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The content of this site is intended for use by individual nurses as continuing
nursing education only.
This site is not to be used as a substitute for medical advice from a health
care provider.
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Click on links in the Table of Contents frame on the left side of the
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time.
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Access the Exam and Evaluation Form at the end of the course - or
whenever you're ready. Follow instructions on that page to obtain RN
contact hours, or to just try the questions.
Links to the World Wide Web enrich the course content. Review the
different sites and then click "BACK" on your browser to return to the
course. Or "BOOKMARK" the site now for easy reference!
Scattered throughout the course are Instant Feedback areas, like the one
below. Review information about the Target Audience and give it a try!
For example:
The target audience for this course is health care professionals interested in
learning more about EKG interpretation.
TRUE or FALSE
Course Objectives
Upon completion of this program the learner should be able to:
Target Audience
The target audience for this course is nurses and other health
professionals who would like to learn, or review, basic EKG
dysrhythmia identification.
Nurses and other health professionals may earn 5.0 contact hours
for completing this course.
o To earn 5.0 contact hours, participants must agree to spend no less
than 250 minutes studying course material, exploring Internet
links, and completing exam and evaluation.
Literature Review
According to the current literature, there is firm support for nurses becoming
competent in cardiac monitoring and dysrhythmia identification. According to
Beery (1998), over the last few years nurses outside of critical care have been
asked to take care of patients with cardiac dysrhythmias. These nurses need to
have some basic education regarding the cardiac conditions of their patients.
They must also have an understanding of the fundamentals of cardiac
monitoring, and dysrhythmia interpretation. It is essential that institutions have
emergency policies and procedures in place, along with a continuing
competency education program and yearly refresher programs. The programs
should include validation of dysrhythmia interpretation skills and problem
solving of case studies.
Instant Feedback:
Nurses outside the critical care settings do not need to master EKG
dysrhythmia interpretation.
TRUE or FALSE
In an adult with a healthy heart, the heart rate is usually about 72 beats per
minute.
The excitatory and electrical conduction system of the heart is responsible for
the contraction and relaxation of the heart muscle. The sinoatrial node (SA
node) is the pacemaker where the electrical impulse is generated. This node is
located along the posterior wall of the right atrium right beneath the opening of
the superior vena cava. It is crescent shaped and about 3 mm wide and 1 cm
long.
The impulse travels from the SA node through the internodal pathways to the
atrioventricular node (AV node). The AV node is responsible for conduction of
the impulse from the atria to the ventricles. The impulse is delayed slightly at
this point to allow complete emptying of the atria before the ventricles
contract.The impulse continues through the AV bundle and down the left and
right bundle branches of the Purkinje fibers. The Purkinje fibers conduct the
impulse to all parts of the ventricles, causing contraction (Guyton, 1982).
Abnormal heart rhythms occur for several reasons.
Instant Feedback:
Parasympathetic stimulation of the heart can:
A. Increase the heart rate
Please visit this "Cardiac Care" website for educational information about
the heart geared towards patients/clients.
EKG paper is a grid where time is measured along the horizontal axis.
When the rhythm is regular, the heart rate is 300 divided by the number
of large squares between the QRS complexes.
o For example, if there are 4 large squares between regular QRS
complexes, the heart rate is 75 (300/4=75).
The second method can be used with an irregular rhythm to estimate the
rate. Count the number of R waves in a 6 second strip and multiply by
10.
o For example, if there are 7 R waves in a 6 second strip, the heart
rate is 70 (7x10=70).
Instant Feedback:
On a typical EKG grid, 5 small squares, or 1 large square, represent 0.20
seconds of time
TRUE or FALSE
Normal Components of the EKG Waveform
P wave
QRS complex
T wave
ST segment
PR interval
QT interval
Instant Feedback:
Normal QRS duration is 0.15 - 0.25 seconds.
TRUE or FALSE
Skin preparation:
Shave hair away from electrode placement site.
Rub site briskly with alcohol pad.
Rub site with 2x2 gauze.
Place electrode. Be sure that the electrode has adequate gel and is
not dry.
3 lead placement:
Five lead placement allows viewing of all leads within the limits of the
monitor.
Lead selection
Sinus Bradycardia
Treatment includes:
Instant Feedback:
Sinus bradycardia is always abnormal and must be treated.
TRUE or FALSE
Sinus Tachycardia
Rate 101-160/min
P wave sinus
QRS normal
Conduction normal
Rhythm regular or slightly irregular
Instant Feedback:
Sinus tachycardia is a normal response to pain.
TRUE or FALSE
Sinus Arrhythmia
Rate 45-100/bpm
P wave sinus
QRS normal
Conduction normal
Rhythm regularly irregular
The rate usually increases with inspiration and decreases with expiration.
However, if they occur frequently, they may lead to a more serious atrial
dysrhythmias.
They can also result from CHF, ischemia and COPD.
Instant Feedback:
With PACs, all the P waves look identical.
TRUE or FALSE
Sinus Arrest
Rate normal
those that are present are
P wave
normal
QRS normal
Conduction normal
The basic rhythm is regular.
The length of the pause is not
Rhythm
a multiple of the sinus
interval.
This may occur in individuals with healthy hearts. It may also occur with
increased vagal tone, myocarditis, MI, and digitalis toxicity.
Instant Feedback:
Atropine should never be used to treat sinus arrest.
TRUE or FALSE
Sinoatrial Block
*In a type I SA block, the P-P interval shortens until one P wave is dropped.
*In a type II SA block, the P-P intervals are an exact multiple of the sinus
cycle, and are regular before and after the dropped P wave.
Rate 100-250/bpm
two or more ectopic P waves with
P wave
different morphologies
QRS normal
Conduction P-R intervals vary
Rhythm irregular
Instant Feedback:
In MAT, all P waves are identical in morphology, and P-R intervals are constant
TRUE or FALSE
Instant Feedback:
In MAT, all P waves are identical in morphology, and P-R intervals are constant
TRUE or FALSE
Atrial Flutter
atrial 250-350/min;
ventricular conduction
Rate depends on the capability of
the AV junction (usually rate
of 150-175 bpm).
not present; usually a "saw
P wave
tooth" pattern is present.
QRS normal
2:1 atrial to ventricular most
Conduction
common.
usually regular, but can be
Rhythm irregular if the AV block
varies.
Instant Feedback:
In atrial flutter, instead of P waves there is commonly a "sawtooth" pattern
seen.
TRUE or FALSE
Atrial Fibrillation
Treatment includes:
Instant Feedback:
The hallmark sign of atrial fibrillation is:
A. A sawtooth pattern
C. A compensatory pause
PJCs may occur in both healthy and diseased hearts. If they are occasional, they
are insignificant. If they are frequent, junctional tachycardia may result.
The clinical significance of this rhythm depends upon the basic rhythm
disturbance. If the ventricular rate is rapid, cardiac output may decrease.
Treatment includes:
Treatment depends upon the underlying cause and the baseline dysrhythmias.
Instant Feedback:
With a junctional rhythm, P waves are inverted in leads where they are usually
upright.
TRUE or FALSE
Rate variable
P wave normal
QRS normal
impulse originates in the SA
node but has prolonged
Conduction conduction in the AV
junction; P-R interval is >
0.20 seconds.
Rhythm regular
This is the most common conduction disturbance. It occurs in both healthy and
diseased hearts.
inferior MI,
digitalis toxicity
hyperkalemia
increased vagal tone
acute rheumatic fever
myocarditis.
Instant Feedback:
In first degree AV block, the P-R interval is:
Rate variable
normal morphology with
P wave
constant P-P interval
QRS normal
the P-R interval is
progressively longer until one
Conduction P wave is blocked; the cycle
begins again following the
blocked P wave.
Rhythm irregular
Second degree AV block type I occurs in the AV node above the Bundle of His.
Instant Feedback:
The Mobitz type I second degree AV block usually does not require any
treatment.
TRUE or FALSE
This block usually occurs below the Bundle of His and may progress into a
higher degree block.
It can occur after an acute anterior MI due to damage in the bifurcation or the
bundle branches.
Complete block of the atrial impulses occurs at the A-V junction, common
bundle or bilateral bundle branches.
Another pacemaker distal to the block takes over in order to activate the
ventricles or ventricular standstill will occur.
digitalis toxicity
acute infection
MI and
degeneration of the conductive tissue.
Treatment modalities include:
Instant Feedback:
In a third degree heart block, the P waves are "married" to the QRS complexes.
TRUE or FALSE
Rate variable
normal if the underlying
P wave
rhythm is sinus
QRS wide; > 0.12 seconds
This block occurs in the right
or left bundle branches or in
both. The ventricle that is
Conduction
supplied by the blocked
bundle is depolarized
abnormally.
regular or irregular depending
Rhythm
on the underlying rhythm.
Left bundle branch block is more ominous than right bundle branch block
because it usually is present in diseased hearts. Both may be caused by
hypertension, MI, or cardiomyopathy. A bifasicular block may progress to third
degree heart block.
Rate variable
usually obscured by the QRS,
P wave
PST or T wave of the PVC
wide > 0.12 seconds;
morphology is bizarre with
the ST segment and the T
QRS wave opposite in polarity.
May be multifocal and
exhibit different
morphologies.
the impulse originates below
the branching portion of the
Conduction Bundle of His; full
compensatory pause is
characteristic.
irregular. PVC's may occur in
singles, couplets or triplets;
Rhythm
or in bigeminy, trigeminy or
quadrigeminy.
PVCs can occur in healthy hearts. For example, an increase in circulating
catecholamines can cause PVCs. They also occur in diseased hearts and from
drug (such as digitalis) toxicities.
Interventions include:
lidocaine,
pronestyl, or
quinidine.
Instant Feedback:
Treatment is usually required if there are more than six PVCs per minute.
TRUE or FALSE
Ventricular Tachycardia
CAD
acute MI
digitalis toxicity
CHF
ventricular aneurysms.
Instant Feedback:
Ventricular tachycardia is characterized by:
Torsade de Pointes
usually between 150 to
Rate
220/bpm,
P wave obscured if present
QRS wide and bizarre morphology
Conduction as with PVCs
Rhythm Irregular
Hallmark of this rhythm is the upward and downward deflection of the QRS
complexes around the baseline. The term Torsade de Pointes means "twisting
about the points."
Caused by:
Treatment:
Ventricular Fibrillation
Rate unattainable
may be present, but obscured
P wave
by ventricular waves
QRS not apparent
Conduction chaotic electrical activity
Rhythm chaotic electrical activity
Almost always occurs with serious heart disease, especially acute MI.
Idioventricular Rhythm
Rate 20 to 40 beats per minute
P wave Absent
QRS Widened
Conduction Failure of primary pacemaker
Rhythm Regular
Absent P wave
Widened QRS > 0.12 sec.
Also called " dying heart" rhythm
Pacemaker will most likely be needed to re-establish a normal heart rate.
Causes:
Myocardial Infarction
Pacemaker Failure
Metabolic imbalance
Myoardial Ischemia
Options include:
Atropine
Pacing
Asystole/Ventricular Standstill
Rate none
may be seen, but there is no
P wave
ventricular response
QRS none
Conduction none
Rhythm none
Interventions include:
CPR,
artificial pacing, and
atropine
Artifact
Artifact occurs when something causes a disruption in monitoring.
Nursing Interventions:
Nursing Interventions:
Apply the knowledge that you now have after taking this basic course by taking an
intermediate level course "Cardiac Case Studies: Apply Your Knowledge". You can
refer back to this course for basic information as you take the case study course.