Palpitations

Palpitations: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses

Defined as a conscious awareness of one’s own heartbeat, palpitations are usually felt over the precordium or in the throat or neck. The patient may describe them as pounding, jumping, turning, fluttering, or flopping, or as missing or skipping beats. Palpitations may be regular or irregular, fast or slow, paroxysmal or sustained.

Although usually insignificant, palpitations may result from a cardiac or metabolic disorder and from the effects of certain drugs. Nonpathologic palpitations may occur with a newly implanted prosthetic valve because the valve’s clicking sound heightens the patient’s awareness of his heartbeat. Transient palpitations may accompany emotional stress (such as fright, anger, or anxiety) or physical stress (such as exercise and fever). They can also accompany use of stimulants, such as tobacco and caffeine.

To help characterize the palpitations, ask the patient to simulate their rhythm by tapping his finger on a hard surface. An irregular “skipped beat” rhythm points to premature ventricular contractions, whereas an episodic racing rhythm that ends abruptly suggests paroxysmal atrial tachycardia.

Emergency Actions

If the patient complains of palpitations, ask him about dizziness and shortness of breath. Then inspect for pale, cool, clammy skin. Take the patient’s vital signs, noting hypotension and irregular or abnormal pulse. If these signs are present, suspect cardiac arrhythmia. Prepare to begin cardiac monitoring and, if necessary, to deliver electroshock therapy. Start an I.V. line to administer an antiarrhythmic, if needed.

History

If the patient isn’t in distress, take a complete cardiac history. Ask if he has a cardiovascular or pulmonary disorder, which may produce arrhythmias. Does the patient have a history of hypertension or hypoglycemia? Be sure to obtain a drug history. Has the patient recently started cardiac glycoside therapy? Also, ask about caffeine, tobacco, and alcohol consumption.

Physical assessment

Perform a complete cardiac and pulmonary assessment. Then explore associated symptoms, such as weakness, fatigue, and angina. Be sure to auscultate for gallops, murmurs, and abnormal breath sounds.

Medical causes

Anemia

Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

Anxiety attack (acute)

Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

Cardiac arrhythmias

Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; chest pain; syncope; oliguria; and diaphoresis.

Hypertension

With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness (LOC).

Hypocalcemia

Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

Hypoglycemia

Hypoglycemia occurs when blood glucose levels drop significantly and the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually, the patient may develop central nervous system reactions, including blurred or double vision, muscle weakness, hemiplegia, and altered LOC.

Mitral prolapse

Mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

Mitral stenosis

Early features of mitral stenosis typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S₁ or opening snap, and a rumbling diastolic murmur at the apex. Patients may also experience such related signs and symptoms as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillations.

Pheochromocytoma

This adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign of pheochromocytoma is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

Thyrotoxicosis

A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

Other causes

Drugs

Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics such as cocaine; ganglionic blockers; beta blockers; calcium channel blockers; atropine; and minoxidil.

Exercise

Exercise can normally cause palpitations. In patients with coronary heart disease, exercise can also cause hypertension, mitral valve prolapse, and cardiomegaly.

Special considerations

Monitor the patient for signs of reduced cardiac output, such as hypotension and reduced urinary output. Administer medications as needed, and prepare for procedures such as cardioversion. Provide supplemental oxygen, and take measures to reduce the workload of the heart, such as providing rest periods.

Pediatric pointers

Palpitations in children commonly result from fever and congenital heart defects, such as patent ductus arteriosus and septal defects. Because many children can’t describe this complaint, focus your attention on objective measurements, such as cardiac monitoring, physical examination, and laboratory tests.

Patient counseling

Prepare the patient for diagnostic tests, such as an electrocardiogram and Holter monitoring. Remember that even mild palpitations can cause the patient much concern. Maintain a quiet, comfortable environment to minimize anxiety and perhaps decrease palpitations.

Pictures

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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• Back to disease: Tachycardia: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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