B11 · Irregular heartbeat
Actual Breathing and circulation
Definition
The heart rhythm is too fast, too slow, or uneven, which may cause palpitations, dizziness, or weakness.- Heart disease
- electrolyte imbalance
- stimulants
- stress
- Pounding or skipping heartbeat
- uneven pulse
- dizziness
- fainting
- chest discomfort
📋 Scenario
A patient says "my heart is skipping" and the monitor shows an uneven rhythm.
Subjective (S): "My heart is skipping and I feel dizzy."
Objective (O): Pulse irregular at 120/min; monitor shows uneven rhythm; blood pressure 105/68; oxygen saturation 96%.
Assessment tools for this scenario: CP-BREATH Breathing & Circulation Check CP-SKIN Skin & Wound Score
Validated scales to consider: NEWS2, SpO₂, ECG, Braden Scale, TIME wound chart
**CarePath diagnosis:** Irregular heartbeat related to heart disease, as evidenced by pounding or skipping heartbeat and uneven pulse.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Check pulse and blood pressure. | Pulse and blood pressure show how the uneven rhythm is affecting blood flow, since a fast irregular rhythm can lower the heart's output. |
| Connect to monitor if ordered. | A monitor shows the exact rhythm continuously, so changes are seen promptly and the doctor can identify the type. |
| Report symptoms. | Reporting symptoms such as dizziness or chest pain gives the doctor the information needed to judge urgency and treat. |
| Give heart rhythm medicine as ordered. | Rhythm medicines help control the heart rate or restore a steady rhythm, which improves pumping. |
| Keep the patient calm. | Anxiety releases stress hormones that can speed the heart and worsen palpitations, so staying calm helps. |
**Expected outcomes**
- Heart rate and rhythm within the doctor's range.
- No dizziness or fainting.
- Patient names when to report palpitations or chest pain.
**Linking the data to the diagnosis**
The patient says his heart is skipping and he feels dizzy. The nurse finds an irregular pulse of 120/min, an uneven rhythm on the monitor, blood pressure 105/68 and oxygen saturation 96%. This is an actual problem because the abnormal rhythm is already present and measured. Weak heart pumping could follow if the rhythm lowers blood flow, but the finding here is the rhythm itself, so this statement is the better fit. The plan aims for heart rate and rhythm within the doctor's range, no dizziness or fainting, and the patient naming when to report palpitations or chest pain.
CarePath diagnosis
Irregular heartbeat related to heart disease, as evidenced by pounding or skipping heartbeat and uneven pulse.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Check pulse and blood pressure. | Pulse and blood pressure show how the uneven rhythm is affecting blood flow, since a fast irregular rhythm can lower the heart's output. |
| 2. Connect to monitor if ordered. | A monitor shows the exact rhythm continuously, so changes are seen promptly and the doctor can identify the type. |
| 3. Report symptoms. | Reporting symptoms such as dizziness or chest pain gives the doctor the information needed to judge urgency and treat. |
| 4. Give heart rhythm medicine as ordered. | Rhythm medicines help control the heart rate or restore a steady rhythm, which improves pumping. |
| 5. Keep the patient calm. | Anxiety releases stress hormones that can speed the heart and worsen palpitations, so staying calm helps. |
Expected outcomes
- Heart rate and rhythm within the doctor's range.
- No dizziness or fainting.
- Patient names when to report palpitations or chest pain.
Linking the data to the diagnosis
The patient says his heart is skipping and he feels dizzy. The nurse finds an irregular pulse of 120/min, an uneven rhythm on the monitor, blood pressure 105/68 and oxygen saturation 96%. This is an actual problem because the abnormal rhythm is already present and measured. Weak heart pumping could follow if the rhythm lowers blood flow, but the finding here is the rhythm itself, so this statement is the better fit. The plan aims for heart rate and rhythm within the doctor's range, no dizziness or fainting, and the patient naming when to report palpitations or chest pain.