do not respond to medicati ons and are not suitable for antitachycardia pacing may be treated by methods ot her than medications and devices. Such methods include endocardial isolation, en docardial resection, and ablation. An ICD may be used with these surgical interv entions.