Prof. Maila Claire A.

Lichauco, RN,MAN

 Records

the hearts electrical activity as waveforms that depict depolarization (contraction) and repolarization (relaxation)
is used to diagnose and monitor certain disorders

It

Allows

identification of rhythm disturbances, conduction abnormalities, and electrolyte imbalance

The purpose of cardiac monitor:

to pick up electrical signals generated by the heart and to display them on screen in the form of a continuous electrocardiogram. By analyzing the electrocardiographic waveforms, any disturbance in cardiac rate, rhythm, or conduction can be identified

1.

Vagal stimulation of the parasympathetic nervous system

1. 2.

decrease in the rate at the SA node decreased excitability of the AV junction fibers Increases the rate at the SA node Increases the force of myocardial contraction

2.

Sympathetic stimulation
1. 2.

3.

A small area of the heart can become more excitable than normal, which causes abnormal heartbeats called ectopy

The

SA node, internodal tracts, AV node, bundle of His, right and left bundle branches, and Purkinje Fiber make up the system that conducts electrical impulses and coordinates chamber contraction.

On a typical EKG grid, 5 small squares, or 1 large square, represent 0.20 seconds of time
a. b.

True False

P wave represents electrical activity associated with original impulse from the SA node and its passage thru the atria Atrial depolarization and contraction of the atria Concave and small; no notching or peaking

PR interval (period from the start of the P wave to the

beginning of the QRS complex)
Indicates

AV conduction time 0.12-0.20 second

QRS Complex Indicates ventricular depolarization or contraction of the ventricles Less than 0.12 sec R waves are deflected positively and the Q and S waves are negative

ST Segment Indicates early ventricular repolarization isoelectric

T wave Indicates ventricular repolarization Rounded and asymmetrical

Normal QRS duration is 0.15-0.20 second

a. b.

True False

RA

LA

LL

Lead I RA LA

Lead II

Lead III

LL

1. Calculate heart rate (atrial and ventricular)

Atrial rate - # of P waves x 10 Ventricular rate - # of R waves x 10

You need 6 second strip

300 divided by the number of large squares between regular QRS complexes

 2.

Check for regularity of rhythm

check for equality of R-R distance

3. Rhythm is there a P wave for every QRS?

if yes Sinus/ normal if no Atrial fibrillation pattern

4. Measure the PR interval 5. Measure the QRS interval

6. Determine if T waves are present and have a normal shape, normal amplitude, and the same deflection as the QRS. 7. Determine QT interval duration. Count the small squares between the beginning of the QRS complex and the end of the T wave.

8. Evaluate other components. Note ectopic beats or other abnormalities. Check the ST segment for abnormalities. Look for U wave

What is the rate? Is the rhythm regular? Is there a P wave for every QRS complex? What is the PR interval? What is the QRS interval?

What is the rate? Is the rhythm regular? Is there a P wave for every QRS complex? What is the PR interval? What is the QRS interval?

 Term

used when either the rate, rhythm, or contour of the individual waves does not meet normal standards

Classification of arrhythmias: 1. Disturbance of impulse formation according to site of origin 2. Disturbance of conduction abnormal delay or block in the passage of the cardiac impulse from the SA node thru the Purkinje fibers in the ventricle

Sinus Tachycardia Sinus Bradycardia Sinus Arrest/Block

ECG features: Rate: usually 100-150 bpm Rhythm: regular P waves: Normal PR interval: Normal QRS: Normal

Rate: 40-59 bpm P wave: sinus QRS: normal Conduction: PR normal or slightly prolonged at slower rates Rhythm: regular or slightly irregular

 All atrial and ventricular rhythms normal except for missing Complex Normal P wave preceding each QRS complex

PACs Atrial Flutter Atrial Fibrillation

Rate: Normal or accelerated P wave: usually have a different morphology than sinus P waves because they originate from an ectopic pacemaker QRS: normal Conduction: normal Rhythm: PACs occur early in the cycle

 Rate:

atrial rate usually between 400-650/bpm P wave: not present; only fibrillatory waves QRS: normal Conduction: variable Rhythm: irregularly irregular (HALLMARK)

Rhythm
Atrial: regular Ventricular: typically regular, although cycles may alternate Rate: atrial 250-400bpm ventricular 60-100bpm

wave abnormal, sawtooth appearance or flutter waves of F waves PR interval not measurable QRS duration usually within normal limits T wave not identifiable QT interval not measurable

The hallmark sign of atrial flutter

a. b.

Irregularly irregular rhythm Sawtooth appearance

1st degree AV block 2nd degree AV Block 3rd degree AV block

Atrial and ventricular rhythms regular PR interval > 0.20 second P wave precedes QRS complex QRS complex normal

Second-degree AV block Mobitz I (wenckebach)

Atrial rhythm regular Ventricular rhythm irregular PR interval progressively, but only slightly, longer with each cycle until QRS complex disappears (dropped beat); PR interval shorter after dropped beat

Atrial rate regular Ventricular rate slow and regular no relation between P waves and QRS complexes No constant PR interval QRS interval normal

In a third degree heart block, the P waves are married to the QRS complexes
a. b.

True False

PVCs Vtach Vfib

Rate: Variable P wave: usually obscured by the QRS,PST or T wave of the PVC QRS: wide> 0.12 sec, bizarre morphology, occurs earlier than expected Conduction: impulse originates below the branching portion of the bundle of His Rhythm: irregular May occur singly, in pairs(couplets, triplets),in patterns (bigeminy, trigeminy, or quadrigeminy), maybe unifocal or multifocal T wave appears differently with QRS

DANGEROUS PVCs:

R-on-T pattern

Bigeminy

Multifocal

More than 6/minute

Sequential/Couplets

Rate: Usually between 100-250 bpm P wave: obscured QRS: wide and bizarre Conduction: as with PVCs Rhythm: three or more ventricular beats in a row, may be regular or irregular May stop or start suddenly

Torsades de Pointes

 Ventricular

rhythm rapid and chaotic QRS complex wide and irregular, no visible P waves

 Continue

CPR, ACLS protocol

DIAGNOSTIC TESTS AND PROCEDURES

Potassium

Hypokalemia causes increased cardiac electrical instability, ventricular dysrhythmias, and increased risk of digitalis toxicity In hypokalemia, the electrocardiogram would show flattening and inversion of the T wave, the appearance of a U wave, and sagging of the ST segment

Hyperkalemia causes asystole and ventricular dysrhythmias

Calcium Hypocalcemia can cause ventricular dysrhythmias, prolonged QT interval, and cardiac arrest Hypercalcemia can cause a shortened QT interval, Av block, tachycardia or bradycardia, digitalis hypersensitivity, and cardiac arrest

A low magnesium level can cause ventricular tachycardia and fibrillation

A high magnesium level can cause muscle weakness, hypotension, bradycardia, and a prolonged PR interval and wide QRS complex

Description

Done to determine the size, silhouette, and position of the heart Specific pathological changes are difficult to determine via xray, but anatomical changes can be seen

Implementation

Prepare the patient for x-ray film, explaining the purpose and procedure Remove jewelry

Description
A common noninvasive diagnostic test that evaluates the hearts function by recording the electrical activity

Implementation

Determine the clients ability to lie still, and advise the client to lie still, breathe normally, and refrain from talking during the test Reassure the client that an electrical shock will not occur Document any cardiac medications the client is taking

Description A noninvasive test in which the client wears a Holter monitor and an ECG tracing is recorded continuously over a period of 24 hours or more It identifies dysrhythmias if they occur and evaluates the effectiveness of antidysrhythmics or pacemaker therapy

Implementation

Instruct the client to resume normal daily activities and to maintain a diary documenting activities and any symptoms that may develop

Description
A noninvasive procedure based on the principles of ultrasound It evaluates structural and functional changes in the heart

Implementation

Determine the clients ability to lie still, and advise the client to lie still, breathe normally, and refrain from talking during the test

 Assess

indicators of cardiac output and oxygenation, especially changes in level of consciousness. Physical assessment includes:

Rate and rhythm of apical and peripheral pulses Assess heart sounds Blood pressure and pulse pressure Signs of fluid retention

Health

history: include presence of coexisting conditions and indications of previous occurrence Medications

 Decreased
Anxiety Deficient

cardiac output

knowledge

 Cardiac

arrest Heart failure Thromboembolic event, especially with atrial fibrillation

 Goals

may include eradicating or decreasing the occurrence of the dysrhythmia to maintain cardiac output, minimizing anxiety, and acquiring knowledge about the dysrhythmia and its treatment.

Monitoring
ECG

monitoring Assessment of signs and symptoms

Administration

of medications and assessment of medication effects Adjunct therapy: cardioversion, defibrillation, pacemakers

Anxiety
Use

a calm, reassuring manner. Measures to maximize patient control to make episodes less threatening Communication and teaching
Teaching
Include

self-care

family in teaching

 An

electronic device that provides electrical stimuli to the heart muscle Types:

Permanent Temporary

 Infection Bleeding

or hematoma formation Dislocation of the lead Skeletal muscle or phrenic nerve stimulation Cardiac tamponade Pacemaker malfunction

 Treat

tachydysrhythmias by delivering an electrical current that depolarizes a critical mass of myocardial cells. When cells repolarize, the sinus node is usually able to recapture its role as heart pacemaker. In cardioversion, the current delivery is synchronized with the patients ECG. In defibrillation, the current delivery is unsynchronized.

Ensure good contact between skin and pads or paddles. Use a conductive medium and 20-25 pounds of pressure. Place paddles so that they do not touch bedding or clothing and are not near medication patches or oxygen flow. If cardioverting, turn the synchronizer on. If defibrillating, turn the synchronizer off. Do not charge the device until ready to shock. Call clear three times; follow checks required for clear and ensure that no one is in contact with the patient, bed, or equipment.

device that detects and terminates life-threatening episodes of tachycardia or fibrillation NASPE-BPEG code Antitachycardia pacing