Bradycardia is an abnormally slow heart rhythm. A normal heart rate is between 60 to 100 beats per minute. With bradycardia, the rate is less than 60 beats per minute.
Bradycardia results from an abnormality in the sinus node, the heart’s natural pacemaker. A disruption in the sinus node can cause slow or missed beats. Bradycardia may also occur from first, second, or third-degree heart blocks when electrical impulses fail to reach the atria.
This condition can prevent organs from receiving adequate oxygenated blood to function. It may cause additional signs and symptoms, including:
- Chest pain
- Memory problems
- Confusion
- Lightheadedness
- Dizziness
- Fatigue
- Weakness
- Syncope
- Shortness of breath
Bradycardia may be caused by an underlying condition like heart tissue damage related to aging, myocardial infarction, congenital heart defects, myocarditis, hypothyroidism, electrolyte imbalances, obstructive sleep apnea, inflammatory diseases like lupus, and certain medications such as sedatives.
Some patients may have asymptomatic bradycardia. Young adults, athletes, and patients in restful sleep commonly experience a lower heart rate without cause for concern.
Tests that can help confirm bradycardia include electrocardiogram, Holter or event monitoring, tilt table test, and stress exercise test. Laboratory tests can assess underlying causes such as imbalanced electrolyte levels.
Nursing process
The treatment for this condition will depend on the severity of the symptoms and their underlying cause. Nursing care for patients with bradycardia includes initial stabilization, respiratory and circulation support, continuous telemetry monitoring, management of any symptoms and underlying causes, and the prevention of complications.
Nursing Care Plans Related to Bradycardia
Ineffective Peripheral Tissue Perfusion
With bradycardia or a slow heart rate, ineffective peripheral tissue perfusion may cause complications if oxygenated blood cannot reach organs and extremities.
Nursing Diagnosis: Ineffective Tissue Perfusion (Peripheral)
Related to:
- Disease process
- Decreased cardiac output
As evidenced by:
- Absence of peripheral pulses
- Decreased blood pressure
- Delayed peripheral wound healing
- Edema
- Generalized weakness
- Paresthesia
- Dyspnea
- Dizziness
- Confusion
Expected outcomes:
- Patient will demonstrate adequate tissue perfusion with warm extremities, palpable peripheral pulses, and blood pressure within acceptable limits.
- Patient will remain alert and oriented without confusion or dizziness.
Assessment:
1. Assess peripheral pulses bilaterally.
Bradycardia causes decreased peripheral pulses due to the inability of the heart to contract effectively and provide adequate oxygenated blood to the extremities.
2. Assess capillary refill.
Capillary refill can indicate ineffective peripheral tissue perfusion. Capillary refill time of more than 3 seconds is abnormal.
3. Assess skin integrity.
Skin color, temperature, and moisture can indicate compromised tissue perfusion and may manifest as cold, clammy, mottled, and pale skin.
Interventions:
1. Encourage the patient to wear compression stockings while ambulating.
Compression stockings can help increase venous return and promote peripheral circulation.
2. Administer medications as indicated.
Symptomatic bradycardia may require atropine, epinephrine, or dopamine to increase the heart rate.
3. Treat electrolyte imbalances.
If bradycardia is caused by hyper or hypokalemia, medications can help increase or lower the electrolyte.
4. Assist with testing.
A tilt table test assesses if the patient is predisposed to fainting or syncope with position changes. A stress exercise test measures the heart’s activity during exercise.
Risk for Decreased Cardiac Output
Bradycardia can be serious if the heart rate is too slow to pump blood to the rest of the body.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Bradycardia
- Decreased heart rate
- Altered afterload
- Altered contractility
- Altered heart rhythm
- Altered preload
- Altered stroke volume
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at preventing signs and symptoms.
Expected outcomes:
- Patient will demonstrate adequate cardiac output with blood pressure and heart rate within normal limits.
- Patient will demonstrate normal sinus rhythm on EKG.
Assessment:
1. Assess symptoms of hypoperfusion and acute coronary syndrome.
Patients experiencing bradycardia are at risk of experiencing sudden and reduced blood flow to the heart, leading to acute coronary syndrome. Manifestations may include chest pain, dyspnea, dizziness, nausea, and fatigue.
2. Perform continuous telemetry monitoring.
For safe assessment, the client with a cardiac history or symptomatic bradycardia should be connected to continuous telemetry monitoring.
3. Assess the patient’s cardiac history.
Assessment of the patient’s cardiac history, such as myocardial infarction, heart failure, or congenital conditions, can further affect cardiac output and alterations in perfusion.
Interventions:
1. Monitor the use of sedatives.
Carefully administer opioid analgesia, sedatives, and benzodiazepines, as these medications can further reduce the heart rate and cause respiratory depression.
2. Administer supplemental oxygenation.
Emergency cardiovascular care includes supplemental oxygenation for respiratory distress associated with decreased cardiac output and bradycardia.
3. Instruct on the use of a Holter monitor or an event recorder.
A Holter monitor is a wearable device that records the heart rate and rhythm to detect abnormalities when the patient is experiencing symptoms like chest pain, dizziness, and dyspnea to help pinpoint the cause and assist with treatment planning. An event recorder is similar but isn’t worn at all times.
4. Prepare for pacemaker insertion.
A pacemaker is implanted in the chest to control the heart rate and prevent bradycardia. The nurse assists with preparing the patient prior to surgery, monitoring for complications post-op, and providing discharge instructions.
Deficient Knowledge
Patient education is a vital part of the effective management of bradycardia. Certain lifestyle modifications may be needed to help control the symptoms and prevent complications.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Inadequate access to accurate healthcare information
- Misinformation
- Inadequate interest in learning
- Inadequate knowledge of resources
- Inadequate participation in care planning
- Deficient instructions on testing or procedures
As evidenced by:
- Inaccurate follow-through of instructions
- Inaccurate statements about bradycardia
- Poor adherence to wearing a Holter monitor
- Misuse of medications
- Development of complications
Expected outcomes:
- Patient will verbalize lifestyle modifications to prevent bradycardia.
- Patient will verbalize the symptoms and complications of bradycardia.
Assessment:
1. Assess the patient’s knowledge about bradycardia.
Understanding what the patient knows and understands about their current condition can help determine areas and topics to include in patient education.
2. Assess for substance use.
Smoking, excessive alcohol use, misuse of narcotics, and cannabis use can alter the heart rate.
3. Review the patient’s medications.
If the patient is taking medication to lower their blood pressure, such as a beta blocker or calcium channel blocker, these medications also reduce the heart rate. The patient may need the medications discontinued, or the dosage changed.
Interventions:
1. Teach the patient how to monitor their pulse.
Devices such as a pulse oximeter can quickly assess the heart rate, but the patient can also be taught how to count their radial pulse.
2. Teach symptoms related to bradycardia.
Not all patients will experience symptoms of a slow heart rate. Ensure the patient understands that symptoms of dizziness, chest pain, shortness of breath, and exercise intolerance should be reported to their healthcare provider.
3. Encourage the patient to quit smoking and limit alcohol use.
A healthier lifestyle can reduce the risk of developing bradycardia and other complications.
4. Refer the patient to a cardiologist.
The patient with symptomatic bradycardia should receive follow-up care from a cardiologist.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Bradycardia. Cleveland Clinic. Reviewed: June 23, 2022. From: https://my.clevelandclinic.org/health/diseases/17841-bradycardia
- Bradycardia. Johns Hopkins Medicine. 2023. From: https://www.hopkinsmedicine.org/health/conditions-and-diseases/bradycardia
- Bradycardia. Mayo Clinic. Reviewed: May 7, 2022. From: https://www.mayoclinic.org/diseases-conditions/bradycardia/symptoms-causes/syc-20355474
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. 2020. Elsevier, Inc.
- What is Bradycardia? WebMD. Reviewed: August 17, 2022. From: https://www.webmd.com/heart-disease/atrial-fibrillation/bradycardia
