I think the funniest thing I ever heard our current President's father say was in response to a common arrthymia encountered in nursing today, atrial fibrillation. I cannot remember the exact circumstances of the address, whether it was a speech or a press conference, but he said this " I thank you from the bottom of my recently fibrillating heart." That just struck me as really funny. But the condition he referred to is one that we see in medicine very frequently and so need to have a working knowledge of in our intellectual arsenal in assessing our patients. 

  When assessing a patient , the first thing you will notice when checking the pulse is an irregularity of the rhythm. If you patient is on a cardiac monitor, the visualization of the irregularity will give you a clue as well.
In assessing the rhythm, the first thing you look for is P waves. Is there a P wave in front of every QRS complex? Are the QRS complexes regular?  Do you see additional P waves between QRS complexes where there should be none? And then of course, how about the rate? How does the patient look? Are they symptomatic ? Vital signs? Oxygen saturation?
 
  FIRSTLY, treat the patient if they are symptomatic!
 
  THEN,  the question becomes why did they do that? I had a friend of mine tell me that the easiest way to run through possibilities is with this little jewel of a mnemonic.....CPRHEARTS.

C  Coronary artery disease, acute MI or acute CHF
P   Pericarditis or myocarditis
R  Rheumatic heart disease or valvular cardiomyopathy
H  Hypertrophic or Hypertensive cardiomyopathy or severe hypoxia
E  Embolism,principally pulmonary
A  Alcohol
R  Rule out other causes
T  Trauma, theophyllin toxicity, thyrotoxicosis
S  Surgery (post coronary artery bypass grafting CABG), sick sinus syndrome, sympathomametic toxicity

  This really helps me in the trenches when I am figuring out what is going on, or what could rear it's ugly head if I see someone has a history of any of these things.

  We run into people that are in chronic Afib all the time. They are frequently on some combination of Digoxin, aspirin, warfarin, diltiazem, metoprolol, and more recently we are seeing them on Amiodarone. We need to know Digoxin levels and the PT/INR if appropriate. Knowledge of whether or not these folks have had previous elective cardioversions is helpful. They may be more resistant to chemical cardioversion on your watch.

  But for the sudden or acute onset of Afib, you need to be able to recognize what is contributing to your patient's stress at that moment in time that could set up the right conditions for this to occur. Is it something that you ,as a nurse, can work towards relieving and therefore decrease the overall systemic stress? Can you increase their oxygen some to decrease hypoxia? Are they ventilating adequately? Are they volume overloaded therefore increasing myocardial oxygen demand? Are they having pain? Could they need some steroids for inflammation if appropriate? Do they have any symptoms of a pulmonary embolus? What about a urine tox? Are they a post op CABG or valve? What about blunt chest trauma?

  You may need a chest xray and some labs. You definitely need an EKG and possibly some cardiac enzymes. You may need some ABG's. This depends on the situation.You may need an Echocardiogram, again situationally dependent. And, last but not least, you may need to cardiovert....NOW. Again, depends on the patient.

  If a cardiologist is not yet involved with this patient, it may be a consideration. All of the things mentioned above are things that you can bring forward to the physician when treating the patient. In some areas, like ER, Tele, and ICU, there are guidelines to work under when these situations occur. On the floor, these are just some things that you can run through your mind to figure out the puzzle that is facing you and your patient