NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session 10

LESSON TITLE: Dysrhythmias Materials: MS notebook, paper, pen, index card,

and bond paper (short & long size)
LEARNING TARGETS:
References:
At the end of the lesson, the student nurses will be to: Smeltzer S.C., & Bare B.G. (2010) Brunner and
1. Differentiate the types of dysrhythmias; Suddarth’s Textbook of Medical- Surgical Nursing.
2. State the causes of dysrhythmias; and, Lippincott William & Wilkins
3. Explain the management of each type of
dysrhythmias. Sommer S., Johnson J. (2013) RN Adult Medical
Surgical Nursing. Assessment Technology
Institute, LLC.
https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: You will be sharing your NCP from previous session.

MAIN LESSON (60 minutes)

DYSRHYTHMIAS

This lecture is best paired with videos. Refer to this link. https://nurseslabs.com/how-to-identify-cardiac-arrhythmias-with-
videos/

Dysrhythmias are disorders of the formation or conduction (or both) of the electrical impulse within the heart. These
disorders can cause disturbances of the heart rate, the heart rhythm, or both.
Dysrhythmias may initially be evidenced by the hemodynamic effect they cause (eg, a change in conduction may change
the pumping action of the heart and cause decreased blood pressure).

Dysrhythmias are diagnosed by analyzing the electrocardiographic (ECG) waveform. Their treatment is based on
frequency and severity of symptoms produced.

Dysrhythmias are named according to the site of origin of the impulse and the mechanism of formation or conduction
involved.

The Electrocardiogram

The electrical impulse that travels through the heart can be viewed by means of electrocardiography, the end product of
which is an ECG. Each phase of the cardiac cycle is reflected by specific waveforms on the screen of a cardiac monitor or
on a strip of ECG graph paper. An ECG 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 they all have two components: (1) an adhesive substance that attaches
to the skin to secure the electrode in place and (2) a substance that reduces the skin’s electrical impedance and promotes
detection of the electrical current. The number and placement of the electrodes depend on the type of ECG needed. Most
continuous monitors use two to five electrodes, usually placed on the limbs and the chest. These electrodes create an
imaginary line, called a lead.

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Types of Dysrhythmias

Dysrhythmias include sinus, atrial, junctional, and ventricular dysrhythmias and their various subcategories.
Sinus Tachycardia

Sinus tachycardia is a heart rate greater than 100 beats per minute that originated from the sinus node.
 Rate: 100 to 180 beats per minute
 P Waves precede each QRS complex
 PR interval is normal
 QRS complex is normal
 Conduction is normal
 Rhythm is regular
Causes of sinus tachycardia may include exercise, anxiety, fever, drugs, anemia, heart failure, hypovolemia and shock.
Sinus tachycardia is often asymptomatic.

Management however is directed at the treatment of the primary cause. Carotid sinus pressure (carotid massage) or a
beta blocker may be used to reduce heart rate.

Sinus bradycardia is a heart rate less than 60 beats per minute and originates from the sinus node (as the term “sinus”
refers to sinoatrial node). It has the following characteristics
 Rate is less than 60 beats per minute
 P Waves precede each QRS complex
 PR interval is normal
 QRS complex is normal
 Conduction is normal
 Rhythm is regular
Causes may include drugs, vagal stimulation, hypoendocrine states, hypothermia, or sinus node involvement in MI. This
arrythmia may be normal in athletes as they have quality stroke volume. It is often asymptomatic but manifestations may
include: syncope, fatigue, dizziness.

Management includes treating the underlying cause and administering anticholinergic drugs like atropine sulfate as
prescribed.

Premature Atrial Contraction are ectopic beats that originates from the atria and they are not rhythms. Cells in the heart
starts to fire or go off before the normal heartbeat is supposed to occur. These are called heart palpitations and has the
following characteristics:
 Premature and abnormal-looking P waves that differ in configuration from normal P waves
 QRS complex after P waves except in very early or blocked PACs
 P waves often buried in the preceding T wave or identified in the preceding T wave.

Causes includes coronary or valvular heart diseases, atrial ischemia, coronary artery atherosclerosis, heart failure,
COPD, electrolyte imbalance and hypoxia.

Usually there is no treatment needed but may include procainamide and quinidine administration (antidysrhythmic drugs)
and carotid sinus massage.

Atrial flutter is an abnormal rhythm that occurs in the atria of the heart. Atrial flutter has an atrial rhythm that is regular but
has an atrial rate of 250 to 400 beats/minute. It has sawtooth appearance. QRS complexes are uniform in shape but often
irregular in rate.
 Normal atrial rhythm
 Abnormal atrial rate: 250 to 400 beats/minute
 Sawtooth P wave configuration
 QRS complexes uniform in shape but irregular in rate

Causes includes heart failure, tricuspid valve or mitral valve diseases, pulmonary embolism, cor pulmonale, inferior wall
MI, carditis and digoxin toxicity.

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Management if the patient is unstable with ventricular rate of greater than 150 bpm, prepare for immediate cardioversion.
If patient is stable, drug therapy may include calcium channel blocker, beta-adrenergic blockers, or anti arrhythmics.
Anticoagulation may be necessary as there would be pooling of blood in the atria.

Atrial fibrillation is disorganized and uncoordinated twitching of atrial musculature caused by overly rapid production of
atrial impulses. This arrhythmia has the following characteristics:
 Atrial Rate: 350 to 600 bpm
 Ventricular Rate: 120 to 200 bpm
 P wave is not discernible with an irregular baseline
 PR interval is not measurable
 QRS complex is normal
 Rhythm is irregular and usually rapid unless controlled.
Causes includes atherosclerosis, heart failure, congenital heart disease, chronic obstructive pulmonary
disease, hypothyroidism and thyrotoxicosis. Atrial fibrillation may be asymptomatic but clinical manifestation may include
palpitations, dyspnea, and pulmonary edema.
Nursing goal is towards administration of prescribed treatment to decrease ventricular response, decrease atrial irritability
and eliminate the cause.

Premature Junctional Contraction (PJC) occurs when some regions of the heart become excitable than normal. It has
the following characteristics.

 PR interval less than 0.12 seconds if P wave precedes QRS complex

 QRS complex configuration and duration is normal
 P wave is inverted
 Atrial and ventricular rhythms irregular
Causes of PJC may include myocardial infarction or ischemia, digoxin toxicity, excessive caffeine or amphetamine use.
Management includes correction of underlying cause, discontinuation of digoxin if appropriate.

Atrioventricular Blocks
AV blocks are conduction defects within the AV junction that impairs conduction of atrial impulses to ventricular pathways.
The three types are first degree, second degree and third degree.
First Degree AV Block
 Rate is usually 60 to 100 bpm
 PR intervals are prolonged for usually 0.20 seconds
 QRS complex is usually normal
 Rhythm is regular
First degree AV block is asymptomatic and may be caused by inferior wall MI or ischemia, hyperkalemia, hypokalemia,
digoxin toxicity, calcium channel blockers, amiodarone and use of antidysrhythmic.

Management includes correction of underlying cause. Administer atropine if PR interval exceeds 0.26 second or
symptomatic bradycardia develops.
Second Degree AV Block Mobitz I (Wenckebach)
 Atrial rhythm is regular
 Ventricular rhythm is irregular
 Atrial rate exceeds ventricular rate
 PR interval progressively but only slightly, longer with each cycle until QRS complex disappears (dropped beat)
 PR Interval shorter after dropped beat.

Clinical manifestations include vertigo, weakness, and an irregular pulse. This may be caused by Inferior wall MI,
cardiac surgery, acute rheumatic fever, vagal stimulation.
Treatment includes correction of underlying cause, atropine or temporary pacemaker for symptomatic bradycardia and
discontinuation of digoxin if appropriate.

Third Degree AV Block (Complete Heart Block)

 Atrial rhythm regular
 Ventricular rhythm regular and rate slower than atrial rate
 No relation between P waves and QRS complexes
 NO constant PR interval

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  QRS interval normal or wide and bizarre

Manifestations include: hypotension, angina and heart failure. This may be caused by congenital abnormalities, rheumatic
fever, hypoxia, MI, LEv’s disease, Lenegre’s disease and digoxin toxicity. Management includes atropine, epinephrine,
and dopamine for bradycardia. Installation of pacemaker may also be considered.

Premature Ventricular Contractions (PVC)

Early or premature ventricular contractions are caused by increased automaticity of ventricular muscle cells. PVCs usually
are not considered harmful but are of concern if more than six occur in 1 minute, if they occur in pairs or triplets if they are
multifocal or if they occur or near a T wave.
 Atrial rhythm is regular
 Ventricular rhythm is irregular
 QRS complex premature, usually followed by a complete compensatory pause
 QRS complex is also wide and distorted, usually >0.14 second.
 Premature QRS complexes occurring singly, in pairs, or in threes

Clinical manifestations include palpitations, weakness, lightheadedness but it is most of the time asymptomatic.
Management includes assessment of the cause and treat as indicated. Treatment is indicated if the client has underlying
disease because PVCs may precipitate ventricular tachycardia or fibrillation. Assess for life threatening PVCs. Administer
antiarrhythmic medication as prescribed.

Ventricular tachycardia (VT) is three or more consecutive PVCs. it is considered a medical emergency because cardiac
output (CO) cannot be maintained because of decreased diastolic filling (preload).
 Rate is 100 to 250 beats per minute
 P wave is blurred in the QRS complex but the QRS complex has no associate with P wave.
 PR Interval is not present
 QRS complex is wide and bizarre; T wave is in the opposite direction
 Rhythm is usually regular
 May start and stop suddenly

Clinical manifestations of VT include lightheadedness, weakness, dyspnea and unconsciousness.

Causes includes MI, aneurysm, CAD, rheumatic heart diseases, mitral valve prolapse, hypokalemia, hyperkalemia,
and pulmonary embolism. Anxiety may also cause VT.

Pulseless Ventricular Tachycardia

Management for Pulseless VT: Initiate cardiopulmonary resuscitation; follow ACLS protocol for defibrillation, ET
intubation and administration of epinephrine or vasopressin.

Ventricular Tachycardia with Pulse

Management with Pulse VT: If hemodynamically stable, follow ACLS protocol for administration of amiodarone, if
ineffective, initiate synchronized cardioversion.

Ventricular Fibrillation
Ventricular fibrillation is rapid, ineffective quivering of ventricles that may be rapidly fatal.
 Rate is rapid and uncoordinated, with ineffective contractions
 Rhythm is chaotic
 QRS complexes wide and irregular
 P wave is not seen
 PR interval is not seen
Causes of ventricular fibrillation is most commonly myocardial ischemia or infarction. It may result from untreated
ventricular tachycardia, electrolyte imbalances, digoxin or quinide toxicity, or hypothermia. Clinical manifestations may
include loss of consciousness, pulselessness, loss of blood pressure, cessation of respirations, possible seizures and
sudden death.

Start CPR is pulseless. Follow ACLS protocol for defibrillation, ET intubation and administration of epinephrine or
vasopressin.

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Other Arrhythmias:
 Atrial Tachycardia
 2nd Degree AV Block Type 1, Mobitz I
 Torsade de Pointes
 Pulseless Ventricular Tachycardia
 Supraventricular Tachycardia
 ST Depression

NURSING CARE MANAGEMENT OF PATIENT WITH A DYSRHYTHMIA

Assessment
 Major areas of assessment include possible causes of the dysrhythmia, contributing factors, and the
dysrhythmia’s effect on the heart’s ability to pump an adequate blood volume. When cardiac output is reduced,
the amount of oxygen reaching the tissues and vital organs is diminished. This diminished oxygenation produces
the signs and symptoms associated with dysrhythmias. If these signs and symptoms are severe or if they occur
frequently, the patient may experience significant distress and disruption of daily life.
 A health history is obtained to identify any previous occurrences of decreased cardiac output, such as syncope
(fainting), lightheadedness, dizziness, fatigue, chest discomfort, and palpitations.
 Coexisting conditions that could be possible causes of the dysrhythmia (eg, heart disease, chronic obstructive
pulmonary disease) may also be identified.
 All medications, prescribed and over-the-counter (including herbs and nutritional supplements), as well as the
route of administration, are reviewed. If a patient is taking an antiarrhythmic medication, assessment for side
effects, adverse reactions, and potential contraindications is necessary.
 Laboratory results are reviewed to assess levels of medications as well as factors that could contribute to the
dysrhythmia (e.g., anemia).

Diagnosis Nursing Diagnoses

Based on assessment data, major nursing diagnoses of the patient may include:
 Decreased cardiac output
 Anxiety related to fear of the unknown
 Deficient knowledge about the dysrhythmia and its treatment

Collaborative Problems/Potential Complications

Potential complications that may develop include the following:
 Cardiac arrest
 Heart failure
 Thromboembolic event, especially with atrial fibrillation

Planning and Goals

The major goals for the patient may include eliminating or decreasing the occurrence of the dysrhythmia (by decreasing
contributory factors) to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia, tests
used to diagnose the problem, and its treatment.

Nursing Interventions
1. Monitoring and Managing the Dysrhythmia
 The nurse regularly evaluates the patient’s blood pressure, pulse rate and rhythm, rate and depth of respirations,
and breath sounds to determine the dysrhythmia’s hemodynamic effect.
 The nurse also asks the patient about episodes of lightheadedness, dizziness, or fainting as part of the ongoing
assessment.
 The nurse assesses and observes for the benefits and adverse effects of each medication.
 The nurse, in collaboration with the physician, also manages medication administration carefully so that a
constant serum level of the medication is maintained.
 The nurse may also conduct a 6-minute walk test as prescribed, which is used to identify the patient’s ventricular
rate in response to exercise. The patient is asked to walk for 6 minutes, covering as much distance as possible.
 The nurse monitors the patient for symptoms.
 At the end, the nurse records the distance covered and the pre exercise and post exercise heart rate as well as
the patient’s response.

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  The nurse assesses for factors that contribute to the dysrhythmia (eg, oxygen deficits, acid-base and electrolyte
imbalances, caffeine, or nonadherence to the medication regimen). The nurse also monitors for ECG changes
(eg, widening of the QRS, prolongation of the QT interval, increased heart rate) that increase the risk of a
dysrhythmic event.
2. Minimizing Anxiety
 When the patient experiences episodes of dysrhythmia, the nurse stays with the patient and provides assurance
of safety and security while maintaining a calm and reassuring attitude. This assists in reducing anxiety (reducing
the sympathetic response) and fosters a trusting relationship with the patient.
 The nurse seeks the patient’s view of the events and discusses the emotional response to the dysrhythmia,
encouraging verbalization of feelings and fears, providing supportive or empathetic statements, and assisting the
patient to recognize feelings of anxiety, anger, or sadness.
 The nurse emphasizes successes with the patient to promote a sense of self-management of the dysrhythmia
 In addition, the nurse can help the patient develop a system to identify possible causative, influencing, and
alleviating factors (eg, keeping a diary). The nursing goal is to maximize the patient’s control and to make the
episode less threatening.

Promoting Home and Community-Based Care

When teaching patients about dysrhythmias, the nurse first assesses the patient’s understanding, clarifies misinformation,
and then shares needed information in terms that are understandable and in a manner that is not frightening or
threatening.

CONTINUING CARE.
A referral for home care usually is not necessary for the patient with a dysrhythmia unless the patient is hemodynamically
unstable and has significant symptoms of decreased cardiac output.
Home care may be warranted if the patient has significant comorbidities, socioeconomic issues, or limited self-
management skills that could increase the risk of nonadherence to the therapeutic regimen.

Evaluation Expected Patient Outcomes Expected patient outcomes may include:

1. Maintains cardiac output
 Demonstrates heart rate, blood pressure, respiratory rate, and level of consciousness within normal ranges
 . Demonstrates no or decreased episodes of dysrhythmia
2. Experiences reduced anxiety
 Expresses a positive attitude about living with the dysrhythmia
 Expresses confidence in ability to take appropriate actions in an emergency
3. Expresses understanding of the dysrhythmia and its treatment
 Explains the dysrhythmia and its effects
 Describes the medication regimen and its rationale
 Explains the need to maintain a therapeutic serum level of the medication
 Describes a plan to eliminate or limit factors that contribute to the dysrhythmia
 States actions to take in the event of an emergency

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1 A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse
responds that this procedure may stimulate the:
A. Vagus nerve to slow the heart rate
B. Vagus nerve to increase the heart rate; overdriving the rhythm
C. Diaphragmatic nerve to slow the heart rate
D. Diaphragmatic nerve to overdrive the rhythm
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

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Education (Department of Nursing) 6 of 9
2. A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS
complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:
A. Premature ventricular contractions
B. Ventricular tachycardia
C. Ventricular fibrillation
D. Sinus tachycardia
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

3. A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at
the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be
responsible for the artifact?
A. Frequent movement of the client
B. Tightly secured cable connections
C. Leads applied over hairy areas
D. Leads applied to the limbs
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

4 A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the
following, if prescribed, during an episode of ventricular tachycardia?
A. Breathe deeply, regularly, and easily
B. Inhale deeply and cough forcefully every 1 to 3 seconds
C. Lie down flat in bed
D. Remove any metal jewelry
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

5 When ventricular fibrillation occurs in a CCU, the first person reaching the client should:
A. Administer oxygen
B. Defibrillate the client
C. Initiate CPR
D. Administer sodium bicarbonate intravenously
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

6. A nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There are no P waves; instead there
are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The
nurse interprets this rhythm as:
A. Sinus tachycardia
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

7. A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the
preceding beat. The client’s rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there
are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be:

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Education (Department of Nursing) 7 of 9
A. Ventricular tachycardia
B. Ventricular fibrillation
C. Atrial fibrillation
D. Asystole
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

8. When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is
characterized by:
A. The presence of occasional coupled beats
B. Long pauses in otherwise regular rhythm
C. A continuous and totally unpredictable irregularity
D. Slow but strong and regular beats
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

9. A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of
the following items?
A. Blood pressure and peripheral perfusion
B. Sensation of palpitation
C. Causative factor such as caffeine
D. Precipitating factors such as infections
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

10. A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe:
A. Sagging ST segment
B. Absence of P wave configurations
C. Inverted T waves following each QRS complex
D. Widening of QRS complexes to 0.12 seconds or greater
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Student Response Cards

Instruction: Get your index cards, write the word YES in one card and NO in another card. As your instructor pose a
question, you can raise the card with either YES or NO as your response to each question.

(For Related Learning Experience, please refer to your clinical instructor.)

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