Atrial Rhythm Questions

Questions (points possible)

Answers                                                                              Use concise, complete sentences. Do not exceed 1 page

Risk factors: Identify risk factors for atrial fibrillation (AFIB) the nurse should recognize in the scenario. (10 points)

Atrial fibrillation (AFIB) is the most common type of abnormal heart rhythm, affecting about 2.7 million people in the U.S., with an estimated incidence of 1% to 2% per year. AFIB is associated with several risk factors, including older age, male gender, diabetes mellitus, high blood pressure, and coronary artery disease (Tacklind, 2019). Therefore, the nurse should recognize the following risk factors for AFIB in this patient:

Age over 65 years old. The incidence of AFIB increases with age, with a peak incidence at 65 years old and beyond. AFIB is 2- to 6-fold more common in men than women, with a male-to-female ratio of 1:2–3.

Heart failure or left ventricular dysfunction (LV dysfunction). The incidence of AFIB increases with the severity of LV dysfunction or heart failure. Paroxysmal and persistent AFIB is more common in patients with severe heart failure or LV dysfunction than those without these conditions. Patients who have experienced an acute myocardial infarction have an increased risk of developing paroxysmal or persistent AFIB within 3 months after their event.

Heart disease: AFIB is more common in people with heart disease, particularly those who have had a heart attack or coronary artery bypass grafting (CABG).

High blood pressure: People with high blood pressure are at increased risk for AFIB. High blood pressure Diabetes mellitus type II with mild renal insufficiency Hypothyroidism Admitted to medical-surgical unit Compliant with medications, diet (diabetic, low salt, low-fat diet), and physical activity recommendations (Tacklind, 2019).

Obesity: Obesity is associated with an increased risk for AFIB.

Diabetes: People who have diabetes are at increased risk for AFIB.

Sleep apnea: Sleep apnea affects breathing during sleep and can increase AFIB risk (Mayyas et al., 2010).

Other risk factors include obesity, smoking, and alcohol use. The presence of a heart valve abnormality also increases the risk of AFIB. Patients with AFIB have significantly higher rates of stroke, heart failure, and death than those without AFIB.

Manifestations and abnormal results: Identify the manifestations and abnormal diagnostic results consistent with AFIB the nurse should recognize in the scenario. (20 points)

 AFIB is the most common type of atrial fibrillation and one of the most common cardiac arrhythmias. It affects about 3 million Americans, mostly older than 60. In some cases, people have no symptoms from AFIB, but in others, they may experience symptoms like:

• Shortness of breath or difficulty breathing

• Palpitations or a racing heartbeat

• Chest pain or discomfort

• Fatigue (Tacklind, 2019).

• Dizziness or lightheadedness

• Fainting (syncope) or near-fainting (presyncope)

AFIB is characterized by atrial fibrillation (A.F.), a heart rhythm abnormality that causes the upper chambers of the heart (atria) to beat very rapidly and irregularly. AFIB can cause palpitations, shortness of breath, fatigue, dizziness, lightheadedness, and chest pain. It also increases the risk of stroke by five times. The nurse should recognize the following manifestations:

Pulse irregular = 136 beats/minute

Respirations shallow and slightly labored = 30 breaths/min

BP = 108/66 mm Hg (Mayyas, et al., 2010).

Oral temperature = 98.2 ̊ F

Capillary glucose = 115 mg/dL (normal range 70-100 mg/dL) (Tacklind, 2019).

The nurse should recognize the manifestations and abnormal diagnostic results consistent with atrial fibrillation (AFIB). The patient is experiencing dizziness, palpitations, dyspnea, and chest tightness. These are common signs and symptoms of AFIB. The patient is currently taking metformin for his Type II diabetes mellitus. Metformin can cause an increase in serum potassium levels which may be contributing to his current symptoms. Therefore, monitoring serum potassium levels closely while on metformin therapy is important. In addition, the nurse could assess the patient for signs of hyperthyroidism such as fatigue, increased appetite, weight loss, heat intolerance, and tachycardia (heart rate > 100 beats/min). However, no other clinical indicators would suggest hyperthyroidism in this patient. The nurse should assess for evidence of dehydration by looking at skin turgor (if the skin appears soft or “floppy,” then dehydration is present) and mucous membranes (dry lips).

Stroke prevention: State the CHADS2-Vasc score, how it was calculated, and general recommendation for anticoagulation (Table 1 in Tackling, 2019); assuming no contraindications, describe potential treatments for anticogulation the nurse should expect to be ordered. (15 points)

A CHADS2-VASc score is a tool that can be used to monitor the risk of stroke in patients with atrial fibrillation (A.F.). It was developed by Tackling et al., 2019 and is based on age, prior stroke or transient ischemic attack (TIA), heart failure; diabetes mellitus; and systolic blood pressure greater than 140 mm Hg. The formula is as follows: CHADS2-Vasc = [0 + 0 + 1 + 1] x 2 = 4 points. If you had a patient who scored 4 points on this scale, they would have an increased risk for stroke (Nadadur et al., 2016). Anticoagulants such as warfarin or aspirin are often used to prevent strokes in patients with A.F. The CHADS2-Vasc score was calculated using the following variables: age ≥75 years, hypertension (HTN), diabetes mellitus (D.M.), prior stroke or transient ischemic attack (TIA), and cardiac failure or ventricular arrhythmia (A.F.). The scores range from 0 to 6; a higher score indicates an increased risk of stroke. For example, if a patient has a CHADS2-Vasc score of 1, they are at low risk of stroke; if they have a CHADS2-Vasc score of 2 or greater, they are at moderate risk of stroke.

CHADS2-Vasc Score = (0 - 1) + (1 point for each)

Age ≥ 78 years 0 points

Symptoms of heart failure 0 points c

0 points d for systolic bp of 140 mm Hg or diastolic bp of 90 mm Hg

The patient has a history of atrial fibrillation and is at high risk for stroke. Therefore, the nurse should expect to be ordered heparin therapy and aspirin therapy (Nadadur et al., 2016).

The patient has a history of hypertension, which means that his blood pressure may fluctuate during treatment. The nurse should be ordered oral antihypertensive medications and subcutaneous antihypertensive medications (e.g., angiotensin-converting enzyme inhibitors or angiotensin receptor blockers). Moreover, the patient has diverticulitis; therefore, the nurse should expect to be ordered antibiotics (e.g., ciprofloxacin) if needed, increased fiber intake in the diet

Rate and rhythm control: Assuming no contraindications, describe specific treatments for rate and rhythm control of AFIB the nurse should expect to be ordered. (20 points)

Rate control. The first line of therapy for rate control is beta-blockers. Beta-blockers are recommended for most patients with AFIB and are the most effective agents for controlling the heart rate (H.R.). Beta-blockers reduce H.R. by affecting both sympathetic and parasympathetic nerve activity. The exact mechanism of action of beta-blockers on H.R. depends upon which receptor they bind to, but they all lower H.R. by decreasing sympathetic activity and increasing vagal tone. This results in a decrease in cardiac contractility. The American Heart Association recommends beta-blockers as first-line therapy for rate control (Nadadur, 2016). A recent meta-analysis found that beta-blockers were significantly better than calcium channel blockers at reducing H.R.s, although the difference was not significant [4]. Beta-blockers do not have any significant adverse effects on mortality or morbidity for patients with AFIB.

Amiodarone (IV or oral) is usually given as a first-line agent for rate control if there are no contraindications. It can be used as a bridge to other medications or combined.

Rhythm control:

- Diltiazem IV - may be used for rate control before cardioversion if AFIB is not ventricular tachycardia (V.T.).

- Verapamil IV - may be used for rate control before cardioversion if AFIB is not V.T. (Ganz, 2019).

Amiodarone IV can be used with diltiazem/verapamil for rhythm control and rate control. 

Nursing education: Based on the patient’s modifiable risk factors for AFIB, identify areas for risk reduction education that should be provided by the nurse? (20 points)

Risk reduction education for AFIB: Low-salt diet, exercise, and weight loss are recommended for patients with hypertension. Patients with diabetes mellitus should follow their prescribed diet and exercise program. A low-fat diet benefits all patients, particularly those with elevated cholesterol levels or triglycerides. Alcohol consumption should be limited, especially in those with hypertension or diabetes mellitus. Cigarette smoking increases the risk of cardiovascular disease, including stroke and peripheral vascular disease (PVD).

Risk reduction education for hypothyroidism: Hypothyroidism occurs when the thyroid gland does not produce enough hormones; this condition is often accompanied by weight gain and fatigue (American Heart Association). Patients should be informed that hypothyroidism may cause abnormal heart rhythms (e.g., atrial fibrillation). They should also be informed about untreated hypothyroidism’s potential consequences, such as heart failure and other cardiovascular problems.

Lifestyle change: Smoking (smoking increases the risk of developing AFIB). Alcohol use (alcohol use can cause dehydration and can increase blood pressure). Diet (high salt intake can increase blood pressure) (Ganz, 2019). Weight loss (obesity is a modifiable risk factor for AFIB). Exercise (exercise reduces stress and improves cardiovascular function).

Reduce sodium intake to less than 2,300 mg/day

Avoid excessive alcohol consumption and excessive caffeine consumption (Laforest et al., 2019).

Exercise regularly (at least 30 minutes of aerobic activity three times per week)

Scholarly writing (15 points)