- Critical Drips: Administer Metoprolol IV bolus of 2.5mg to 5mg infused over 2 minutes. Monitor for bradycardia. Reassess heart rate after 15 minutes, and if the heart rate exceeds 100 beats per minute, repeat the bolus up to a maximum total dose of 15mg at 5-minute intervals. If the patient converts to sinus rhythm (SR), switch to oral Metoprolol and discontinue the IV 30 minutes after administration.
- **(In the case of a patient with a history of heart failure or lung disease, an order for Diltiazem IV bolus of 0.25mg/kg over 2 minutes would have been prescribed instead. Reassess heart rate after 15 minutes, and if the heart rate exceeds 100 beats per minute, repeat the bolus at 0.35mg/kg over 2 minutes. Then, continue an infusion at a rate of 5mg to 15mg per hour until sinus rhythm is achieved, within approximately 5 minutes). These patients may also present with shortness of breath, so a supplemental oxygen order may be necessary as indicated by Wyse, D. G. (2009).
- Respiratory: Oxygen: **Administer supplemental oxygen without respiratory therapy consultation if the patient becomes short of breath to maintain oxygen saturation above 90%.
- Medications: Discontinue the patient’s home medication Lisinopril 20mg daily until the heart rate is controlled. After achieving heart rate control, add medications for rhythm control.
- Nursing Orders: Notify if the patient’s atrial fibrillation persists for more than 20 minutes after the follow-up bolus of cardiac drip. Monitor heart rate for bradycardia (< 60bpm). NURS 6566 Week 2 Cardiac Arrhythmia Admission Orders
Follow-Up Lab Tests:
- Diagnostic Testing: Obtain thyroid-stimulating hormone (TSH), complete blood count (CBC), comprehensive metabolic panel (CMP), and arterial blood gas (ABG) if oxygen is applied and demand exceeds 4L/min via nasal cannula.
- *** If heart failure is suspected or if the patient does not respond to IV medications, consider ordering an echocardiogram (ECHO) in the future.
Consults:
- Consider a cardiology consult for evaluation of new-onset atrial fibrillation if the patient does not convert to normal sinus rhythm after 24 hours, and rate control cannot be achieved (McNamara & Tamariz, et al., 2013).
Patient Education and Health Promotion:
- Provide the patient with instructions regarding the side effects of administered medications, adverse effects on the gastrointestinal (GI) system, potential anticholinergic effects of continued medications, and monitoring for persistent arrhythmia. NURS 6566 Week 2 Cardiac Arrhythmia Admission Orders
Discharge Planning and Required Follow-Up Care:
- Patients with a new diagnosis of atrial fibrillation will be discharged with anticoagulant drug therapy.
- Schedule a follow-up appointment with the patient’s primary care physician (PCP) 1 week after discharge. If the patient is admitted with electrolyte imbalances or a heart failure diagnosis, consider referring the patient to a cardiologist for outpatient follow-up.
- Repeat lab work in one week.
- Advise the patient to return if they experience palpitations, increased anxiety, or symptoms of tachycardia, or if they experience shortness of breath without exertion. NURS 6566 Week 2 Cardiac Arrhythmia Admission Orders
References:
Dell’Orfano, J. T., Patel, H., Wolbrette, D. L., Luck, J. C., & Naccarelli, G. V. (1999). Acute treatment of atrial fibrillation: spontaneous conversion rates and cost of care. The American journal of cardiology, 83(5), 788–A10.
McNamara, R. L., Tamariz, L. J., Segal, J. B., & Bass, E. B. (2013). Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Annals of internal medicine, 139(12), 1018-1033.
Wyse, D. G. (2009). Pharmacotherapy for rhythm management in elderly patients with atrial fibrillation. Journal of interventional cardiac electrophysiology, 25(1), 25-29.
