ECG Basics Outline: 1. Review of the conduction system 2. ECG waveforms and intervals 3. ECG leads 4.

Determining heart rate THE NORMAL CONDUCTION SYSTEM

Drug toxicity (i.e. digoxin and drugs which prolong the QT interval) ECG LEADS Leads are electrodes which measure the difference in electrical potential between either: 1. Two different points on the body (bipolar leads) 2. One point on the body and a virtual reference point with zero electrical potential, located in the center of the heart (unipolar leads) EKG Leads 3 Standard Limb Leads 3 Augmented Limb Leads 6 Precordial Leads The axis of a particular lead represents the viewpoint from which it looks at the heart.

WHAT IS AN ECG?  The electrocardiogram (ECG) is a representation of the electrical events of the cardiac cycle.  Used to measure the rate and regularity of heartbeats, as well as the size and position of the chambers, presence of any damage to the heart, and effects of drugs or devices used

WHAT TYPES OF PATHOLOGY CAN WE IDENTIFY AND STUDY FROM EKGS? Arrhythmias Myocardial ischemia and infarction Pericarditis Chamber hypertrophy Electrolyte disturbances (i.e. hyperkalemia, hypokalemia)

 Take the number of big boxes between neighboring QRS complexes, and divide this into 300. The result will be approximately equal to the rate  Although fast, this method only works for regular rhythms.

DETERMINING THE HEART RATE Rule of 300 10 Second Rule RULE OF 300

10 SECOND RULE  As most EKGs record 10 seconds of rhythm per page, one can simply count the number of beats present on the EKG and multiply by 6 to get the number of beats per 60 seconds.  This method works well for irregular rhythms.

 Accessory cephalic vein  Select a site distal to the heart and move proximally as necessary

INTRAVENOUS THERAPY Insertion of a needle or catheter / cannula into a vein based on a physician s written prescription. The needle or catheter / cannula is attached to a sterile tubing and fluid container to provide medicine and fluid. PURPOSE:  To maintain / correct dehydration in clients unable to tolerate sufficient volume of oral fluids / medicine.  Parenteral nutrition  Administer drugs  Transfusion of blood or blood components  To provide a lifeline for rapidly needed medications or blood COMMON TYPES OF IV SOLUTIONS  a.) Hypotonic Solutions have less dissolved particles than plasma, good route for medications but not good choice for fluid replacers because it leaves the vascular space (D5W)  b.)Hypertonic Solutions have more dissolved particles then plasma and have initial effect of drawing water from intracellular spaces to intravascular space but once sugar content is metabolized, solution becomes hypotonic. (D5LR, D10, 0.45%NaCl)  c.) Isotonic Solution have roughly the same amount of dissolved particles as plasma and good choice for fluid replacement (NSS, LR) SITES FOR IVF INFUSION      Dorsal metacarpal veins Cephalic vein Basilic vein Radial vein Medial antebrachial vein

CONSIDERATION IN THE SELECTION OF THE SITE  Select a vein large enough to accommodate the needle that will be used  Type of solution  Client s age Equipments 1. Container of sterile intravenous solution IV solutions comes in different sizes a) 150 ml b) 250 ml c) 500 ml d) 1000ml 2. Solution should be sterile and in proper condition a) Check expiration date b) There should be no particulate matter in the solution c) Check for any leaks indicative of contamination 3. Administration set 1. Macrodrip or macroset (10,15 or 20 drops per ml of solution) 2. Microdrip or microset (60 drops per ml of solution) d) Insertion spike inserted into the solution container and kept sterile e) Drip chamber to prevent air from entering the line f) Roller or screw clamp to control the rate of flow of the solution g) Tubing h) Protective cap maintains the sterility of the end of the tubing

so that it can be attached to a sterile needle inserted in the client s vein i) Needle adapter 3. Volume-control set or solute set 4. IV poles  The higher the solution container is suspended, the greater the force of the solution as it enters the client and the faster the rate of flow. 5. Intravenous needle or catheter a. Butterfly or win-tipped needles (25 to 17 gauge) b. Catheter or angiocatheter c. The larger the gauge number, the smaller the diameter of the shaft 6. IV Tray  Contains sterile swabs, antiseptic solution, plaster, tourniquet, splint, local anesthetic, sterile 2X2 gauze squares  The initiation of IV therapy is upon the written prescription of a licensed physician which is checked for the:  Type of solution  Flow rate  Amount of solution  Dose and frequency of medicine to be incorporated

Setting up: 1. Check doctor's order and make IV label 2. Prepare necessary set, IV stand or IV hook, IV tray, cotton balls with alcohol, plaster, tourniquet and splint. 3. Explain procedure to client and assess client's vein. 4. Check the solution and set for sterility. 5. Place IV label on IVF bottle. 6. Wash hands before and after setting up IV. 7. Maintain sterility of IV solution container while opening port 8. Disinfect rubber port with cotton ball dipped in alcohol 9. Open administration set aseptically (Venoset) and close the roller clamp

10.Spike the container without contaminating port. 11.Hang the IV bottle using the IV stand or hook. 12.Fill drip chamber to at least half 13.Prime the tubing while maintaining sterility of the end of tubing (use kidney basin) 14.Remove all air from tubing (get ready for IV insertion) A. Changing an IV Infusion 1. Check doctor's order in the Doctor's Order Sheet and IV sheet; Countercheck IV label, IV card, bottle number or bottle sequence, type, amount, additives (if any), duration of infusion. 2. Prepare necessary materials (IV solution, IV label, disinfectant, kidney basin or tray) 3. Check sterility of IV solution 4. Calibrate IV bottle according to duration of infusion 5. Bring necessary materials at the bedside and explain procedure to the client 6. Wash hands before and after procedure 7. Disinfect rubber port of new IV solution prior to inserting spike of the previous administration set 8. Close roller clamp or kink tubing of administration set when changing IV solution bottle 9. Spike the container without contaminating port 10.Regulate the flow rate based on duration of infusion. Remove air bubbles (if any) 11.Document in client's IV sheet and Kardex B. DISCONTINUING AN IV INFUSION 1. Verify written doctor's order to discontinue IV 2. Prepare necessary materials (IV tray with cotton balls with alcohol, plaster) 3. Wash hands before and after procedure 4. Explain procedure to client 5. Wet all adhesive tapes with alcohol before removing them.

6. Clamp tubing 7. Get another cotton ball with alcohol; Remove needle or IV cannula quickly 8. Place cotton ball with pressure and tape 9. Document time of discontinuance, status of insertion site. Calculating the Infusion Rate Total number of ml to be given = ml to be given / hour Hours in which the solution is to be infused Volume X drop factor = drops per min. #of hours X 60 min. INCORPORATION OF DRUG INTO IVF BOTTLE / BAG 1. Verify the written medication card against the M.D. prescription; observe hospital policy on drug administration. 2. Observe 10 R s when preparing and administering medication. 3. Explain procedure (medication and action) to reassure patient and significant others and check patency and IV site. 4. Verify for skin test of drug of IV incorporation (if skin testing is necessary) 5. Do hand hygiene before and after the procedure. 6. Prepare necessary material needed for the procedure such as: injection tray, syringes needed, right drug to be incorporated either in vial or ampule. 7. Disinfect injection port of the vial & the ampule before breaking then aspirate the right dose aseptically. 8. Remove the cover of the administration set, maintain sterility and incorporate prepared drug into the airway aseptically.  Note: if the administration set has no airway, pull out the set and incorporate the prepared drug and re-spike the IV set to the bottle then place the label. (all these should be done aseptically) 9. Swirl the IV bottle to mix the drug with the IVF and regulate the flow rate accordingly.

10. Observe for 5-10 minutes for any drug interaction while reassuring the patient; monitor VS. 11. Document in the patient s chart 12.Discard the sharp and other wastes according to Health Care Waste Management (DOH / DENR) IV PUSH THROUGH THE IV PORT 1. Verify the written medication card against the M.D. prescription; observe hospital policy on drug administration. 2. Observe 10 R s when preparing and administering medication. 3. Explain procedure to reassure patient and significant others (the name of the medicine and action / interaction of medication) before administration. 4. Do hand hygiene before and after the procedure. (use gloves especially for chemotherapeutic & other vesicant drugs) 5. check patency and other signs of swelling, redness, phlebitits, etc do not give the drug 6. check for skin test result of drug for IV push, drug-drug, drug IV fluid incompatibility, dosage (computation) 7. Prepare the necessary materials for the procedure such as: right drug, right diluent needed, IV injection tray, syringes and needles, alcohol, etc 8. Disinfect the injection port of the diluent, vial or ampule as appropriate 9. Aspirate right amount of diluent for the drug (if drug needs to be diluted) 10. Aspirate the right drug dose; disinfect the Y- injection port of the IV administration set / catheter IV port. 11. Close the roller clamp of the IV tubing from the bottle and push IV drug aseptically and slowly or according to the manufacturer s recommendation. 12. Using same syringe aspirate 1-2cc of IVF to flush the medicine given. 13. Regulate rate of IV fluid infusion as prescribed. (if needed)

14. Reassure patient and observe for signs and symptoms of adverse drug reaction. 15. Discard sharps and other waste according to Health Care Waste Management. DRUG INCORPORATION INTO VOLUMETRIC CHAMBER 1. Verify the written medication card against the M.D. prescription; follow hospital policy on drug administration. 2. Observe 10 R s when preparing and administering medication. 3. Explain procedure to patient (medicine and action) and check IV site. Verify for skin test of the drug before IV incorporation. 4. Do hand hygiene before and after procedure. 5. Prepare the necessary materials for the procedure such as right drug and dose, right diluent needed IV injection tray. Syringes and needles. 6. Check the present IV fluid label, level and the incorporated medicine in the Volumetric Chamber or IV bottle if with incorporated medicine, check for drug-drug incompatibility and if the ongoing IV fluid in the Volumetic Chamber is to be consumed in 6-8 hours, request a prescription for IVF to be used solely for drug administration and keep whole set sterile for succeeding doses. 7. Aspirate prepared right drug with correct dose. 8. Add desired IVF diluent into Volumetric Chamber by opening the sliding clamp from the bottle then close the clamp. 9. Disinfect rubber injection port of the volumetric chamber and incorporate the drug, mix gently. 10. Open the clamp of the airway at the volumetric chamber. 11.Regulate flow rate of IVF infusion accordingly. 12.Place IV label on volumetric chamber indicating drug incorporated and flow rate.

13.Reassure / monitor patient when incorporated medicine is consumed,, clamp airway of V. C add IVF & regulate flow rate of main IVF as prescribed. 14.Discard waste according to Health Care Waste Management (DOH / DENR). 15.Document in patient s chart the drug administered & patient condition. 16.Document in patient s chart IVF sheet and Kardex (of changes in IV rate / time due) PUSH THROUGH HEPARIN LOCK DEVICE 1. Check medication card against the written doctor s prescription. 2. Observe 10 R s when preparing and administering medication. 3. Explain procedure to the patient (name of medicine and action) before administration. 4. Do hand hygiene before and after the procedure (use gloves especially in chemo drugs) 5. Gather equipment to include / but not limited to IV tray, Heparin solution, normal saline diluent or isotonic solution, 2.5 cc syringes 3 pieces tuberculin / TB syringe 1pc. 6.Prepare medication to be administered e.g., antibiotic, and draw it up into a syringe. 7.Fill in tuberculin syringe with Heparin Solution. N.B. Heparin solution is usually prepared with 0.1cc Heparin plus .9cc Normal Saline or Isotonic solution. 8.Fill the 2.5cc syringe with Isotonic solution or Normal Saline 1cc each. 9.If using Hep. Loc device with 3 way stop cock with luer-lock, rotate the stop cock so that the line going to the patient is closed (this will prevent backflow of blood) 10.Remove the cover of the injection port aseptically and keep the sterility of the cover. 11.Check the patency, open the IV line, and inject NSS or Isotonic Solution to flush the Heparin solution. 12.Close the IV line & remove saline syringe and insert medication syringe into port.

13.Open the IV line & inject medication into the vein, timing the flow rate according to doctor s prescription of drug manufacturer s instructions. 14.Observe patient for any adverse reactions & do nursing intervention accordingly. 15.Close the IV line and remove medication syringe. 16. Insert the saline syringe, open the line & flush Catheter tubing / IV cannula to flush the line. 17. Close & remove saline syringe. 18. Close the IV line, remove syringe and return the cover of the injection port aseptically. 19. Document in the patients chat and Kardex. 20.Discard waste according to Health Care Waste Management. (DOH / DENR).  Note: Normal saline can take the place of Heparin. Studies have shown the efficacy of NSS. Heparin solution can be used if normal saline or isotonic solution is not available.