Cardiac arrhythmias, also known as cardiac dysrhythmias, are abnormal electrical conduction or automaticity changes in heart rate and rhythm. Arrhythmias vary in severity, from those that are mild, asymptomatic, and require no treatment to catastrophic ventricular fibrillation, which necessitates immediate resuscitation. 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).
Below are 3 Cardiac Arrhythmia (Digitalis Toxicity) Nursing Care Plans.
- Prevent/treat life-threatening dysrhythmias.
- Support patient/SO in dealing with anxiety/fear of potentially life-threatening situation.
- Assist in identification of cause/precipitating factors.
- Review information regarding condition/prognosis/treatment regimen.
- Free of life-threatening dysrhythmias and complications of impaired cardiac output/tissue perfusion.
- Anxiety reduced/managed.
- Disease process, therapy needs, and prevention of complications understood.
- Plan in place to meet needs after discharge.
1. Risk for Decreased Cardiac Output
- Cardiac Output, risk for decreased
Risk factors may include
- Altered electrical conduction
- Reduced myocardial contractility
- Maintain/achieve adequate cardiac output as evidenced by BP/pulse within normal range, adequate urinary output, palpable pulses of equal quality, usual level of mentation.
- Display reduced frequency/absence of dysrhythmia(s).
- Participate in activities that reduce myocardial workload.
|Palpate pulses (radial, carotid, femoral, dorsalis pedis), noting rate, regularity, amplitude (full or thready), and symmetry. Document presence of pulsus alternans, bigeminal pulse, or pulse deficit.||Differences in equality, rate, and regularity of pulses are indicative of the effect of altered cardiac output on systemic or peripheral circulation.|
|Auscultate heart sounds, noting rate, rhythm, presence of extra heartbeats, dropped beats.||Specific dysrhythmias are more clearly detected audibly than by palpation. Hearing extra heartbeats or dropped beats helps identify dysrhythmias in the unmonitored patient.|
|Monitor vital signs. Assess adequacy of cardiac output and tissue perfusion, noting significant variations in BP/pulse rate equality, respirations, changes in skin color, temperature, level of consciousness, sensorium, and urine output during episodes of dysrhythmias.||Although not all dysrhythmias are life-threatening, immediate treatment may be required to terminate dysrhythmia in the presence of alterations in cardiac output and tissue perfusion.|
|Determine type of dysrhythmia and document with rhythm strip (if cardiac/telemetry monitoring is available):|
|Sinus tachycardia||Useful in determining need for/type of intervention required. Tachycardia can occur in response to stress, pain, fever, infection, coronary artery blockage, valvular dysfunction, hypovolemia, hypoxia, or as a result of decreased vagal tone or of increased sympathetic nervous system activity associated with the release of catecholamines. Although it generally does not require treatment, persistent tachycardia may worsen underlying pathology in patients with ischemic heart disease because of shortened diastolic filling time and increased oxygen demands. These patients may require medications.|
|Sinus bradycardia||Bradycardia is common in patients with acute MI (especially anterior and inferior) and is the result of excessive parasympathetic activity, blocks in conduction to the SA or AV nodes, or loss of automaticity of the heart muscle. Patients with severe heart disease may not be able to compensate for a slow rate by increasing stroke volume. Therefore, decreased cardiac output, HF, and potentially lethal ventricular dysrhythmias may occur.|
|PACs||PACs can occur as a response to ischemia and are normally harmless but can precede or precipitate atrial fibrillation.|
|atrial flutter||Acute and chronic atrial flutter and/or fibrillation (the most common dysrhythmia) can occur with coronary artery or valvular disease and may or may not be pathological.|
|Atrial supraventricular tachycardias (PAT, MAT, SVT);||Rapid atrial flutter/fibrillation reduces cardiac output as a result of incomplete ventricular filling (shortened cardiac cycle) and increased oxygen demand.|
|Premature ventricular contractions or ventricular premature beats (PVCs/VPBs), ventricular tachycardia (VT), ventricular flutter or fibrillation (VF);||PVCs or VPBs reflect cardiac irritability and are commonly associated with MI, digitalis toxicity, coronary vasospasm, and misplaced temporary pacemaker leads. Frequent, multiple, or multifocal PVCs result in diminished cardiac output and may lead to potentially lethal dysrhythmias, e.g., VT or sudden death/cardiac arrest from ventricular flutter/fibrillation. Intractable ventricular dysrhythmias unresponsive to medication may reflect ventricular aneurysm. Polymorphic VT (torsades de pointes) is recognized by inconsistent shape of QRS complexes and is often drug related, e.g., procainamide (Pronestyl), quinidine (Quinaglute), disopyramide (Norpace), and sotalol (Betapace). Reflect altered transmission of impulses through normal conduction channels (slowed, altered) and may be the result of MI, coronary artery disease with reduced blood supply to sinoatrial (SA) or atrioventricular (AV) nodes, drug toxicity, and sometimes cardiac surgery.|
|Heart blocks||Progressing heart block is associated with slowed ventricular rates, decreased cardiac output, and potentially lethal ventricular arrhythmias or cardiac standstill.|
|Provide quiet and calm environment. Review reasons for limitation of activities during acute phase.||Reduces stimulation and release of stress-related catecholamines, which can cause or aggravate dysrhythmias and vasoconstriction, increasing myocardial workload.|
|Demonstrate and encourage use of stress management behaviors,: relaxation techniques, guided imagery, slow/deep breathing.||Promotes patient participation in exerting some sense of control in a stressful situation.|
|Investigate reports of chest pain, documenting location, duration, intensity (0–10 scale), and relieving or aggravating factors. Note nonverbal pain cues: facial grimacing, crying, changes in BP/heart rate.||Reasons for chest pain are variable and depend on underlying cause. However, chest pain may indicate ischemia due to altered electrical conduction, decreased myocardial perfusion, or increased oxygen need.|
|Be prepared to initiate cardio-pulmonary resuscitation (CPR) as indicated.||Development of life-threatening dysrhythmias requires prompt intervention to prevent ischemic damage/death.|
|Monitor laboratory studies:|
|Electrolytes||Imbalance of electrolytes, such as potassium, magnesium, and calcium, adversely affects cardiac rhythm and contractility.|
|Drug levels||Reveal therapeutic or toxic level of prescription medications or street drugs that may affect or contribute to presence of dysrhythmias.|
|Administer supplemental oxygen as indicated.||Increases amount of oxygen available for myocardial uptake, which decreases irritability caused by hypoxia.|
|Administer medications as indicated:|
|Potassium||Dysrhythmias are generally treated symptomatically. Correction of hypokalemia may be sufficient to terminate some ventricular dysrhythmias. Potassium imbalance is the number one cause of atrial fibrillation.|
|Class I drugs||Class I drugs depress depolarization and alter repolarization, stabilizing the cell.These drugs are divided into groups a, b, and c, based on their unique effects. These drugs increase action potential, duration, and effective refractory period and decrease membrane responsiveness, prolonging both QRS complex and QT interval. Useful for treatment of atrial and ventricular premature beats, repetitive arrhythmias (atrial tachycardias and atrial flutter or fibrillation). Myocardial depressant effects may be potentiated when class Ia drugs are used in conjunction with any drugs possessing similar properties.|
|Class Ia: disopyramide (Norpace), procainamide (Pronestyl, Procan SR), quinidine (Quinaglute, Cardioquin);||These drugs shorten the duration of the refractory period (QT interval), and their action depends on the tissue affected and the level of extracellular potassium.|
|Class Ib: lidocaine (Xylocaine), phenytoin (Dilantin), tocainide (Tonocard), mexiletine (Mexitil); moricizine (Ethmozine);||Drugs of choice for ventricular dysrhythmias, they are also effective for automatic and reentrant arrhythmias and digitalis-induced dysrhythmias. These drugs may aggravate myocardial depression.|
|Class Ic: flecainide (Tambocor), propafenone (Rythmol), encainide (Enkaid);||These drugs slow conduction by depressing SA node automaticity and decreasing conduction velocity through the atria, ventricles, and Purkinje fibers. The result is prolongation of the PR interval and lengthening of the QRS complex. They suppress and prevent all types of ventricular dysrhythmias. Flecainide increases the risk of drug-induced dysrhythmias post MI. Propafenone can worsen or cause new dysrhythmias, a tendency called the “proarrhythmic effect.” Encainide is available only for patients who demonstrated a good result before the drug was removed from the market.|
|Class II drugs: atenolol (Tenormin), propranolol (Inderal), nadolol (Corgard), acebutolol (Sectral), esmolol (Brevibloc), sotalol (Betapace); bisoprolol (Zebeta)||Beta-adrenergic blockers have antiadrenergic properties and decrease automaticity. Therefore, they are useful in the treatment of dysrhythmias caused by SA and AV node dysfunction (SVTs, atrial flutter or fibrillation). These drugs may exacerbate bradycardia and cause myocardial depression, especially when combined with drugs that have similar properties.|
|Class III drugs: bretylium tosylate (Bretylol), amiodarone (Cordarone), sotalol (Betapace), ibutilide (Corvert);||These drugs prolong the refractory period and action potential duration, consequently prolonging the QT interval. They are used to terminate ventricular fibrillation and other life-threatening ventricular dysrhythmias or sustained ventricular tachyarrhythmias, especially when lidocaine and procainamide are not effective. Sotalol is a nonselective beta-blocker with characteristics of both class II and class III.|
|Class IV drugs: verapamil (Calan), nifedipine (Procardia), diltiazem (Cardizem)||Calcium antagonists (also called calcium channel blockers) slow conduction time through the AV node (prolonging PR interval) to decrease ventricular response in SVTs, atrial flutter/fibrillation. Calan and Cardizem may be used for bedside conversion of acute atrial fibrillation.|
|Class V drugs: atropine sulfate, isoproterenol (Isuprel)||Miscellaneous drugs useful in treating bradycardia by increasing SA and AV conduction and enhancing automaticity.|
|cardiac glycosides: digoxin (Lanoxin)||Cardiac glycosides may be used alone or in combination with other antiarrhythmic drugs to reduce ventricular rate in presence of uncontrolled or poorly tolerated atrial tachycardias or flutter and fibrillation. First-line treatment for paroxysmal supraventricular tachycardia (PVST).|
|Adenosine (Adenocard)||Slows conduction and interrupts reentry pathways in AV node. Note: Contraindicated in patients with second- or third-degree heart block or those with sick sinus syndrome who do not have a functioning pacemaker.|
|Prepare and assist with elective cardioversion.||May be used in atrial fibrillation or certain unstable dysrhythmias to restore normal heart rate and relieve symptoms of heart failure.|
|Assist with insertion and maintenance of pacemaker function.||Temporary pacing may be necessary to accelerate impulse formation or override tachydysrhythmias and ectopic activity, to maintain cardiovascular function until spontaneous pacing is restored or permanent pacing is initiated.|
|Insert and maintain IV access.||Patent access line may be required for administration of emergency drugs.|
|Prepare for invasive diagnostic procedures and surgery as indicated.||Differential diagnosis of underlying cause may be required to formulate appropriate treatment plan. Resection of ventricular aneurysm may be required to correct intractable ventricular dysrhythmias unresponsive to medical therapy. Surgery: CABG, may be indicated to enhance circulation to myocardium and conduction system.|
|Prepare for implantation of cardioverter or defibrillator (ICD) when indicated.||This device may be surgically implanted in those patients with recurrent, life-threatening ventricular dysrhythmias unresponsive to tailored drug therapy. The latest generation of devices can provide multilevel (“tiered”) therapy, that is, antitachycardia and antibradycardia pacing, cardioversion, or defibrillation, depending on how each device is programmed.|
2. Risk for Poisoning
- Risk for Poisoning
Risk factors may include
- Limited range of therapeutic effectiveness, lack of education/proper precautions, reduced vision/cognitive limitations
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
- Verbalize understanding of individual prescription, how it interacts with other drugs/substances, and importance of maintaining prescribed regimen.
- Recognize signs of digitalis overdose and developing heart failure, and what to report to physician.
- Be free of signs of toxicity; display serum drug level within individually acceptable range.
|Explain patient’s specific type of digitalis preparation and its specific therapeutic use.||Reduces confusion due to digitalis preparations varying in name (although they may be similar), dosage strength, and onset and duration of action. Up to 15% of all patients receiving digitalis develop toxicity at some time during the course of therapy because of its narrow therapeutic range.|
|Instruct patient not to change dose for any reason, not to omit dose (unless instructed to, depending on pulse rate), not to increase dose or take extra doses, and to contact doctor if more than one dose is omitted.||Alterations in drug regimen can reduce therapeutic effects, result in toxicity, and cause complications.|
|Advise patient that digitalis may interact with many other drugs (barbiturates, neomycin, cholestyramine, quinidine, and antacids) and that physician should be informed that digitalis is taken whenever new medications are prescribed. Advise patient not to use OTC drugs (laxatives, antidiarrheals, antacids, cold remedies, diuretics, herbals) without first checking with the pharmacist or healthcare provider.||Knowledge may help prevent dangerous drug interactions.|
|Review importance of dietary and supplemental intake of potassium, calcium, and magnesium.||Maintaining electrolytes at normal ranges may prevent or limit development of toxicity and correct many associated dysrhythmias.|
|Provide information and have the patient or SO verbalize understanding of toxic signs and symptoms to report to the healthcare provider.||Nausea, vomiting, diarrhea, unusual drowsiness, confusion, very slow or very fast irregular pulse, thumping in chest, double or blurred vision, yellow or green tint or halos around objects, flickering color forms or dots, altered color perception, and worsening heart failure (dependent or
generalized edema, dyspnea, decreased amount and/or frequency of voiding) indicate need for prompt evaluation or intervention. Mild symptoms of toxicity may be managed with a brief drug holiday. In severe or refractory heart failure, altered cardiac binding of digitalis may result in toxicity, even with previously appropriate drug doses.
|Discuss necessity of periodic laboratory evaluation:|
|Serum digoxin (Lanoxin) or digitoxin (Crystodigin) level||Digitalis has a narrow therapeutic serum range, with toxicity occurring at levels that are dependent on individual response. Laboratory levels are evaluated in conjunction with clinical manifestations and ECG to determine individual therapeutic levels or resolution of toxicity.|
|Electrolytes, BUN, creatinine, liver function studies||Abnormal levels of potassium, calcium, or magnesium increase the heart’s sensitivity to digitalis. Impaired kidney function can cause digoxin (mainly excreted by the kidney) to accumulate to toxic levels. Digitoxin levels (mainly excreted by the bowel) are affected by impaired liver function.|
|Administer medications as appropriate: Other antiarrhythmic medications, lidocaine (Xylocaine), propranolol (Inderal), and procainamide (Pronestyl) Digoxin immune Fab (Digibind).||May be necessary to maintain and improve cardiac output in presence of excess effect of digitalis. A digoxin or digitoxin antagonist that increases drug excretion by the kidneys in acute or severe toxicity when standard therapies are unsuccessful.|
|Prepare patient for transfer to CCU as indicated (dangerous dysrhythmias, exacerbation of heart failure).||In the presence of digitalis toxicity, patients frequently require intensive monitoring until therapeutic levels have been restored. Because all digitalis preparations have long serum half-lives, stabilization can take several days.|
3. Deficient Knowledge
- Knowledge Deficit
May be related to
- Lack of information/misunderstanding of medical condition/therapy needs
- Unfamiliarity with information resources
- Lack of recall
Possibly evidenced by
- Questions, statement of misconception
- Failure to improve on previous regimen
- Development of preventable complications
- Verbalize understanding of condition, prognosis, and function of pacemaker (if used).
- Relate signs of pacemaker failure.
- Verbalize understanding of therapeutic regimen.
- List desired action and possible adverse side effects of medications.
- Correctly perform necessary procedures and explain reasons for actions.
|Assess patient and SO level of knowledge and ability and desire to learn.||Necessary for creation of individual instruction plan. Reinforces expectation that this will be a “learning experience.” Verbalization identifies misunderstandings and allows for clarification.|
|Be alert to signs of avoidance: changing subject away from information being presented or extremes of behavior (withdrawal or euphoria).||Natural defense mechanisms, such as anger or denial of significance of situation, can block learning, affecting patient’s response and ability to assimilate information. Changing to a less formal or structured style may be more effective until patient and SO is ready to accept or deal with current situation.|
|Present information in varied learning formats: programmed books, audiovisual tapes, question-and-answer sessions, group activities.||Multiple learning methods may enhance retention of material.|
|Provide information in written form for patient/SO to take home.||Follow-up reminders may enhance patient’s understanding and cooperation with the desired regimen. Written instructions are a helpful resource when patient is not in direct contact with healthcare team.|
|Reinforce explanations of risk factors, dietary and activity restrictions, medications, and symptoms requiring immediate medical attention.||Provides opportunity for patient to retain information and to assume control and participate in rehabilitation program.|
|Encourage identification and reduction of individual risk factors: smoking and alcohol consumption, obesity.||These behaviors and chemicals have direct adverse effect on cardiovascular function and may impede recovery and increase risk for complications.|
|Review normal cardiac function and electrical conduction.||Provides a knowledge base to understand individual variations and to understand reasons for therapeutic interventions.|
|Explain and reinforce specific dysrhythmia problem and therapeutic measures to patient and SO.||Ongoing or updated information (hether the problem is resolving or may require long-term control measures) can decrease anxiety associated with the unknown and prepare patient/SO to make necessary lifestyle adaptations. Educating the SO may be especially important if patient is elderly, visually or hearing impaired, or unable or even unwilling to learn and follow instructions. Repeated explanations may be needed because anxiety and/or bulk of new information can block or limit learning.|
|Identify adverse effects and complications of specific dysrhythmias: fatigue, dependent edema, progressive changes in mentation, vertigo.||Dysrhythmias may decrease cardiac output, manifested by symptoms of developing cardiac failure and/or altered cerebral perfusion. Tachydysrhythmias may also be accompanied by debilitating anxiety and feelings of impending doom.|
|Instruct and document teaching regarding medications. Include why the drug is needed (desired action), how and when to take the drug, what to do if a dose is forgotten (dosage and usage information), and expected side effects or possible adverse reactions and interactions with other prescribed or OTC drugs or substances (alcohol, tobacco, herbal remedies), as well as what and when to report to the physician.||Information necessary for patient to make informed choices and to manage medication regimen. Note: Use of herbal remedies in conjunction with drug regimen may result in adverse effects (cardiac stimulation, impaired clotting), necessitating evaluation of product for safe use.|
|Encourage development of regular exercise routine, avoiding overexertion. Identify signs and symptoms requiring immediate cessation of activities: dizziness, lightheadedness, dyspnea, chest pain.||When dysrhythmias are properly managed, normal activity should not be affected. Exercise program is useful in improving overall cardiovascular well-being.|
|Review individual dietary needs and restrictions: potassium, caffeine.||Depending on specific problem, patient may need to increase dietary potassium, such as when potassium-depleting diuretics are used. Caffeine may be limited to prevent cardiac excitation.|
|Demonstrate proper pulse-taking technique. Recommend weekly checking of pulse for 1 full minute or daily recording of pulse before medication and during exercise as appropriate. Identify situations requiring immediate medical intervention: dizziness or irregular heartbeat, fainting, chest pain.||Continued self-observation and monitoring provides for timely intervention to avoid complications. Medication regimen may be altered or further evaluation may be required when heart rate varies from desired rate or pacemaker’s preset rate.|
|Review safety precautions, techniques to evaluate and maintain pacemaker or ICD function, and symptoms requiring medical intervention: report pulse rate below set limit for demand pacing or less than low-limit rate for rate- adaptive pacers, prolonged hiccups.||Promotes self-care, provides for timely interventions to prevent serious complications. Instructions and concerns depend on function and type of device, as well as patient’s condition and presence or absence of family or caregivers.|
|Recommend wearing medical alert bracelet or necklace and carrying pacemaker ID card.||Allows for appropriate evaluation and timely intervention, especially if patient is unable to respond in an emergency situation.|
|Discuss environmental safety concerns, e.g., microwave ovens and other electrical appliances (including electrical blankets, razors, radio/TV), can be safely operated if they are properly grounded and in good repair. There is no problem with metal detectors, although pacemaker may trigger sensitive detectors. Although cordless phones are safe, cellular phones held directly over pacemaker may cause interference, so it is recommended that patient not carry phone in shirt pocket when phone is on. Additionally, high-voltage areas, magnetic fields, and radiation can interfere with optimal pacemaker function, so patient should avoid high-tension electric wires, arc welding, and large industrial magnets, e.g., demolition sites and MRI.||Aids in clarifying misconceptions and fears, and encourages patient to be proactive in avoiding potentially harmful situations.|
Other Possible Nursing Diagnosis
- Activity Intolerance—imbalance between oxygen supply/demand.
- Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, decisional conflicts, economic difficulties, inadequate number/types of cues to action.
- risk for Poisoning [digitalis toxicity]—risk factors may include limited range of therapeutic effectiveness, lack of education/proper precautions, reduced vision/cognitive limitations.
- Anxiety—may be related to perceived threat of death, possibly evidenced by increased tension, apprehension, and expressed concerns.