adult health nursing ii block 7.0 topic: cardiovascular nursing, & ekg monitoring, part 3...

Adult Health Nursing IIBlock 7.0

Topic: Cardiovascular Nursing, & EKG Monitoring, part 3Module: 2.4

Block 7.0 Module 2.4

Cardiovascular--- EKG’s / Cardiac Monitoring

Digitalis pupurea (Foxglove)

Lead II

Dynamic Presentation

Static Presentation

Part III

Key TermsArrhythmia &

DysrhythmiaElectrical

CardioversionDefibrillationThe “Names” of all

of the rhythms & dysrhythmias

atropineamiodarone lidocaine

(Xylocaine ®)adenosine

(Adenocard ®)dopamineepinephrine nitroprusside

(Nipride ®)

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Physical Assessment: S/S of Decreased Cardiac Output

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General Method….

General Impression Rate= ________ Rhythm =_______ P Waves =_______

PRI=_______ QRS = _______

Fast, “tight” QRS’s, fairly regular, no “FLB’s”

Rate= 120’s Rhythm = Regular P Waves = Present, upright, uniform,

1:1 ratio w/QRS’s, (precede QRS) PRI = 0.16 seconds, = throughout strip QRS = 0.08 secondsBlock 7.0 Module 2.4

General Impression

Rate=___________Rhythm=_________P Waves: ________

PRI= __________QRS = __________

Medium rate, funny-looking P’s, no FLB’s

100’s Regular Present, upright, ~,

biphasic, inverted, or “s”-shaped, 1:1 w / QRS’s

0.10 seconds 0.08 seconds

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Normal Sinus Rhythm

RATE: 60-100RHYTHM: RegularP Waves: Upright, uniform (~), 1:1 with QRS ComplexesPR Interval: 0.12 – 0.20 secondsQRS: < 0.12 sec, ~

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Sinus Bradycardia

RATE: < 60RHYTHM: RegularP Waves: Upright, uniform, 1:1 with QRS ComplexesPR Interval: 0.12 – 0.2 seconds, uniformQRS: < 0.12 sec, ~

Discussion: May be benign; Treatment Atropine IVP for Symptomatic BradycardiaBlock 7.0 Module 2.4

Sinus Tachycardia

RATE: 100 -150RHYTHM: RegularP Waves: Upright, uniform (~), 1:1 with QRS ComplexesPR Interval: 0.12 – 0.20 seconds, uniform (~)QRS: < 0.12 sec, ~

Discussion: Etiology?Block 7.0 Module 2.4

Atrial Flutter

RATE: Variable; RHYTHM: Regular or IrregularP Waves: Absent; Instead, heave F – Waves, or Flutter WavesPR Interval: N/AQRS: < 0.12 sec

Discussion: Rhythm may be regular or irregular, depending on ventricular response. Typically expressed as a “ratio,”, e.g., the above would be described as “Atrial flutter with a 3:1 block.”

VERY COMMON AFTER ANY TYPE OF CARDIAC SURGERY;FREQUENTLY PROGRESSES TO ATRIAL FIBRILLATION;MAY “BOUNCE BACK & FORTH” “A-Fib-Flutter” or “A-Flutter-Fib”

Block 7.0 Module 2.4

Atrial Fibrillation

RATE: Variable; Rate may indicate effect on Cardiac Output (Loss of “Atrial Kick,” ~ 20 % C.O.) RHYTHM: IrregularP Waves: AbsentPR Interval: N/AQRS: < 0.12 sec

Discussion: -Most common dysrhythmia-Classified as “AF with controlled ventricular response,” “AF with rapid ventricular response,” “Uncontrolled AF.”-Treatment: Digoxin; cardioversion-Embolus Role in CVA & PE

CHFBlock 7.0 Module 2.4

DISCUSSION: Atrial Fibrillation

Untreated or “uncontrolled Atrial fibrillation “ is a rapid and irregular heart arrhythmia, caused by chaotic electrical impulses in the atria of the heart (the two upper chambers). (Loss of “Atrial Kick,” i.e., ~ 20% of Cardiac Output)

In anatomical terms, the AV node and the ventricles (the two lower chambers) are therefore bombarded with frequent, irregular electrical impulses.

As a result, the heart rate becomes fast and irregular, and the normal coordination between the atria and the ventricles is lost.

There are several types, depending on how long the AF lasts.

When atrial fibrillation is always present, it is referred to as chronic atrial fibrillation.

When the arrhythmia is usually present, such that episodes of normal rhythm are infrequent or short-lived, it is referred to as persistent atrial fibrillation.

When a normal heart rhythm is usually present but occasional episodes of the arrhythmia occur, the patient is said to have paroxysmal atrial fibrillation.Block 7.0 Module 2.4

Supraventricular Tachycardia

RATE: 151 – 220+RHYTHM: RegularP Waves: Absent (buried in QRS)PR Interval: N/AQRS: < 0.12 sec

Discussion: C.O. is decreased due to lack of ventricular filling time.Treatment: Vagal Maneuvers (Carotid Massage) Adenosine IVP Cardioversion

REMEMBER:“Narrow-Complex Tachycardia”

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Discussion:Supraventricular tachycardias (SVT--PSVT)

The SVTs are generally benign (that is, non-life-threatening) tachycardias that either arise in the atria (that is, “supra” the ventricles), or involve the atria in the mechanism of the tachycardia.

Many SVTs are due to extra, abnormal electrical connections between the atria and the ventricles. Individuals with SVT are often born with these extra pathways. The existence of such extra pathways (often called “bypass tracts”) allow the formation of “reentrant” arrhythmias, in which an electrical impulse is established that spins continuously between the atria and the ventricles, thus causing one form of SVT.

Wolff-Parkinson-White (WPW) syndrome is a common example, but there are several other varieties of bypass tracts that can cause episodes of SVT.

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Wolf-Parkinson White Syndrome

"WPW is a form of supraventricular tachycardia (fast heart rate originating above the ventricles).

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WPW….

"WPW is a form of supraventricular tachycardia (fast heart rate originating above the ventricles).

When you have WPW, along with your normal conduction pathway, you have extra pathways called accessory pathways. They look like normal heart muscle, but they may: --conduct impulses faster than normal --conduct impulses in both directions

The impulses travel through the extra pathway (short cut) as well as the normal AV-HIS Purkinje system. The impulses can travel around the heart very quickly, in a circular pattern, causing the heart to beat unusually fast. This is called re-entry tachycardia. Re-entry arrythmias occur in about 50 percent of people with WPW; some may have atrial fibrillation (a common irregular heart rhythm distinguished by disorganized, rapid, and irregular heart rhythm). The greatest concern for people with WPW is the possibility of having atrial fibrillation with a fast ventricular response that worsens to ventricular fibrillation, a life-threatening arrhythmia,.

Block 7.0 Module 2.4

Junctional Rhythms

RATE: 40-60RHYTHM: RegularP Waves: Inverted, absent, or retrograde (after QRS)PR Interval: < 0.12 sec, or absentQRS: < 0.12 sec, ~

Discussion: Rate > 60= “Accelerated Junctional Rhythm;” Greater than 100= “Junctional Tachycardia”

A.K.A. “AV Junctional Rhythms”But, this rate can be widely variable!

Block 7.0 Module 2.4

Junctional TachycardiaRate: 101Rhythm: Regular P Wave: inverted, = , ~, 1:1

w/QRS’sPRI = 0.08-0.10 sec, ~QRS = 0.06- 0.08 sec, ~

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AV Blocks

The specialized conduction system is responsible for transmitting the heart’s electrical impulses from the atria to the ventricles.

Disease in the AV node, bundle of His, or the bundle branches can lead to a condition called “heart block.”

Heart block occurs when the electrical impulses in the atria are stopped from reaching the ventricles. The heart rate can reach dangerously low levels when heart block is present.

A permanent pacemaker, however, takes care of the problem. Block 7.0 Module 2.4

1st Degree AV Block

RATE: VariableRHYTHM: RegularP Waves: Present, upright, uniform, 1:1 ratio with QRSPR Interval: Uniform, > 0.20 secQRS: < 0.12 sec

Discussion: usually benign The above rhythm would be described as: “Sinus Rhythm, 1st Degree AV Block, Rate=_______

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Sinus Tachycardia, 1st Degree AV Block

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2nd Degree AV Block(Mobitz I --”Wenkebach”--and Mobitz II)

RATE: Variable, usually slowRHYTHM: IrregularP Waves: Upright, uniform; More P waves than QRS’s PR Interval: VariableType I: Gradually lengthening PRI until a QRS is dropped; then the pattern is repeatedQRS: < 0.12 sec, ~Block 7.0 Module 2.4

3rd Degree AV Block

RATE: Ventricular Rate 20 - 40RHYTHM: IrregularP Waves: Upright, uniform; More P waves than QRS’s; do not correlate to QRS complexes PR Interval: VariableType I: Gradually lengthening PRI until a QRS is dropped; then the pattern is repeatedQRS: > 0.12 sec

Medical Emergency: Require PacemakerBlock 7.0 Module 2.4

Ventricular Tachycardia

RATE: 200+RHYTHM: RegularP Waves: N/A PR Interval: N/A

QRS: > 0.12 sec“WIDE & BIZARRE”

Medical Emergency: V Tach with a Pulse Pulseless V-TachSynchronized CardioversionAntiarrhythmic such as Lidocaine IVP followed by continuous infusion

Block 7.0 Module 2.4

DISCUSSION

Ventricular tachycardia (VT) is a rapid heart rhythm originating within the ventricles.

VT tends to disrupt the orderly contraction of the ventricular muscle, so that the ventricle’s ability to eject blood is often significantly reduced. That, combined with the excessive heart rate, can reduce the amount of blood actually being pumped by the heart during VT to dangerous levels.

Consequently, while patients with VT can sometimes feel relatively well, often they experience – in addition to the ubiquitous palpitations – extreme lightheadedness, loss of consciousness, or even sudden death.

In general, there are two kinds of VT: VT with a Pulse and VT without a pulse

Block 7.0 Module 2.4

Ventricular Fibrillation

RATE: Ventricular Rate 0RHYTHM: IrregularP Waves: PR Interval: N/AQRS: N/A

Medical Emergency: “Cardiac Arrest”

GREATEST CHANCE OF SURVIVAL= IMMEDIATE DEFIBRILLATION

“Fine” Ventricular fibrillation

Block 7.0 Module 2.4

DISCUSSION:

Ventricular fibrillation (VF) is a rapid, chaotic ventricular arrhythmia that immediately brings to a halt all meaningful ventricular contractions.

Blood (Cardiac Output) therefore immediately stops flowing, and loss of consciousness occurs within seconds.

Unless cardiopulmonary resuscitation measures are initiated within a few minutes of the onset of VF, death will occur.

“Electricity is the answer!”Block 7.0 Module 2.4

“ACLS”Advanced CardiacLifeSupport

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“Coarse” Ventricular Fibrillation

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PACED RHYTHMS

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100% AV-Paced, 1st Degree AV BlockRate:Rhythm: P Waves + ~ =PRI=0.22 secQRS= ~ = 0.08 sec

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Asystole

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“Artifact”

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“ECTOPY”

PVC (Premature Ventricular Contraction)Identification: Irregular Rhythm -Ventricular depolarization Occurs earlier than predicted -QRS “Wide & Bizarre,” > 0.12 seconds -Uniform or multiform -Unifocal or multifocal -“Frequent PVC’s” = More than 6 PVC’s per minute -2 or more PVC’s in a row (couplets, triplets, more…)>>Unsustained V-Tach -PVC Patterns: PVC every other complex = BIGEMINY Increasing presence / severity PREDISPOSES TO V TACH V FIB

BIGEMINY

Pharmacologic Treatment:

Lidocaine IVPLidocaine Gtt;

Amiodarone IVP & gtt

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SR w/ PJCRate: 60’sRhythm : IrregularP Waves: +, upright, ~ not 1:1 with QRSPRI = 0.18 secQRS = 0.06-0.08 sec

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What Rhythm is This?

NO !Check the Patient!It isn’t any rhythm until you

correlate it with the patient’s clinical

condition and cardiac output !Block 7.0 Module 2.4

PEA P. E. A. “Pulseless Electrical Activity”

ANY RHYTHM NORMALLY ASSOCIATED WITH A PULSE,WHERE NO PULSE IS PRESENT

( so if monitor shows Asystole, VF, or VT it is NOT P.E.A., since these rhythms Are NOT normally associated with a pulse).

CAUSES: Cardiac TamponadeOthers

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Sinus Tachycardia w/ BBB; PJC or PAC converting to Sinus Tachycardia w/ Ventricular Asystole

P Waves: = ~ 150 / minuteQRS = 0.12 sec (BBB) ~ until stopPRI = unable to measure

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Atrial Fibrillation w/ Ventricular Pacing (& PVC)

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VT Versus SVT

“Narrow versus Wide”Block 7.0 Module 2.4

Diagnostic Tests•Serial Cardiac Enzymes

•--CK-MB

•--Myoglobin

•--Troponin

•Serial EKG’s

Pagana & Pagana, p. 322

NormalRange

2X

3X

4X

5X

2 4 6 8 10 12 14 16

DAYS AFTER INFARCTION

CK MB

TROPONIN

Myoglobin

Chest Pain

CARDIAC MARKERSCARDIAC ENZYMESa.k.a. “isoenzymes”Serum Levels Over Time:

Rapid diagnosis in E.R.: ~15-20 minutes

SX

EKG changesMARKERS

Block 7.0 Module 2.4

REMEMBER:At the ‘end of the day,’

IT’S ALL ABOUT

CardiacOutput!

C.O. = H R & R x S V

B.P. = C.O. X P V R S V R

*

* Tissue perfusion of vital organs…and everything else….

Correlate M

onitor W

aveforms

to the Patie

nt’s Conditio

n !!!

Is it a

perfusin

g rhythm?

Is the Patie

nt PERFUSIN

G ?!

Block 7.0 Module 2.4

Work On Your Own (and/or in groups)…

Practice Strips 1-29Determine Rate, Rhythm, P Waves, PR

Interval, QRS IntervalGeneral Impression (Out to the side) Rate = #Rhythm = Regular vs IrregularP Waves: Presence (?) , Upright (?), ~

Similarity / Uniformity (?) ,1:1 w /QRS’s (?)PRI = Measure & Assess: 0.12 – 0.2seconds ?

QRS = Measure & Assess; < 0.12 seconds ?

Comment: Normal or abnormal ? Cardiac Output?Block 7.0 Module 2.4