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NR202 Test 2 ECG monitoring

Terms

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ECG tracing
Isoelectric line
P-Wave---
⬢ Atrial Depolarization (Electrical activation of muscle cells-usually indication of contraction)
⬢ Alike in size and shape- usually smooth and rounded
⬢ Upright lead II
⬢ On fast rhythms-look for a hump on the T Wave
ECG tracing
Isoelectric line
P-R interval
⬢ Beginning of p wave to beginning of QRS complex
⬢ Normally 0.12-0.20 seconds
⬢ Over age 65 up to 0.24 is normal
ECG tracing
Isoelectric line
QRS complex
⬢ The Q wave is the first negative deflection in the QRS complex
⬢ Not every QRS complex has a Q wave
⬢ R wave is the first positive deflection after the P wave
⬢ S is a negative wave that follows the R
⬢ Normal duration is 0.06-0.10
⬢ Wider width indicates slower conduction of impulse through ventricles
J Point-Point at which the QRS complex and the ST segment meet-called junction or j point
ECG tracing
Isoelectric line
ST segment-the line that follows the QRS complex and connects it to the T wave.
ST segment-the line that follows the QRS complex and connects it to the T wave.
⬢ Under normal circumstances, should be isoelectric (same height as the P-R interval)
⬢ May be depressed or elevated when myocardium is hypoxic
⬢ Digitalis causes a depression (scoop) of the ST segment
ECG tracing
Isoelectric line
T-Wave-Follows the QRS complex
⬢ Represents ventricular repolarization (resting returns to ready
⬢ Refractory period- a stage of resistance to stimulation
⬢ Last half of T-wave is relative refractory period
⬢ Stimulus can send heart into chaos.
ECG rhythm analysis
• Step 1. Determine Rate
• P-waves = atrial and R waves = ventricular
• 6 second method= #R’s X 10
• Memorize sequence 300, 150, 100, 75, 60, 50, 43, and sequence with large boxes between two consecutive complexes for rate
Step 2. Determine regularity
Step 3 Assess P wave morphology (smooth and rounded=sinus not origination)
Step 4. Assess P to QRS relationship (?1 P wave/QRS)
Step 5. Determine interval durations (PRI & PRS)-
Measure with calipers or count small squares
Step 6. Identify abnormalities= ectopic (premature) beats, deviation of the ST segment above or below baseline and abnormalities in waveform shape and duration
Normal Sinus Rhythm
• Rate 60-100
• Regular
• Consistent P waves – smooth and rounded
• 1 P wave/QRS
• PRI 0.12-0.20 & QRS 0.12 or below (0.6-0.10)
• Normal-no treatment
• Identification NSR – Every part is normal
• All waves are positive in lead 2
Sinus dysrhythmia
Sinus dysrhythmia-Normal phenomenon that occurs with respiration change in intrathoracic pressure
⬢ Rate 60-100 beats per minute
⬢ Rhythm: irregular (R-R intervals shorten during inspiration and lengthen during expiration
⬢ P Waves Normal appearance, one before each QRS
⬢ PR interval 0.12-0.20 seconds
⬢ QRS: usually 0.10 seconds or less
⬢ Etiologies: Normal
Sinus Bradycardia
Sinus Bradycardia
⬢ Slower, treat whenever person gets symptomatic
⬢ Rate: less than 60 bpm
⬢ P waves: uniform in appearance, upright in Lead II, one before each QRS
⬢ PR interval: 0.12-0.20
⬢ QRS: usually 0.10 seconds or less
Sinus Bradycardia
Etiologies
Etiologies
• Often seen normally in athletes
• Parasympathetic stimulation—Increased vagal tone, (vagal maneuvers—Carotid massage, vomiting, straining at stool, increased intracranial pressure
• Myocardial disease
• Hypothermia
• Pharmacologic agents precipitating (causing) sinus bradycardia:
o Digitalis
o Beta Blockers
o Calcium Channel Blockers
Sinus Bradycardia
Associated Symptoms:
• Decreased Cardiac output—chest pains, SOB, change in level of consciousness, dizziness, hypotension—Drop in persons normal BP of 20 mmHg or more
Sinus Bradycardia
Nursing Implications:
Nursing Implications: No treatment required unless patient is symptomatic
• Place patient in head flat position if respiratory status permits—Brings BP up
• Assess need for oxygen supplement
• Assure patent has patent IV access
• Document rhythm strip, vita signs, and patient activity prior or during the brady event
Sinus Bradycardia
Pharmacological and medical management:
Pharmacological and medical management:
⬢ Administer Atropine per protocol
Sinus Tachycardia:
⬢ Rate: greater than 100 beats per minute (usually 100-160 but may be higher in children)
⬢ Rhythm: Regular
⬢ P waves: uniform in appearance, upright in Lead II, one before each QRS
⬢ PR interval-0.12-0.20
⬢ QRS: usually 0.10 seconds or less
Sinus Tachycardia:
Etiologies:
Etiologies: Sinus Tachycardia
• Normal in children 10 years and younger
• Occurs as normal response to body’s demand for increased oxygen
• Fever, pain, and anxiety, hypoxia, CHF, MI, infection, sympathetic stimulation, hypovolemia, dehydration, exercise.
• Pharmacologic agents precipitating (causing) tachycardia
• Epinephrine
• Atropine
• Bronchodilators
• Caffeine, nicotine, and Cocaine
Sinus Tachycardia:
Associated symptoms:
⬢ Signs of decreased cardiac output related to decreased ventricular filling time.
⬢ May cause angina due to increased oxygen demand of the heart muscle itself
Sinus Tachycardia:
Nursing Implications:
• Treatment aimed at identifying and treating underlying cause
• Institute measures to reduce the body’s metabolic demands. How??
Supraventricular Tachycardia (SVT)
⬢ Called paroxysmal supraventricular Tachy (PSVT) when I suddenly starts and stops
⬢ Rate: Greater than 100 beats per minute (Usually 150-200BPM)
⬢ Rhythm: Regular
⬢ P waves: often not identifiable
⬢ PR interval: May be < 0.12 seconds
⬢ QRS: Usually 0.10 seconds or less
Supraventricular Tachycardia (SVT)
Etiologies:
Etiologies:
• Sympathetic nervous stimulation—fever, sepsis, hyperthyroidism
• Heart Diseases-CHD, MI, rheumatic Heart disease, myocarditis
• Abnormal conduction pathways: Wolff Parkinson-White syndrome
Supraventricular Tachycardia (SVT)
Associated Symptoms
⬢ Complaints of palpitations and racing heart
⬢ Signs of Decreased Cardiac output related to decreased ventricular filling time
⬢ May cause Angina due to increased oxygen demand of heart muscle itself
⬢ Anxiety, dyspnea, diaphoresis, Extreme fatigue, polyuria (UO may reach 3 liters in first few hours- Fluid collecting in Atria secreted out through the kidney
Supraventricular Tachycardia (SVT)
Nursing implications:
No treatment required unless patient symptomatic.
⬢ Assess need for oxygen supplement.
⬢ Assure patient has patent IV access
⬢ Document rhythm strip, vital signs and patient activity prior or during SVT
Supraventricular Tachycardia (SVT)
Pharmacological and medical management:
⬢ Vagal maneuvers: bear down like straining at stool, gag or vomit
⬢ MD⬝s only-carotid sinus massage-periorbital pressure
⬢ Oxygen therapy
⬢ Meds:
o Adenosine, med given fast as you can shoot it in, and flush fast
o Verapamil
o Procainamide
o Propranolol
o Esmolol
⬢ Synchronized Cardioversion
⬢ Ablation if frequently recurrent
Atrial Flutter
⬢ Rate: Depends on degree of AV block per minute (Usually <150)
⬢ Rhythm: Regular or Irregular
⬢ P waves: F (flutter) waves-sawtooth or picket fence appearance of P waves
⬢ PR interval usually not measured
⬢ QRS: usually 0.10 seconds or less
Atrial Flutter
Etiologies:
Etiologies: Sympathetic stimulation—anxiety, caffeine or alcohol
• Tyrotoxicosis
• Heart disease-MI, rheumatic heart, valvular disorders
• Abnormal conduction syndromes—Wolf Parkinson-White
Atrial Flutter
Associated Symptoms:
Associated Symptoms:
• Signs of decreased Cardiac Output related to decreased “atrial kick” filling and Contraction
• May cause angina due to increased oxygen demand of heart muscle itself
• Nursing Implications: Assess need for oxygen supplement
• Assure patient has patent IV access
• Document rhythm strip, vital signs
Atrial Flutter
Pharmacological and medical management
Pharmacological and medical management
⬢ Synchronized cardioversion
⬢ Meds to slow heart rate-beta blockers and calcium channel blockers
Atrial Fibrillation
• Rate: Varies-Chart ventricular response as “moderate” (<100) or rapid (>100)
• Rhythm: Irregularly irregular
• P waves: F (fibrillation waves)
• PR interval: not measurable
• QRS: Usually 0.10 seconds or less
Atrial Fibrillation
Etiologies:
Etiologies:
⬢ Thyrotoxicosis, hyperthyroidism
⬢ Heart diseases-CHF, Rheumatic heart, valvular disorders
Atrial Fibrillation
Associated symptoms:
Associated symptoms:
• Signs of Decreased cardiac output related to decreased “atrial kick” filling and contraction
• Peripheral pulses irregular
Atrial Fibrillation
Nursing Implications:
Nursing Implications:
⬢ Assess need for Oxygen supplement
⬢ Assure patient has patent IV access
⬢ Document Rhythm Strip, vital signs
⬢ Monitor anticoagulant administration and related symptoms
Atrial Fibrillation
Pharmacological and medical management
Pharmacological and medical management
⬢ Synchronized cardioversion
⬢ Meds to slow ventricular rate- digitalis and beta blockers
⬢ Anticoagulant therapy (Coumadin)- Decreases incidence of emboli and stroke
Junctional Rhythm AKA Nodal Rhythm
⬢ Rate 40-60 beats per minute (possible 60-140)
⬢ Rhythm: regular
⬢ P waves: absent, inverted, or behind QRS
⬢ PR interval: frequently <0.10 if visible
⬢ QRS: usually 0.10 seconds or less
Junctional Rhythm AKA Nodal Rhythm
Etiologies:
Etiologies:
⬢ Failure of higher pacemakers (sinus)
⬢ Overdose of digitalis, beta blockers, and calcium channel blockers
⬢ Heart disease-CHF, MI
⬢ Increased vagal tone
⬢ Hypoxemia
⬢ Hyperkalemia
Junctional Rhythm AKA Nodal Rhythm
Associated Symptoms:
Associated Symptoms:
• Signs of decreased Cardiac output related to decreased “atrial kick” filling, and contraction
• Ndx decreased Cardiac output
Junctional Rhythm AKA Nodal Rhythm
Nursing Implications
Nursing Implications
⬢ Assess need for oxygen supplement (only treat if symptomatic (Atropine)
⬢ Assure patient has patent IV access
⬢ Document rhythm strip, vital signs
⬢ Report signs and symptoms of med toxicity
⬢ Monitor anticoagulant administration and related symptoms
Junctional Rhythm AKA Nodal Rhythm
Pharmacological and Medical management
Pharmacological and Medical management
⬢ Evaluate for med toxicity
⬢ Treat cause if client is symptomatic
Premature ectopic beats-Premature atrial contraction (PAC)
Premature ectopic beats-Occurs early, originating from a different focus

Premature beat occurs and has a P wave of a different form than other beats. QRS same as all other beats. Interpret underlying rhythm first and then analyze premature beat
Premature ectopic beats-Premature atrial contraction (PAC)
Etiologies:
Etiologies:
⬢ Often seen normally in children
⬢ Alcohol and caffeine intake
⬢ Stress
⬢ Smoking
Premature ectopic beats-Premature atrial contraction (PAC)
Associated symptoms
Associated symptoms
⬢ Frequently Asymptomatic
⬢ Heart disorders-MI, PE, valve disorders, hypoxemia, digitalis toxicity.
⬢ Electrolyte imbalance. Decreased Potassium and Decreased Magnesium
Premature ectopic beats-Premature atrial contraction (PAC)
Nursing Implications
Nursing Implications: No treatment required unless patient symptomatic.
⬢ Document rhythm strip with estimate of frequency (Frequent may progress to A-Fib)
⬢ Advise PT to reduce intake of stimulants-smoking, alcohol, and caffeine
Premature Junctional Contraction (PJC) Ectopic focus in junction
Premature beat occurs and has absent, inverted or retrograde P wave. QRS usually < 0.12. Interpret underlying rhythm first and then analyze premature beat.
Premature Junctional Contraction (PJC) Ectopic focus in junction

Etiologies
Associated Symptoms
Nursing implications
Etiologies
⬢ Cardiac ischemia or injury
Associated Symptoms
⬢ Frequently asymptomatic
Nursing implications: no treatment required unless patient symptomatic.
⬢ Document rhythm strip with estimate of frequency
Premature ventricular contractions (PVCs) Ectopic focus in ventricles
Premature beat occurs and no P wave
QRS usually >0.12 with wide and bizarre complex.
T wave frequently in opposite direction of QRS. Interpret underlying rhythm first and then analyze premature beat
Types of PVC’s for charting
• Uniform-All look the same (initiated from same focus in ventricle)
• Multiform-Look different
• Pattern of occurrence
o Bigeminal PVC’s Occur every other beat
o Trigeminal PVC’s – occur every third beat
o Quadrageminal PVC’s occur every fourth beat.

• Couplet’s-PVC’s that occur in pairs-no normal beat between
• Run, salvo or burst of V-Tachy- indicates extreme irritability
• Triplets or more are considered a burst of V-Tachy

• PVC’s that fall on the T wave of the preceding beat (R on T phenomenon)
Premature ventricular contractions (PVCs) Ectopic focus in ventricles
Etiologies:
Etiologies:
⬢ Can occur in healthy people with no apparent reason
⬢ The most common ventricular dysrhythmia
⬢ Arises from an irritable site within either ventricle
⬢ Increase in catecholamines (drugs ex epinephrine) and stimulants (alcohol, caffeine, and tobacco)
⬢ Electrolyte disorders- lowered potassium, lowered calcium, lowered magnesium
⬢ Hypoxemia-Cardiac ischemia or injury
⬢ Digitalis toxicity
⬢ Drug induced (epinephrine, dopamine, phenothiazines, isoproterenol)
⬢ Stress, emotions, fear
⬢ Acidosis
⬢ Congestive heart failure
Premature ventricular contractions (PVCs) Ectopic focus in ventricles
Associated symptoms
Associated symptoms
• May be asymptomatic
• Patient indicates “heart skipping”
• Decreased cardiac output if frequent
Premature ventricular contractions (PVCs) Ectopic focus in ventricles
Nursing implications:
Nursing implications:
• Assess perfusion of PVC-Pulse deficit—pulse may not be felt with PVC
• Do PVC’s occur with activity or increase with exertion?
• Are PVC’s associated with client c/o angina
• Document rhythm strip with estimate of frequency and type
• No treatment required if infrequent and asymptomatic.
• Advise patient against stimulant use (caffeine, nicotine) consider aminophylline, dopamine, epinephrine
• Monitor ECG continuously during lidocaine or amiodarone administration; may monitor lidocaine blood levels and observe for neurological side effects.
Premature ventricular contractions (PVCs) Ectopic focus in ventricles
Pharmacological and medical management
Pharmacological and medical management
⬢ Treat underlying cause. Ex. Give potassium, magnesium, or calcium, Or 02
⬢ Meds: Lidocaine bolus then maintenance drip to infuse: 1-3 mg/min
⬢ Amiodarone
Ventricular Tachycardia (VT)
Ventricular Tachycardia (VT) – 3 or more consecutive PVCs
• Rate: 100-250 beats per minute
• Rhythm: regular
• P waves: usually not identifiable
• PR interval: none visible
• QRS: usually >0.12 bizarre shape
Ventricular Tachycardia (VT)
Etiologies:
Etiologies:
• Myocardial ischemia and injury—hypoxemia
• Drug toxicity
• Heart disease-valvular, rheumatic, cardiomyopathy
Ventricular Tachycardia (VT)
Associated Symptoms:
Associated Symptoms:
⬢ Signs of decreased cardiac output
Ventricular Tachycardia (VT)
Nursing implications:
Nursing implications:
• Check Pulse—If no pulse (call code) or unstable, then defibrillate
• Assure patient has patent IV access
• Administer lidocaine, or amiodarone or procainamide per protocol
• Assess need for oxygen supplement-pulse oximetry
• Document rhythm strip, vital signs
Ventricular Tachycardia (VT)
Pharmacological and medical management
Pharmacological and medical management
⬢ Evaluate for med toxicity
⬢ Lidocaine
⬢ Amiodarone
⬢ Procainamide
⬢ AICD Placement
Stable
Unstable
Steps in a code
Stable
Evaluate O2, IV, Bolus Amiodarone and IV gtt Lidocaine

Unstable
Premedicate-Versed
Cardiovert
Bolus-Amiodarone, Lidocaine, or Pronestyl, maybe Mag sulfate
O2 monitored

Steps in a code
Check A, B, C
Defib x 3 up to 360 joules
Epinephrine/Vasopressin
Intubate
Bolus IV and gtt
Amiodarone
Lidocaine
Maybe mag Sulfate
Ventricular Fibrillation
Rapid ventricular quivering without contraction-Heart does not pump
⬢ Rate: uncountable-Chaotic
⬢ Rhythm-Grossly irregular
⬢ P waves: not identifiable
⬢ PR interval: none visible
⬢ QRS: usually > 0.12 bizarre varying shapes
Ventricular Fibrillation
Etiologies:
Associated Symptoms:
Etiologies:
⬢ Myocardial ischemia and injury-hypoxemia
⬢ Drug toxicity
⬢ Heart disease-Valvular, rheumatic, cardiomyopathy

Associated Symptoms:
⬢ Unresponsive
⬢ Pulseless
⬢ Nursing Implications:
⬢ Check Pulse-if no pulse (call code) then defibrillate
⬢ Assure patient has patent IV access
⬢ Administer epinephrine, lidocaine, or amiodarone or procainamide per protocol
⬢ Follow code protocols
⬢ Document rhythm strip, vital signs
Ventricular Fibrillation
Pharmacological and medical management
Pharmacological and medical management
⬢ Medications
o Epinephrine
o Lidocaine
o Amiodarone
o Procainamide
⬢ Intubate and oxygenate

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