# Treatment of Sinus Bradycardia (Nursing)

by Rhonda Lawes, PhD, RN

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00:01 Hi, welcome to our video series on electrocardiogram.

00:08 Now, remember, sinus bradycardia is like a really slow version of sinus rhythm.

00:14 So the heart rate is less than 60, the rhythm is still regular.

00:18 You have a P wave before every QRS, the PR interval is normal 0.12 to 0.20, and the QRS is less than 0.12.

00:31 So here's a question for you. Take a look at the monitor.

00:34 Note the heart rate, the blood pressure, and then you've got the respiratory sat.

00:39 So what do you think? Does this patient require treatment? Pause the video, write yourself some notes.

00:47 Commit to your answer. Write yourself some quick notes, and we'll come back and walk through the possible answers.

01:00 Alright, let's go back to that monitor.

01:02 You know those numbers can seem kind of scary.

01:05 We know sinus rhythm is at least 60. And look at that heart rate, that is definitely lower than 60.

01:12 Textbook normal blood pressure is 120/80 that blood pressure is lower than normal blood pressure.

01:20 Now, the bottom number is the SAT.

01:22 That we're kind of comfortable with.

01:24 But it's those other two numbers, I really want you to think about.

01:27 How do we know if this patient requires treatment for their sinus bradycardia? Well, here's a caveat.

01:34 I want you to think about, people with sinus bradycardia can be a sign of health.

01:40 So if you have a higher level of cardiovascular fitness, you have a very efficient cardiovascular system.

01:47 Yeah, you're the one in the gym on the stairmaster acting like you're having fun while I'm dying.

01:55 But see, their systems may support their body's needs with a lower heart rate, and a lower blood pressure.

02:02 So, how do we know for sure if treatment is needed or not? Aha, that's up to you. That's what a nurse will do.

02:10 You look at what the normal heart rate and blood pressure is for the patient.

02:14 You ask them if they feel dizzy, or weak, or lightheaded.

02:18 You're assessing for them to be symptomatic with this sinus bradycardia or to see, if they're being perfused adequately.

02:26 I've actually had patients with lower vital signs than this.

02:29 And they were absolutely fine.

02:31 They just had incredible cardiovascular systems.

02:35 So treatment for sinus bradycardia is only needed if the patient is symptomatic.

02:42 You'll see if you can recall what would be the symptoms somebody would be need to be treated for with sinus bradycardia.

02:49 Well, it would be, well below their normal blood pressure.

02:54 They would feel dizzy, or lightheaded, or maybe even nauseated.

02:58 So nurses will assess the patient for signs or symptoms that say this patient is not receiving adequate oxygen to the tissues.

03:07 Oh, whoa, whoa, wait a minute, what number up there would tell us that? Look at the bottom one that tells us the SB O2.

03:14 That's a fairly good indicator that this patient is doing, okay.

03:19 Okay, sometimes in videos and teaching and in class, we go through signs and symptoms pretty quickly.

03:26 But one skill I've picked up in helping me study is that when I'm looking at a list of signs and symptoms, if I can picture someone in my mind that's experiencing all these.

03:38 So meet Bill. Here he is.

03:40 Bill needs some help.

03:43 His bradycardia is not normal for him, his blood pressure is too low, and he's suffering from hypoxemia.

03:50 So instead of being like our marathon runner who's fit and ready to go, Bill is really feeling the effects of bradycardia.

03:58 So, he's feeling like he's going to faint and Bill's a pretty big guy. I'm afraid.

04:02 I'm going to have him faint on me.

04:04 So, I want to get him safely to a place where he won't hurt himself.

04:09 He also said he's feeling dizzy and lightheaded and just has been feeling very tired today.

04:15 Now, as he's talking to me, he could be really short of breath and tell me that his chest is starting to hurt.

04:25 Again, that's an oxygen delivery problem.

04:28 As I'm asking him more questions, he might seem confused and not be able to think clearly.

04:34 And there's no way I could walk Bill from that chair over to the bed, because I can tell he would tire out with even a short walk that small amount of physical activity.

04:47 Now, what are the possible causes that got Bill into trouble? Well, he may have some heart tissue damage related to aging.

04:56 He might have damaged a heart tissue from heart disease or heart attack.

05:00 And Bill may not even be aware that he had a heart attack.

05:03 He might have some heart disorder that was present at birth, he has some type of congenital defect, he has infection of his heart tissue called myocarditis, or a complication of heart surgery.

05:16 So we've got a big long list here.

05:19 I don't know about you, but about option two and a half, I start to take a nap.

05:23 My brain can't remember all those things.

05:27 So here's what I would recommend for you to do when you're studying.

05:30 Let's look at those causes of sinus bradycardia.

05:34 What do they have in common? Ah, easy.

05:39 The heart has been damaged in some way. Right? So damage related to aging, that's unfortunate.

05:45 Damage related to heart disease or heart attack, heart disorder at birth, infection of the tissue, complication of heart surgery.

05:54 So, would I be able to remember, 1, 2, 3, 4, 5 things? Not likely.

05:59 Short term memory is really tough to move to working memory for me to get it into long-term memory.

06:06 So I'm going to look at, ah...

06:09 a possible cause of sinus bradycardia could be damage to the heart.

06:14 Now, we've got some other ones look, the list keeps going on.

06:19 If you have hypothyroidism, that's an under active thyroid gland.

06:25 Those patients will have a very slow heart rate.

06:29 You get an imbalance of chemicals in your blood, such as potassium or calcium.

06:34 You can have a repeated disruption of breathing during your sleep that's called obstructive sleep apnea.

06:41 You also can have an inflammatory disease like rheumatic fever or lupus.

06:46 And finally, keep in mind, medication.

06:50 Some of the drugs for other heart rhythm disorders, and for high blood pressure can cause sinus bradycardia.

06:57 So for example, if we are using a beta-blocker, anything a drug does, well. It can do overwhelm, and that could lead to a sinus bradycardia.

07:08 Also, some of the specific psych medications could cause bradycardia.

07:13 Well, we have it again, right? We have a list.

07:17 I want you to pause the video and look for ways that you can chunk information together, so it will make sense in your brain.

07:25 Don't memorize a list.

07:27 Look for ways that you can chunk information together, so it makes sense to you.

07:33 Okay, so let's talk about our friend the SA or sinoatrial node.

07:37 Remember, the impulse starts in the SA node, which is known as the pacemaker of the heart, and it travels to the AV node.

07:45 Now stop and look at the picture.

07:47 Do you see it starting in the SA node? Do you see it moving through to the AV node? Good deal.

07:54 Sinus bradycardia happens when the electrical signals are slowed down or blocked.

08:00 So that's what sinus brady is. Still starting in the SA node, but the signals are slowed down or blocked.

08:09 and that's why you have the slower heart rate.

08:12 So sinus node problems are a cause of sinus brady.

08:16 I want you to think of three major ways the SA node can be involved in sinus bradycardia or start with a sinus node.

08:25 The first one is, the SA node just discharges electrical impulses slower than normal.

08:31 The second one, the SA node pauses, or it fails to discharge at a regular rate.

08:37 And the third one, the SA node discharges an electrical impulse that is blocked before the atria can contract.

08:45 Okay, so the first two seem kind of similar, right? Either it's coming slower than normal, or it pauses or fails to discharge at a regular rate.

08:55 Those two I think we can safely chunk together.

08:58 And the last one is there some type of block.

09:02 Another cause of bradycardia are heart blocks.

09:05 Here's an animation of a first degree AV block for example.

09:09 As mentioned previously, the role of the AV node is to delay the impulse coming from the SA node.

09:16 In cases, of first degree heart block, this is exacerbated or made worse.

09:21 So the delay is prolonged which causes a long PRI as seen in the animation.

09:30 So let's get back to Bill. What are our options for him? Well, we consider medication like atropine.

09:37 That's an anti-muscarinic drug.

09:40 That is gonna speed Bill's heart rate up because remember, Bill is symptomatic.

09:46 He is not feeling it. He's so tired, dizzy and weak.

09:51 We also might consider a pacemaker.

09:53 Now we've got two options for pacemaker.

09:55 If we think that Bill is going to need this for a period of time, we can start with an external pacemaker.

10:01 So you just put pads on the patient's chest and hook them up to a machine that will deliver electrical impulses to keep the heart stimulated at a faster rate.

10:10 And then we can plan for procedure by a cardiologist for an implantable pacemaker.

10:17 Now, you look at that we've shown you a picture of what that is.

10:20 It's a small, really small box that they put underneath the skin of the patient, and it remains there can do some really cool stuff.

10:30 You do all different types of pacing.

10:32 One chamber, two chamber does all kinds of things.

10:35 And there are ways that we can keep a really close eye on the patient's heart through monitoring in that pacemaker.

10:42 So those are our options. Medication like atropine.

10:46 but once it wears off, if he's still having the problem, it's not going to fix it long term.

10:52 We can try an external pacemaker to kind of try to get him over the hump.

10:56 But if this is going to be a chronic and long term problem, the physician will place an implantable pacemaker.

11:05 So let's wrap up this part of the video series.

11:08 Remember, sinus bradycardia meets the same criteria as normal sinus rhythm, except that the heart rate is less than 60.

11:16 Sinus bradycardia may not require treatment, unless the patient is symptomatic or hemodynamically unstable.

11:24 Treatment for acute symptomatic bradycardia may include atropine, which is a medication and an external or temporary pacemaker.

11:33 And finally, treatment for chronic symptomatic bradycardia may include an implanted pacemaker in the patient's chest wall.

11:42 Thank you for watching our video series today.

The lecture Treatment of Sinus Bradycardia (Nursing) by Rhonda Lawes, PhD, RN is from the course Analysis of Abnormal ECG Strips (Nursing).

### Included Quiz Questions

1. 50 bpm
2. 80 bpm
3. 65 bpm
4. 120 bpm
1. 0.12–0.20s
2. 0.06–0.10s
3. 0.20–0.30s
4. 0.16–0.20s
1. Confusion
2. Memory problems
3. Fatigue
4. Dizziness
5. Dementia
1. Congenital heart defect
2. Damaged heart tissue from a heart attack
3. Infection of heart tissue
4. Complication from heart surgery
5. Infection of brain tissue
1. Atropine
2. Pacemaker
3. Epinephrine
4. Lidocaine
5. Magnesium sulfate

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