[Exam 2/NO] Chapter 26 - Management of Patients with Dysrhythmias and Conduction Problems Flashcards
(268 cards)
1
Q
Dysrhythmias: What is this
A
Disorders of the formation or conduction (or both) of the electrical impulse within the heart. Can be disturbance of heart rate, rhythm, or both
2
Q
Dysrhythmias: How are they initially evidenced?
A
By hemodynamic effect they cause (change in conduction may change pumping action and decrease BP)
3
Q
Dysrhythmias: How are they diagnosed?
A
By analyzing the electrocardiogram (ECG) waveform
4
Q
Dysrhythmias: Treatment is usually based on what
A
the frequency and severity of symptoms produced
5
Q
Dysrhythmias: How are they named?
A
According to their site of origin of electrical impulse and mechanism of formation involved.
6
Q
Normal Electrical Conduction: What is the SA Node?
A
`The electrical impulse that stimulates and paces the cardiac muscle normally originates here.
7
Q
Normal Electrical Conduction: Normal rate of an electrical impulse?
A
60-100 times a minute
8
Q
Normal Electrical Conduction: What is the process of conduction?
A
When the electrical impulse travels from the SA node through atria to the AV node.
9
Q
Normal Electrical Conduction: What does the structure of the AV node do?
A
Slows the electrical impulse, giving atria time to contract and fill ventricles with blood
10
Q
Normal Electrical Conduction: Name for Electrical Stimulation / Mechanical Contraction?
A
Depolarization
Systole
11
Q
Normal Electrical Conduction: Name for Electrical Relaxation / Mechanical RElaxation?
A
Repolarization
Diastole
12
Q
Influences on HR and Contractility: Heart rate is stimulated by what?
A
Autonomic nervous system
13
Q
Influences on HR and Contractility: What does stimulation of the sympathetic system do?
A
Increases HR and constricts peripheral blood vessels , therefore increasing blood pressure
14
Q
Influences on HR and Contractility: What does the parasympathetic system do?
A
Reduces the heart rate. Results in dilation of arteries, lowering blood pressure
15
Q
Influences on HR and Contractility: What may cause an increase in sympathetic stimulation?
A
Exercise, anxiety, fever, or dopamine
16
Q
Influences on HR and Contractility: What may cause a decrease in sympathetic sitmulation?
A
Rest, anxiety reduction methods, and beta-adrenergic blocking agents
17
Q
Obtaining an Electrocardiogram: All ECGs have what two components?
A
1, Adhesive substance that attaches to skin
- Substance that reduces the skins electrical impedance, enhancing conductivity
18
Q
Obtaining an Electrocardiogram: What helps reduce skin impedance?
A
Abrading skin with clean dry gauze pad to exposed inner layer of epidermis
19
Q
Obtaining an Electrocardiogram: Poor electrode adhesion will cause significant what
A
artifact (distorted, irrelevant ECG waveforms)
20
Q
Obtaining an Electrocardiogram: Electrodes create an imaginary line called a lead which serves as what?
A
As a reference point form which the electrical activity is viewed.
21
Q
Obtaining an Electrocardiogram: How does hardwire monitoring work?
A
Cardiac monitor at the patient’s beside for continuous reading, like ICU
22
Q
Obtaining an Electrocardiogram: How does telemetry work?
A
Small box that patient carries and continuously transmits the ECG to central monitor
23
Q
Obtaining an Electrocardiogram: What is an electrophysiology study?
A
Electrodes are placed inside the heart in order to obtain an intracardiac ECG
24
Q
Obtaining an Electrocardiogram: What may be done during open heart surgery to obtain this?
A
Temporary pacemaker wires may be lightly sutured to the epicardium and brought to chest wall.
25
Obtaining an Electrocardiogram: What is included in the standard 12-lead ECG?
10 electrodes (6 on the chest, and 4 on the limbs).
26
Obtaining an Electrocardiogram: Where are limb electrodes placed?
On areas that are not bony and do not have significant movement.
27
Obtaining an Electrocardiogram: Limb electrodes provide the first what?
Six leads. Leads include I, II, III, aVR, aVL, and aVF
28
Obtaining an Electrocardiogram: How do you locate V1?
Locate the fourth intercostal space, and then place at sternal angle
29
Obtaining an Electrocardiogram: What are the locations of the five leads?
V1 is below the fourth intercostal. V2 crossed the sternum. V3 flows down and the rest go around the bottom of the breast.
30
Obtaining an Electrocardiogram: Standard 12-lead ECG reflects electrical activity of what
the left ventricle
31
Components of ECG: Offers important information abut what
electrical activity of the heart and is useful in diagosing dysrhythmias
32
Components of ECG: What is measured on horizontal and vertical axis?
Horizontal: Time and rate
Vertical: Amplitude or voltage.
33
Components of ECG: What is a positive deflection?
When the waveform moves toward the top of the paper
34
Components of ECG: What is a negative deflection?
When the waveform moves toward the bottom of the paper.
35
Components of ECG: ECG is composed of what waveforms?
P Wave
QRS Complex
T Wave
Possible U Wave
36
Components of ECG: ECG is composed of what segments and intervals?
PR Interval
ST Segment
QT Interval
37
Components of ECG: P Wave represents what?
Impulse starting in SA node and spreading through atria. Is atrial depolarization
38
Components of ECG: How long does P Wave last and how high?
0.11 seconds or less, and is 2.5 mm or less in height
39
Components of ECG: What does the QRS complex represent?
Ventricular depolarization.
40
Components of ECG: Information to know about Q wave?
First negative deflaction after P. Less than 0.04 seconds, and less than 25% of R amplitude
41
Components of ECG: Information to know about R wave?
First positive deflection after P wave.
42
Components of ECG: Informaiton to know about S wavE?
First negative deflection after the R wave.
43
Components of ECG: What to do when QRS wave is less than 5 mm?
Use small letters of qrs
44
Components of ECG: What to do when QRS wave is greater than 5 mm?
Use capital letters , QRS
45
Components of ECG: How long is the QRS wave usually?
< 0.12 seconds
46
Components of ECG: What to know about T waave?
Ventricular repolarization (cells regain negative charge, resting state). Follows QRS.
47
Components of ECG: Why is atrial repolarization not visible?
Not visible during T wave because occurs at same time as ventricular depolarization
48
Components of ECG: What to know about U wave?
Represents repolarization of Purkinje fibers. Appears with hypokalemia, hypertension, or heart disease. Follows T wave, smaller than P wave.
49
Components of ECG: What is the PR interval?
Measured from beginning of P wave to beginning of QRS. Represents time needed for sinus node stimulation, atrial depolarizations.
50
Components of ECG: Normal PR time length?
0.12 to 0.20 seconds
51
Components of ECG: What does the ST segment represent?
Early ventricular repolarizations, lasting from end of QRS to beginning of T wave.
52
Components of ECG: Beginning of ST segment identified by what?
Change in thickness or terminal portion of QRS complex.
53
Components of ECG: Why is the ST segment normally analyzed?
To identify whether it is above or below the isoelectric line, which is a sign of cardiac ischemia
54
Components of ECG: What is the QT interval?
Total time for ventricular depolarization and repolarization. Lasts 0.32 - 0.40 seconds if heart between 65 - 95 bpm.
55
Components of ECG: What may happen if meds prolong the QT interval?
Place the patient at risk for a leth ventricular dysrhythmias called torsades de pointes.
56
Components of ECG: What happens when theres no electrical activity in TP interval?
Isoelectric line, graph remains flat.
57
Components of ECG: PP interval is used to determine what?
Atrial rate and rhythm.
58
Components of ECG: RR interval is measures from what?
From one QRS complex to the next. Determine ventricular rate and rhythm
59
Analyzng ECG Rhythm Strip: This must be analyzed to determine what?
Patients cardiac rate and rhythm, and to detect dysrhythmias and conduction disorders.
60
Determining HR from ECG: East and accurate way to determine this?
Count number of small boxes within an RR interval,and divide 1500 by that number. Determines beats per minute.
61
Determine Heart Rhythm from ECG: What is used to identify ventricular and atrial rhythm?
Ventricular: RR Interval
Atrial: PP Interval
62
Determine Heart Rhythm from ECG: What is used to determine whether rhythm is regular or irregular?
If difference between them is less than or greater than 0.8 seconds
63
Normal Sinus Rhythm: This has what characteristics?
```
Rate
Rhythm
QRS Shape
P Wave
PR Interval
P:QRS Ratio
```
```
RatE: 60-100
Rhythm: Regular
QRS Shape: Normal
P Wave: Normal Shape, in front of QRS
PR Interval: 0.12-0.20 seconds
P:QRS Ratio - 1:1
```
64
Sinus Node Dysrhythmias - Sinus Bradycardia: When does this occur?
When the SA node creates an impulse at a slower-than-normal rate
65
Sinus Node Dysrhythmias - Sinus Bradycardia: Causes of this?
Lower metabolic needs, vagal stimulation, medications, and increased intracranial pressure.
66
Sinus Node Dysrhythmias - Sinus Bradycardia: Unstable and symptomatic bradycardai due to what
Hypoxemia, AMS, and acute decompensated heart failure
67
Sinus Node Dysrhythmias - Sinus Bradycardia: Characteristics of this?
```
Rate
Rhythm
QRS Shape
P Wave
Pr Interval
P:QRS
```
```
Rate: < 60 bpm
Rhythm: Regular
QRS Shape: Usually normal
P Wave: Normal, always in front of QRS
PR Interval: 0.12-0.20
P:QRS Ratio - 1:1
```
68
Sinus Node Dysrhythmias - Sinus Bradycardia: What to do HR decrease caused by vagus nerve?
Try to prevent bearing down during defecation, and other attempts to prevent this
69
Sinus Node Dysrhythmias - Sinus Bradycardia: What risk factors does sick sinus syndrome include?
Age, white race, obesity, hypertension, lower hr
70
Sinus Node Dysrhythmias - Sinus Bradycardia: What is tachy-brady syndrome?
When bradycardia alternates with tachycardia
71
Sinus Node Dysrhythmias - Sinus Bradycardia Med Mx: What may be given if bradycardia produces signs of clinical instability?
0.5 mg of atropine via IV bolus every 3-5 mins until max dosage of 3 mg given.
72
Sinus Node Dysrhythmias - Sinus Tachycardia: When does this happen?
When the sinus node creates an impulse at a faster-than-normal rate
73
Sinus Node Dysrhythmias - Sinus Tachycardia: What are some physiologic causes?
Acute blood loss, anemia, shock, hypervolemia, hypovolemia, heart failure, pain, fever, exercise
74
Sinus Node Dysrhythmias - Sinus Tachycardia: What are some meds that can cause this?
Sitmulats and illicit drugs
75
Sinus Node Dysrhythmias - Sinus Tachycardia: What is inapprorpiate sinus tachycardia?
Enhanced use of SA node or excessive sympathetic tone with reduced parasympathetic tone out of proprortion to demands
76
Sinus Node Dysrhythmias - Sinus Tachycardia: What is an autonomic dysfunction?
Type of sinus tachycardia known as postural orthostatic tachycardia syndrome, which is tachycardia without hypotension until they stand.
77
Sinus Node Dysrhythmias - Sinus Tachycardia: Characteristics of this?
```
Rate
Rhythm
Shape
P Wave
PR Interval
P:QRS Ratio
```
```
Rate: > 100 but < 120
Rhythm: Regular
QRS: Normal, but regularly abnormal
P Wave: In front of QRS, but may be buried in preceding T Wave
PR Interval: Between 0.12-0.20
P:QRS Ratio: 1:1
```
78
Sinus Node Dysrhythmias - Sinus Tachycardia: What happens to the heart as heart rate increases?
Diastolic filling time decreases, reducing CO and producing symptoms of low blood pressure . Acute pulmonary edema may develop .
79
Sinus Node Dysrhythmias - Sinus Tachycardia Med Mx: Treatment of choice if persistent and causing hemodynamic instability?
Synchronized cardioversion.
80
Sinus Node Dysrhythmias - Sinus Tachycardia Med Mx: What can help interrupt tachycardia?
Vagal maneuvers like carotid sinus massage, gagging, bearing down, forceful coughing, or applying cold stimulus to face or admin of Adenosine.
81
Sinus Node Dysrhythmias - Sinus Tachycardia Med Mx: What is given for narrow QRS?
Beta blockers and calcium channel blockers.
82
Sinus Node Dysrhythmias - Sinus Tachycardia Med Mx: What is given for wide QRS?
Adenosine.
83
Sinus Node Dysrhythmias - Sinus Arrhythmia: When does this occur?
When the sinus node creates an impulse at an irregular rhythm, increasing with inspiration and decreasing with expiration.
84
Sinus Node Dysrhythmias - Sinus Arrhythmia: Nonrespiratory causes include what?
Heart disease and valcular disease.
85
Sinus Node Dysrhythmias - Sinus Arrhythmia: Characteristics of this?
```
Rate,
Rhythm
Duration
P WAve
PR Interval
P:QRS Ration
```
```
Rate: 60-100 bpm
Rhythm: Irregular
QRS Shape: Regularly abnormal
P Wave: Always in front of QRS
PR Interval: 0.12-0.20
P:QRS Ratio: 1:1
```
86
Sinus Node Dysrhythmias - Sinus Arrhythmia Med Mx: What is done to treat?
Does not cause any significant hemodynamic effect and therefore not typically treated
87
Atrial Dysrhythmias: These originate from where?
Foci within the atria and not the SA node.
88
Atrial Dysrhythmias - Premature Atrial Complex: What is this?
A Single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node
89
Atrial Dysrhythmias - Premature Atrial Complex: This may be caused by what?
Caffeine, alcohol, nicotine, stretched atrial myocardium , anxiety, hypokalemia or infarction
90
Atrial Dysrhythmias - Premature Atrial Complex: Characteristics of this?
```
Rate
Rhythm
QRS Shape
P Wave
PR Interval
P:QRS Ratio
```
Rate: Depends on underlying rhythm (sinus tachycardia)
Rate: Irregular due to early P waves, creating short PP Interval
QRS Shape: Follows teh early P Wave
P Wave: May be early or hidden in T Wave
Pr Interval: 0.12-0.20 seconds, but early P wave has shorter PR interval
P:QRS Ratio: 1:1
91
Atrial Dysrhythmias - Premature Atrial Complex: What may the patient complain of?
My heart skipped a beat, which there being a pulse deficit
92
Atrial Dysrhythmias - Premature Atrial Complex Medical Mx: What to do if they are frequent?
This may be a sign of worsening disease state or onset of more serious dysrhythmias, liek atrial fibrillation. Treat underlying cause.
93
Atrial Dysrhythmias - Atrial Fibrillation: What does this result from?
Abnormal impulse formation that occurs when structural or electrophysiological abnormalities alter atrial tissue, cuasing rapid, disorganized, uncoordinated twitching.
94
Atrial Dysrhythmias - Atrial Fibrillation: What systems play an important role here?
Extrinsic (central) and intrinsic crdiac autonomic nervous sytems (CANS)
95
Atrial Dysrhythmias - Atrial Fibrillation: What do hyperactive autonomic ganglia in CANS play a role in?
Atrial finrilation, resulting in impulses that are initiated from pulmonary veins.
96
Atrial Dysrhythmias - Atrial Fibrillation: Characteristics of this?
```
Rate
Rhythm
QRS Shape
P Wave
PR Interval
P:QRS Ratio
```
Rate: Atrial - 300-600 bpm and Ventricular is 120-200
```
Rhythm - Irrregular
QRS Shape: May be abnormal
P Wave: No discernible P Waves
PR Interval: Can't be measured
P:QRS - Many:1
```
97
Atrial Dysrhythmias - Atrial Fibrillation: These people are at an increased risk for what?
Heart failure, MI, and Embolic Events like stroke
98
Atrial Dysrhythmias - Atrial Fibrillation: What does a rapid and irregular ventricular response cause?
Reduces time for ventricular filling, resulting in smaller stroke volume. Some experiernce palpitations and CMs of HF (SOB, hypotension, dyspnea)
99
Atrial Dysrhythmias - Atrial Fibrillation: These patients may exhibit a pulse deficit, which is what?
Numeric difference between apical and radial pulse rates.
100
Atrial Dysrhythmias - Atrial Fibrillation: Erratic nature of atrial contraction, alterations in ventricular ejection, and atrial myocardial dysfunction promote formation of what
thrombi, espeically within left atrium.
101
Atrial Dysrhythmias - Atrial Fibrillation , Assess/Diagnostic Finding: Why is 12-lead ECG performed?
To verify the atrial fibrillation rhythm, and also identify the presence of left ventricular hypertrophy
102
Atrial Dysrhythmias - Atrial Fibrillation , Assess/Diagnostic Finding: What can a transthoracic echocardiogram (TEE) identify?
Presence of valvular heart disease, provide information about left ventricular (LV) and right ventricaular (RV) size and function
103
Atrial Dysrhythmias - Atrial Fibrillation , Assess/Diagnostic Finding: Blood tests to screen for diseases that are known to cause atral fibrillation?
Thyroid, renal, and hepatic functions .
104
Atrial Dysrhythmias - Atrial Fibrillation Med Mx: What may happen if nothing is done for treatment?
Spontaneously converts to sinus rhythm within 24-48 hours and without treatment
105
Atrial Dysrhythmias - Atrial Fibrillation Med Mx: This revolves around what?
Preventing embolic events such as stroke with antithrombotic drugs , controlling the ventricular rate of response
106
Atrial Dysrhythmias - Atrial Fibrillation, Antithrombotic Meds: What drugs may this include?
Anticoagulants and antiplatelet drugs.
107
Atrial Dysrhythmias - Atrial Fibrillation, Antithrombotic Meds: Patients with a low stroke risk may be placed on what med therapy?
Aspirin therapy dosed at 75-325 mg daily
108
Atrial Dysrhythmias - Atrial Fibrillation, Antithrombotic Meds: Patients with moderate risk may be placed on what?
Warfarin or a direct-acting oral anticoagulant.
109
Atrial Dysrhythmias - Atrial Fibrillation, Antithrombotic Meds: Treatment with warfarin will require weekly what?
INR testing during initiation of therapy
110
Atrial Dysrhythmias - Atrial Fibrillation, Meds to Control HR: What is the strategy here?
Control the ventricular rate of response so that resting HR less than 80 bpm
111
Atrial Dysrhythmias - Atrial Fibrillation, Meds to conver HR or prevent atrial fibrillation: What is recommended for atrial fibrilation lasting > 48 hours
anticoagulation
112
Atrial Dysrhythmias - Atrial Fibrillation, Meds to conver HR or prevent atrial fibrillation: What may be done if anticoagulation cannot be performed?
TEE may be performed prior to cardioversion to identify left atrial thrombus formation
113
Atrial Dysrhythmias - Atrial Fibrillation, Meds to conver HR or prevent atrial fibrillation: Preferred medication here?
Defetilide, but QT interval and renal function need to be monitored.
114
Atrial Dysrhythmias - Atrial Fibrillation, Meds to conver HR or prevent atrial fibrillation: Prevention of atrial fibrilation following cardiac surgery achieved how
through administration of beta-blockers.
115
Atrial Dysrhythmias - Atrial Fibrillation, Electrical Cardioversion for Atrial Fibrillation: When is this recommended?
For patients with atrial fibrillation that is hemodynamically unstable (acute AMS, chest discomfort, hypotension)
116
Atrial Dysrhythmias - Atrial Fibrillation, Electrical Cardioversion for Atrial Fibrillation: Because Atrial function may be impaired for several weeks after this, what is recommended?
Warfarin is indicated for at least 4 weeks.
117
Atrial Dysrhythmias - Atrial Fibrillation, Catheter Ablation Therapy: What is this?
It destroys specific cells that are the cause of tachydysrhythmia.
118
Atrial Dysrhythmias - Atrial Fibrillation, Catheter Ablation Therapy: How does Ablation work?
Involves special catheter that advanced to origin of dysrhythmia, where high-frequency , low-energy sound waves passed through catheter causing thermal injury to dysrhythmic tissue.
119
Atrial Dysrhythmias - Atrial Fibrillation, Catheter Ablation Therapy: What is the goal of each ablation procedure?
To eliminate dysrhythmia, by prevenitn ectopic activity from arising from pulmonary veins from reaching atria, thereby stopping fibrillation
120
Atrial Dysrhythmias - Atrial Fibrillation, Catheter Ablation Therapy: What precautions are taken immediately after postablation
Monitor for 30-60 mins, and then retest vital signs. Successful with dysrhythmia cannot be induced.
121
Atrial Dysrhythmias - Atrial Fibrillation, Catheter Ablation Therapy: Major risks of this?
AV block, pericardial tamponade, phrenic nerve injur, stroke.
122
Atrial Dysrhythmias - Atrial Fibrillation, Catheter Ablation Therapy: How can some pain be relieved from this procedure?
Pain meds, or rolled towels can be placed under the patient's knees and waist
123
Atrial Dysrhythmias - Atrial Fibrillation, Maze/Mini-Maze Procedure: What is the maze procedure?
Open heart surgical procedure for refractory atrial fib. Incisions made throughout atria. New scar tissue prevents reentry conduction of aberrant electrial impulse.
124
Atrial Dysrhythmias - Atrial Fibrillation, Maze/Mini-Maze Procedure: Whatmay someone need after this proedure?
Permanent pacemaker due to injury to SA node.
125
Atrial Dysrhythmias - Atrial Fibrillation, Maze/Mini-Maze Procedure: How is Mini-Maze performemd?
Small incisions made between ribs, and video guided instrument inserted. Pulmonary veins encircle with incisions within left atrium. This eliminated need for opening the sternum.
126
Atrial Dysrhythmias - Atrial Fibrillation, Convergent Procedure: How does this work?
Few incisions made in abdomen, so special catheter with visuals can be inserted through diaphragm. Ablation performed aroudn epicardial wall. Results in 3-days tay
127
Atrial Dysrhythmias - Atrial Fibrillation, Convergent Procedure: What may they experience afterwards?
Mild dull chest pain caused by inflammation from ablation. Resolves within few days.
128
Atrial Dysrhythmias - Atrial Fibrillation, Left Atrial Appendage Occlusion (LAAO): Why is the LAA ara problematic?
Area where majority of stroke-causing blood clots form in patients with nonvalvular atrial fibrillation.
129
Atrial Dysrhythmias - Atrial Fibrillation, Left Atrial Appendage Occlusion (LAAO): How does this work?
Small incision made in femoral area and a catheter inserted that guides device. Parachute-shaped device threaded through opening of the LAA, sealing it off and preventing release of clots
130
Atrial Dysrhythmias - Atrial Fibrillation, Left Atrial Appendage Occlusion (LAAO): What device is usually inserted?
WATCHMAN device.
131
Atrial Dysrhythmias - Atrial Fibrillation, Left Atrial Appendage Occlusion (LAAO): What must patients do after procedure?
Prescribed aspirin/warfarin. 6 weeks later, should return for TEE to confirm device has been effectively occluded. Can stop warfarin then but must take pplavis for 6 months, then always aspirin
132
Atrial Dysrhythmias - Atrial Fibrillation, Wolff-Parkinson-White Syndrome: What is this?
When atrial fibrillation, QRS wide, and ventricular rhythm is fast and irregular.
133
Atrial Dysrhythmias - Atrial Fibrillation, Wolff-Parkinson-White Syndrome: How to fix this?
Electrical cardioversion. Avoid meds that block AV conduction (digoxin) because they can increase rate.
134
Atrial Dysrhythmias - Atrial Fibrillation, Wolff-Parkinson-White Syndrome: What meds recommended to restore sinus rhythm?
Procainamide, propafenone, flecinide
135
Atrial Dysrhythmias - Atrial Flutter: This occurs why?
Because conduction defect in atrium and causes a rapid, regular atrial impulse between 250-400 bpm.
136
Atrial Dysrhythmias - Atrial Flutter: Importantfeature of this?
Not all atrial impulses conducted into ventricle, causing therapeutic block in AV node.
137
Atrial Dysrhythmias - Atrial Flutter:
```
Ventricular/Atrial Rate?
Ventriaular/Atrial Rhythm?
QRS Shape/Duration
P-Wave:
PR Interval:
P:QRS Ratio:
```
Ventricular/Atrial Rate: 250-400 / 75-150
Ventricular/Atrial Rhythm: Both regular, atrial may be irregular due to change in AV conduction
QRS: May be abnormal or absent
P Wave: Saw-tooth shaped, , called F-Waves
PR: Multiple F waves make it difficult to know
P:QRS Ratio: 2:1, 3:1, 4:1
138
Atrial Dysrhythmias - Atrial Flutter / Med Mx: This can cause what sort of sings?
Chest pain, SOB, low BP.
139
Atrial Dysrhythmias - Atrial Flutter / Med Mx: Med Mx involves what?
Vagal maneuvers, or trial administration of adenosine, which causes sympathetic block and slowing of conduction through AV node.
140
Atrial Dysrhythmias - Atrial Flutter / Med Mx: How is this treated?
Antithrombotic therapy, rate control, and rhythm control .
141
Junctional Dysrhythmias - Premature Junctional Complex: What is this?
Impulse that starts in AV node before normal sinus impulse reaches AV node.
142
Junctional Dysrhythmias - Premature Junctional Complex: Causes of this?
Digitalis toxicity, HF, and coronary heart disease.
143
Junctional Dysrhythmias - Premature Junctional Complex: What to know about P wave and PR Interval for this?
P wave may be absent, may follow QRS and may occur beore QRS. PR interval less than 0.12
144
Junctional Dysrhythmias - Junctional Rhythm: What is this?
Occurs when AV node, instead of sinus node, become pacemaker of heart. AV discharges impulse when sinus node slows (from increased vagal tone) or when impulse can't be conducted through AV node
145
Junctional Dysrhythmias - Junctional Rhythm:
Ventricular/Atrial Rate
Ventricular/Atrial Rhythm
QRS Shape/Rhythm
P Wave:
PR Interval:
P:QRS Interval
V/A Rate: V = 40-60 BPM, A = 40-60 if P waves disceernible
V/A Rhythm: Regular
QRS Shape: May be anormal
P: Maybe be absent before or after QRS. May be inverted
PR: If P in front of QRS, < 0.12
P:QRS Ratio: 1:1 or 0:1
146
Junctional Dysrhythmias - Junctional Rhythm: What to do if this produces reduced CO?
;Treatment same as sinus bradycardia. Emergency pacing may be needed
147
Junctional Dysrhythmias - Nonparoxysmal Junctional Tachycardia: What causes this
Enhanced automaticity in the junctional area, with rate of 70-120 bpm. May indicate underlying conditions
148
Junctional Dysrhythmias - Nonparoxysmal Junctional Tachycardia: What underlying conditions may this indicate?
digitalis toxicity MI, hypokalemia, or COPD
149
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia: When does this occur?
When an impulse is conducted to an area in AV node that causes impulse to be rerouted back into same area over and over again at fast rate. Causes fast ventricular rate.
150
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia: Factors associated with causing this include what
caffeine, nicotine, hypoxemia, and stress.
151
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia:
```
V/A Rate
V/A Rhythm
QRS Shape
P Wave
PR Interval
P:QRS Ratio
```
V/A Rate: V= 120-200 A= 150-250
V/A Rhythm Regular, sudden onset and termination of tachycardia
QRS Shape: May be abnormal
P Wave: Difficult to discern
PR Interval: If P in front of QRS , < 0.12
P:QRS Ratio : 1:1 or 2:1
152
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia: The temporary fast heart rate may reduce CO, causing what signs?
REstlessness, chest pain, SOB, pallor, hypotension, and loss of consciousness
153
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia Med Mx: Goal of med management?
Alleviate symptoms and improve quality of life.
154
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia Med Mx: Initial treatment of choice?
Catheter ablation , used to eliminate area that permits rerouting of the impulse that causes tachycardia.
155
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia Med Mx: Why may vagal manuvers be useful?
Increase parasympathetic stimulation, causing slower conduction through AV node and blockign reentry of rerouted impulse.
156
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia Pharm Therapy: What med may work if vagal maneuvers ineffective?
Adenosine, but it is short lived. If reoccurs, follow with larger dose or with calcium channel blocker.
157
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia Pharm Therapy: What is this called when P waves cannot be identified?
Rhythm may be called supraventricular tachycardia (SVT), or paroxysmal supraventricular tachycardia (PSVT).
158
Junctional Dysrhythmias - Atrioventricular Nodal Reentry Tachycardia Pharm Therapy: What can be done to help allow visualziation of P Waves?
Vagal maneuvers and adenosine may be used.
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Ventricula rdysrhythmias - Premature Ventricular Complex: What is this?
Impulse that starts in the ventricle and is conducted through the ventricles before the next normal sinus impulse.
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Ventricula rdysrhythmias - Premature Ventricular Complex: This can occur with what population?
Healthy poeple, especially with caffeine, nicotine, or alcohol intake.
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Ventricula rdysrhythmias - Premature Ventricular Complex: What may cuase this?
Cardiac ischemia or infarction, increased workload of heart, digitalis toxicity, hypoxia, acodisos, or electrolyte imbalance.
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Ventricula rdysrhythmias - Premature Ventricular Complex:
```
V/A Rate
V/A Rhythm
QRS Shape
P Wave
PR Interval
P:QRS Ratio
```
V/A Rate: Depends on underlying rhythm
V/A Rhythm: Irregulr due to early QRS, creating one RR that is shorter than others.
QRS Shape: > 0.12 seconds.
P Wave: May be absent (hidden in QRS or T) or in front of QRS
Pr Interval: IF P in front of QRS , < 0.12
P:QRS is 0:1 or 1: 1
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Ventricula rdysrhythmias - Premature Ventricular Complex: How may patient feel with this?
May say that heart skipped a beat.
164
Ventricula rdysrhythmias - Premature Ventricular Complex Med Mx: May be treated with what?
Amiodarone or Sotalol.
165
Ventricular Dysrhythmias - Ventricular Tachycardia: What is this?
When there are 3 or more PVCs in a row, occuring at rate > 100 bpm.
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Ventricular Dysrhythmias - Ventricular Tachycardia: Why is this an emergency?
Because patient is nearly always unresponsive and pulseless.
167
Ventricular Dysrhythmias - Ventricular Tachycardia
```
V/A Rate
V/A Rhythm
QRS Shape
P Wave
PR Interval
P:QRS Ratio
```
V/A Rate , V = 100-200 and A varies
V/A Rhythm: Usually regular
QRS Shape: > 0.12 seconds, bizzare abnormal shape.
P Wave: Difficult to detect
Pr Interval, Very irregular
P:QRS Ratio: If P waves present, there are usually more QRS than P.
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Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: What helps determine the initial treatment?
Identify rhythm as monomorphic (consistent QRS shape) or polymorphic (having varying QRS)
Determining existence of prolonged QT interval before VT
Patients heart function
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Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: What is given for those without acute MI or severe HF
Procainamide , a monomorphic stable VT state.
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Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: What is given for those with impaired cardiac function or acute MI
IV Amiodarone , Sotalol may also be considered
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Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: Treatment of choice for monophasic VT?
Cardioversion
172
Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: Tx of chocice for pulseless VT?/
Defibrillation.
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Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: What is the long-term mx for someone with ejection fraction < 35%
Implantable cardioverter defibrillator (ICD)
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Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: Those with EF > 35% may be managed with what?
Amiodarone.
175
Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: What should be suspected if ventricular rate above 200 bpm?
Presence of accessory pathway should be suspected.
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Ventricular Dysrhythmias - Ventricular Tachycardia Med Mx: What is the Torsades de pointes?
Polymorphic VT preceded by prolonged QT interval , which could be congenital or acquired.
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Ventricular Dysrhythmias - Ventricular Fibrillation: THis is most common with which patient
those with acute mi or coronary artery disease.
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Ventricular Dysrhythmias - Ventricular Fibrillation: what is this
rapid, disorganized, ventricular rhythm that causes ineffective quivering of the ventricles. no atrial acivity seen on ECG
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Ventricular Dysrhythmias - Ventricular Fibrillation: ANother common cause of this is brugada syndrome, which is what
patient (frequently asian) has a structurally normal heart, with few or no risk factors for CAD and fam history of sudden cardiac death
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Ventricular Dysrhythmias - Ventricular Fibrillation:
V Rate?
V Rhythm?
QRS Shape
V Rate = > 300 bpm
R Rhythm = Extremely irregular, without specific pattern
QRS Shape = Irregular, undulating waves.
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Ventricular Dysrhythmias - Ventricular Fibrillation Med mX: This is always characterized with what signs?
No heartbeat, pulse, or respirations. This is because theres no coordinated cardiac activity, so cardiac arrest and death are imminent.
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Ventricular Dysrhythmias - Ventricular Fibrillation Med mX: What is critial to survive this?
Early defibrillation, with CPr given until defibrillator is available.
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Ventricular Dysrhythmias - Ventricular Fibrillation Med mX: What is given for refractory ventriular fibrillation?
Amiodarone and epinephrine
184
Ventricular Dysrhythmias - Idioventricular Rhythm: What is this?
Occurs when impulse starts in conduction system below the AV node. Sinus node fails to create impulse or impulse is created but cannot be conducted through AV node.
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Ventricular Dysrhythmias - Idioventricular Rhythm: Characteristics when not caused by AV block?
V Rate:
V rhythm:
QRS Shape:
V Rate = 20-40 bpm. If > 40, known as accelerated
V Rhythm = Regular
QRS Shape = Bizarre , abnormal shape , > 0.12 duration
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Ventricular Dysrhythmias - Idioventricular Rhythm Med Mx: This commonly does what to the patient?
Causes them to lose consciousness and experience other signs of reduced cardiac output.
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Ventricular Dysrhythmias - Idioventricular Rhythm Med Mx: What interventions are done?
Identify underlying cause, initiate emergency transcutaneous pacing, administer iv epinephrine, atropine, and vasopressor meds.
188
Ventricular Dysrhythmias - Ventricular Asystole: Common known as what
flatline. Absent QRS complexes. no heartbeat, no pulse, and no respiration
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Ventricular Dysrhythmias - Ventricular Asystole, Med Mx: Treated thesame as what?
PEA, focusing on CPR. Rapid Assessment of the Hs andTs.
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Ventricular Dysrhythmias - Ventricular Asystole, Med Mx: What is included in the Hs and Ts?
Hypoxia, Hypovolemia , Hydrogen Ion (Acid-Base Imbalance), Hypoglycemia, Hyperkalemia, Hyperthermia, Toxins, Tamponade, Tension Pneumothorax or Thrombus
191
Conduction Abnormalities: What steps occur when assessing rhythm strip?
Underlying rhythm identified.
Then PR Interveral assessed for AV block, which occurs when impulsse through AV node is decreased or blocked.
192
Conduction Abnormalities: What can cause an AV block?
Meds (digitalis, calcium channel b lockers), lyme disease, MI, infarction
193
Conduction Abnormalities: What is usually accompanied by increased vagal tone?
Sinus bradycardia.
194
Conduction Abnormalities: What kind of symptoms can AV blocks produce?
First rarely caused hemodynamic effects. Other may result in decrease HR, decrease in perfusion to vital organs.
195
Conduction Abnormalities, 1st Degree AV Block: When does t his occur
When all atrial impulses are conducted through AV node into ventricles at rate slower than normal
196
Conduction Abnormalities, 1st Degree AV Block:
```
V/A Rate
V/A Rhythm
QRS Shape
P Wave
PR Interval
P:QRS
```
V/A Rate - Depends on underlying rhythm
V/A Rhythm: Depends on underlying rhythm
QRS Shape: May be abnormal
P Wave: In front of QRS Complex
Pr Interval: > 0.20 seconds
P:QRS Ratio - 1:1
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Conduction Abnormalities, 2nd Degree AV Block Type I: When doe sthis occur?
When there is a repeated pattern in which all but one of atrial impulses conducted through AV node into ventricles. Each impulse take longer in conduction than one before, until one blocked.
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Conduction Abnormalities, 2nd Degree AV Block Type I: What happens because the AV node is not depolarized by the blocked atrial impulse?
AV node has time to fully repolarize so that next atrial impulse can be conducted within shortest amount of time
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Conduction Abnormalities, 2nd Degree AV Block Type I:
```
V/A Rate
V/A Rhythm
QRS Shape
P Wave
PR Interval
P:QRS
```
V/A Rate = V Rate lower than A
V/A Rhythm = RR gradually shortens until theres another long RR
QRS Shape: May be abnormal
P Wave , in front of QRS
PR Interval: Become longer with each succeeding ECG until P wave not followed by QRS
P:QRS Ratio - 3:2 , 4:3, 5:4 and so forth
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Conduction Abnormalities, 2nd Degree AV Block Type II: What is this?
Occurs when only some of the atrial impulses are conducted through AV node into ventricles.
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Conduction Abnormalities, 2nd Degree AV Block Type II:
V/A Rate
V/A Rhythm
QRs Shape
P Wave
PR Interval
P:QRS
V/A Rate - V Rate lower than A
V/A Rhythm: RR interval is usually regular
QRS Shape: Usually abnormal
P Wave: In front of QRS complex
Pr Interval: Constant for P waves before QRS complexes
P:QRS Ratio: 2:1 , 3:1, 4:1, 5:1 nd so forth
202
Conduction Abnormalities, 3rd Degree AV Block: When does this occur
When theres no atrial impulse conducted through AV node into ventricles. Two impulses stimulate the heart. One stimulates the ventricles represented by QRS complex and one stimulates atria, represented by P wave.
203
Conduction Abnormalities, 3rd Degree AV Block: Having two impulses stimulate the heart results in what condition?
AV Dissociation, which may occur during VT
204
Conduction Abnormalities, 3rd Degree AV Block:
```
V/A Rate
V/A Rhythm
QRS Shape
P Wave
Pr Interval
P:QRS Ratio
```
V/A Rate - Depends on escape rhythm. V is lower than A
V/A Rhythm: PP regular, RR Regular, but not equal to each other
QRS: Depends on escape rhythm
P Wave: Depends on underlying rhythm
PR: Very iregular
P:QRS - More P waves than QRS compelxes
205
Conduction Abnormalities, Med Mx: Treatment geared toward what?
Increasing HR to maintain a normal cardiac output.
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Conduction Abnormalities, Med Mx: Initial treatment of choice?/
IV bolus of atropine, through not effective in second-degree AV block, type II or third-degree AV block.
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Conduction Abnormalities, Med Mx: What to do if patient doesn't respond to atropine?
Temporary transcutaneous pacing may be started.
208
Pt With Dysrhythmia - Assessment: Previous occurences of decreased CO may produce what signs?
Syncope (fainting), lightheadedness, dizziness, fatigue, chest discomfort, and palpitations.
209
Pt With Dysrhythmia - Assessment: Possible causes of dysrhytmias?
Heart disease, COPD, meds.
210
Pt With Dysrhythmia - Assessment: What meds are known to cause this?
Digoxin
211
Pt With Dysrhythmia - Assessment: What physical signs may be detected during assessment?
Pale and cool skin. Signs of fluid retention with neck vein distention and crackles and wheezes.
212
Pt With Dysrhythmia - Assessment: What problems may occur from this?
Cardiac arrest, HF, and Thromboembolic event
213
Pt With Dysrhythmia - Assessment: Major goal of this type of patient?
Eliminating or decreasing the occurence of dysrhythmia, maintain CO,
214
Monitoring and Managing Dysrhythmia to Maintain CO: What does nurse assess to determine the hemodynamic effect?
Patients blood pressure, rate and depth of respirations and breath sounds.
215
Monitoring and Managing Dysrhythmia to Maintain CO: Why is usually prescribed to treat this?
Antiarrhythmic medication
216
Monitoring and Managing Dysrhythmia to Maintain CO: Why may a 6-minute walk test be prescribed?
To identify the patient's ventricular rate in response to exercise.
217
Reducing Anxiety for Dysrhytmia: What should nurse do when patient has anxiety?
Stay with patient and provide assurance of safety and security while maintaining calm and reassuring attitude.
218
Reducing Anxiety for Dysrhytmia: What should patient be taught if med has potential to alter heart rate?
Should be taught how to take their pulse before each dose and notify provider if it is abnormal
219
Adjunctive Modalities and Mx: Acute dysrhythmias may be treated with what
medications or external electrial therapy (emergency defib, cardioversion, or pacing).
220
Adjunctive Modalities and Mx: choice of medication depends on what ?
specific dysrhythmia and its duration, presence of heart disease, and patients resposne to treatment.
221
Adjunctive Modalities and Mx: Most common therapies of meds ineffective?
Electric cardioversion and defibrillation for acute tachydysrhytmia and implantable devices (pacemakers for bradycardia and ICD for chronic tachydysrhytmias).
222
Cardioversion and Defib: How do they work and treat what?
Treat tachydysrhythmias by delivering electrical curent that depolarizes a critical mass of myocardiac cells. SA node then able to recapture its role as pacemaker.
223
Cardioversion and Defib: When does cardioversion deliver shock?
Electrical current synchronized with patients electrical events
224
Cardioversion and Defib: How do biphasic types of defibrillators work?
Deliver an electrical charge from one paddle. Causes less myocardiac damage.
225
Cardioversion and Defib: How do defibrillator multifunction conductor pads work?
Contain a conductive medium and are connected to defib to allow for hands off defib, Reduces risk of touching patient during procedure.
226
Electrical Cardioversion: What is this?
Delivery of a "timed" electrical current to terminate a tachydysrhythmia. Synchronizes with ECG on cardiac monitor and discharges during ventricular depolarization (QRS complex)
227
Electrical Cardioversion: Why is this important that this goes does ventricular depolarization (QRS complex)?
Prevents discharge form occuring during vulnerable period of repolarization (T wave), which could result in VT.
228
Electrical Cardioversion: What happens when the synchronizer is on?
No electrical current is delivered if QRS complex not there. Ensure discharge buttons must be held down until shock delivered.
229
Electrical Cardioversion: What is done if cardioversion is elective and dysrhythmia lasted longer than 48 hours
anticoagulation for a few weeks before cardioversion. Digoxin usually withheld 48 hours before.
230
Electrical Cardioversion: Indications of this being successful include what?
Conversion to sinus rhythm, adequte peripheral pulses, and adequate blood pressure.
231
Defibrillation: When is this used?
Emergency, and treatment of choice for ventricular fibrillation and pulseless VT.
232
Defibrillation: What power setting should this be set to?
360 joules. Initial may be at 150-200.
233
Defibrillation: What is given after successful defibrillation?
Epinephrine , to make it easier to convert the dysrhythmia to a normal rhythm with next defibrillation.
234
Electrophysiology Studies: What is this?
EP is an invasive procedure used to evaluate and treat various chronic dysrhythmias that caused cardiac arrest and significant symptoms.
235
Electrophysiology Studies: This is used to identify wwhat?
Identify the impulse formation
Assess function or dysfunction of SA/AV Node
Identify location and mechanism of dysrhythmogenic foci
Assess effectiveness of antiarrhythmic meds
236
Electrophysiology Studies: How is this performed?
Through a small incision in the femoral m threaded through inferior vena cava, and advanced into heart. Electrodes positioned in specific positions. Allows electrical signal to be corded form within heart.
237
Electrophysiology Studies: What locations are these placed in?
Coronary sinus, near tricuspid valve, and apex of right ventricle.
238
Electrophysiology Studies: Electrodues allow the clinician to do what?
Introduce a pacing stimulus to the intracardiac are at precisely timed interval and rate, thereby stimulating area.
239
Electrophysiology Studies: What does it mean if it takes a prolonged time for sinus node to resume control when this removed?
Indicates dysfunction of the sinus node.
240
Electrophysiology Studies: One of the main purposes of programmed stimulation is to assess what
ability of the area surrounding the electrode to carry a reentry dysrhythmia.
241
Electrophysiology Studies: What is it called when dysrhythmia can be reproduced by programmed sitmulation?
Called inducible. If on follow-up it cannot be induced, treatment considered effective.
242
Pacemaker Therapy: What is this?
An electronic device that provides electrical stimuli to the heart muscles. Used when patient has slow-than normal impulse formation, or symptomatic AV or ventricular conduction disturbance.
243
Pacemaker Therapy: When are temporary pacemakers used?
To support patients until they improve or receive a permanent pacemaker.
244
Pacemaker Designs and Types: Consist of what two components?
Electronic pulse generator and pacemaker electrodes. Generator deermiens rate and strength or output.
245
Pacemaker Designs and Types: What is sensitivity?
Level that the intracardiac electrical activity must exceed to be sensed by the device.
246
Pacemaker Designs and Types: Where can the endocardial lead be placed permanently?
Passed into the heart through the subclavian, axillary, or cephalic vein and conected to a permanent generator.
247
Pacemaker Designs and Types: Why are permanent pacemaker generators insulated/
To protect against body moisture and warmth and have filters that protect them from electrical interference.
248
Pacemaker Designs and Types: What happens if patient suddenly develops bradycarida, symptomatic an dhas a pulse and unresponse to atropine?
Emergency pacing may be starting with transcutaneous pacing.
249
Pacemaker Generator Functions: The pacemaker usually paces what?
Atrium, and then the ventricle when no ventricular activity in sensed for a period of time.
250
Pacemaker Generator Functions: How does this appear on a ECG?
Straight line on ECG when pacing initiated. Line that represents pacing called pacemaker spike. P and QRS should follow their spikes.
251
Pacemaker Generator Functions: What does VVI pacing cause loss of? (Paces ventricle, senses ventricular activity, and paces if ventricles do not depolarize)
AV synchrony and atrial kick.
252
Pacemaker Generator Functions: Pacemaker syndrome causes symptoms of what
chest discomfort , SOB, fatigue, activity intolerance and postural hypotension.
253
Pacemaker Generator Functions: AAI (single chamber atrial pacing) ensures what?
Synchrony between atrial and ventricular stimulation, as long as patient has no conduction disturbance sin AV node.
254
Pacemaker Generator Functions: cardiac resynchronization therapy has been found to mofidy what?
Intraventricular, interventricular and AV conduction defects associated with left ventricular dysfunction and HF
255
Complications of Pacemaker Use: Most common complication after insertion?
Dislogement of pacing electrode, so make sure to minimize patient activity. Restrict side of implantation.
256
Complications of Pacemaker Use: What signs may a patient experience with malfunction?
Bradycardia and symptoms of decreased CO (diaphoresis, postural hypotension, syncope)
257
Complications of Pacemaker Use: Typical follow-up schedule for this?
Every 2 weeks forfirst month, then every 4-8 weeks for 3 years, and every 4 weeks after
258
Implantable Cardioverter Defibrillator: What is this?
Electronic device that detects and terminates life-threatening episodes of tachycardia or fibrillation, especially those ventricular in origin. Those at higih risk for VT or ventricular fibrillation benefit from tis.
259
Implantable Cardioverter Defibrillator: What type of person would this be indicated for?Those
Those with coronary heart disease who are 40 days postacute MI with moderate to severe left ventricular dysfunction at risk for sudden cardiac death
260
Implantable Cardioverter Defibrillator: What may be given while they wait for htis surgery?
May be prescribed vestlike automated defibrillator, which works like AED. Vest vibrates and issues alarm saying shock kis imminent.
261
Implantable Cardioverter Defibrillator: What does this do for a batteru?
Has a generator implanted in SQ pocket.
262
Implantable Cardioverter Defibrillator: Designed to respond to what two crieria?
Rate that exceeds a predetermined level and change in isoelectric line segments. When dysrhythmia occurs, it prepares and analyzes for shock.
263
Implantable Cardioverter Defibrillator: What may be given with this to reduce occurence of tachydysrhythmia and reduce frequency of ICD discharge?
Antiarrhythmic medication.
264
Implantable Cardioverter Defibrillator: What are three different ways ICDs can respond to a situation?
Antitachycarida pacing, where electrical impulses delivered at fast rate to disrupt trahcycarida
Low energy cardioversion
Defibrillation
265
Implantable Cardioverter Defibrillator: Why is pacing used?
To terminate tachycardias caused by conduction disturbance called reentry, which is repetitive restimulation of the heart by same impulse.
266
Implantable Cardioverter Defibrillator: What complications can occur with this?
Surgery-related infection, or complications related to the defibrillator.
267
Implantable Cardioverter Defibrillator: What is the incision site observed for?
Bleeding, hematoma formation or infection
268
Implantable Cardioverter Defibrillator: Chest X-Ray done after procedure why
To document position of leads in addition to ensuring that proccedure did not cause pneumothroax.
