Atrial Fibrillation Nursing Care Plans Diagnosis and Interventions
Atrial Fibrillation NCLEX Review and Nursing Care Plans
Atrial fibrillation, or Afib, is a type of arrhythmia characterized by irregular and rapid heart rhythm that can lead to blood clot formation in the heart. The presence of Afib increases a patient’s susceptibility to developing stroke, heart failure, and other cardiac issues.
Therapeutic management of A-fib may include pharmacologic, cardioversion, or surgical measures in order to address the aberrant signals produce in the heart.
Causes of Atrial Fibrillation
Knowing the mechanisms of circulation and the functions of the heart is oftentimes necessary in order to understand the causes of atrial fibrillation.
The normal heart is composed of two types of chambers namely – two atria (the upper chambers) and two ventricles (the lower chambers). Located in the right atrium is the sinus node, a group of cells tagged as the heart’s natural pacemaker.
The sinus node is where the signal is produced that starts each heartbeat.
The normal and regular heart rhythm is produced in the following process:
- From the sinus node, the signal travels through the two atria.
- The signal passes through a pathway between the atria and ventricles, in the atrioventricular node.
- The transport of this signal stimulates the heart to contract, and therefore sending blood to the general circulation.
In atrial fibrillation, the signal pathways in the atria are garbled. Due to this, the atria quiver and fail to follow the natural pacing.
As this happens, the atrioventricular node is barraged with uncoordinated signals trying to go through the ventricles. The end result is the manifestation of a fast and irregular heart rhythm.
Atrial fibrillation is often times associated with problems in the heart’s structure. However, possible causes may be as follows:
- Coronary artery disease
- Heart attack
- Congenital heart defect
- Heart valve problems
- Lung diseases
- Undue physical stress related to surgery, pneumonia or other illnesses
- Previous heart surgery
- Sick sinus Syndrome, or the problem with the heart’s natural pacemaker
- Sleep apnea
- Thyroid conditions such as hyperthyroidism, other metabolic imbalances
- Stimulant usage such as caffeine, tobacco, alcohol, certain medications
- Viral infections
Risk Factors to Atrial Fibrillation
Risk factors associated with atrial fibrillation are as follows:
- Age. The risk of atrial fibrillation increase as the patient gets older.
- Heart disease. Patients with heart issues, such as congenital heart disease, congestive heart failure, coronary artery disease, history of heart attack, surgeries on the heart, and heart valve issues, increases the risk for atrial fibrillation.
- Hypertension. Hypertension, especially uncontrolled hypertension not managed with lifestyle modifications or medications, increases the risk for the condition.
- Thyroid disease. Thyroid problems may trigger arrhythmias in some people, including the development of atrial fibrillation.
- Other chronic health conditions. Conditions such as diabetes, metabolic syndrome, long-term kidney disease, lung issues, and apnea predispose a patient in developing atrial fibrillation.
- Alcohol use. Alcohol consumption may trigger episodes of atrial fibrillation in some people. Uncontrolled alcohol consumption further increases the risk.
- Obesity. Patients who are overweight have greater risks for atrial fibrillation.
- Familial history. Atrial fibrillation in the family may be passed down from generation to generation.
Signs and Symptoms of Atrial Fibrillation
Clinical manifestations of atrial fibrillation comprise of the following:
- Presence of palpitations, characterized by fast and pounding heartbeat (may have flutter features)
- Chest pain
- Shortness of breath
- Decreased ability to physical activity (i.e., exercise)
Atrial fibrillation can be classified under these subtypes:
- Occasional – Also known as paroxysmal atrial fibrillation, this subtype have symptoms that comes and goes, with durations of a few minutes to hours. In this subtype, manifestations may occur for as long as a week; they may occur repeatedly and may alleviate without treatment. However, occasional A-fib would still need therapeutic management.
- Persistent – This subtype is characterized as atrial fibrillation with tenacious manifestations that do not revert to normal heart rhythm. Because of this, and its associated life-threatening effects, persistent atrial fibrillation would need cardioversion or other medical therapies in order to reinstate and sustain normal heart rhythm.
- Long-standing persistent – Another subtype wherein the patient experiences consistent atrial fibrillation that lasts more than 12 months.
- Permanent – In this subtype, the condition is persistent and therefore would need medications to regulate the heart rate and therefore, address the irregular heart rhythm.
Diagnosis of Atrial Fibrillation
Diagnosing atrial fibrillation involves the following:
- Comprehensive physical examination and history taking. A physical exam, including listening for the patient’s heart, can reveal abnormalities. Complete patient history can reveal predisposing factors that may contribute to the condition. Both of these aides the healthcare provider in evaluating the patient’s condition and in guiding the therapeutic management.
- Electrocardiogram (ECG). It is a diagnostic test wherein it measures the electrical activity of the heart through the use of electrodes properly placed on the chest, and sometimes the arms and legs. It is quick and non-invasive and is the primary diagnostic tool for atrial fibrillation.
- Blood tests. There are no definitive blood tests in assessing for atrial fibrillation however, it is still utilized to diagnose conditions that may contribute to its development. Examples of which are:
- Complete blood count is done to rule out infections.
- Cardiac enzyme markers such as Troponins, creatine kinase (CK) and brain natriuretic peptide (BNP) may be done to look for injuries of the heart.
- Prothrombin time (PT) and International normalized ratio (INR) may be extracted to assess for coagulation issues and effectiveness of warfarin treatment.
- Serum electrolytes such as potassium and sodium levels may be facilitated so as to check for the patient’s ECG and cardiac health.
- Thyroid function tests may be done to check for hyperthyroidism.
- Holter monitor. It is a modified ECG that is made portable and worn in the pocket or in the belt. It is used while doing activities of daily living with the purpose of recording the heart’s activity continuously for 24 hours or more.
- Event recorder. It is a device similar to the Holter monitor and is worn longer, usually for 30 days. It is different from a Holter monitor wherein the goal is to record only at times of symptom occurrence.
- Stress test. Also known as exercise testing that involves facilitating tests on the heart while the patient uses a treadmill or a stationary bike.
- Chest x-ray. Radiographic imaging of the heart can help evaluate for complications such as fluid in the lungs that may otherwise contribute to the condition.
- Echocardiogram or transesophageal echocardiogram. It is a type of ultrasound used to visualize the heart’s structures, size, and movement.
Treatment for Atrial Fibrillation
The therapeutic management for atrial fibrillation will depend on the following:
- Duration of the condition
- Clinical manifestations
- Predisposing and precipitating factors of the condition.
The goals of treatment for atrial fibrillation include the following:
- Retune the heart rhythm
- Regulate the heart rate
- Avoid blood clot development that can lead to stroke
Considering the goals above, the therapeutic management can be classified into three and they are:
- Medications. Pharmacologic measures are prescribed in order to address the irregular and rapid heart rhythm that is classical with atrial fibrillation. The following medications utilized are the following:
- Beta-blockers – These drugs assists by slowing the heart at rest and during activity.
- Calcium channel blockers – These medicines also slow down the patient’s heart rate but are contraindicated to those with heart failure or hypotension.
- Cardiac glycosides – These drugs assist in controlling heart rate at rest but are used in combination with other drugs (such as beta-blockers, calcium channel blockers).
- Anti-arrhythmic medications – These medications are utilized not only to regulate heart rate but also to sustain a normal heart rhythm. Because of this, anti-arrhythmic medications have more side effects than others.
- Blood thinners – Due to the high susceptibility to develop stroke, patients with atrial fibrillation are prescribed blood thinners to reduce the risk.
- Cardioversion therapy. Cardioversion therapy is a complicated procedure with the goal of attempting to retune the patient’s heart rhythm. It is usually utilized on the first episode of atrial fibrillation. Cardioversion can be done in two different approaches:
- Electrical cardioversion – this involves the use of low voltage shock to the patient’s heart through paddles or electrodes placed on the patient’s chest.
- Drug cardioversion – this involves intravenous or per mouth administration of drugs to reset the condition.
- Surgical intervention. Cardiac ablation is the surgical management for atrial fibrillation that involves the creation of scars in various locations in the heart with the goal of blocking erratic electrical signals. This may be done through the application of heat (radiofrequency energy), cold (cryoablation) or less commonly using a scalpel (through open-heart surgery). Some techniques used to treat atrial fibrillation include:
- Atrioventricular (AV) node ablation – an ablation technique that uses heat or cold to the cardiac tissues at the AV node to eliminate erratic electrical connections of the heart. Because of this, the patient would need a pacemaker for life.
- Maze procedure – an ablation technique that uses, heat, cold, or a scalpel, to create a maze of scar tissue in the patient’s atria. Because of this, erratic electrical signals will not pass through and therefore, blocking these pathways by the created scar tissues.
Prevention of Atrial Fibrillation
Preventing atrial fibrillation involves the following lifestyle modifications:
- Eating healthy foods, specifically a diet rich in fruits, vegetables, and whole grains.
- Exercising regularly and increasing physical activity
- Quitting tobacco smoking
- Sustaining a healthy weight.
- Ensuring that blood pressure and cholesterol levels are controlled.
- Limiting alcohol and caffeine intake.
- Managing unnecessary stress.
- Ensuring regular check-ups with a healthcare provider.
Atrial Fibrillation Nursing Diagnosis
Atrial Fibrillation Nursing Care Plan 1
Nursing Diagnosis: Deficient Knowledge related to lack of understanding of the interrelatedness of cardiac disease secondary to atrial fibrillation as evidenced by statements of misconception regarding the condition.
Desired Outcome: The patient will be able to identify the relationship of ongoing therapies and initiate necessary lifestyle changes in terms of the patient’s present condition.
|Atrial Fibrillation Nursing Interventions||Rationale|
|Discuss with the patient the difference between normal and abnormal heart function, especially the corresponding variances of the condition.||Gaining knowledge regarding the causes of the condition will ensure patient adherence to the prescribed therapeutic regimen.|
|Emphasize the rationale of the therapeutic regimen. Make sure to include the significant others as necessary, especially complicated treatment.||Patients may have a sense of false security from the treatment once relief is felt and may adjust it against professional advice. Ensuring the importance of compliance to the treatment will prevent the risk of exacerbating symptoms and improve patient cooperation.|
|Discuss the significance of being active as much as possible without the risk of exhaustion and the benefit of timely and adequate rest periods.||Excessive physical activity resulting to over exertion can compound the condition which will require modifications on the exercise regimen.|
|Explore with the patient the significance of limiting sodium in the diet. Supply the patient with a list of common foods and their sodium content. Advise the patient to scrutinize food labels and medication packages.||Highlighting the importance of limiting sodium within prescribed limits ensures the prevention of the exacerbation of symptoms. Educating the patient on the significance of reading labels will ensure that dietary limits are maintained.|
|Evaluate the patient’s medications, purpose, and their side effects. Make sure to include written and oral instructions.||Understanding the purpose of the treatment regimen and the significance of timely reporting of side effects can impede untoward drug complications.|
|Educate and require a return demonstration of the taking of the patient’s blood pressure and heart rate. It should also include triggers when to notify a health professional for changes in characteristics, etc.||Educating the patient on proper monitoring of the vital signs and reporting any significant changes ensures the promotion of self-care. It also allows for the timely monitoring of side effects so as to prevent further complications.|
|Educate the patient’s role in controlling the associated factors of atrial fibrillation, including aggravating factors.||Giving this vital information to the patient will allow him to take an active role in his care. It also provides a better understanding for the patient of his therapeutic regimen concerning his condition.|
|Give the patient and significant others to air their concerns, ask questions as needed and relevant to the condition.||Caregiver fatigue may result from long-term care of the patient with debilitating conditions. Allowing them to air their concerns and questions to be answered and addressed professionally ensures better coping with the disease.|
|Identify external and community resources, support groups, and outpatient health services that are easily accessible to the patient.||The patient may need additional professional support, especially in the home setting. Ensuring their accessibility will provide compliance to the regimen and prevention of complications.|
Atrial Fibrillation Nursing Care Plan 2
Nursing Diagnosis: Activity Intolerance related to an imbalance between oxygen and supply secondary to atrial fibrillation as evidenced by changes in vital signs and presence of dysrhythmias
Desired Outcome: The patient will be able to tolerate activities of daily living as appropriate and within the acceptable limits.
|Atrial Fibrillation Nursing Interventions||Rationale|
|Take and record the patient’s vital signs before and after activities, especially if the patient is on cardiac medications such as beta-blockers, etc.||Orthostatic hypotension may follow if the patient is exposed to strenuous activities while on cardiac medications as its side effect. Ensuring that vital signs are within normal limits will prevent orthostatic hypotension and other complications from happening.|
|Assess for other reasons of fatigue that the patient is suffering from. (i.e., medications, treatments, etc.)||Some medications for atrial fibrillation such as beta-blockers can have fatigue as a drug side effect of usage. Stressful procedures can also lower a patient’s energy levels, therefore limiting the patient’s tolerance to activities.|
|Record and evaluate the patient’s response to activity, especially the vital signs.||The patient’s vital signs and oxygen saturations recorded before, during, and after any activity yields important data that can be utilized to adjust the patient’s activity and therapeutic regimen.|
|Employ using the 6-minute walk test (6MWT) to gauge the patient’s physical abilities.||The 6MWT is a test meant to gauge the patient’s cardiopulmonary health by having the patient walk a certain distance in a span of six minutes.|
|Assist the patient with activities of daily living (ADL), especially self-care activities while allowing for independence.||Helping the patient with his ADL’s ensures that his needs are met despite his condition. Involving them with their self-care needs promotes self-reliance and reduces powerlessness.|
|Ensure to slow the pace when caring for the patient, including adequate rest periods after exertion.||Allowing the patient additional time to accomplish tasks ensures for conservation of energy and promotion of patient safety. This is especially true for older patients where fatigue may settle in earlier, thus increasing their risk for falls or injuries.|
|Cluster nursing activities to promote adequate rest.||Following a schedule in accomplishing nursing tasks for the patient, with adequate rest periods in between, will address the patient’s needs efficiently without bringing undue stress.|
|Regulate the patient’s ADLs, including the intensity levels as necessary. Avoid exposing the patient to unnecessary psychological or physical stress.||Regulating the patient’s ADLs and their intensity prevents the overexertion by the patient. Educating the patient into stopping activities once with symptoms of fatigue should be given to prevent complications.|
|Encourage the patient to have adequate rest periods. Promote a quiet and calm atmosphere for the patient.||Adequate rest periods allow for proper healing of the body. It also promotes the patient’s general well-being.|
|Motivate the patient in maintaining a positive outlook. Give evidence of progress to the patient.||Motivating the patient improves his general well being and increases his morale. Having the patient know of his progress with the treatment regimen will motivate him more to follow through and comply.|
Atrial Fibrillation Nursing Care Plan 3
Nursing Diagnosis: Anxiety related to breathlessness from inadequate oxygenation secondary to atrial fibrillation as evidenced by verbalizations of uncertainty and decreased concentration
Desired Outcome: The patient will be able to identify strategies to reduce anxiety by utilizing coping patterns.
|Atrial Fibrillation Nursing Interventions||Rationale|
|Evaluate the patient’s physical reactions to anxiety.||Anxiety sometimes could cause physical symptoms such as pain, nausea, etc. which are vital for recognizing episodes that would need immediate intervention.|
|Authenticate observations to the patient by asking his or her current anxiety levels.||Anxiety is highly reliant on an individual’s response to external or internal stressors; may it be physical or psychological. Determining this allows for the taking of baseline data that is crucial for management.|
|Become aware of the patient’s anxiety.||Recognizing the patient’s feelings validates them and therefore conveys acceptance of the patient’s anxiety.|
|Approach and interact with the patient calmly.||This approach reduces the patient’s latent anxiety and may promote decreased cardiac load.|
|Acquaint the patient to a new environment, experiences, or people as necessary.||Awareness of a new environment will help reduce the patient’s anxiety and provide familiarization. A reduced feeling of anxiety would also mean reduced stress to the heart.|
|During anxiety episodes, ensure availability of comfort and support, both psychologically and physically.||Reassuring the patient, especially with the help of significant others would be helpful in reducing the anxiety. Other therapies such as the presence of pets may also help with stress and anxiety reduction.|
|Interact with the patient using brief statements in an easily understood language.||On episodes of moderate to severe anxiety, the patient is overwhelmed and could only respond and understand simple and brief directions.|
|Assist the patient in taking on ways to control anxiety and avoid uncertain situations.||Anxiety-reducing techniques help the patient to address and handle stress as effectively as possible, thereby preventing the development of a more severe form.|
|Help the patient in recognizing contributory factors to his anxiety.||Conversing with the patient about the factors related to his anxiety allows for a better understanding and management of his condition.|
|Instruct the patient and his family about the manifestations of anxiety.||Learning the ability to recognize early on manifestations of anxiety will help the family and the patient to address timely and provide effective intervention as soon as possible.|
Atrial Fibrillation Nursing Care Plan 4
Nursing Diagnosis: Acute pain related to decreased myocardial blood flow and increased cardiac workload or oxygen consumption secondary to atrial fibrillation as evidenced by reports of pain with varying frequency, duration and intensity, narrowed focus, distraction behaviors (e.g., moaning, crying, pacing, restlessness), and autonomic responses (e.g., diaphoresis, blood pressure, and pulse rate changes, pupillary dilation, increased/decreased respiratory rate)
- For the patient to report anginal episodes that have decreased in frequency, duration, and severity.
- For the patient to demonstrate pain relief as evidenced by the absence of muscle tension and restlessness, and stable vital signs.
|Atrial Fibrillation Nursing Interventions||Rationale|
|Ask the patient to call the nurse’s attention immediately when chest pain occurs.||Pain and diminished cardiac output can activate the sympathetic nervous system to release disproportionate amounts of norepinephrine, which then increases platelet aggregation and the release of thromboxane A2. Thromboxane A2 is a potent vasoconstrictor which causes coronary artery spasm, which can trigger, complicate, and or lengthen the duration of an anginal attack. Unbearable pain may cause a vasovagal response, thereby decreasing the patient’s blood pressure and heart rate.|
|Evaluate and monitor the patient’s response to medication.||Monitoring the patient’s response to medication can provide information on disease progression. This also helps in assessing the effectiveness of the administered interventions and may reveal the need to change the therapeutic regimen, in cases of unresponsiveness to treatment.|
|Identify what triggers the anginal attack (if any) and specify the frequency, duration, intensity, and location of pain.||This can help evaluate possible progression to unstable angina and differentiate this type of chest pain among others.|
|Observe and monitor for associated symptoms such as nausea, vomiting, dyspnea, dizziness, palpitations, and desire to urinate.||During ischemic myocardial episode, it may decrease the patient’s cardiac output, which in turn will stimulate the sympathetic and parasympathetic nervous system. This causes different vague sensations which may be difficult for the patient to identify and distinguish as related to an anginal episode.|
|Assess if the patient feels pain in the jaw, shoulder, neck, arm, or hand (usually on the left side).||Cardiac pain may radiate on the mentioned sites. Referred pain is experienced on more superficial sites which are supplied by the same dermatome (spinal cord nerve) level.|
|Situate the patient at complete rest during episodes of angina.||Rest decreases the oxygen demand of the myocardium, thereby minimizing the risk of tissue injury.|
|If the patient experiences dyspnea (shortness of breath), elevate the head of the bed.||Elevation of the head permits gas exchange to reduce the occurrence of hypoxia and further dyspnea.|
|Evaluate and monitor the patient’s heart rate and rhythm.||Patients with unstable angina are at an increased risk of developing acute, sometimes fatal, dysrhythmias. Dysrhythmias occur as a compensatory response to ischemic changes and/ stress.|
|Evaluate and monitor vital signs at 5-minute increments during the initial anginal attack.||Due to sympathetic activation, blood pressure may initially rise. It will eventually decrease if the cardiac output is compromised. Heart rate can also increase excessively (tachycardia) in response to sympathetic stimulation and may be prolonged to compensate for the decreased cardiac output.|
Atrial Fibrillation Nursing Care Plan 5
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for decreased cardiac output related to altered heart rate rhythm and altered myocardial contractility secondary to atrial fibrillation
- The patient will demonstrate and maintain adequate cardiac output as evidenced by normal blood pressure and pulse, adequate urinary output, and palpable pulses of equal quality, and normal mental status.
- The patient will demonstrate reduced frequency or absence of dysrhythmias.
- The patient will participate in activities that aim to reduce myocardial workload.
|Atrial Fibrillation Nursing Interventions||Rationale|
|Obtain the patient’s 12 lead electrocardiogram (ECG).||ECG is used to diagnose atrial fibrillation. If the patient has atrial fibrillation, the ECG strip will show chaotic and random waves with irregular beats. There are no discernible P waves and the atria are quivering between the QRS complex. Typically, the ventricular rate is at 110-160 beats per minute (bpm) and the QRS complex is usually less than 120 milliseconds.|
|Prepare for and assist with diagnostic and treatment procedures such as electrophysiological (EP) studies, radiofrequency ablation (RFA), and cryoablation (CA).||The first-line treatment for several tachycardia dysrhythmias is catheterization or angiographic procedures. Following rhythm confirmation via an EP study, the patient will be subjected to an RFA or CA to stop or disrupt the abnormal rhythm pattern. Medication may be administered first or added after ablation to increase the success of treatment.|
|Prepare the patient by gaining consent and assist with electro cardioversion as required.||Elective cardioversion aims to restart the heart’s electricity. This treatment is indicated for patients with sporadic episodes of atrial fibrillation. This is also indicated when the trials of first-line drugs such as beta-blockers and calcium channel blockers failed to control the patient’s heart rate or, in certain unstable dysrhythmias, bring back the heart rate to normal.|
|Administer medications to control heart rate as indicated.||It is vital to control the heart rate because the heart cannot sustain rapid beating a prolonged period. Sustained beating may increase the heart’s oxygen demand, thereby increasing the chance of developing ischemic changes and tissue injury. Administration of beta-blockers, calcium channel blockers, and cardiac glycosides will aid in controlling heart rate. Take note also of possible contraindications and drug interactions to avoid further complications.|
|Assist with the insertion and maintenance of pacemaker function. This can either be external or temporary, or internal or permanent.||Temporary pacing may be necessary to hasten impulse formation in bradycardias, harmonize electrical impulsivity, or reverse tachycardias and ectopic activity to maintain cardiac function until spontaneous pacing is restored and permanent pacing is commenced. These devices may support single-chamber or dual-chamber pacing and may include atrial and ventricular pacemakers.|
|Auscultate for heart sounds and note for the rate, rhythm, presence of extra heartbeats, and dropped beats.||Some dysrhythmias can be better detected through auscultation than palpation. Monitor the patient for the presence of extra heartbeats or dropped beats aids in identifying the type of dysrhythmia present in the patient.|
|Provide a calm and quiet environment for the patient.||This reduces the stimulation of the sympathetic nervous system and the release of catecholamines. This can cause or worsen dysrhythmias, further causing vasoconstriction, thereby resulting to increased myocardial workload.|
Atrial Fibrillation Nursing Care Plan 6
Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective breathing pattern related to fatigue, pulmonary congestion, and decreased lung expansion secondary to atrial fibrillation as evidenced by productive cough, rales on BLF, weakness, frothy sputum, tachypnea, and pursed-lip breathing.
- The patient will demonstrate an effective breathing pattern without causing fatigue.
|Atrial Fibrillation Nursing Interventions||Rationale|
|Establish rapport with the patient.||Establishing rapport with the patient is vital in order to gain trust from the patient and their family members. This will also help in increasing their participation in the treatment course.|
|Monitor and record the patient’s vital signs.||This will serve as baseline data that can be used to compare with further measurements to be conducted in the future.|
|Assess the patient’s respiratory rate and depth. Note if there is evidence of respiratory effort such as shortness of breath, nasal flaring, or use of accessory muscles.||This helps in identifying if the patient has increased work of breathing. It is important to recognize and treat abnormal ventilation as early as possible to prevent further complications. It must be noted that the responses of the patient vary from one another. Respiratory rate and effort may be increased by fear, fever, pain, or decreased circulating volume secondary to fluid loss, hypoxia, gastric distension, or accumulation of secretions.|
|Inspect chest excursion. Observe if there is decreased lung expansion or asymmetrical chest movement.||This procedure determines if the patient’s breathing is adequate. The presence of air or fluid in the pleural space prevents complete lung expansion and this permits further assessment of the patient’s ventilation status.|
|Elevate the head of the bed and put the patient in upright or semi-Fowler’s position.||This position improves respiratory function and lung expansion. This can help prevent and resolve pulmonary congestion.|
|Encourage the patient to participate and perform deep breathing exercises.||These exercises can help in reducing muscle tension, thereby decreasing the work of breathing. These can also help in lung expansion and maintenance of patency of small airways.|
|Evaluate the patient’s emotional response and report signs of respiratory distress, decreased or absent breath sounds, tachycardia, severe agitation, and hypotension.||This can help in detecting hyperventilation as a causative factor.|
|Measure the patient’s tidal volume and vital capacity.||These measurements indicate the volume of air that enters and exits the lung. Tidal capacity refers to the volume of air that enters or exits the lung per respiratory cycle and is normally 500 mL in a healthy adult male, and 400 ml in a healthy adult female. On the other hand, vital capacity refers to the total volume of air that is evacuated from the lungs after maximal expiration. It usually ranges between 3-5 liter in healthy adults.|
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Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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