rhythm notes Flashcards
A fib
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate – varies (atrial rate > 400 bpm, ventricular rate 100-175 bpm)
Rhythm – irregular
P wave – absent, not before QRS
PR int – none
QRS – normal
ST segment
v fib
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate – not measurable
Rhythm – irregular
P wave – none
PR int – none
QRS – none
ST segment –
A fib
NSR
Rate – varies (atrial rate > 400 bpm, ventricular rate 100-175 bpm)
Rhythm – irregular
P wave – absent, not before QRS
PR int – none
QRS – normal
ST segment
A fib
Rate – varies (atrial rate may be >250 bpm, ventricular rate slower)
Rhythm – irregular or regular
P wave – absent
PR int – none
QRS – normal
ST segment -
A flutter
VTACH
Rate – not measurable
Rhythm – irregular
P wave – none
PR int – none
QRS – none
ST segment –
V fib
NSR
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate 60-100
Rhythm regular
P wave – present, one before every QRS
PR interval – normal
WRS interval – normal
ST segment – normal
Rate 150-250
Rhythm - regular or irregular
P wave – none
PR int – none
QRS - WIDE
ST segment –
VTACH
A fib and A flutter
3. s/s?
- depends on (3)
- typically, s/s of _____
which is most common dysrhythmia?
which one do we see prevalence increases with age?
- depends on
- ventricular rate
- how long rhythm has been present
- CV status
- typically, s/s of tachydysrhythmia ***
- most common dysrhythmia = A fib
- prevalence increases with age = A fib
Rate – not reported in rate, count number of ______
Rhythm – regular or irregular (name the underlying rhythm)
P wave – absent on the _____
PR interval – none
QRS – WIDE
ST segment –
PVC
PAC
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate – not reported in rate, count number of PACs
Rhythm – regular or irregular (name the underlying rhythm)
P wave – present, before QRS, but looks different on the PAC
PR interval – N/A (don’t measure)
QRS – normal
ST segment – normal
what could cause sinus brady?
1. excessive vagal nerve stimulation or inhibition?
2. Carotid sinus massage
3. Vomiting/gagging
4. Valsalva maneuvers
5. anxiety
6. Eyeball pressure
7. Administration of parasympathomimetic drugs
8. hypoxia
9. digoxin toxicity
10. Hyp___kalemia
11. low BP
12. MI
13. may be a normal rhythm in athletes and during sleep
- excessive vagal nerve stimulation (causes rest and digest)
- Carotid sinus massage
- Vomiting/gagging
- Valsalva maneuvers
X5. anxiety - Eyeball pressure
- Administration of parasympathomimetic drugs
X8. hypoxia - digoxin toxicity
- Hyperkalemia – slows depolarization
X11. low BP - MI
- may be a normal rhythm in athletes and during sleep
PAC
Rate >130
Rhythm – regular
P wave – not discernable
PR int – not measurable
QRS – normal
ST segment
PSVT
a flutter
PSVT
1. what would be the next best nursing action or related nursing interventions or treatment?
1st
2nd
third
1st vagal maneuvers – trigger vagal response/PNS, brings pt out of PSVT
- Valsalva maneuver – most effective, hold breath 10-15 secs, should see JVD, then resume breathing
- Coughing
- Carotid sinus massage – HCP only
Or diving reflex/cold water submersion
2nd (If that doesn’t work) adenosine
- IV push followed with rapid NS flush (may use stop cock)
- Warn pt may see pause on rhythm strip – flat line
- Onset is 10-40 secs
- Duration – 1-2 mins
- very short half life
3rd (if that doesn’t work and pt becomes hemodynamically unstable)
- cardioversion, synchronized switch on
PSVT
Rate 60-100
Rhythm regular
P wave – present, one before every QRS
PR interval – normal
WRS interval – normal
ST segment –
NSR
V fib
sinus arrhythmia
PVC
1. what would be the next best nursing action or related nursing interventions, How is this treated?
Nursing action:
(2)
Treatment:
(2)
Nursing action:
- monitor for new PVC or increasing frequency
- contact HCP if new PVC or increasing frequency (could be turning into VTACH)
Treatment:
- treat the cause
- drugs
- beta blockers
- lidocaine
- amiodarone
VTACH
2. what could cause this rhythm?
- MI
- CAD
- electrolyte imbalance
- HF
- fever
- drug toxicities
- s/s?
- where does the impulse originate in this rhythm?
2.
- MI
- CAD
- electrolyte imbalance
- HF
X- fever
- drug toxicities
- will be symptomatic very quickly unless converts back to other rhythm
- ectopic focus within the ventricles takes controls and fires repeatedly
- no atrial contractions occurring (very decreased cardiac output)
sinus arrhythmia
1. what would be the next best nursing action or related nursing interventions, How is this treated?
- what could cause this rhythm?
- s/s?
- where does the impulse originate in this rhythm?
- what would be the next best nursing action or related nursing interventions, How is this treated?
- Normal cardiac rhythm
- document
- No treatment necessary - what could cause this rhythm?
- Seen in young healthy people
- A result from changes in intrathoracic pressure w/ breathing. - s/s?
none - where does the impulse originate in this rhythm?
Sinus/sinoatrial/SA node
- where does the impulse originate in PAC?
ectopic pacemaker
(group of cells in the heart, other than the SA node, that spontaneously generates electrical impulses)
in atrium fires before SA node fires
sinus brady
1. what would be the next best nursing action, related nursing interventions, how is this treated?
1st
2nd, 2nd
3rd
4th
1st check if pt is symptomatic
- asymptomatic =
2nd monitor (may be normal in some people like athletes and during sleep) - symptomatic***
2nd atropine - Vagolytic = blocks vagus nerve, will increase HR
3rd transcutaneous pacing of heart (temp)
4th pacemaker (permanent)
If QRS is absent = (2)
V fib
Asystole
A fib
2. what could cause this rhythm?
- can occur with any underlying heart disease
- electrolyte imbalance
- hypoxia
- cardiac surgery
- fever
- can occur with any underlying heart disease
- electrolyte imbalance
- hypoxia
- cardiac surgery
X- fever
sinus brady
causes of sinus tachy?
1. vagal inhibition or stimulation?
2. physical activity
3. digoxin toxicity
4. anxiety
5. pain
6. Hyperkalemia
7. stress
8. fever
9. anemia
10. hypoxia
11. Administration of parasympathomimetic drugs
12. low BP
13. dehydrate
14. Valsalva maneuvers
15. hypovolemia
16. low SV
17. MI
18. Carotid sinus massage
19. HF
- vagal inhibition
- physical activity
X3. digoxin toxicity - anxiety
- pain
X6. Hyperkalemia - stress
- fever
- anemia = r/t lack of RBC to oxygenate
- hypoxia
X 11. Administration of parasympathomimetic drugs - low BP = sinus tachy is a compensatory mechanism for low BP
- dehydrate = low BP
X14. Valsalva maneuvers - hypovolemia= low BP
- low SV = low BP
- MI = low BP
X18. Carotid sinus massage - HF = low BP
NSR
1. what would be the next best nursing action or related nursing interventions, how is this treated?
- what could cause this rhythm?
- s/s?
- where does the impulse originate in this rhythm?
Normal cardiac rhythm, document, No treatment necessary
Normal cardiac rhythm following normal conduction pattern
none
Sinus/sinoatrial/SA node
- what could cause PAC?
- benign (common)
- electrolyte imbalance
- CVD
- stress
- cardiac stimulants – caffeine
- atrial pathology (any disease or abnormality that affects the atria of the heart, includes: A fib, A flutter)
- fever
- benign (common)
- electrolyte imbalance
X- CVD - stress
- cardiac stimulants – caffeine
- atrial pathology (any disease or abnormality that affects the atria of the heart, includes: A fib, A flutter)
X- fever
rate >100
rhythm - regular
p wave – present and before every QRS
PR interval – normal
QRS – normal
ST segment – normal
sinus tachy
v fib
1. what would be the next best nursing action or related nursing interventions, How is this treated?
(3)
- where does the impulse originate in this rhythm?
- CPR
- ACLS
- defibrillation (synch switch turned off, no QRS)
- ventricles are quivering
- no effective contractions = NO cardiac output
PVC
A flutter
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate – varies (atrial rate may be >250 bpm, ventricular rate slower)
Rhythm – irregular or regular
P wave – absent
PR int – none
QRS – normal
ST segment -
VTACH
1. what would be the next best nursing action or related nursing interventions, How is this treated?
(4)
1- check if patient has pulse or is pulseless
- treatment depends on pulse (perfusion) or pulseless (no perfusion)
2- ACLS
3- anti-dysrhytmic drug – beta blocker, calcium channel blockers, amiodarone
4- electrolyte replacement
sinus tachy
3. s/s
- where does the impulse originate in this rhythm?
Sinus/sinoatrial/SA node
Rate – not reported in rate, count number of ____
Rhythm – regular or irregular (name the underlying rhythm)
P wave – present, before QRS, but looks different on the ____
PR interval – N/A (don’t measure)
QRS – normal
ST segment – normal
PAC
sinus brady
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate – <60
Rhythm – regular
P wave – normal
PR interval – normal
QRS complex – normal
ST segment – normal
P wave and PR interval will be normal in only (4)
Sinus brady
Sinus tachy
Sinus arrythmia
Normal sinus rhythm
sinus arrhythmia
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate – varies
Rhythm – irregular
P wave – normal
PR interval – normal
QRS complex – normal
ST segment – normal
PSVT
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate >130
Rhythm – regular
P wave – not discernable
PR int – not measurable
QRS – normal
ST segment
PAC
1. what would be the next best nursing action or related nursing interventions or treatment?
nursing action:
(2)
Treatment:
(2)
nursing action:
- Monitor for new or increasing PACs
- contact the HCP if new or increasing PACs (could indicate pt is about to convert to A fib)
Treatment:
- benign = no treatment
- if atrial pathology is the cause = same treatment as A fib
sinus tachy
1. what would be the next best nursing action, related nursing interventions, how is this treated?
(2)
- treat the cause
Ex:
-If FVD = fluid volume replacement - If in pain = give analgesic
- If febrile = give anti-pyretic
- If panic attack/anxiety = give benzo/anxiolytic
- give beta adrenergic blockers – reduce HR and myocardial oxygen consumption
Rate – varies
Rhythm – irregular
P wave – normal
PR interval – normal
QRS complex – normal
ST segment – normal
sinus arrhythmia
PVC
2. what could cause this rhythm?
- if it’s an isolated PVC – may be benign
- stimulants
- vomiting
- electrolyte imbalance
- Hypoxia
- fever
- exercise
- emotional stress
- CVD
- where does the impulse originate in this rhythm?
- if it’s an isolated PVC – may be benign
- stimulants
X- vomiting - electrolyte imbalance
- Hypoxia
- fever
- exercise
- emotional stress
- CVD
- ectopic focus in the ventricles (not the atria)
- it comes earlier (premature) than the QRS should come
- doesn’t follow a normal rhythm or p wave
VTACH
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate 150-250
Rhythm - regular or irregular
P wave – none
PR int – none
QRS - WIDE
ST segment –
PSVT
2. what could cause this rhythm?
- overexertion
- fever
- emotional stress
- stimulants
- digitalis toxicity
- various forms of heart disease
- overexertion
X- fever - emotional stress
- stimulants
- digitalis toxicity
- various forms of heart disease
If QRS is wide = (2)
PVC
V Tach
A fib
4. where does the impulse originate in this rhythm?
- NOT the SA node (it’s being taken over and is no longer the pacemaker of the heart)
- multiple ectopic foci firing all at the same time = loss of effective atrial contraction/kick (p wave)
- total disorganization of atrial electrical activity
PSVT
3. s/s?
- depends on
(2)
- s/s of
- where does the impulse originate in this rhythm?
- s/s?
- depends on
- How long it lasts
- How fast the ventricular rate is (tachycardia), if it’s too high CO is reduced
- s/s of *** - ectopic focus anywhere above bifurcation of bundle of His, anywhere in atria (“supraventricular”)
Rate – <60
Rhythm – regular
P wave – normal
PR interval – normal
QRS complex – normal
ST segment – normal
sinus brady
A flutter
- what could cause this rhythm?
- can occur with any underlying heart condition
- electrolyte imbalance
- hypoxia - where does the impulse originate in this rhythm?
- can occur with any underlying heart condition
- electrolyte imbalance
X- hypoxia
a single ectopic focus firing = loss of effective atrial contraction/kick (p wave)
sinus brady
- s/s
- where does the impulse originate in this rhythm?
- Sinus/sinoatrial/SA node
PVC
Rate
Rhythm
P wave –
PR interval –
WRS interval –
ST segment –
Rate – not reported in rate, count number of PVCs
Rhythm – regular or irregular (name the underlying rhythm)
P wave – absent on the PVC
PR interval – none
QRS – WIDE
ST segment –
A fib and A flutter (and PAC if not a benign cause)
1. what would be the next best nursing action or related nursing interventions or treatment?
1st
2nd
3rd (if that didnt work)
4th (if that didnt work)
1st - check if they are hemodynamically stable and if they are symptomatic
2nd - if hemodynamically unstable (VS are not ok): synchronized cardioversion/cardiovert/life pack and synchronized switch is turned on
2nd - if hemodynamically stable (VS are ok), but symptomatic***: Slow ventricular rate with either IV
- calcium channel blockers
- beta blockers
- digitalis
- amiodarone
(“Bolus and start a drip” may be ordered)
48 hours later
3rd - planned cardioversion - with anticoagulation therapy (warfarin/coumadin) before cardioversion for 3-4 weeks AND after cardioversion for 3-4 weeks
- TEE may be performed before cardioversion
4th - long term anti coagulation required
- drug of choice - warfarin/coumadin
- alternatives – dabigatran, apixaban, rivaroxaban, eboxaban
warfarin/coumadin vs alternatives – dabigatran, apixaban, rivaroxaban, eboxaban
1. anticoagulants
2. Have to monitor INR regularly
3. Don’t require routine lab testing
4. Antidote – vitamin K
5. More expensive
6. May have to takes >once per day
7. Contraindicated with renal dysfunction
8. No antidote
W/C & A 1. anticoagulants
W/C 2. Have to monitor INR regularly
A 3. Don’t require routine lab testing
W/C 4. Antidote – vitamin K
A 5. More expensive
A 6. May have to takes >once per day
A 7. Contraindicated with renal dysfunction
A 8. No antidote
A fib vs A flutter
single ectopic focus firing
multiple ectopic focus firing
A flutter - single ectopic focus firing
A fib - multiple ectopic focus firing
which do you check for pulse with
VTACH
treat the cause for (2)
PVC, sinus tachy
atropine ___ HR
treats ___
beta blockers
lidocaine
amiodarone
___ HR
treats ___
adenosine ___ HR
treats ___
beta blockers
CCB
amiodarone
___ HR
treats ___
beta blockers
CCB
amiodarone
digitalis
___ HR
treats ___
increases
sinus brady
decreases
PVC
decreases
PSVT
decreases
VTACH
decreases
A fib
