Tachycardia

Tachycardia

Clinical Findings

Neuro: Dizziness, lightheadedness, anxiety, ALOC, restlessness. Resp: Shortness of breath, hyperventilation. CV: HR >100 beats/minute, chest discomfort, palpitations, dysrhythmias. Skin: Cool and moist, warm and flushed, tingling sensation. GI/GU: Nausea and vomiting. MS:Weakness, fatigue.

Nursing Interventions

■ Note: if Pt is exhibiting signs of unstable tachycardia (CP, shortness of breath, ALOC, hypotension, cyanosis), call code/notify physician STAT and refer immediately to Unstable Tachycardia in ACLS. ■ Place Pt in position of comfort and offer reassurance. If tachycardia results from anxiety or agitation, attempt to reduce external stressors (e.g., reduce noise and bright lights, adequate pain management, adjust room temperature). ■ Lay Pt flat; elevate foot of bed 10–15 degrees if Pt is feeling dizzy, lightheaded, or faint. ■ 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, cyanosis, decreased LOC). ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Obtain and document orthostatic VS (each set, 1 minute apart) from supine, sitting, and standing positions. Note: An increase in HR or decrease in SBP by 20 points from baseline is positive for orthostatic hypotension. ■ 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 a CCU. ■ Document assessments, any interventions, and outcome.