Nursing Care Plan for Atrial Fibrillation (AFib)

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Outline

Pathophysiology

An electrical activity disturbance in the heart that causes an irregular and often rapid heartbeat. The atria quiver sending confusing electrical signals to the ventricles, leaving them unsure of when to contract thus beating irregularly. During atrial fibrillation, the heart is a less effective pump because of the quivering as well as not emptying completely. This causes the blood to pool and a clot can form. The clot can venture out of the heart into the lungs (PE), brain (stroke) or extremities (DVT).

Etiology

The specific cause of atrial fibrillation is unknown but there are risk factors that put someone at higher risk of developing afib. Risk factors such as smoking, hypertension, and obesity as well as conditions such as diabetes or heart disease increase the likelihood that a patient may get atrial fibrillation. Post surgical interventions present a major risk for atrial fibrillation as well. Approximately 30%-40% of cardiac surgery patients develop atrial fibrillation.

Desired Outcome

Decreasing risks of clot formation, a heart rate within normal limits and rhythm control. The ultimate outcome is converting back to normal sinus rhythm, however, many people live with atrial fibrillation, especially if rhythm control doesn’t work or isn’t necessary.

Atrial Fibrillation (AFib) Nursing Care Plan

Subjective Data:

Subjective Data:

  • Heart Palpitations
  • Feeling like the heart is beating out of the chest
  • Feeling a fluttering sensation in the chest
  • Nausea
  • Lightheadedness
  • Weakness
  • ***Patient may not have any symptoms at all***

Objective Data:

Objective Data:

  • Irregular heartbeat
  • Tachycardia

Nursing Interventions and Rationales

  • Obtain a 12 lead ECG

 

  • Used to diagnose atrial fibrillation
  • The waves are more chaotic and random
  • The beat is irregular
  • You can see the atria quivering between the QRS (ventricles pumping)
  • No discernible P waves The ventricular rate is often 110-160 bpm and the QRS complexes is usually less than 120 ms.

 

  • Potential rhythm control: Electrocardioversion, Ablation, Pacemaker

 

  • -Electrocardioversion: AKA cardioversion, is used to “reset” the heart’s electricity.The patient will be shocked on the outside of the chest wall. This treatment is used for patients who have infrequent episodes of atrial fibrillation because if the patient has it frequently, they have a high probability of the afib returning after being cardioverted.***If there is a blood clot in the atria, cardioverting may send the clot out of the heart to the brain, lungs, or extremities. The chance of a blood clot increases the longer the patient is in afib, consider anticoagulation prior to cardioversion***Ablation: used for patient’s that have not been able to control their afib for a long time with medications or cardioversion. A catheter is inserted into the patient’s heart and destroys cardiac muscle cells so they scar, causing the electrical activity to stop in those cells, thus eliminating the passing of chaotic electrical activity.Pacemaker: This is placed under the skin and is a device that sends electrical signals to the heart to help it beat with the right rhythm and pace.

 

  • Heart rate control: Beta Blockers: -Propranolol -Metoprolol -Atenolol Calcium Channel Blockers: -Diltiazem -Verapamil Cardiac Glycosides: -Digoxin

 

A heart can only sustain rapid beating for so long before it tires out. Using beta blockers, calcium channel blockers and cardiac glycosides will help control the rate of the heart beat.

Beta Blockers: They block beta 1 receptors from being stimulated. Stimulation of Beta 1 causes positive inotropic (force of contraction) and chronotropic (pace of heart beat) effects. If you block beta 1 you will have decreased force of contraction and decreased heart rate.

Calcium Channel Blockers: They block calcium channels… Duh. When calcium enters the cell in causes the cell to contract, thus when the channels are blocked, it decreases the production of electrical activity innately decreasing the heart rate.

Cardiac Glycosides: This medication stimulates the Vagus nerve, which when stimulated slows the heart rate down. The vagus nerve is a CNS nerve that also works with the PNS- specifically the autonomic parasympathetic system… AKA rest and digest… So if this is stimulated your body will rest/slow down, thus decreased heart rate.

It also blocks the Na+/K+ channel in cardiac myocytes. When this channel is open, K+ moves into the cell and Na+ moves out of the cell, called repolarization and is the relaxation part of a heart beat. When it is blocked it causes increased contractility of the heart. If your heart is beating stronger it will inherently slow down.

 

  • Anticoagulant Therapy: Coumadin Aspirin Lovenox Plavix Eliquis

 

  • Thinning the blood helps to disintegrate and break up the clot as well as increasing flow of blood. There are many options for blood thinners each with their own pro’s and con’s. The most common are listed to the left.

 

  • Fall education

 

  • Being on a blood thinner, the patient needs to be informed of their risk of bleeding out especially if they fall and hit their head.
  • Make sure to go over environmental hazards such as good lighting and eliminating throw rugs.
  • If a patient does fall and hit their head they need to go to the ER immediately, even if they are not experiencing any adverse effects.

 

  • Stroke education Use the FAST Mnemonic: F: Facial drooping A: Arm weakness S: Slurred speech T: Time to call 911

 

  • The risk of a blood clot forming and moving to the brain is fairly high. It is important to teach the patient and their family members the signs and symptoms of stroke.
  • Teach the patient that if they feel confused or feel weakness on one side to call for help.

 

  • Cardiac enzyme monitoring: Troponin I Creatine Kinase MB

 

  • Initial measurement of the cardiac enzymes is important because it helps with any trending information, the sooner you get this information the better. Also getting trending results over specific periods of time is helpful.
  • Troponin I: Is an enzyme that helps the interaction of myosin and actin in the cardiac muscle. When necrosis of the myocyte happens, the contents of the cell eventually will be released into the bloodstream.
  • Troponin can become elevated 2-4 hours after in ischemic cardiac event and can stay elevated for up to 14 days.
  • Creatine Kinase MB: This enzyme is found in the cardiac muscle cells and catalyses the conversion of ATP into ADP giving your cells energy to contract. When the cardiac muscle cells are damaged the enzyme is eventually released into the bloodstream.
  • CKMB levels should be checked at admission, and then every 8 hours afterwards.

 


References

Transcript

I am going to be showing you how to write a nursing care plan on atrial fibrillation also known as AFib. We’re going to be formulating the care plan, but we’re also going to talk about how to care for these patients, as well as how to educate them for care planning. 

 

We’re always going to start with our assessment here. So, the patient comes in, they tell us that they are experiencing some dizziness, as well as their heart just feels like it’s fluttering. They’re probably not going to use this word, but what they’re experiencing is palpitations and sometimes, patients will describe this as fluttering. Sometimes they’ll describe it as a pounding. It feels like their heart’s beating out of their chest. Sometimes they might not even notice. It might not feel like anything at all. That’s all really common with AFib. We decide to check out their heart and we discover that they have a very irregular heartbeat. AFib is one of the most irregular heart rhythms you will ever see or experience, so that’s a key that they’re probably experiencing AFib as well as having tachycardia. This patient is having 164 beats per minute. The heart is freaking out. 

 

Let’s look at some diagnoses. With the atria freaking out, sending all these signals, the ventricles don’t really know what they’re doing either, so that can cause problems with output. We’re going to have decreased cardiac output. The heart is just a hot mess. It’s not pumping the way it should. Now, whenever we don’t have enough blood flowing out, it means that blood is going to be pooling somewhere, and that can cause the patient to develop blood clots. So, whenever you think of AFib, I want you to think okay, we’re worried about blood clots. We’re worried about decreased cardiac output. Those are both super, super important. 

 

Some goals that this patient can work on include wearing EKG leads. This is very important, so we can monitor the heart. They also need to receive some medications. We want to be able to control the heart rate, as well as the rhythm, and we want to prevent clots. There’s quite a few different medications that this patient is going to be on in order to try to manage their AFib. We always want to move from the least invasive to the most invasive, right, so there are a lot of options that we can use to treat AFib, but let’s go ahead and start with medications. 

 

Okay, we want them, of course, to have these medications work and we want to have an improved rate and improve rhythm. If that’s not an issue, then hopefully they’re not going to be forming the clots because there’s no stagnant blood. They still might end up on a blood thinner when they go home, depending on what we figure out throughout their stay. Some ways that the nurse can support these goals is to continuously monitor the EKG, make sure that the leads are working, that the battery’s working, as well as their cardiovascular status. Putting on a stethoscope, listening to that heart and seeing what they are doing online? Are they staying in AFib, or are they, you know, going back and forth. I say all night, because I’m a night shift nurse, but you know what I mean, all day, all night, however long we’re monitoring for. We will be administering these here per the doctor’s orders, as well as providing some education about how they should be working, and maybe some side effects that they will be experiencing. We also can educate about AFib in general, what things they need to report, how often they need to see a physician and monitoring their heart rate. 

 

It’s actually really cool that we have so many more options that are very affordable for monitoring the heart rate at home? A lot of us have smart watches or watches that can track heart rate and steps and those are actually not a bad idea for these patients to do in their home, because they can monitor very easily and see if they’re getting tachycardic. Let’s evaluate our goals here. So, this one was met, the EKG was completed. It was red and determined that the patient is in AFib continuously, this goal was also met. The patient did receive the medications that were appropriate. This goal right here, unfortunately, was not met. The patient is still in AFib despite this medication attempt. So, what we have to do at this point is just reevaluate. We’re going to go back here and we’re going to work with the rest of our healthcare team and decide if we try different medications? Do we move forward with cardioversion or cardiac ablation? There’s tons of different options that we can do, and we just want to make sure that we have the patient’s best benefit in mind, and that we’re doing again, something that is the least invasive that will work for this patient. 

 

Alright, we learned how to educate as well as care for these patients and you rocked it. We love you guys. Go out and be your best selves today and as always, happy nursing!