EKG Interpretation Pt 2: Effective Management of A-Fib

Whether you’re working in a hospital or currently doing your clinical, there will be instances that you will encounter clients who will have atrial fibrillation. To manage atrial fibrillation effectively, you must first get acquainted with what it is and what mainly causes it.  

Causes of Atrial Fibrillation

Before treating atrial fibrillation, you should first know what caused the condition. What are some of these causes?

  1. Ischemia

Ischemia is decreased oxygenation to the heart. Ischemia usually happens with myocardial infarction which is mainly caused by decreased oxygen levels of the heart; this then can lead to necrosis.

Lung disease is another viable reason for ischemia; this is because of the decreased oxygen going inside the lungs that can deliberately affect how the heart receives oxygen. Remember, very little, or no oxygen at all will lead to organ failure and eventually, death.

  1. Valve disease

Diseases concerning the heart valves primarily result in the chambers’ inability to open and close at a certain period. When this happens, it can adversely affect the heart because if there are not enough succinct pumps going to the heart, it will result in the decreased cardiac output.

We’ve discussed cardiac output in our previous lectures. To jog your memory, cardiac output is the amount of blood pumped by the heart in a whole minute. If the heart is not contracting efficiently, it is not filled adequately, and the contractions will fail as well.

Without a normal cardiac output, the body will not receive a satisfactory amount of blood and oxygen that are mainly required for proper functioning.

  1. Atrium Problems

When there are issues concerning the atriums of the heart, blood will not be pushed down all the way to the ventricles because the atriums are not contracting properly. There will be minor contractions, but they are not enough to sustain the needs of the heart.

The Atrial Kick

What is an atrial kick? How does one interpret an atrial kick once it’s encountered?

You can think of an atrial kick as someone slamming the door and pushing blood forcefully into the ventricles, slamming the valve shut.

An atrial kick is also similar to packing suitcases wherein you have to try to fill it in with items, then kick the overflowing clothes inside the bag so that you can zip them all in. In atrial fibrillation, this zip-kick motion is almost non-existent.

Formation of Clots

If the chamber is full of blood, it starts pooling in the atriums. Pooling will cause the blood to eventually dry up and start forming fibrinogen and fibrin which is also known as a clot. Clot formation will block the atriums entirely or will be sent out to the system as tiny clots which are the main causes of cerebrovascular accident (CVA), myocardial infarction (MI), or deep vein thrombosis (DVT).

Clots are deadly enough to shut down the lungs in a condition known as pulmonary embolism (PE).

Managing Atrial Fibrillation

How does one combat clot and other issues that cause atrial fibrillation?

  1. Warfarin (Coumadin) treatment is given to thin out blood over long periods of time which leads to de-coagulation. Plavix, an anti-platelet congregator is also given.
  2. A positive inotrope to make the atriums contract better is also used. Inotropes are concerned with the contractility force, and one popular example is Digoxin. Digoxin is a cardiac glycoside that helps with the heart’s atrial kick.
  3. Amiodarone is a used to slow down dysrhythmia, helping the heart contract succinctly and eliminating sporadic contractions.
  4. Calcium channel blockers help the blood vessels and the muscles of the heart to relax. By blocking calcium, excitability is reduced. Increased excitement due to calcium deposits in the heart can lead to its stiffening. The goal is to achieve a soft, supple heart that contracts normally and is relaxed.
  5. Oxygen is given for obvious reasons.
  6. Electrical cardioversion is also given to restart the SA node.

Remember, the main goal when managing a client with atrial fibrillation is to make the atrium contract efficiently and prevent clot formation from happening.

In our following lecture, we will discuss what atrial flutter is. For other nursing-related lectures, just drop by SimpleNursing.com.

Key Terms for NCLEX® Delegation and Management Questions

Recent NCLEX® topics are primarily focused on delegation, prioritization and leadership. Among those that were mentioned, delegation type questions are going to be a huge part of nursing schools.

Fortunately, Mike is here to provide the gist and the important keywords that you have to watch out for every time you encounter delegation and management questions on your comprehensive exams, especially on your NCLEX®.

The PACET Method

When dealing with client and task delegations, there are five things that you cannot entrust to other people and that is broken down into the acronym, PACET (pronounced as “paket”). As a registered nurse, you cannot delegate the nursing process which is also known in other schools as SOAPIE, ADPIE, or DAR. Mike simplifies this as PACET.

P for Planning

If you are an RN, one of your main tasks is to plan and collaborate for client goals; thus you cannot delegate planning to an LPN or a CNA. This is because it is expected of you, as a registered nurse, to take on full responsibility of your client and you cannot share that responsibility with other healthcare teams.

A for Assessment

Secondary assessments can be delegated; however, you cannot pass primary assessments to anybody. That said, can you pick which is the right answer to the question below?

Q: Which of the following clients would you delegate?

  1. A post-op client who just came out from the operating room
  2. New admissions
  3. Three-day-old chest pain

When picking the right answer, you always have to remember that nurses do the first assessment. Now, among the three situations given above, which do you think needs first assessment?

Answer: The client who just came out of the operating room is unstable and needs initial assessment which is also termed as vigilant assessment. On the other hand, nurses are required to gather more information from new admissions. Therefore, both post-op (A) and new admissions (B) are NOT to be delegated.

So now, you’re left with the post-operative client who’s already been in the hospital for a couple of days and is considered stable. So the answer for the question above is “C”.

C for Collaboration

Collaboration is for working with other members of the healthcare team to achieve client goals. Some of the collaborations inside the hospital are wound consult, social services, dietary services, and if the client needs a respiratory therapist. Only the RN does this kind of collaboration, not the LVNs.

E for Evaluation

LPNs and CNAs can take note of the pain scale and vital signs but are not allowed to evaluate because it’s specifically the RN’s role – to think critically and evaluate efficiently. Therefore, the nurse should evaluate:

  • Care plans
  • Client goals
  • Vital signs
  • Pain scale

T for Teaching

Primary education or client teaching cannot be delegated. LVNs can reinforce education but they are not responsible for providing exemplary client education to decrease complications that might occur after discharge.

During the exam

Keep in mind, during your NCLEX®, that if you see any of the PACET keywords the multiple choice questions, it’s automatically the correct answer under the topic of delegation. Once again, those that you should not delegate and are your primary responsibilities are:

  • Planning
  • Assessment
  • Collaboration
  • Evaluation
  • Teaching

As registered nurses, you have to assume obligation and accountability for the five keywords mentioned above. Furthermore, being keen on identifying if it’s primary or secondary evaluation can help you quickly point out the right answer to your NCLEX®.

Don’t forget PACET.

For more information and other easy-to-understand nursing lectures and videos, visit our website at SimpleNursing.com.

See you in the next video!