Bradycardia

Bradycardia

Clinical Findings

Neuro: Dizziness, lightheadedness, ALOC, syncope. Resp: Shortness of breath. CV: HR >60 beats/minute, hypotension, pulmonary congestion. Skin: Cyanosis, coolness, pallor, diaphoresis. GI/GU: Nausea and vomiting. MS:Weakness, lethargy, fatigue, exhaustion.

Nursing Interventions

■ Note: if Pt is exhibiting signs of unstable bradycardia (CP, shortness of breath, ALOC, hypotension, cyanosis), call code/notify physician STAT and refer immediately to Unstable Bradycardia in ACLS. ■ Assess LOC and orientation. ■ Lay Pt flat and elevate foot of bed 10–15 degrees. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Assess for associated symptoms (chest pain, respiratory distress, and/or hypotension). ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering STAT 12-lead ECG, labs (cardiac-specific markers, CBC, electrolytes, and coagulation studies), chest x-ray, and/or transfer to CCU. ■ Document assessments, any interventions, and outcome.