Nursing Management of Atrial Fibrillation

Nursing management of atrial fibrillation is an important skill for bedside nursing to master when caring for hospitalized patients. But, it’s not as intuitive as one might thing.

Let’s discuss some of the important aspects of this situation, and practical steps that you can take as a bedside nurse.

Nursing Management of Atrial Fibrillation

Atrial fibrillation is something many acute care nurses will deal with, as it is a common complication after various surgeries. Patients can also have chronic afib, but it may become more difficult to control due to whatever has necessitated their hospitalization, or interventions.

It’s important for the new nurse to know the basics of nursing management of atrial fibrillation and what to do. Let’s discuss it!

Basic Atrial Fibrillation Definition

The atria are “fibrillating” – or they are quickly and irregularly quivering and not fully contracting. This is caused by irritable cells in the atria. Certain surgeries or procedures put patients at high risk for this complication.  Cardiac surgery is a major factor, as as many as 30-40% of post-op cardiac surgery patients will flip into this rhythm.  

The reason this is so concerning is that when the atria are merely quivering and not giving you this full contraction, blood pools in the atria. When blood pools, it clots. And these clots can move and cause damage (pulmonary embolism, stroke, and so forth).

“Controlled” afib is typically considered a heart rate of less than 100 BPM.

“Uncontrolled” afib is typically considered a heart rate above 100 BMP. This is also called “afib with RVR” or “afib with a rapid ventricular response”.  

Afib with RVR is concerning and needs to be corrected to normal sinus rhythm (ideally), and if that’s not possible, bringing the heart rate down below 100. This risk for embolism is much higher with a rapid ventricular response. Therefore, if a patient is in afib with a heart rate over 100, typically the medical team will want to address it quickly.

Nursing Management of Atrial Fibrillation: What to Do

If they are in controlled afib and it is new, take note, assess (get a full set of vitals) and call the medical team to let them know and see if there are any necessary orders they would like implemented. This is a minimal freak-out situation.  They need to know about it, but it’s not an emergency by any means.  (Also, look back at their telemetry and try to find the time they flipped, because the medical team will ask you!)

If they are in uncontrolled afib, this is now your priority.  Whatever you were doing before can wait.  Go look at your patient, see if they’re diaphoretic, sweaty, nauseated, etc. Get blood pressure immediately.

Nurse tip: Sometimes your automated blood pressure cuff doesn’t read the blood pressure correctly if the patient has an extremely high heart rate. You may need to get a manual blood pressure.

(If you want my thorough step-by-step walk through, sign-up below for a free email course that gives you all of the details!)

Once you have a fresh set of vitals, have their latest labs/meds available to you, call your NP/PA/doctor and let them know.  Be ready for a bunch of new orders.  Depending on their preference, the patient’s history, comorbidities, etc., they may do synchronized cardioversion, chemical cardioversion, or utilize medications to convert them.   Again, it is all very situational so this cannot be strictly applied to everyone. Chances are, they’ll want Cardizem or Amiodarone (medications used to convert and the least invasive way to do so).  These orders need to be put in STAT.

Teamwork, baby!

Now it would be a great time for some teamwork!  See if a coworker can grab an IV pump to prime your drip while you get your bolus or vice versa.  Time is a factor here, you don’t want them stroking out on you! Please refer to your hospital’s policies and procedures regarding drips.  Some typically require a bolus, titration instructions, protocols for increased vital sign frequency, as well as when to notify the physician.

Make sure you are documenting everything per policy.

Tell your patient to stay in bed and tell PT/OT that they’ll need to wait to see your patient until a later time if they happen to come by.  You’re going to use your awesome nurse judgment and put them on an informal bed rest order for the time.  (No, don’t call the doctor for an order, just tell them they can’t get out of bed until their heart rate is better.) At this sensitive time, we do not want their heart working any harder.

The typical goal = conversion to normal sinus rhythm OR afib with a rate of less than 100.

If it has been over an hour and their heart rate is not consistently less than 120 and coming down (and your drip is maxed out), you will need to call for further orders.  If they flipped into normal sinus rhythm, you fixed them!  Good job!

What now?

Let’s say you’ve got their rhythm converted or rate controlled and it’s been there for a while.  

Be proactive and think about the next step for the patient.  So, if they’ve been on a Cardizem drip for two days and are doing fine, what are our plans to get off of the drip?  We need to know if the medical team wants to transition them to some sort of oral agent or not.  If so, you as the nurse will facilitate that process.  Again – follow your policies and procedures but many times this includes giving an oral dose two hours before shutting the drip off.

More cardiac nursing resources

• 5-Lead ECG Interpretation Tips for Nurses – Blog post
• Tips for Cardiac Nurses – Podcast Episode
• ECG Rhythm Master – Self-paced course
• Tips for Cardiac Nurse Assessment – Blog post
• Telemetry Basics Brush-Up – Self-paced mini course
• When Nurses Should Call the Rapid Response Team – Podcast episode