Pulse rhythm abnormality

An abnormal pulse rhythm is an irregular expansion and contraction of the peripheral arterial walls. It may be persistent or sporadic, and rhythmic or arrhythmic. Detected by palpating the radial or carotid pulse, an abnormal rhythm is typically reported first by the patient, who complains of feeling palpitations. This important finding reflects an underlying cardiac arrhythmia, which may range from benign to life-threatening. Arrhythmias are commonly associated with cardiovascular, renal, respiratory, metabolic, and neurologic disorders as well as the effects of drugs, diagnostic tests, and treatments. (See Abnormal pulse rhythm: A clue to cardiac arrhythmias, pages 542 to 545.)

Emergency Actions

Quickly look for signs of reduced cardiac output, such as decreased level of consciousness (LOC), hypotension, or dizziness. Promptly obtain an electrocardiogram (ECG) and possibly a chest X-ray, and begin cardiac monitoring. Insert an I.V. line for administration of emergency cardiac drugs, and give oxygen by nasal cannula or mask. Closely monitor vital signs, pulse quality, and cardiac rhythm because accompanying bradycardia or tachycardia may result in poor tolerance of the abnormal rhythm and cause further deterioration of cardiac output. Keep emergency intubation, cardioversion, and suction equipment handy.

History

If the patient’s condition permits, ask if he’s experiencing pain. If so, find out about onset and location. Does the pain radiate? Ask about a history of heart disease and treatments for arrhythmias. Obtain a drug history and check compliance. Also, ask about any caffeine or alcohol intake. Digoxin toxicity, cessation of an antiarrhythmic, and use of quinidine, a sympathomimetic (such as epinephrine), caffeine, or alcohol may cause arrhythmias.

Physical assessment

Check the patient’s apical and peripheral arterial pulses. An apical rate exceeding a peripheral arterial rate indicates a pulse deficit, which may also cause associated signs and symptoms of low cardiac output. Evaluate heart sounds: A long pause between S₁ (lub) and S₂ (dub) may indicate a conduction defect. A faint or absent S₁ and an easily audible S₂ may indicate atrial fibrillation or flutter. You may hear the two heart sounds close together on certain beats — possibly indicating premature atrial contractions — or other variations in heart rate or rhythm. Take the patient’s apical and radial pulses while you listen for heart sounds. With some arrhythmias, such as premature ventricular contractions, you may hear the beat with your stethoscope but not feel it over the radial artery. This indicates an ineffective contraction that failed to produce a peripheral pulse. Next, count the apical pulse for 60 seconds, noting the frequency of skipped peripheral beats.

Medical causes

Cardiac arrhythmias

An abnormal pulse rhythm may be the only sign of a cardiac arrhythmia. The patient may complain of palpitations, a fluttering heartbeat, or weak and skipped beats. Pulses may be weak and rapid or slow. Depending on the specific arrhythmia, dull chest pain or discomfort and hypotension may occur. Associated findings, if any, reflect decreased cardiac output. Neurologic findings, for example, include confusion, dizziness, light-headedness, decreased LOC and, sometimes, seizures. Other findings include decreased urine output, dyspnea, tachypnea, pallor, and diaphoresis.

Special considerations

The patient may require cardioversion therapy, before which he may need to be sedated. Prepare the patient for transfer to a cardiac or intensive care unit. To prevent falls and injury, don’t leave him unattended while he’s sitting or walking. Check vital signs frequently to detect bradycardia, tachycardia, hypertension or hypotension, tachypnea, and dyspnea. Also, monitor intake, output, and daily weight.

Collect blood samples for serum electrolyte, cardiac enzyme, and drug level studies. Prepare the patient for a chest X-ray and a 12-lead ECG. If possible, obtain a previous ECG with which to compare current findings. Prepare the patient for 24-hour Holter monitoring.

Pediatric pointers

Arrhythmias also produce pulse rhythm abnormalities in children.

Patient counseling

Explain to the patient the importance of keeping a diary of his activities and any symptoms that develop to correlate with the incidence of arrhythmias. Instruct the patient to avoid tobacco and caffeine, which increase arrhythmias. If he has a history of failing to comply with prescribed antiarrhythmic therapy, help him develop strategies to improve compliance.

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Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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