Adult Health Nursing II Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring, part 2 Module:...

Adult Health Nursing IIBlock 7.0

Topic: Cardiovascular Nursing & EKG Monitoring , part 2Module: 2.3

Block 7.0 Module 2.3

Cardiovascular--- EKG’s / Cardiac Monitoring

Digitalis pupurea (Foxglove)

Lead II

Dynamic Presentation

Static Presentation

Part II

Block 7.0 Module 2.3

At the conclusion of this class (and after some practice) the nurse will be able to:

1. State the four characteristics of cardiac muscle, and relate these characteristics to cardiac output. 2. Trace the flow of blood through the heart & lungs, naming all associated

structures3. Trace electrical conduction through the cardiac conduction system and

correlate to the EKG Tracing.4. State the intrinsic rates of SA node, atria, AV node, and Ventricles5. Identify waveforms, landmarks on the EKG tracing: P, QRS, T, U, baseline

6. Identify and measure P-R Interval (PRI), QRS duration, ST Segment

7. Using an EKG tracing, Calculate heart rate and rhythm

8. Using data from EKG analysis, determine name of cardiac rhythm

9. Based upon identified cardiac rhythm, correlate & determine rhythm’s effect on cardiac output.

10. Identify NSR, SB, ST, SVT, A-fib, A-flut, 1st-2nd-3rd degree AV Blocks, PVC’s, PAC’s, V-Tach, V-Fib, Toursades, Asystole, PEA

11. Identify nursing actions related to cardiac monitor readings and care of the cardiac patient.

12. Be familiar with the following medications and their effect on the cardiac output: Alpha Blockers, Beta Blockers, Ca Channel Blockers, Atropine, Lidocaine, amiodarone, epinephrine, digoxin

13. Nursing care of the cardiac patient, including considerations related to all aspects of physical assessment, including cardiac monitoring, activities of daily living, diet, and medications.

Block 7.0 Module 2.3

Concept Map: Selected Topics in Cardiovascular Nursing

PATHOPHYSIOLOGYMyocardial InfarctionAcute Coronary SyndromeValvular Heart DiseasePacemakersCABGAbdominal Aortic AneurysmPericarditisPeripheral Vasc Disease (PVD)Fem-Pop Bypass GraftShock / Fluid DeficitRaynaud’s PhenomenonArrhythmias / Dysrhythmias

PHARMACOLOGYCardiac GlycosidesACE InhibitorsAlpha BlockersBeta BlockersAntiarrhythmicsCatecholaminesAnticoagulants

ASSESSMENTPhysical Assessment Inspection Palpation Percussion AuscultationCardiac MonitoringLab Monitoring

Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…

Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary

Block 7.0 Module 2.3

Block 7.0 Module 2.3

REMEMBER:At the ‘end of the day,’

IT’S ALL ABOUT

CardiacOutput!

C.O. = H R & R x S V

B.P. = C.O. X P V R S V R

*

* Tissue perfusion of vital organs…and everything else….

An Affirmation

“It’s all about cardiac output. Boy, don’t I know it now.”

Block 7.0 Module 2.3

It’s All About…

Cardiac Output = HR X SVC.O. = Heart Rate x Stroke Volume

SympatheticNervousSystem

ParasympatheticNervous System

BloodVolume

BloodVolume

Baroreceptors

Chemoreceptors

Medications

Medications

Preload,Afterload

Condition ofCardiac ConductionSystem* Condition of

Heart Valves

ConditionOfMyocardium

It’s AllAboutCardiac Output !

ViscosityOf Blood

And,Many more factors !

What FactorsAffectCardiac Output ?

Block 7.0 Module 2.3

Example of Multiple Factors in Cardiac Output Chemoreceptors

Baroreceptors

The SinoAtrial Node:60-100 impulses / minute

Sympathetic Effects:

Parasympathetic Effects:

Block 7.0 Module 2.3

Recall / Quiz : 1. Distinguishing Characteristics of Cardiac

Muscle: C________, C________, A__________, R___________.

2. Intrinsic ‘Rates’ if Cardiac Tissue: SA Node =____; (Atrial Muscle=_____) AV

Node=_____; Ventricular Muscle =_____. 3. Conduction Pathways in the Heart:

____>_____+_____>_____>_____>______>_________ 4. “Interval Times,” i.e., how long it takes these

impulses to reach certain points within the conduction pathway:

P-R Interval=_____ QRS=_____ 5. FORMULA FOR CARDIAC OUTPUT:____________ 6. FORMULA FOR BP:_________________ 7. “IT’S ALL ABOUT:_________ ________”Block 7.0 Module 2.3

LUNGS

Superior Vena Cava

R & L Common Carotid Arteries

Left SubclavianArtery

Lungs

Lungs

Block 7.0 Module 2.3

Cardiac Conduction Pathways

SA Node >>Inter nodal & Intra atrial pathways

(Bachmann’s Bundle)>>AV Node >>Bundle of His >>Right & Left Bundle Branches >>Purkinje Fibers

Block 7.0 Module 2.3

Intrinsic Rates… “automaticity”

Sino Atrial Node

(SA Node)

60-100 ipm

Atrial Muscle

~ 60 ipm

Atrio-Venticular Node

(AV Node)

40 – 60 ipm

Ventricular Muscle20-40 ipm

“Rate & Rhythm”Block 7.0 Module 2.3

“Automaticity”Intrinsic ratesSA Node = 60 – 100 i.p.m.Atrial Muscle = 60 i.p.m.AV Node = 40 – 60 i.p.m.Ventricular Muscle = 20 -40 i.p.m.

Block 7.0 Module 2.3

Conduction Pathways and rough correlation to the ECG Waveform

SA Node

AV Node

PRI: 0.12-0.20 seconds

QRS : < 0.12 seconds

Baseline

T Wave

Bundle of His

(R) & (L)Bundle Branches

PurkinjeFibers

Internodal & Intra-atrialPathways

Block 7.0 Module 2.3

Block 7.0 Module 2.3

Causes Of Dysrhythmias / Arrhythmias

1. Drugs (Medications & Others) Digoxin, quinidine, caffeine, nicotine,

alcohol, cocaine..others….2. Acid-Base & Electrolyte Imbalances: K+, Ca++, Mg+3. Marked Thermal Changes4. Disease & Trauma (Including

Surgery) 5. Stress

Block 7.0 Module 2.3

Block 7.0 Module 2.3

Rhythm IdentificationEach Has Specific Criteria…

Normal Sinus Rhythm (NSR)

Sinus Rhythm Sinus Bradycardia Sinus Tachycardia Sinus Arrhythmia

Atrial Flutter Atrial Fibrillation Junctional Rhythms Supraventricular

Tachycardia (SVT & PAT)

Heart Blocks: 1st, 2nd, 3rd

Ventricular Tachycardia Toursades de Pointes Ventricular Fibrillation Asystole Pulseless Electrical Activity

(PEA)

“Paced Rhythms”

Individual Ectopics: Premature Atrial Contractions Premature Junctional Contractions Premature Ventricular Contractions Artifact

POTENTIALLYLETHAL

Terminology:Bradyarrhythmias versus tachyarrhythmiasWide-complex tachycardia versus narrow-complex tachycardia

Block 7.0 Module 2.3

REMEMBER:At the ‘end of the day,’

IT’S ALL ABOUT

CardiacOutput!

C.O. = H R & R x S V

B.P. = C.O. X P V R S V R

*

* Tissue perfusion of vital organs…and everything else….Block 7.0 Module 2.3

An Important Caveat / Caution….

Cardiac Monitoring is a powerful diagnostic and patient care tool (only)

Correlate the monitor reading to the patient’s condition !

Check / Assess your patient for cardiac output!

The terms “EKG” and “ECG”ARE INTERCHANGEABLE

Block 7.0 Module 2.3

The “Stepwise” Method

Block 7.0 Module 2.3

EKG PAPER

Block 7.0 Module 2.3

EKG PAPER

“Amplitude”

Or Strength ofElectrical Impulse

TIMENote: Standard EKG Machines “run” at 25 mm/sec

Small Block = 0.04 sec5 Small Blocks = 1 Large Block = 0.20 sec5 Large Blocks = 1 second

Block 7.0 Module 2.3

“Standard” Limb Leads

Lead II“universal”--

Most useful

Block 7.0 Module 2.3

“ Chest Leads “ (for 12-Lead ECG)

Block 7.0 Module 2.3

The ECG Complex, Wave forms, Intervals, Segments

Block 7.0 Module 2.3

P Waves

Signal from the Sino Atrial Node (SA Node)“Normal Pacemaker of the heart”Should be upright ( Lead II )Should all look ~ alikeShould have 1:1 ratio with QRS ComplexesRhythms generated by this called “Sinus”, e.g., Sinus Rhythm, Normal Sinus Rhythm, Sinus Bradycardia, Sinus Tachycardia, Sinus Arrhythmia

Block 7.0 Module 2.3

P-R Interval (PRI)

Measure from beginning of P Wave to first deflection (up or down) from baseline to start QRS Complex

Time it takes for impulse to go from SA Node to ventriclesNormal time = 0.12 to 0.2 seconds ( 3-5 little blocks…)

(3 x 0.04= 0.12… 5 x 0.04= 0.20)Less than 0.12 sec PRI may indicate AV

Node--“junctional” problemGreater than 0.20 sec indicates AV Block

(1st – 2nd- 3rd degree) PRI’s should all be ~ equal

Block 7.0 Module 2.3

General Overview: Are they narrow or wide?Electrical conduction through the ventricles

Ventricular Function ~ = Cardiac OutputAppearance is generally consistent with ventricular function

Normal = < 0.12 seconds“3 little boxes” (3 x 0.04 = 0.12 sec)

QRS should all be ~ same form / shapeIf greater than 0.12 seconds, indicates “trouble,”

i.e., a conduction delay in the ventricles

QRS Complex

Block 7.0 Module 2.3

S T Segment

Time from ventricular depolarization to ventricular repolarization

Frequently “speaks” of trouble within the ventricles

Elevated or depressed ST segment may indicate previous or ongoing ischemia or damage to ventricular myocardium

General rule of thumb: ST Depression ↓ = Ischemia ST Elevation ↑ = Infarction

?

Block 7.0 Module 2.3

Block 7.0 Module 2.3

T Waves

Represent repolarization of Ventricles, i.e., “preparing to beat again”

Should be upright (lead II)Should appear ~ same“Flipped or inverted T waves” may be

sign of prior or ongoing ventricular damage

Prolonged QT Interval may represent problems with ventricular repolarization— due to damage or medication effectBlock 7.0 Module 2.3

“U” WAVES

Potassium EffectHYPOKALEMIA Fairly Rare….

P QRS T U P QRS T U P QRS T U P QRS T U

TALL “TENT-LIKE” T WavesCaused by: K+ Hyperkalemia

Either One, if not corrected,Means that ventricular tachycardia,And / or ventricular fibrillationIS on the way!

Block 7.0 Module 2.3

Block 7.0 Module 2.3

Repetition—Repetition--Repetition

1. General Overview of strip2. Rate3. Rhythm4. P Waves5. P-R Interval (PRI)6. QRS Interval7. Q-T Interval

Overview— Develop Your Method Practice IT & Follow IT !

Apply findings and

observations to CRITERIA

Block 7.0 Module 2.3

REMEMBER:At the ‘end of the day,’

IT’S ALL ABOUT

CardiacOutput!

C.O. = H R & R x S V

B.P. = C.O. X P V R S V R

*

* Tissue perfusion of vital organs…and everything else….Block 7.0 Module 2.3

Measuring Time and Events…

Baseline orIsoelectric line

P P

Block 7.0 Module 2.3

Three Methods for rate determination…

300 150 100 60start

120

Easy Way:12 x 10 (almost 11)= 120’sAccurate if the rhythm is REGULAR

Memorize…. OR divide 300By # of Big Boxes Between QRS complexes…or divide 60 by # secondsbetween qrs’s

75

Block 7.0 Module 2.3

Discussion …Measuring PRI & QRS

Block 7.0 Module 2.3

Rates…Intervals…Remember the “normals”:

PRI= 0.12 – 0.20 seconds(SA Node to Ventricles)

QRS = < 0.12 secondsTime Through the Ventricles

Block 7.0 Module 2.3

End of Cardiovascular Disease AH II Part 2We Will Continue in a moment

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Block 7.0 Module 2.3

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Block 7.0 Module 2.3

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~END OF PRESENTATION~GO TO THE NEXT PRESENTATION,

Module 2.4