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A/P Review and EKG Interpretation

by: Lexi P

A/P Review and EKG Interpretation NURS 479

Marketplace > Catholic University of America > NURSING > NURS 479 > A P Review and EKG Interpretation
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About this Document

These notes include pictures of EKG and the different types of arrhythmias that patients may have.
Adults in Health and Illness
Connor-Ballard, P.
Class Notes
Nursing, medsurg, EKG, Heart, Arrhythmias, cardiac, anatomy




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This 22 page Class Notes was uploaded by Lexi P on Friday September 23, 2016. The Class Notes belongs to NURS 479 at Catholic University of America taught by Connor-Ballard, P. in Fall 2016. Since its upload, it has received 37 views. For similar materials see Adults in Health and Illness in NURSING at Catholic University of America.


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Date Created: 09/23/16
Nurs 479 Adults in Health and Illness – Cardiac Nursing – A/P Review and EKG Interpretation Slide 1 – Title Slide 2  EKG’s have been around for about 50 years Slide 3  Coronary Care units were primarily for patients with AMI o Cardiac Care = Coronary Care  1962 – Bethany Hospital in Kansas City, KS – first CCU  1963 – Presbyterian Hospital in Philadelphia  1965 – NY Hospital-Cornell Medical Centre in NYC  Holy Cross Hospital was the 4 in Silver Spring (1965)  In just 4 years (1962-1966), the US went from 0  250 CCUs o This was made possible by technology  EKG interpretation, mechanical ventilators, further advancement in cardiac drugs Slide 4  1964-1965 – CCU guidelines were published  The 7 essentials for the ideal CCU o Cardiac arrest team o Quiet, peaceful environment o Adequate space for resuscitation in each patient cubicle o Adequate and specialized training for nurses  This was difficult to implement because nurses were being educated in 3-year hospital programs Slide 5  1966 – nurse educators and cardiologists had a meeting to devise the “Criteria and Guidelines for Nurse Training Courses in a Coronary Care Unit”  1967 – there were 13 SONs funded to offer short-term training courses to CCU RNs o CUA was one of them – part of our SON legacy is in cardiac Slide 6  1960s CCU o ward-like setting o main telemetry screens were at the nurses’ stations o at the bedside there was: O2, suction, and outlets Slide 7  In the 1960s they also created ICUs for medical and surgical patients Slide 8  1965 CCU there was a one distinct nurse every shift that would just monitor the screens Slide 9  There are 4 chambers of the heart – atria and ventricles  Blood goes to the heart by the IVC and the SVC  In the wall of the left ventricle, there is more muscle because this ventricle has to pump blood to the body  Travelling with the blood o Right atrium  tricuspid valve  Right ventricle  lungs for O2  oxygenated blood to Left atrium  bicuspid valve  Left ventricle  aorta  Body Slide 10  The coronary arteries branch off of the aortic root and supply the heart itself with oxygenated blood o The aortic root is the very beginning of the aorta, where it first comes out of the heart  The left coronary artery goes down the left anterior of the heart and descends to the back o The back part of the left coronary artery is called the “circumflex branch of the left coronary artery” Slide 11  Key elements of EKG assessment o Heart rate o R-R interval (rhythm)  The distance between 2 R’s in 2 back-to-back QRS waves = rhythm o P/QRS, T waves…U when present  U wave = abnormal o PR and QT intervals o ST segment depression or elevation o Is the cardiac rhythm tolerated by the patient? Is there adequate tissue/organ perfustion?  Tolerated = the patient is continuing to be perfused  Look at: BP, color, pulses, pain, etc Slide 12  Electrical current o 1. Sinoatrial (SA) Node  o 2. Atrioventricular (AV) node  o 3. Atrioventricular bundle (Bundle of His)  o 4. Left and right bundle branches  o 5. Purkinje fibers Slide 13  The impulse conduction that goes through the process listed above, creates the wave on the EKG Slide 14  P – impulse goes through the atria o Should be above baseline  QRS – impulse through ventricles o Should be above baseline o Tall, thin, spiked, taller than P  T – electrical recovery, rebooting system, heart settling to get ready for the next impulse o Should be above baseline  PR interval – want it to be less than 0.2 seconds  ST segment – should be at baseline Slide 15  Heart Rate (HR) – 60-100 bpm at rest o Regular even spaces between the R’s o Based on # ventricular contractions (QRS) per min  Heart Rhythm – consistency of P-P and R-R intervals  Repolarization – recovery  Depolarization – stimulation  P wave (atrial depoloarization) o Want one before each QRS o Consistent shape and size o Deflected from baseline  PR interval (atrial depolarization/impulse delay by AV node) o Consistent 0.12-0.20 seconds in length on EKG  QRS wave (ventricular depolarization) o 0.4-0.10 seconds in length o Consistent size/shape, deflection from the baseline  QT interval (both ventricular de- and repolarization) o 0.10 seconds or less in length o Ventricles active, stimulation and recovery o Note if prolonged – risk for ventricular arrhythmias  T wave (ventricular repolarization) o Preparation for next impulse o 1 post QRS, consistant size/shape o note peaking or inversion  U wave (hypokalemia v. unconducted P wave?) o Occurs after and is smaller than T wave  ST segment (estimated time of ventricular muscle contraction) o Flat at baseline o Note depression below or elevation above baseline Slide 16  Reduced Cardiac output can result from: o Bradycardia o Tachycardia o Irregular heart rate o Loss of atrial “kick”  Happens in the Right atrium, blood should flow from RA to RV  The last 1/3 of blood in the RA gets pushed into the RV with a little contraction  but when this doesn’t happen, the blood can pool  atrial fibrillation/flutter Slide 17  Signs and symptoms the patient is not tolerating the arrhythmia o Skin pallor o Altered LOC o Hypotension o Slow capillary refill o Weak/thread peripheral pulses o Reduced urine output – with ongoing arrhythmias o Dizziness, weakness o Palpitations – feel own heart racing o Angina pain  Chest pain = serious  This means that coronary arteries are not getting sufficient blood and the myocardia is not getting what it needs Slide 18  12-perspective view of impulses o chest, peripheral Slide 19 W B W W B R B Brown G G R R  An example of a continues EKG format  Best to monitor p wave Slide 20  Telemetry lead placement hints o White on the Right o Clouds (white) above the grass/trees (green) o Smoke (black) above fire (red) o Dirt (brown) in the middle of the garden  White = RU chest  Green = RL chest  Black = LU chest  Red = LL chest  Brown = middle Slide 21  Telemetry data collection system – 24 hour Holter EKG Monitoring Slide 22  Normal Sinus Rhythm (NSR) o 60-100 bpm o Regular rhythm (R-R wave), normal QRS complexes at rest, PQRST  Sinus Tachycardia (ST) o 100-150 bpm o Regular rhythm, normal QRS complexes at rest o Often due to pain, fever, stress, and exercise o Gradual onset and gradual termination  Sinus Bradycardia o Less than 60 bpm o Regular rhythm, normal QRS complexes o Extremely athletic – heart is at this point but not a problem  Sinus Dysrhythmia (formerly sinus arrhythmia o NSR but with an irregular rate correlating to respirations o Increase HR on inspiration, decrease on exhalation  NSR vs. ST = HR   NSR vs. SB = HR   NSR vs. SD = HR  when you breathe in, and HR  when you exhale Slide 23  Normal Sinus rhythm  Black marker at the top, is the “3 second marker” used to help calculate the rate Slide 24  Sinus tachycardia  (Compare to the 3 second marker from slide 23)  R-R interval is normal but shorter  P and T waves can almost be blended if the heart is beating fast enough Slide 25  Sinus Bradycardia  R-R interval is longer Slide 26  Sinus Arrhythmia / Dysrhythmia  The first three beats are on inhalation, so they are faster  The second two are on exhalation and they are slower Slide 27  Common Atrial Arrhythmias – has something to do with the AV node or Bundle of His o Premature Atrial Contraction  Underlying sinus rhythm with a premature beat  Abnormal or absent P wave  The heart beats so quickly o Atrial Tachycardia  150-200 bpm  impulse from somewhere around the atrial node  “Narrow complex (QRS) tachycardia”  AT vs Sinus Tachy = rate is much faster and AT is not tolerated for very long o Paroxysmal Atrial Tachycardia  Sudden (paroxysmal), abnormal P waves o Atrial Fibrilation  60 (controlled) to >100 (uncontrolled) irregular rhythm  Heart is quivering – usually requires digoxin  Not one impulse is in control of the system  Instead of a P wave, there is a wavy baseline without the presence of P o Atrial Flutter  “Sawtooth” = atrial flutter (F) wave at 250-350 flutter bpm  Count the F waves per QRS o Reported as a ratio  Lacks single control, multiple sparks with atria trying to respond  No real baseline  More F before QRS, worse, impulse not dropping into ventricles Slide 28 Norm Norm Norm premature pause  There is a compensatory pause – before it falls back into rhythm  Impulse is short, smaller P wave on the premature beat Slide 29 Flips switch to normal  Cound the QRS between 3 seconds and multiple by 20 to get a full minute (bpm)  First 3 seconds – short R-R and blended P+T waves Slide 30  4 flutter – blocking 4 waves until one is accepted  A flutter – no flat baseline  wavy, sawtooth baseline o Varying flutter to QRS ration is concerning  A fib – wavy baseline o Determinable QRST, no P; Irregular rhythm between R-R Slide 31  Premature Ventricular Contractions (easier to understand with pictures) o PVC  Underlying EKG rhythm, the impulse comes from the ventricular tissue  Irregular rhythm due to the premature beat  Beat will cause irregularity of rhythm, no P wave or PR interval, large and wide QRS  It is isolated in the EKG and surrounded by normal beats, not a constant arrhythmia o Unifocal  PVCs share the same QRS shape o Multifocal  PVCs with differing QRS shapes, each representing different ventricular foci  Each different one comes from a different place in the ventricle o When there are multiple sites, there is more to worry about o Interpolated  PVC between 2 normal EKG complexes, usually without a compensatory pause o Couplet  2 consecutive PVCs o Triplet  3 consecutive PVCs (3-beat run of V tach) o Bigeminy  Every other beat is a PVC o Trigeminy  Every third beat is a PVC o R on T  PVC occurs on the proceeding T wave, triggers Vtach or Vfib  This is very concerning  T wave = recouping period of irritability; when R on T occurs, it can trigger Vtach or Vfib – both are deadly Slide 32  PVC with compensatory pause N N  These PVCs look the same, so they have the same foci (UNIFOCAL) – there is one area of irritation  It looks negative, but it is only because of the lead that was used, it helps to visualize it upside down Slide 33  Unifocal PVCs  Another view of the same sort of PVC, but just right side up  These QRS intervals are wide, large and bizarre on the PVCs Slide 34  Multifocal PVCs o They have different sizes and shapes, they are coming from two different irritated places in the ventricles Slide 35  Interpolated PVCs – occurs between sinus beats without a compensatory pause N N  System reboots without a pause  There is supposed to be a pause between these two normal waves, but instead there is an extra beat Slide 36  PVC couplet  Concerning because two beats can lead to three beats, and three beats can lead to Vtach  These PVC beats are unifocal – coming from the same irritated part of the ventricle Slide 37  PVC triplet N N Pause  Unifocal  3 beats in a row can lead to tachycardia, need to act on this Slide 38  PVC Bigeminy N N  Unifocal but concerning  Singular area but taking over the impulse system  The longer it goes on, the more symptomatic the patient is  Over time (minutes) the heart and body stop tolerating this, the patient gets dizzy, light headed, CP, decreased BP, pulses weaker Slide 39  Ventricular trigemini N N N N  Unifocal but concerning  The longer it goes on, the more symptomatic the patient is  Over time (minutes) the heart and body stop tolerating this, the patient gets dizzy, light headed, CP, decreased BP, pulses weaker Slide 40  PVC “R on T” Phenomenon QRS P T  PVC on descent Slide 41  Common Ventricular Arrhythmias  Very serious – untreated = life threatening – short term only o Premature Ventricular Contraction (PVC)  See slide 31 o Idioventricular ventricular rhythm  “last resort paymaker” – SA failed, AV failed  ventricular tissue  20-40 bpm  Absent P wave and PR interval  Wrde, bizarre QRS  3 degree AV heart block (complete) o Ventricular Fibrillation (Vfib)  Entire EKG complex is replaced by a coarse or fine wavy baseline  Cardiac arrest situation o Ventricular tachycardia (VT)  >100 bpm  Wide bizarre QRS  Cardiac arrest situation  PVC after PVC, ventricular tissue controls o Torsade de pointes  VT with “twisting” of the QRS complexes  Rare o Asystole  “Flat line”  Complete absence of EKG complexes Slide 42  Idioventricular Rhythm  Pause with nothing coming so the ventricles step in  No P, No QRS  20-40 bpm  *The body can only be sustained on this rhythm for a short amount of time Slide 43  Ventricular Fibrillation Best time for defibrillation – shocks them out of this; more electric activity; starts as this Quickly flattens (minor quivering); harder for defibrillation  Loss of impulse, no impulse through ventricles  Electrical flickering  No adequate outflow Slide 44  Ventricular Tachycardia (R on T?) N N  So fast, the intervals between R’s is short  No P or T  Possible R on T first beat of Vtach  During this display of VT, the patient is probably semi-conscious Slide 45  Ventricular Tachycardia Run N N N  Rapid beats from ventricle, goes away as quickly as it came; may or may not be conscious Slide 46  Torsades de Pointes (rare)  High risk for people who have a long QT segment (more than usual)  Twisting appearance  It is dangerous because it is hard to get out of  Prevented if monitored Slide 47  V-fib – lack QRS, wavy baseline, course  fine  V-tach – impulse by ventricular tissue, fast rate, not sustainable, no cardiac output  Asystole – complete flat line Slide 48  AV heart block  Heartblock gets worse over time o 1 degree heart block  Underlying heart rhythm and normal EKG wave except for prolonged PR interval (> 0.20 seconds)  Impulse generated but held at AV node/bundle of His area o 2 nddegree Mobitz Type 1 AV heart block (“Wenckebach”)  Progressively increasing PR intervals until a non-conducted P wave occurs (No QRS), then a pause, then the cycle restarts  P wave keeps getting longer then dropped nd o 2 degree Mobitz Type 2 AV heart block  More P waves than QRS complexes due to unconducted P waves  PR interval remains normal and consistent  Unconducted P, no QRS behind it o 3 degree AV heart block  “complete” heartblock  complete wall between atria and ventricles  SA  AV  ventricles o Ventricles are creating their own impulses  Usually HR slows to 20-40 bpm  2 completely separate rhythms  atria and ventricles Slide 49 st  1 Degree AV Heart Block  PR interval longer than 0.2 seconds Slide 50  2 nddegree AV Heart Block Type 1 (Mobitz 1) P P P P Pause, did not go down to ventricles  “Wenckebach” Slide 51  2ndDegree AV Heart Block Type 2 (Mobitz 2) Dropped P waves Slide 52  3 Degree AV heart block R P TP P  Consistent, 20-40 bpm  rate of ventricular pace maker  what pulse is like  Wall between atria and ventricles o Impulse does not go from one to the other o Two rhythms occurring without regard of the other Slide 53  Junctional Arrhythmias  Pulse occurs at the junction of all four chambers o Impulse generated by the AV node, with simultaneous impulse transition up to atria (retrograde), and forward to ventricles  Impulse goes down then up o P waves are often abnormal, absent, inverted, or behind the QRS complex o Junctional rhythm is usually 40-60 bpm o SV node 60-100 bpm  AV node 40-60 bpm  Vent. Tissue 20-40 bpm  20-40 bpm is not sustainable Slide 54  Junctional Rhythm  P behind QRS; impulse sent down then up Slide 55  (For awareness)  Should go down Right and Left bundle branch at the same time  One goes down before the other, the QRS is notches Slide 56  Sick Sinus Syndrome o Requires pacemaker  SA node works and then it doesn’t o Does not get better on it’s own Sinus pause, rhyth restarts m asystole Paus Paus e e Paus Paus Paus e e e Slide 57  Cardiac Changes due to Aging o Calcification and degeneration of cardiac valves  risk for murmurs, regurgitation, heart failure o Changes in impulse formation and conduction  Risk of arrhythmias o Fibrotic changes in Left Ventricle  Decreased SV o Stiffness in arterial walls  Increased BP o Ineffective baroreceptors  Orthostatic hypotension o Changes in muscle fibers o Not uncommon for pacemakers to be placed due to age and breakdown Slide 58  QSEN: Telemetry  *Treat the patient not the monitor o Telemetry v. 12 lead EKG  Telemetry for ongoing care; Leads are for short term  Skill – lead placement  Attitude – Pt at risk for arrhythmia, requires frequent monitoring  Never turn the alarm off o Lead placement  Skill – Use of EKG monitor and setting parameters  On dry, clean, hairless skin  Attitude – Artifact or improper lead placement can hinder EKG interpretation o Clinical indication for telemetry  Risk for arrhythmias  Skill – EKG wave; Interpretation and measurement (PR, QT)  Attitude – Assess patient 1 st whenever any change in rhythm (LOC, BP, skin color, cap refill, apical/pedal pulses, breath sounds, O2 sat%…) o Normal EKG wave  Before you can determine what is abnormal, have to know what’s normal  Skill – Arrhythmia recognition o NSR v. arrhythmia  Which arrhythmia  Skill – Cardiac assessment (physical)  Attitude – do not rely 100% on automatic telemetry interpretation o Arrhythmia interpretation  Skill – BLS/CPR  Attitude – consult more experienced RN or MD prn o Emergency Rx for arrhythmias  Skill – code blue activation and resuscitation skills  Attitude – consult more experienced RN or MD prn Slide 59  An 82-yo F is admitted with a Dx of rapid atrial fibrillation. The RN has initiated telemetry monitoring per MD order. 2 hours later, an alarms sound at the central monitoring station: the patient is in what appears to be ventricular tachycardia. Which of the following actions should the RN take FIRST? o 1. Call a code blue  (no code blue based on monitor) o 2. Silence the alarms and change the alarm parameters  (never change alarm for peace and quiet) o 3. Notify the MD of a change in rhythm  (MD not first) o 4. Assess the client and check lead placement Slide 60 - Closing


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