Vitals & EKG

Question 1

What should you assess in tachycardic patients?

Answer 1

if they are febrile, dehydrated (nausea/vomiting/diarrhea?), perfusing (skin color, skin temperature and skin dryness), and always match the rate with a blood pressure.

Question 2

What should you assess in bradycardic patients?

Answer 2

assess their alertness, medications, ask about any existing cardiac conditions or if the patient has passed out recently, and again always match the heart rate with a blood pressure

Question 3

Is hypotension concerning?

Answer 3

According to the American Heart Association, hypotension isn’t concerning unless it is symptomatic.

Question 4

Pre-hypertensive systolic blood pressure

Answer 4

between 120 and 129 mmHg with the diastolic blood pressure still being less than 80 mmHg.

Question 5

Stage 1 Hypertension

Answer 5

SBP starts at 130 mmHg

DBP between 80-89 mmHg.

Question 6

Stage 2 Hypertension

Answer 6

SBP 140 or higher

DBP higher than 90 mmHg.

Question 7

Hypertensive Urgency

Answer 7

BP higher than 180/120 W/O any end organ failure.

Question 8

Hypertensive Emergency

Answer 8

a BP higher than 180/120 mmHg WITH end organ failure

Question 9

Neurological S/S of end organ failure include

Answer 9

Signs and symptoms of encephalopathy
Altered LOC
Dizziness
Headache
Stroke
Seizures

Question 10

Ophthalmology S/S of end organ failure include

Answer 10

Retinopathy
Papilloedema (optic disc swelling)
Retinal Hemorrhage

Question 11

Cardiovascular S/S of end organ failure include

Answer 11

EKG changes
Chest pain
S3 and S4 heart sounds

Question 12

Renal S/S of end organ failure include

Answer 12

Hematuria (blood in urine)

Oliguria

Question 13

How is MAP calculated?

Normal values?

Answer 13

(SBP + (2xDBP) ) /3 = MAP

the heart spends twice as much time in diastole than systole.

Generally the goal for a MAP is between 60 and 100 mmHg.

Question 14

What is pulse pressure?

Normal values?

Answer 14

a measurement of the difference between the systolic blood pressure and diastolic blood pressure. A normal pulse pressure is between 30-40 mmHg.

Question 15

What is Pulmonary Wedge Pressure (PWP)?

Normal values?

Answer 15

• Pt would be in ICU*
• a measurement of left atrial pressure.
• a balloon to be placed in a patient’s pulmonary artery branch
• helps to diagnose left ventricular failure and is the gold standard for diagnosis of acute pulmonary edema

~systolic (normal range 15-30 mmHg) and diastolic (normal range 4-12 mmHg)

Question 16

What signifies if a patient is positive for orthostatic hypotension?

Answer 16

If the SBP is greater or less than than 20 mmHg, the heart rate is greater or less than 20 BPM, or the patient is symptomatic (dizziness, lightheadedness, or fainting with position changes)

Question 17

What can orthostatic hypotension indicate?

Answer 17

can indicate GI bleeding/blood loss, anemia, dehydration, etc. The first line of treatment, if appropriate, is to give fluids (orally if tolerated) and reassess orthostatics to eliminate dehydration. It is likely that the provider will want to also check for any blood in the stool as well as a CBC for the hemoglobin results.

Question 18

If a patient is suspicious for an aortic dissection or aneurysm, how are VS assessed?

Answer 18

take the blood pressure in both arms and compare SBPs together and DBPs together. If the blood pressure is more than 20 mmHg of difference, there is a possibility that the patient is having a dissection. Check radial pulses at the same time and assess if they are equal in rate and intensity.

Question 19

When do you hold cardiac medications?

Answer 19

systolic blood pressure is less than 90 mmHg or if the heart rate is less than 50 or 60 BPM

Question 20

What is Cardiac Output (CO)?

Calulation?

Answer 20

• how much blood (in liters) the left heart is pumping out to the body per minute through the aorta
• calculated by multiplying how much blood is ejected with each cardiac contraction, which is called stroke volume (SV) multiplied by the number of heart beats per minute.
• In a “normal” patient, this number will be anywhere from 4-10 liters per minute.

Question 21

What are sensitive indicators your patient is not getting the blood they need (perfusing)?

Answer 21

Skin signs such as a delayed capillary refill over 3 seconds, neuro signs such as altered mentation, and decreased urine output below 0.5mg/kg/hr or 30ml/hr minimum in an adult

Question 22

Stroke Volume (SV)

Answer 22

the amount of blood in the left ventricle that ejects out with each contraction of the heart.

-arrhythmias like atrial fibrillation or premature beats can affect the ability of the left ventricle to completely fill on diastole and this will alter how much is being ejected.

Question 23

What is a normal EF?

Answer 23

• A normal EF is 60-80%, and anytime you see the EF less than 50-55%, it is commonly referred to as systolic dysfunction and can be chronic, acute, or acute on chronic during a stressor.
• If you’ve got a patient who is in heart failure, the physician/advanced practice provider will typically order a transthroacic echocardiogram (TTE or “echo”) to evaluate the EF.

Question 24

Things that can cause ST in patients?

Answer 24

Hypovolemia (dehydration)
Fever
Caffeine
Stress
Pain
Hypotension
Hyperthyroidism

Question 25

What is happening during bradycardia? Symptoms?

Answer 25

• the time their heart spends in diastole in greatly increased and the cardiac output is decreased.
• Symptoms include:

Dizziness
Weakness/Fatigue
Altered Mental Status
Shortness of Breath/Pulmonary Edema
Hypotension

Question 26

What are the expected interventions for symptomatic bradycardia?

Answer 26

If the patient is symptomatic, this is an urgent situation.

You may need to give the patient some oxygen and prepare for potential transcutaneous pacing by pulling the crash cart over and hooking the patient up to the electrode pads.

The 1st line treatment depends on if the patient has a heart transplant or not. If they do not have a heart transplant and it is their original heart, prepare for the doctor to order 0.5 mg of Atropine. Atropine can be repeated every 3-5 minutes and has a max dose of 3 mg (6 doses of 0.5 mg). If the patient has had a heart transplant, the first line treatment is isoproterenol (Isuprel).

If the first line doesn’t work, second line is transcutaneous pacing. If transcutaneous pacing is not available, the doctor might order an IV drip of epinephrine or dopamine.

Question 27

questions for you to answer to help identify if the ECG is normal sinus rhythm or not

Answer 27

P wave

Is there a P wave?
Is the P wave happening regularly?
Does every P wave have a QRS complex following it?
Do all the P waves look the same?

PR interval

Is the PR interval between 0.12-0.2 seconds?
Does the interval time stay the same or vary?

QRS complex

Is the QRS interval between 0.08-0.1 seconds?
Are they the same height?
Is the R wave to R wave consistent?

T wave

Is there a T wave?
Does it follow a QRS complex?
How tall is the wave?

QT interval

Is the interval less than 0.44 seconds?

ST segment

Is the line flat and inline with the isoelectric line?

Question 28

If your patient is having PACs, what should you monitor for?

Answer 28

PACs can lead to Atrial Fibrillation or Atrial Flutter

Question 29

What is a PAC?

Answer 29

Premature Atrial Contractions (PAC)

the atria contract prematurely/early. The P wave can be irregularly shaped, occurring with or without a QRS complex following it, and this will make the rhythm irregular.

Sometimes, the PAC can contract during the same time the ventricles are repolarizing (AKA the T wave). If this happens the wave will have a camel hump appearance. This is important to note because it might seem like there isn’t a P wave, but there is.

Question 30

Premature Junctional Contraction (PJC)

Answer 30

originating from the lower part of the atria the P wave will be inverted and the PR interval will be very short (less than 0.12 seconds).

Question 31

What does Paroxysmal mean?

Answer 31

sudden onset

Question 32

Supraventricular Tachycardia (SVT)

Answer 32

covers all tachycardias originating from above the ventricles

It occurs when an electrical impulse has found another pathway and enters back into the atrial cycle sending another set of signals much quicker than it is supposed to. The rate will likely be regular and P waves may be lost in the T waves.

Question 33

What classifies Afib w/ RVR?

Answer 33

An uncontrolled afib rate above 100 BPM

Question 34

What is occurring in the heart with Afib?

Answer 34

the signals in the atria are chaotic, causing the atria to quiver. A clear contraction of the atria does not occur, thus the P wave will be absent. In place of the P wave, there will be erratic scribbles. The ventricles receive confusing signals for when to contract so they contract irregularly.

The biggest problem with atrial fibrillation is the blood pooling in the atria causing blood clots to form and then sent into the bloodstream throughout the body.

Question 35

What is occurring in the heart with A-flutter?

Answer 35

the conduction path from the sinoatrial node to the atrioventricular node (AV node) is spiral in nature and no longer the smooth direct pathway. The impulse still reaches the AV node causing the ventricles to contract and the QRS complex to appear at a regular interval.

Question 36

How are junctional rhythms identified?

Answer 36

Due to the short distance that the signal will be traveling, the PR interval is shortened (less than 0.12 seconds) and the P wave is usually inverted.

tend to be between 40-60 BPM since they originate from the AV node

If the rate is between 60-100 BPM, it is called an Accelerated Junctional Rhythm.

If the rate is between 100-200 it is called Junctional Tachycardia.

Question 37

Where do the most dangerous arrhythmias come from and why?

Answer 37

The ventricles.

The ventricles send blood all over the body and if the ventricles are not working the body/organs/tissues/cells are not getting blood.

Question 38

If a pt has 3 or more PVCs in a row, what is it called?

Answer 38

V-tach, life threatening and need to notify MD

Question 39

What causes PVCs?

Answer 39

could be electrolytes K, Mg levels out of whack

occur when the ventricles receive an impulse prematurely, having them contract before they are supposed to, interrupting the cardiac electrical cycle. They can be harmless and common, however, they can also spark an electrical chaos within the heart that can be harmful.