Nursing Care Plan Dysrhytmias (Including Digitalis Toxicity)

CARE SETTING

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.

RELATED CONCERNS

1. Angina
2. Heart failure: chronic
3. Myocardial infarction
4. Psychosocial aspects of care
5. Patient Assessment Database

ACTIVITY/REST

May report: 
Generalized weakness and exertional fatigue

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

CIRCULATION

May report: 

1. History of previous/acute MI (90%–95% experience dysrhythmias), cardiac surgery, cardiomyopathy, rheumatic/HF, valvular heart disease, long-standing hypertension, use of pacemaker
2. Pulse: Fast, slow, or irregular; palpitations, skipped beats

May exhibit: 

1. BP changes (hypertension or hypotension) during episodes of dysrhythmia
2. Pulses may be irregular, e.g., skipped beats; pulsus alternans (regular strong beat/weak beat); bigeminal pulse (irregular strong beat/weak beat)
3. Pulse deficit (difference between apical pulse and radial pulse)
4. Heart sounds: irregular rhythm, extra sounds, dropped beats
5. Skin color and moisture changes, e.g., pallor, cyanosis, diaphoresis (heart failure, shock)
6. Edema dependent, generalized, JVD (in presence of heart failure)
7. Urine output decreased if cardiac output is severely diminished

EGO INTEGRITY

May report: 

1. Feeling nervous (certain tachydysrhythmias), sense of impending doom
2. Stressors related to current medical problems

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

FOOD/FLUID

May report: 

1. Loss of appetite, anorexia
2. Food intolerance (with certain medications)
3. Nausea/vomiting
4. Changes in weight

May exhibit: 

1. Weight gain or loss
2. Edema
3. Changes in skin moisture/turgor
4. Respiratory crackles

NEUROSENSORY

1. May report: 
2. Dizzy spells, fainting, headaches

May exhibit: 

1. Mental status/sensorium changes, e.g., disorientation, confusion, loss of memory; changes in usual speech pattern/consciousness, stupor, coma
2. Behavioral changes, e.g., combativeness, lethargy, hallucinations
3. Pupil changes (equality and reaction to light)
4. Loss of deep tendon reflexes with life-threatening dysrhythmias (ventricular tachycardia, severe bradycardia)

PAIN/DISCOMFORT

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

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

RESPIRATION

May report: 

1. Chronic lung disease
2. History of or current tobacco use
3. Shortness of breath
4. Coughing (with/without sputum production)

May exhibit: 

1. Changes in respiratory rate/depth during dysrhythmia episode
2. 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

SAFETY

May exhibit: 

1. Fever
2. Skin: Rashes (medication reaction)
3. Loss of muscle tone/strength

TEACHING/LEARNING

May report: 

1. Familial risk factors, e.g., heart disease, stroke
2. 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)
3. Stimulant abuse, including caffeine/nicotine
4. Lack of understanding about disease process/therapeutic regimen
5. Evidence of failure to improve, e.g., recurrent/intractable dysrhythmias that are lifethreatening
6. Discharge plan
7. DRG projected mean length of inpatient stay: 3.9 days
8. Alteration of medication use/therapy
9. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. 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).
2. 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.
3. May also be used to evaluate pacemaker function, antidysrhythmia drug effect, or effectiveness of cardiac rehabilitation.
4. 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).
5. Chest x-ray: May show enlarged cardiac shadow due to ventricular or valvular dysfunction.
6. Myocardial imaging scans: May demonstrate ischemic/damaged myocardial areas that could impede normal conduction or impair wall motion and pumping capabilities.
7. 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.
8. Electrolytes: Elevated or decreased levels of potassium, calcium, and magnesium can cause dysrhythmias.
9. Drug screen: May reveal toxicity of cardiac drugs, presence of street drugs, or suggest interaction of drugs, e.g., digitalis and quinidine.
10. Thyroid studies: Elevated or depressed serum thyroid levels can cause/aggravate dysrhythmias.
11. ESR: Elevation may indicate acute/active inflammatory process, e.g., endocarditis, as a precipitating factor for dysrhythmias.
12. ABGs/pulse oximetry: Hypoxemia can cause/exacerbate dysrhythmias.

NURSING PRIORITIES

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.

DISCHARGE GOALS

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.