{ "name": "Cardiac Arrhythmias & Digitalis Toxicity", "slug": "cardiac-arrhythmia", "url": "https://nursingplex.com/care-plans/cardiac-arrhythmia", "category": "Cardiac", "summary": "Rhythm disturbances and drug toxicity; continuous monitoring, electrolyte correction and pulse checks.", "nursing_diagnoses": [ "Decreased cardiac output", "Risk for injury", "Activity intolerance" ], "overview": [ "An arrhythmia is any disturbance in the rate, rhythm, origin or conduction of the cardiac impulse. Some are harmless variants; others reduce cardiac output immediately or degenerate into cardiac arrest. The clinical question is never only 'what is the rhythm' but 'how is the patient tolerating it' — the same rhythm can be an incidental finding in one patient and a code in another.", "Rhythms are grouped by origin. Sinus disturbances are usually secondary to something else — pain, fever, hypoxia, hypovolemia, drugs. Atrial arrhythmias such as atrial fibrillation and flutter lose the atrial kick, dropping cardiac output by up to a third and allowing thrombus to form in the atrium, which is why stroke prevention matters as much as rate control. Junctional and ventricular rhythms come from lower pacemakers and are progressively slower and less reliable. Ventricular tachycardia and ventricular fibrillation are lethal without immediate intervention, and asystole and pulseless electrical activity are non-shockable arrests treated with compressions and epinephrine.", "Most arrhythmias have a correctable driver: myocardial ischemia, electrolyte disturbance (especially potassium and magnesium), hypoxia, acidosis, thyroid disease, stimulants, or drug toxicity such as digoxin or QT-prolonging agents. Nursing care always includes hunting the cause, not simply treating the tracing." ], "key_facts": [ { "label": "First action", "text": "Assess the patient and check a pulse — treat the patient, not the monitor; artifact and lead failure mimic lethal rhythms." }, { "label": "Unstable patient", "text": "Hypotension, altered mental status, chest pain, shock or heart failure with a tachyarrhythmia means synchronized cardioversion." }, { "label": "Shockable rhythms", "text": "Only ventricular fibrillation and pulseless ventricular tachycardia are defibrillated; asystole and PEA are not." }, { "label": "Atrial fibrillation", "text": "Irregularly irregular with no discernible P waves; anticoagulation is guided by stroke risk scoring." }, { "label": "Electrolytes", "text": "Potassium and magnesium abnormalities are the most common reversible triggers; check them with every new arrhythmia." }, { "label": "Torsades de pointes", "text": "Polymorphic VT with a prolonged QT; treated with IV magnesium sulfate and removal of QT-prolonging drugs." } ], "nursing_priorities": [ "Determine hemodynamic stability before anything else.", "Identify the rhythm and any immediately reversible cause.", "Maintain airway, oxygenation and perfusion.", "Correct electrolyte and acid-base abnormalities.", "Administer antiarrhythmic therapy and prepare for cardioversion, pacing or defibrillation.", "Prevent thromboembolism in atrial fibrillation and flutter.", "Reduce anxiety, which itself increases catecholamines and arrhythmia burden.", "Teach pulse monitoring, medication adherence, device care and warning signs." ], "assessment": { "subjective": [ "Palpitations, fluttering, skipped beats or a racing sensation", "Dizziness, lightheadedness, near-syncope or syncope", "Chest pain, pressure or shortness of breath, especially on exertion", "Fatigue, reduced exercise tolerance or a sense of weakness", "Anxiety, and awareness of the heartbeat at rest" ], "objective": [ "Rate, regularity and quality of apical and peripheral pulses, with a pulse deficit when they differ", "Blood pressure trend and evidence of low output — cool skin, poor capillary refill, oliguria", "Continuous ECG with rhythm strip: rate, regularity, P wave presence and relationship, PR, QRS width, QT interval", "Level of consciousness and any new confusion", "Jugular venous distention, crackles, S3 or new murmur suggesting decompensation", "Electrolytes — potassium, magnesium, calcium — plus digoxin level, thyroid studies and cardiac biomarkers", "Device site for pacemaker or defibrillator: incision, swelling, capture on the strip" ], "related_factors": [ "Myocardial ischemia, infarction, cardiomyopathy or valvular disease", "Electrolyte imbalance, particularly potassium and magnesium", "Hypoxia, acidosis and hypovolemia", "Drug effect or toxicity — digoxin, antiarrhythmics, QT-prolonging drugs, stimulants, caffeine, alcohol", "Thyroid dysfunction, fever, pain and anxiety", "Cardiac surgery, catheter manipulation and conduction system disease" ] }, "goals": [ "The client will maintain a stable rhythm with a rate that supports adequate cardiac output and blood pressure.", "The client will remain free of syncope, chest pain and signs of poor perfusion.", "The client will maintain electrolytes within normal limits.", "The client will remain free of thromboembolic events while on prescribed anticoagulation.", "The client will demonstrate correct pulse-taking and state which findings require a call.", "The client will describe medication purpose, dosing and side effects, and device precautions where applicable." ], "interventions": [ { "title": "1. Immediate assessment of stability", "points": [ "Assess responsiveness, pulse, blood pressure and mental status before interpreting the strip; a lethal-looking tracing in a talking patient with a normal pulse is usually artifact or a lead problem.", "Identify instability quickly — hypotension, altered mental status, ischemic chest pain, acute heart failure or shock — because it converts the plan from medication to electricity.", "Obtain a 12-lead ECG for any new or symptomatic rhythm, and keep a printed strip for comparison.", "Place the patient on continuous monitoring with alarms set to meaningful limits, and confirm lead placement and skin prep to avoid false alarms.", "Keep the crash cart, defibrillator and suction immediately available for unstable rhythms." ] }, { "title": "2. Finding and correcting reversible causes", "points": [ "Check potassium and magnesium first; both hypokalemia and hyperkalemia provoke serious arrhythmias, and magnesium deficiency prevents potassium correction.", "Assess oxygenation and treat hypoxia, since it is a frequent and immediately reversible driver.", "Review all medications for proarrhythmic and QT-prolonging effects, and check digoxin level whenever a patient on digoxin develops a new arrhythmia, nausea, visual halos or confusion.", "Treat pain, fever, anxiety, hypovolemia and anemia — sinus tachycardia is a symptom, and slowing it without fixing the cause is harmful.", "Consider thyroid disease, stimulant use, alcohol and caffeine in recurrent atrial arrhythmias." ] }, { "title": "3. Managing tachyarrhythmias", "points": [ "For stable narrow-complex tachycardia, attempt vagal maneuvers as ordered and be ready with adenosine given by rapid IV push followed by an immediate flush, warning the patient about a brief but alarming pause and flushing.", "For unstable tachyarrhythmia with a pulse, prepare for synchronized cardioversion — confirm the sync marker on each QRS, sedate when time allows, and clear the bed before delivery.", "For atrial fibrillation, expect rate control with beta blockers, diltiazem or digoxin, and assess apical rate for a full minute before each dose with parameters for holding.", "For pulseless ventricular tachycardia or ventricular fibrillation, start compressions immediately and defibrillate unsynchronized as soon as the device is charged; resume compressions without pausing for rhythm assessment.", "Give amiodarone, lidocaine or magnesium as ordered, and use magnesium sulfate specifically for torsades de pointes.", "Document the time, energy, drug and patient response for every intervention." ] }, { "title": "4. Managing bradyarrhythmias and conduction block", "points": [ "Assess whether the slow rate is producing symptoms; an asymptomatic athlete at 48 needs no treatment while a symptomatic patient at 52 does.", "Give atropine as first-line for symptomatic bradycardia, recognizing it will not work in high-grade block below the AV node.", "Prepare transcutaneous pacing early: place pads correctly, set rate and output, verify electrical and mechanical capture by feeling a pulse, and provide analgesia and sedation because pacing is painful.", "Anticipate transvenous or permanent pacing for persistent high-degree block, and monitor for failure to capture, sense or pace.", "Hold rate-slowing medications and review for beta blocker, calcium channel blocker or digoxin excess." ] }, { "title": "5. Preventing thromboembolism", "points": [ "Recognize that atrial fibrillation and flutter lasting beyond about 48 hours allow atrial thrombus and require anticoagulation before elective cardioversion.", "Administer anticoagulants as prescribed and monitor the appropriate laboratory test and for signs of bleeding.", "Teach warfarin patients about consistent vitamin K intake, regular INR testing and interaction risk; teach direct oral anticoagulant patients that missing doses matters quickly because of the short half-life.", "Assess for and teach stroke warning signs at every encounter.", "Report new limb pain, coolness or pulselessness, which may indicate peripheral embolism." ] }, { "title": "6. Device care for pacemakers and defibrillators", "points": [ "After implantation, restrict arm movement on the affected side as ordered and inspect the site for hematoma, swelling, redness or drainage.", "Verify appropriate pacing spikes and capture on the monitor and report failure to capture or sense.", "Teach patients to check their pulse daily, keep the device identification card, and inform every provider and airport security about the device.", "Advise avoiding strong magnetic fields, keeping mobile phones on the opposite side, and never lingering near anti-theft gates or arc welders.", "Explain what a defibrillator shock feels like, the plan if shocked once versus repeatedly, and that a family member touching them during a shock is safe.", "Emphasize keeping device check appointments and reporting hiccups, dizziness or a rate below the programmed limit." ] }, { "title": "7. Reducing anxiety and oxygen demand", "points": [ "Explain monitoring and alarms so the patient does not interpret every beep as danger.", "Provide a calm environment, uninterrupted rest and limits on caffeine and stimulants.", "Teach relaxation and paced breathing, both of which reduce sympathetic drive.", "Encourage graded activity within prescribed limits and monitor rhythm and symptoms with activity." ] } ], "patient_teaching": [ "Take your pulse daily for a full minute, record it, and report a rate outside the range your provider gave you.", "Take antiarrhythmic and rate-control medication exactly as prescribed and never stop it abruptly.", "Report dizziness, fainting, chest pain, shortness of breath, or a sudden change in heartbeat.", "If you take an anticoagulant, watch for unusual bruising, bleeding gums, black stools or blood in urine, and keep all blood-test appointments.", "Limit caffeine, avoid energy drinks, stimulant decongestants and recreational stimulants, and stop smoking.", "Keep potassium and magnesium in balance by taking supplements as prescribed and keeping lab appointments.", "Carry a current medication list and, if you have a device, your device identification card at all times.", "Have a household member learn CPR and know when to call emergency services." ] }