Nursing Care Plan (NCP) for Atrial Fibrillation (AFib)
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Study Tools For Nursing Care Plan (NCP) for Atrial Fibrillation (AFib)
Outline
Lesson Objectives for Atrial Fibrillation (AFib)
- Definition and Recognition:
- Define atrial fibrillation (AFib) as a cardiac arrhythmia characterized by irregular and often rapid atrial heartbeats, leading to an irregular and sometimes fast heartbeat.
- Pathophysiology:
- Understand the underlying pathophysiology of AFib, including abnormal electrical impulses in the atria, leading to chaotic and disorganized contractions that result in an irregular heart rhythm.
- Risk Factors:
- Identify common risk factors for AFib, such as age, hypertension, heart disease, diabetes, and lifestyle factors, to recognize individuals at higher risk for developing this arrhythmia.
- Clinical Manifestations:
- Recognize the clinical manifestations of AFib, including palpitations, chest discomfort, fatigue, dizziness, and potential complications such as stroke due to the increased risk of blood clots.
- Management and Interventions:
- Learn about the management and interventions for AFib, including medications, lifestyle modifications, and potential procedural interventions to control heart rate and rhythm, reduce symptoms, and prevent complications.
Pathophysiology of Atrial Fibrillation (AFib)
- Abnormal Electrical Signals:
- AFib is characterized by disorganized and rapid electrical signals originating from the atria, leading to chaotic and irregular contractions.
- Loss of Atrial Contraction Coordination:
- The normal coordinated contraction of the atria is replaced by rapid, irregular quivering or fibrillating movements, resulting in ineffective atrial contractions.
- Incomplete Emptying of Atria:
- Due to the irregular contractions, the atria do not fully empty, leading to blood stasis, which increases the risk of clot formation within the atria.
- Impaired Ventricular Filling:
- The irregular atrial contractions can result in irregular ventricular responses, leading to an irregular heart rate. This can result in impaired ventricular filling and reduced cardiac output.
Etiology of Atrial Fibrillation (AFib)
- Age and Aging:
- Advanced age is a significant risk factor for AFib, and the prevalence increases with age. Aging can contribute to changes in the heart’s structure and function.
- Underlying Heart Conditions:
- Heart conditions, such as hypertension, coronary artery disease, valvular heart disease, and heart failure, can contribute to the development of AFib by affecting the heart’s electrical system.
- Structural Heart Abnormalities:
- Structural abnormalities, including enlarged atria or other anatomical changes, can disrupt normal electrical conduction and increase the likelihood of AFib.
- Systemic Conditions:
- Conditions such as diabetes, hyperthyroidism, and chronic lung diseases can increase the risk of AFib by affecting the overall health and function of the cardiovascular system.
- Lifestyle Factors:
- Lifestyle factors, including excessive alcohol consumption, smoking, obesity, and a sedentary lifestyle, can contribute to the development and exacerbation of AFib.
Desired Outcome for Atrial Fibrillation (AFib)
- Controlled Heart Rate:
- Achieve and maintain a controlled and regular heart rate within the target range to optimize cardiac output and reduce symptoms.
- Prevention of Complications:
- Prevent complications such as stroke and systemic embolism by managing the risk of thromboembolism through anticoagulation therapy based on individual risk factors.
- Symptom Management:
- Alleviate symptoms associated with AFib, including palpitations, fatigue, and dizziness, to improve the patient’s overall quality of life.
- Optimized Cardiovascular Function:
- Enhance cardiovascular function by promoting optimal atrial and ventricular synchronization, contributing to improved cardiac output and circulation.
- Patient Education and Self-Management:
- Educate the patient on AFib, its management, medications, lifestyle modifications, and the importance of regular follow-up to empower them in self-management and adherence to the prescribed treatment plan.
Atrial Fibrillation (AFib) Nursing Care Plan
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:
- Irregular heartbeat
- Tachycardia
Nursing Assessment for Atrial Fibrillation (AFib)
- Cardiovascular Assessment:
- Monitor heart rate and rhythm continuously, assessing for irregularities, rapid heart rate, or irregular pulse. Use electrocardiogram (ECG) monitoring as needed.
- Blood Pressure Monitoring:
- Regularly measure blood pressure to assess for hypertension, a common coexisting condition with AFib, and to evaluate the impact on cardiac function.
- Symptom Assessment:
- Evaluate and document symptoms such as palpitations, chest discomfort, shortness of breath, dizziness, and fatigue to guide the management plan.
- Thromboembolic Risk Assessment:
- Conduct a thorough assessment of thromboembolic risk factors, including age, history of stroke, hypertension, diabetes, and structural heart disease, to determine the need for anticoagulation therapy.
- Medication Review:
- Review the patient’s current medications, including antiarrhythmics, anticoagulants, and other cardiovascular medications, to assess for adherence and potential drug interactions.
- Lifestyle Assessment:
- Assess lifestyle factors such as alcohol consumption, smoking, physical activity, and dietary habits to identify areas for modification and optimization.
- Psychosocial Assessment:
- Perform a psychosocial assessment to evaluate the patient’s emotional well-being, stress levels, and coping mechanisms, as emotional factors can impact AFib symptoms.
- Education and Health Literacy:
- Assess the patient’s understanding of AFib, treatment plan, and medications. Evaluate health literacy levels to tailor education materials and instructions accordingly.
Implementation for Atrial Fibrillation (AFib)
- Rhythm Control Interventions:
- Collaborate with the healthcare team to implement rhythm control interventions such as electrical cardioversion or pharmacological agents to restore and maintain normal sinus rhythm.
- Heart Rate Control:
- Monitor and manage heart rate through medications like beta-blockers, calcium channel blockers, or other rate-controlling agents to keep the heart rate within the target range.
- Anticoagulation Therapy:
- Initiate and monitor anticoagulation therapy based on individual risk factors to prevent thromboembolic events. Educate the patient on the importance of medication adherence and regular monitoring.
- Lifestyle Modifications:
- Advocate and support lifestyle modifications, including maintaining a heart-healthy diet, regular exercise, smoking cessation, limiting alcohol intake, and managing stress to improve overall cardiovascular health.
Nursing Interventions and Rationales
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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.
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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.
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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.
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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.
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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.
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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.
Evaluation for Atrial Fibrillation (AFib)
- Heart Rate and Rhythm:
- Monitor and evaluate the effectiveness of interventions in controlling heart rate and restoring/maintaining sinus rhythm. Use continuous ECG monitoring and periodic Holter monitoring as needed.
- Symptom Improvement:
- Assess the patient for improvements in symptoms such as palpitations, shortness of breath, and fatigue, indicating successful management of AFib.
- Thromboembolic Risk Reduction:
- Evaluate the success of anticoagulation therapy in reducing the risk of thromboembolic events by assessing appropriate INR levels and monitoring for any signs of bleeding complications.
- Medication Adherence:
- Assess and promote medication adherence, ensuring the patient understands the importance of taking prescribed medications consistently. Identify and address any barriers to adherence.
- Quality of Life:
- Evaluate the impact of AFib and its management on the patient’s overall quality of life, considering factors such as physical function, emotional well-being, and social activities.
References
- HEARTORG – Treatment and Prevention of Atrial Fibrillation
- Nrsng.com – Interpret EKGs Strips Like a Boss! (ekg interpretation for nurses)
- HEARTORG – What is Atrial Fibrillation (AFib or AF)?
- STROKEORG – Stroke Warning Signs and Symptoms
- Science Direct – Digitalis and the autonomic nervous system
- Ncbi – The utility of troponin measurement to detect myocardial infarction: review of the current findings
- Cleveland Clinic – Atrial Fibrillation
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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!
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