UNIT 1-ECG AND CODE MANAGEMENT Flashcards
(114 cards)
1
Q
Identify this rhythm
A
Artifact
- You will see artifact on the monitor when leads and electrodes are not sexure, or if there is muscle activity (shievering) or electrical interferce
- Artifact is a distortion of the baseline and waveforms seen on the ECG
2
Q
What are your nursing interventions when you have Artifact on your ECG?
A
Because accurate interpretation of cardiac rhythm is difficult when artifiact is present. If artifact occurs, check the connections in the equipment. You may need to replace the electrodes if the conductive gel has dried out.
3
Q
What are the four properties of cardiac cells that enable the conduction system to start an electrical impulse, send it through the cardiac tissue, and stimulate muscle contraction?
A
- Automaticity
- Excitability
- Conductivity
- Contractility
4
Q
What is automaticity?
A
The ability to initate an impulse spontaneously and continuously
5
Q
What is excitability?
A
Is the ability to be electrically stimulated
6
Q
What is conductivity?
A
The aility to transmit an impusle along a membrane in an orderly manner
7
Q
What is contractility?
A
The ability to respond mechanically to an impulse
8
Q
Describe the function of the conduction system?
A
- Normal cardiac impulse begins in the sinoatrial (SA) node in the upper right atrium.
- It spreads over the atrial myocardium via interatrial pathways and internodal pathways, causing atrial contraction.
- The impulse then travels to the atrioventricular (AV) node, through the bundle branches. It ends in the purkinje fibers, which transmits the impulse to the ventricles.
9
Q
Dysrhythias result from disorders of….
A
impusle formation, conduction of impulses or both
10
Q
The SA node is the normally the ___1___ of the heart? firing at how many times per min?
A
- Pacemaker
- 60-100
11
Q
What should we know about secondary pacemakers from another site?
NOT CLEAR ON THIS
A
Can fire in two ways
1. If the SA node fires more slowly than a secondary pacemaker, the electrical signals from the secondary pacemaker may “escape” The secondary pacemaker will then fire automatically at its intrinisc rate.
2. Another way that secondary pacemakers can start is when they fire more rapidly than the normal pacemaker of the SA node. “triggered beats” (early or late) may come from an ectopic focus or accessory pathway which is outside the normal conduction pathway in the atria, AV node or ventricles. The results in a dysrthmia, which replaces the normal sinus rhythm.
12
Q
What is the intrinsic rate of the AV node or the His- Purkinje system?
A
AV node fires at a rate of 40 to 60 times per minute or the His-purkinje system at a rate of 20-40 times per min
13
Q
The autonomic nervious system play an important role in the rate of….. in the cardiac system.
A
- Impulse formation
- Speed of conduction
- Strength of cardiac contraction
14
Q
What are the components of the autonomic nervous system that affect the heart?
A
- Vagus nerve fibers of the parasympathetic nervous system and nerve fibers of the sympathetic nervous system
15
Q
How does stimulation of the vagus nerve which a part of the parasympathetic nervous system affect the heart?
A
- Decreases rate of firing of the SA node
- Slowed impusle conduction of the AV node
16
Q
How does stimulation of sympathetic nerves in the sympathetic nervous system affect the heart?
A
- Increases rate of SA node
- Increases impulse conduction of AV node
- Increase cardiac contractility
17
Q
What are some sympathetic nervous system responses?
A
Stressed state
1. Pupils expand
2. Fast & shallow breathing
3. Heart pumps faster
4. Gut INACTIVE
18
Q
What are some parasympathetic nervous system symptoms?
A
Calm
1. Pupils shrink
2. Slow deep breaths
3. Heart slows
4. Gut ACTIVE
19
Q
What is Telemetry monitoring?
A
It is the observation of the patients HR and rhythm at a site distant from the patient
20
Q
What are the 2 types of systems used for telemetry monitoring?
A
- Centralized monitoring
- Bedside advanced alarm systems
21
Q
Centeralized monitoring system- ECG requires….
A
The nurse or a telemetry tech to contionusly observe a group of patients ECGs at a central location
22
Q
Advanced alarm system bedside monitoring does not require….
A
Constant survallience. These systems have the cability of detecting and storing data. Advanced alarm systems provide different levels of detection of dysrhythimas, ischemia or infarction.
23
Q
What do we need to remember about computerized monitoring systems?
A
They are not fail proof. We should frequently assess all monitored patients for any signs of hemodynamin instability
24
Q
What should we know about the P wave?
A
- It is the 1st waveform that is normally seen.
- This wave should be upright (postive deflection) with a rounded top in lead
25
The P wave represents what part of the cardiac conduction system?
The P wave represents the SA node sending out an electrical impulse and represents atrial depolarization (contraction)
26
What should we know about the QRS wave (or complex)
1. Normally follows the P wave.
2. Can take on many different forms
3. Normal QRS complexes are usually pointy and skinny in width.
27
The QRS complex represents what in the cardiac conduction system?
This complex represents ventricular depolarization (contraction) The ventricles depolarize from the endocardial layer (inside of the heart) to the epicardial layer (outermost layer of the heart)
28
How do we calculate the HR on an ECG
1. Count the number of QRS complexes in 1 min
2. QRS complexes in 6 seconds and multiply by 10
29
How does regularity determined when looking at the ECG?
Regularity can be determined by counting the boxes between the waveforms being measured, such as p wave to pwave or qrs to qrs complex (r to r). A regular rhythm will have the same number of boxes or equal space between waveforms or complexes
30
What are important concepts and questions to consider with our assessment of cardiac rhythm?
1. Interpret the rhythm AND evaluate the clinical status of the patient
2. Is the patient hemodynamically stable?
3. Determine cause of dysrthymia
- This is a priority. For example, tachycardias may be the result of a fever and may cause a decrease in cardiac output and hypotension. Electrolyte distubances can cause dysrthmias and if not treated can be life-threatening
4. Treat the patient, not the monitor
31
How should we assess the cardiac rhythm?
When assessing a cardiac rhythm, use a consistent and systematic approach.
1. Pwave
- look for its presence, is it upright or more inverted? Is there one for every QRS complex or more than one? Are there atrial fibrillatory or flutter waves?
2. P-R interval
- Is it normal duration or prolonged
3. Ventricular rate and rhythm?
- Is it regular or irregular
4. QRS complex
- Measure the duration of the QRS complex. Is it normal or prolonged
5. ST segment
- Is it isometric (flat), elevated, or depressed
6. Q-T interval
- Measure the duration of the Q-T interval is it normal or prolonged
7. T wave
- Is it upright or inverted
32
Identify this rhythm
Normal Sinus Rhythm which refers to a rhythm that starts in the SA node at a rate of 60-100 times per min and follows the normal conduction path way
33
Identify this dysrhythmias
Sinus Bradycardia
34
What do we need to know about sinus bradycardia
1. Sinus bradycardia may be a normal sinus rhythm in aerobically trained athletes and in some people during sleep
2. May be associated with some disease states
35
What is sinus bradycardia?
It occurs in response to a parasympathetic nerve stimulation and certain drugs, carotid sinus massage, valsalva maneuver, hypothermia, increased introcular pressure, vagal stimulation and administration of certain drugs like adrenergic blockers, calcium channel blockers
36
What are some common disease states associated with sinus bradycardia?
1. Hypothyroidism
2. Increased ICP
3. Hypoglycemia
4. Inferior myocardinal infarction (MI)
37
What are the manifestations of sinus bradycardia
1. Hypotension
2. Pale, cool skin
3. Weakness
4. Angina
5. Dizziness or syncope
6. Confusion or disorienatation
7. SOB
Clinical significance of sinus bradycardia depends on how the patient tolerates it.
38
Symptomatic bradycardia refers to a HR that is....
Less than 60beats/min and is inadequate for the patients condition, causing the patient to experience symptoms
39
Treatment of sinus bradycardia includes?
1. Atropine (anticholinergic drug) usually given to symptomatic patients
2. Pacemaker
3. Stop offending drugs
40
Identify this rhythm?
Sinus Tachycardia
41
Identify this rythem
Sinus Tachycardia
42
What do we need to know about sinus tachycardia
1. The conduction pathway is the same in sinus tachycardia as that in normal sinus rhythm.
2. The p wave is normal, procedes each QRS complex and has a normal shape and duration
3. The P-R interval is normal and the QRS complex has a normal shape and duration
43
What is the rate of sinus tachycardia?
101-180beats/min
44
What causes sinus tachycardia?
1. The discharge rate from the sinus node increases because of vagal inhibition or sympathetic stimulation
2. Sinus tachycardia is associated with physiologic and psycholotic stressors such as exercise, fever, pain, hypovolemia, anemia, hypoxia, hypoglycemia, MI, heart failure, hyperthyridism, axiety and fear
3. It can also be an effect of drugs such as epi, norepinephrine, atropine, caffeine, theophylline, or hydralazine, sudafed
45
What are manifestations of sinus tachycardia?
1. Dizziness
2. Dyspnea
3. Hypotension
4. Angina in patients with CAD
Clinical significance of sinus tachycardia depends on the patients tolerance of increased HR.
46
What is the treatment of sinus tachycardia
1. Guided by cause for example for the patient who is experiencing tachycardia from pain... effective pain managment will treat tachycardia
2. Vagal maneuver
3. B-adrenergic blockers
- Metoprolol can be given to reduce HR and decrease myocardial oxygen consumption
47
Identify this rythem
PSVT- Paroxysmal Suptraventricular tachycardia
48
What is PSVT?
Is a dysrhythmia startin gin an etopic focus anywhere above the bifurcation of the bundle of HIS. Identification of the ectopic focus is often difficult even with a 12 lead.
49
What is the HR of someone experiencing PSVT
151-220 beats/min and the rhythm is regular or slightly irregular
50
What does the rhythm present with PSVT?
The P wave is often hidden in the preceding T wave. If seen, it may have an abnormal shape. The P-R interval may be shortned or normal, and the QRS complex is usually normal.
51
Identify this rhythm?
PSVT
52
Why do PSVT occur?
1. Because of a reentrant phenomenon (reexcitation of the atria when there is a one-way block)
2. Usually a PAC triggers a run of repeated premature beats
53
What is a PSVT?
Paraoxysmal refers to an abrupt onset and ending. Termination is sometimes folled by a brief period of asystole
54
In a normal heart PSVT is associated with...
1. Overexertion
2. EMotional stress
3. deep inspiration
4. Stimulants such as caffeine and tobacco
PSVT is also associate dwith rheumatic heart disease, dig tox, CAD, or cor pulmonale
55
What are the manifestations of PSVT?
1. HR is 150-220 beats/min (add for clarification)
2. HR >180 leads to decreased cardiac output and stroke volume
3. Hypotension
4. Dyspnea
5. Angina
Clinical significance of PSVT dpends on the associated symptoms
56
What is the treatment of PSVT?
1. Vagal stimulation
2. IV Adenosine #1 Drug
3. IV b-adrenergic blockers (Sotalol)
4. Calcium channel blockers (Diltizem)
5. Amiodarone
6. DC cardioversion (direct current)
- used if vagal stimulation and drug therapy are ineffective and the patient becomes hemodynamically unstable.
57
Identify this rhythm
Effect of Adenosine
1. Explain that the patient may feel chest pressure afte med is given
2. Injection site should be as close to heart as possible
3. Monitor patients ECG continously brief periods of asystole is common
4. Assess for flushing,dizziness, chest pain or palpitation
58
Identify this rhythm
Atrial flutter which is a atrial tachydysrthythmia identifed by recurring, regular sawtooth-shaped flutter waves that originate from a signle extopic focus in the right atrum or less commonly, the left atrium
59
What is the atrial rate of atrial flutter
200-350 beats per min
60
What is the ventricular rate of atrial flutter?
150 beats/min
61
How is atrial flutter discribed?
1. Atrial rhythm is regular and ventricular rhythm is usually regular
2. The P-R interval is variable and not measureable
3. The ORS complex is usually normal. Becuase the AV node can delay signal from the atria, there is usually some AV block in a fixed ratio of flutter waves to QRS complexes
62
How is adenosine given?
IV closest to the patient givin in 1-3 seconds followed by a rapid flush of 20ml of saline.
1st dose 6mg, 2nd dose 12 mg,
63
Atrial flutter is typically associated with?
1. Chronic lung disease
2. Cardiomyopathy
3. Hyperthyroidism
4. Hypertention
5. PE
6. drugs
- digoxin, quindine, and epi
Can occur in a healthy heart but its rare.
64
What is the treatment of atrial flutter
1. Pharmacologic agent
- Calcium channel blocker and b adrenergic blockers, antidysrthymic
2. Electrical cardioverson may be performed to convert the atrial flutter to sinus rhythm in an emergency ( The patient is hemodynamically unstable) and electively.
3. Radiofrequency catheter ablation is a treatment of choice for atrial flutter. Usuing a low-voltage, high-frequency form of electrical engery. The tissue is ablated (or destroyed) the dysrhythmia is ended and normal sinus rhythm is restored.
65
Patients with atrial flutter at at an increased risk of?
Stroke because of the risk of thrombus formation in the atria from the stasis of blood. Warfarin is given to prevent stroke in patients with atrial flutter
66
What is the primary treatment goal of atrial flutter?
1. Slow ventricular response by increase AV block.
67
Identify this ryrthm
Atrial Fibrillation
1. Most common clnically significant dysrhymia w/ respect to morbidity and mortality rates and economic impact
2. The dysrhythmia may be paroxymal and end spontanously or be persistent lasting longer than 7days
68
What causes Afib and what can it cause if left untreated?
1. As with atrial flutter-- causes a decrease in CO and increased risk of stroke
2. Often develops acutely with thyrotoxicosis, alcohol intoxication, caffeine, electrolyte disturbances, stress, cardiac surgery
2. A fib results in a decrease in CO because of ineffective atrial contractions (loss of atrial kick) and/or a rapid ventricular response. Thrombi (clots) form in the atria because of blood stasis. An embolized clot may develop and pass to the brain, causing a stroke.
69
Afib is usually occurs in the patient with....
1. Heart disease
2. CAD
3. Rheumatic heart disease
4. Cardiomyopathy
5. HTN heart disease
6. HF
7. Pericadiitis
70
How is afib characterized?
1.By a total disorganization of atrial electrical activity due to multiple ectopic foci resulting in loss of effective atrial contraction
2.During atrial fibrillation, the atrial rate may be as high as 350 to 600 beats/min
3.P waves are replaced by chaotic, fibrillatory waves.
4.Ventricular rate varies and the rhythm is ususally IRREGULAR
71
When the ventricular rate is between 60-100 beats/min in a fib this is considered....
Atrial fibrillation with controlled ventricular response
example b
72
Atrial fibrillation with a ventricular rate greater than 100 beats/min is atrial fibrillation with a ...... response
rapid or uncontrolled ventricular response aka AFIB with RVR
example c
73
What is the treatment of Atrial Fibrillation?
1. Slow the ventrial response by increasing the AV block
2. Drugs to control ventricular rate and/or convert to sinus rhythm (amiodarone and ibutilide most common)
3. Electrical cardioversion
4. Anticoagulation
5. Radiofrequency ablation
6. Maze procedure with cryoblation
74
What is the goal of treatment for afib?
Goal of treatment includes a decrease in a ventricular response (to less than a 100 beats/mins) prevention of stroke and conversion to sinus rhythm, if possible.
75
If a patient is in atrial fibrillation for longer than 48 hours what must we initate before the cardioversion?
anticoagulation therapy with warfarin for 3 to 4 weeks before
76
What might be ordered in order to rule out the presence of clots in the atria before a cardioversion?
A transesophageal echocardiogram
if there are no clots present we can proceed
77
What happens if drugs or cardioversion cannot convert afib to a normal sinus rhythm?
Long-term anticoagulation therapy is required and warfarin is drug of choice
78
Identify this rhythm?
PVC: Premature ventricular contraction which is a contraction coming from an ectopic focus in the ventricles. It is the premature (earlY)occurence of a QRS complex
A PVC is wide and distorted in shape compared to a qrs complex coming down the normal conduction pathway
79
What are PVCs that arise from different foci and appear in a different shape from each other called?
Mulifocal PVC
80
PVCs that have the same shape are called?
Unifocal PVCs
81
When every other beat is a PVC, the rhythm is called...
Ventricular bigeminy
82
When every third beat is a PVCs it is called...
Ventricular trigeminy
83
What occurs when there are three or more consecutive PVCs?
Ventricular tachycardia
84
PVCs are associated with....
1. Stimulants such as caffeine, alcohol, nicotine, aminophylline, epi, isoproterenolm and digoxin, electrolye imbalances, hypoxia, heart disease, emtional stress, fever, exercise
2. Disease states like MI, mitral valve prolapse, HF and CAD
85
Treatment for PVCs include?
1. Correct cause
2. Antidysrthmics
Usually not harmful in the patient with a normal heart
86
Identify this rhythm?
Ventricular Tachycardia
87
Ventricular rate in vtach is how many beats/min
150 to 250 beats/min
Rhythm may be regular or irregular
88
What causes torsades de pointe
Mg deficiency. Can only give mg if you know what the mag level is
89
Ventricular tachycardia is associated with....
1. Heart disease
2. Electrolyte imbalances
3. Drugs
4. CNS disorders
90
Patients in Vtach can be considered __1__ or __2__
1. Stable (has a pulse)
2. Unstable (no pulse)
91
Identify this rhythm
Ventricular fibrillation
Vfib which is a severe derangment of the heart rhythm characterized on ECG by irregular waveforms of varying shapes and amplitude. This represents the firing of multiple ectopic foci in the ventricle. Mechanically the ventricle is simply quievering with no effective contraction, and consequently no CO occurs.
Lethal dysrhythmia- HR not measurable. Irreglar and chaotic.
92
VFIB is associated with
1. MI
2. Ischemia
3. Disease states
4. Procedures
93
How does a patient present in vfib?
Unresponsive, pulseless and apneic
If not treated rapidly, dealth will result
94
How do you treat VFIB?
1. Treat with immediate CPR and ACLS
2. Defibrillation
3. Drug therapy (epinephrine, vasopression)
95
Identify this rhythm
Asystole- represent the total absence of ventricular electrical activity
Occasionally P waves are seen
No ventricular contraction occurs because depolarization does not occur
96
How do patients with asystole present?
Unresponsive, pulseless, and apneic
Lethal and requires immediate tx
You should always assess rhythm in more than one lead..
97
What is the prognosis of a patient in asystole?
Poor
98
Asystole is usually the result of...
Advanced cardiac disease, severe conduction disturbance, or end stage HF
99
How is asystole treated?
Treat with immediate CPR and ACLS measures
Epinepherine and or vasopressin
Intubation
100
Identify this rhythm
HINT NO PULSE
Pulseless electrical activity- Is a situation in which organized, electrical activity is seen on the ECG, but there is no mechanical activity of the ventricles and the patient has NO PULSE
Prognosis is POOR unless the underlying cause is quickly identified and treated
101
What are your Hs and Ts?
| MUST KNOW
6H
5p
H's
1. Hypovolemia
2. Hypoxia
3. Hydrogen ION (acidosis)
4. Hyper-/hypokalemia
5. Hypoglycemia
6. Hypothermia
T's
1. Toxins(drug overdose)
2. Tamponade (cardiac)
3. Thrombosis (MI and pulmonary)
4. Tension Pneumothorax
5. Trauma
102
What is the treatment of PEA?
1. CPR followed by intubaiton and IV epinephrine
2. Treatment is directed toward correction of the underylying cause
103
Identify this rhythm
3rd degree AV heart block (complete heart block)- Constitutes one form of AV dissociation in which no impulses from the atria are conducted to the ventricles. THe atria are stimulated and contract independently of the ventricles. the ventricular rhythm is an escape rhythm, and the ectopic pacemaker may be above or below the vifurcation of the bundle of his
Atrial rate is usually a sinus rate of 60-100
Ventricle rate depends on the site on the site of the block. if its the AV node the rate is 40-60 beats/min and if its in the his-purkinje system it is 20-40 beats/min
103
104
Describe the characteristic of thrid degree AV heart block on the ECG
1. Atrial and ventricular rhythms are regular but unreleated to each other
2. The P wave has a normal shape
3. The P-R interval is variable and there is no relationship between the Pwave and the QRS complex.
4. THe QRS complex is normal if an escape rhythm is initated at the bundle of his or above it is widened if an escape rhythm is initatied below the bundle of his.
105
3rd degree AV heart block (complete heart block) is associated with.... and results in... which can lead to what....
1. Associated with severe heart disease (CAD, MI), some systemic disease (amylodosis), certain drugs (digoxin, b-adrenergic drugs, calcium channel blockers)
2. Usually results in decreased cardiac output with subsequent ischemia, HF, and shock
3. Can Lead to syncope, HR and shock
106
How is 3rd degree AV heart block treated?
1. Pacemaker
2. Drugs to increase heart rate if needed while awaiting pacing. (atropine, dopamine,epi) usually temporary to increase HR and support BP until temporary pacing is started. Will need a permenant pacemaker asap.
107
What is a pacemakers purpose?
1. Control heart rate when conduction is compromised
2. Single chamber pacemaker- paces either the atria or ventricle
3. Dual chamber pacemaker- paces both atrum and ventricle
108
109
What are CPR ratio for an adult?
30:2
110
What is our CPR rate for an adult?
100-120 compressions per min
111
How many breaths per 6 seconds
2
112
How many J do we charge our biphasic defibrillator to?
120-200J
113
How many J do we charge our monophasic defibrillator to?
360
