Care of pats with dysrhythmias

Question 1

atrial depolarization; contraction atria; first wave

Answer 1

P

Question 2

total time for atrial to depolarize and time takes for impulse to travel from SA node through Purkinje fibers

Answer 2

PR interval -

Question 3

big one; ventricular depolarization/contraction

Answer 3

QRS complex -

Question 4

early ventricular repolarization

Answer 4

ST segment -

Question 5

ventricular repolarization - back to resting state

Answer 5

T wave -

Question 6

total time for depolarization and repolarization

Answer 6

QT -

Question 7

Determine heart rate - in a 6 sec strip count number QRS complexes and x10
Determine heart rhythm – can be regular or irregular; same difference between R’s; use calibers and see if difference between Rs sim
Analyze P waves
Small square = .04; large .2
Measure PR interval (normal .12-.20)
Measure QRS duration (normal .06-.12)
Examine the ST segment
Interpret rhythm and differentiate normal and abnormal cardiac rhythms

Answer 7

ECG rhythm analysis

Question 8

Are P waves present?
Are the P waves occurring regularly?
Is there one P wave for each QRS complex? Regularly - space in between each
Are the P waves smooth, rounded, and upright in appearance, or are they inverted?
Do all the P waves look similar?

Answer 8

Analyze P waves

Question 9

Are PR intervals greater than 0.20 second?
Are PR intervals less than 0.12 second?
Are PR intervals constant across the strip?
Measure from the beginning of the P wave to the beginning of the QRS

Answer 9

Measure PR interval (normal .12-.20)

Question 10

Are QRS intervals less than or greater than 0.12 second?
Are the QRS complexes similar in appearance across the ECG paper?
Measure from the beginning of the QRS to end of S wave

Answer 10

Measure QRS duration (normal .06-.12)

Question 11

Elevation may indicate myocardial infarction, pericarditis, hyperkalemia
Depression is associated with hypokalemia, myocardial infarction, ventricular hypertrophy

Answer 11

Examine the ST segment

Question 12

Normal strip
Rate: 60-100 beats/minute
Rhythm: atrial and ventricular rhythms are regular - measure from each P and R wave are equal and consistent
P waves: Present, consistent configuration, one P wave before each QRS complex
PR interval : 0.12-0.20 second and constant; within norm range
QRS duration: 0.06-0.12 second and constant; within norm range
R to R constant; P to P constant
No interventions required

Answer 12

Normal sinus rhythm (NSR)

Question 13

Variant of NSR
Type sinus rhythm; some irregularity
Results from changes in intrathoracic pressure during breathing
Has all the characteristics of NSR except for its irregularity
The PP and RR intervals vary, with the difference between the shortest and the longest intervals being greater than 0.12 second (three small blocks)
Rate: Atrial and ventricular rates between 60 and 100 beats/minute; norm rate
Rhythm: Atrial and ventricular rhythms irregular, with the shortest PP or RR interval varying at least 0.12 second from the longest PP or RR interval
P waves: One P wave before each QRS complex; consistent configuration
PR interval: Normal, constant
QRS duration: Normal, constant
No interventions required.

Answer 13

Sinus arrhythmia (SA)

Question 14

Any disorder of the heartbeat/electrical activity
Tachydysrhythmias – heart rates greater than 100 beats per minute; fast
Bradydysrhythmias – heart rates less than 60 beats per minute; slow
Premature complexes – early rhythm complexes; if they become more frequent, especially those that are ventricular, the patient may experience symptoms of decreased cardiac output; ectopy: early complex; early ventricular/atrial contraction - ventricular more serious and more frequent more serious
Repetitive rhythm complexes
Etiology – may occur for many reasons; MI, electrolyte imbalance - K/Mg; hypoxic, low blood volume, hypovolemia, caffeine, nicotine, stress
Can be classified by their site of origin in the heart (sinus, atrial, ventricular)
Managed with antidysrhythmic drug therapy depending on dysrhythmia

Answer 14

Dysrhythmias

Question 15

Bigeminy
Trigeminy
Quadrigeminy

Answer 15

Repetitive rhythm complexes

Question 16

Vaughn-Williams classification used to categorize drugs according to their effects on the action potential of cardiac cells (classes 1 through IV)
Other drugs – Digoxin, Atropine sulfate, Adenosine

Answer 16

Managed with antidysrhythmic drug therapy depending on dysrhythmia

Question 17

Assess vital signs at least every 4 hours - monitor VS; assessment essential of pat; BP, dizzy, chest pain
Monitor for cardiac dysrhythmias
Evaluate and document patient’s response of dysrhythmia
Encourage patient to notify nurse if chest pain occurs
Assess for chest pain and respiratory difficulty - SOB
Assess peripheral circulation
Administer medication and monitor response
Monitor lab values - abnormalities in lab, Mg, Ca high risk for diff types dysrhythmias so need tight control
Monitor activity tolerance and schedule exercise/rest periods to avoid fatigue - SOB with activity
Promote stress reduction
Offer spiritual support
Close eye for pats with this or at risk

Answer 17

Care of pat with dysrhythmias

Question 18

Common
Sinus tachycardia; heart rate greater than 100 beats/min.
Treatment for sinus tachycardia is to treat the underlying cause. Caffeine, alcohol, nicotine, and some medications may increase the heart rate. Remove offending agent
Initially CO increase with ST but if for too long period time demands of heart and myocardial O2 demands so great that heart not able sustain - compensatory mechanisms wear out
Rate: 101-160 beats/min
Rhythm: regular
P waves: Present, consistent configuration, one P wave before each QRS complex - just fast
PR interval : 0.12-0.20 second and constant
QRS duration: 0.06-0.12 second and constant; looks norm
Regular wave

Answer 18

Sinus dysrythmia - sinus tachycardia (ST)

Question 19

Commonly seen
Rate: Less than 60 beats per minute
Rhythm: regular
P waves: Present, consistent configuration, one P wave before each QRS complex
PR interval : 0.12-0.20 second and constant; norm
P to P and R to R consistent
QRS duration: 0.06-0.12 second and constant; norm
In many cases, the cause may be unknown.
Myocardial O2 demands low because not pumping fast - low CO because not beating as fast
Treatment depends on pat - if symptomatic (diaphoresis, chest pain, dyspnea, syncope, dizziness, weakness, confusion, hypotension): if do give them something: Atropine 0.5 mg IV, IV fluids, oxygen, monitor VS
First thing do if any dysrhythmia is assess the pat
Pacing may be required: Temporary versus permanent

Answer 19

Sinus dysrythmia - sinus bradycardia (SB)

Question 20

Ectopic beat/focus of atrial tissue fires an impulse before next sinus impulse is due - atrial tissue shoots impulse that causes premature beat; outsync norm SA node regulating
Premature P wave may not always be clearly visible because it can be hidden in the preceding T wave - not always obvious; not typ have symp but monitor for pat
A PAC is usually followed by a pause

Answer 20

Atrial dysrhythmia - premature atrial complexes (PAC)

Question 21

Tachycardia being cause by something above ventricles: means atria
Rapid stimulation of atrial tissue occurs at rate of 100-280 beat/minute in adults
P waves may not be visible, because they are embedded in the preceding T wave - going so fast
Paroxysmal supraventricular tachycardia (PSVT) rhythm is intermittent, initiated suddenly by a premature complex such as a PAC and terminated suddenly with or without intervention
Sometimes nonsustained; not know have it; short; if sustained will have symp or feel palpitations in chest - send on heart monitor and see when having episodes of SVT - monitor for; check BP and s/s of pat and if symptomatic/not

Answer 21

Atrial dysrhythmia - supraventricular tachycardia (SVT)

Question 22

Most common dysrhythmia - VERY COMMON
Associated with atrial fibrosis and loss of muscle mass - quivers and not contract normally
Common in heart disease such as hypertension, heart failure, coronary artery disease
Many other risk factors
Cardiac output can decrease by as much as 20% to 30% - atria not fully ejecting so not fully filling ventricles so CO is affected
Above rhythm: Atrial fibrillation
Seen often in pulm pats
Rate: Atrial (350-400 beats/minute) - can vary but very irregular looking, ventricular variable, rate varies; atrial rate very fast
Rhythm: irregularly irregular, always irregular
P waves: Normal P waves are absent; not discernable; little pumps
PR interval : Not discernible; not able measure
QRS duration: 0.06 to 0.12 second; norm
Not regular between R to R
Very fast atrial rate; irregular ventricular rate; no discernable P waves and no way measure PR interval

Answer 22

Atrial fibrillation (AF)

Question 23

Assess pat first always for fatigue, weakness, shortness of breath, dizziness, anxiety, syncope, palpitations, chest discomfort or pain, hypotension; make sure getting good full assessment
Very High risk for PE, VTE, stroke - atria quivering and not fully emptying since not ejecting some blood stays back in atria before moves into ventricles and when pools blood clots and when atria quivering clot gets pushed out and goes anywhere; high risk for emboli
Drug therapy
Want stop dysrhythmia, slow down HR and prevent clots

Answer 23

Assessment and treatment of AF

Question 24

Calcium channel blocker such as diltiazem (Cardizem)
Aminodarone (Cordarone) – class 3 antiarrythmic agent
Beta blockers such as metoprolol (Toprol) and esmolol (Brevibloc) – slows ventricular response; slows down HR
Digoxin (Lanoxin) – for patients with heart failure and AF; slows down HR
Anticoagulants – Heparin, enoxaparin (lovenox), warfarin (coumadin), other newer drugs are now available; unless risk too great
Antiplatelet – Aspirin, clopidogrel (Plavix); may also do in addition/instead of anticoag

Answer 24

Drug therapy

Question 25

Cardioversion - synchronized shock; with dfib; not want during T wave
Percutaneous radiofrequency catheter ablation - ablate area irritable - percutaneously, surgical setting
Bi-ventricular pacing - if low CO
Surgical Maze procedure

Answer 25

Treatment of AF

Question 26

Typ More life-threatening and serious than atrial dysrhythmias
Left ventricle pumps oxygenated blood throughout the body to perfuse vital organs and other tissues - perfuses entire body; anything in ventricle where not fully ejecting then have big issues with perfusion
Most common or life-threatening:

Answer 26

Ventricular dysrhythmias

Question 27

Premature ventricular complexes (PVCs) - ectopic beats
Ventricular tachycardia
Ventricular fibrillation
Ventricular asystole

Answer 27

Most common or life-threatening:

Question 28

Results from increased irritability of ventricular cells and are seen as early ventricular complexes followed by a pause - beat is initiated by something that bypasses the norm conduction sys and then causes contraction; typ has pause after it
May occur as: - classify
Real frequent PVCs needs be monitored and reported because can lead to serious dysrhythmias
PVC’s with acute myocardial infarction can lead to VT or VF, if not treated - sometimes occasional but when frequent need do intervention
Common and increases with age
Treatment depends on cause of PVCs
QRS complex is wide and bizarre looking because bypassing norm conduction sys
Norm sinus rhythm then weird QRS rhythm then pause - then back to NSR

Answer 28

Ventricular dysrhythmia - premature ventricular complexes (PVCs)

Question 29

bigeminy (every other beat is PVC) - more serious
trigeminy (every third beat is PVC)
quadrigeminy (every fourth beat is PVC)
couplet (two consecutive PVCs) - VERY serious
nonsustained ventricular tachycardia or NSVT (three or more consectutive PVCs) - extremely serious

Answer 29

May occur as: - classify

Question 30

Also called V tach—repetitive firing of an irritable ventricular ectopic focus/area in ventricles that just keeps firing, usually at 140-180 beats/minute or more - gets to point where overtaking
Sustained ventricular tachycardia at a rate of 166 beats/min.
May be intermittent (nonsustained VT) or sustained, lasting longer than 15 to 30 seconds and can deteriorate to VF
Wide and bizarre beats
Quick and fast; irritable area just keeps going
Rate: 101-250 beats/minute; 140-180
Rhythm: atrial rhythm not distinguishable, ventricular rhythm usually regular
P waves: not present
PR interval : not distinguishable
QRS duration: wide and bizarre
Key: assessment - stable/unstable which determines treatment

Answer 30

Ventricular dysrhythmia - ventricular tachycardia (VT)

Question 31

Stable VT:
Unstable VT:
Go in and assess pat first to see if stable/not and determine that by doing full VS and full assessment

Answer 31

Treatment for VT

Question 32

Treatment: oxygen - keep on this, amiodarone (Cordarone), lidocaine, or magnesium sulfate, elective cardioversion, radiofrequency catheter ablation, implantable cardioverter debrillation (ICD)
Oral antidysrhythmic agent: mexiletine (Mexitil) or sotalol (Betapace) to prevent further occurrences - after stabilize

Answer 32

Stable VT:

Question 33

Same as vfib - not mulse; very unstable; go through ABCs; will need some sort of defib
Can cause cardiac arrest, unstable VT without a pulse is treated the same way at ventricular fibrillation
Assess patient’s airway, breathing, circulation, level of consciousness, and oxygenation level

Answer 33

Unstable VT:

Question 34

Very serious and Life threatening – no cardiac output or pulse, blood is no longer being pumped out of the heart and brain not receiving blood; ventricles just quivering - no CO and no blood pumped out; need immediate action
May be the first manifestation of CAD
Patients with MI are at high risk
First priority – defibrillate the patient immediately; no pulse
Continue high quality CPR, provide airway management, follow ACLS and BLS protocol to resuscitate
No QRS, P, output, pulse

Answer 34

Treatment for VF

Question 35

Little fib waves - not high and tall as VT
Also called V fib—result of electrical chaos in ventricles - nothing going on
Coarse ventricular fibrillation. - can be narrow/small
Rate: not discernible
Rhythm: rapid, unorganized, not discernible
P waves: not present
PR interval : not distinguishable
QRS duration: no QRS complexes
Nothing to discern

Answer 35

Ventricular dysrhythmia - ventricular fibrillation (VF)

Question 36

Also called ventricular standstill—complete absence of any ventricular/sort of rhythm
Sometimes one complex but typ one flat line
Ventricular asystole with one idioventricular complex.
Rate: none
Rhythm: none
P waves: none
PR interval : none
QRS duration: none

Answer 36

Ventricular dysrhythmia - ventricular asystole

Question 37

Full cardiac arrest – no cardiac output or perfusion to the rest of the body and no pulse
Prognosis for the patient is poor
Start compressions; do ABCs
Manage airway
Administer CPR – compressions, airway, breathing; start chest compressions and get blood circulating as fast as possible prognosis is poor after resuscitation but once on get blood circulating to organs hopefully if get pat back decrease long term comps
Do NOT defibrillate - no electrical activity present
Follow ACLS protocol - epi

Answer 37

Treatment for ventricular asystole

Question 38

Prevention, early recognition, and management
Lifestyle modifications/changes (avoid caffeinated beverages, stop smoking, drink alcohol in moderation, follow prescribed diet) - drugs - exacerbate them
Drug therapy instructions - stay on med
Teach the patient and family how to take a pulse and/or BP and report any changes - need be able check BP
Keep follow-up appointments
Provide oral and written instructions for pacemakers, ICDs, cardiac exercise programs, support groups as applicable - lot more edu; cardiac rehab great so get supervised exercise

Answer 38

Patient teaching