RN.com Flashcards
Small boxes (5 x) inside large box
What does the Vertical length mean?
Horizontal?
Verticle = 1mV millivolt
Horizontal = 0.04 seconds
5 small boxes lengthwise inside a large box = How long
How many large boxes = 1 second?
0.20 seconds
(1 small box = 0.04 seconds)
5 large boxes = 1 second
Blood Flow
Deoxygenated blood leaves vena cava and enters 1. ______
Right Atrium- 2. ______ - Right Ventricle
Right Ventricle- Pulmonary Artery (becomes oxygenated - in lungs)
Lungs to Pulmonary Vein
Pulmonary vein to 3. _____
Left Atrium- 4. ____ - Left Ventricle
Left Ventricle- Aortaic Valve - Aorta
Aorta sends oxygen rich blood through system
- Right Atrium
- Tricuspid Valve
- Left Atrium
- bicuspid valve
Atrial depolarization (contraction)
Is a negative state associated with this wave
This is a resting state where the heart is Polarized and negative
Which wave?
P-wave
Depolarization leads to (Contraction or Relaxation)
Contractions
Repolarization leads to (Contraction / Relaxation)
Relaxation
Electrical conduction
Starts: Which chamber/ Node (BMP)
The starting pulse causes which Wave / Type of polarization
Start: Right Atrium/ SA node - 60 - 100
P-wave / Atrial depolarization (Contraction)
SA node to AV node.
What is the purpose of the AV node?
Slow down the contractions 40 - 60 BPM
Allow the Atrium to empty fully
AV node (Gatekeeper) to the Bundle of Hiss leads to this
Ventricle Depolarization (Contraction)
QRS complex
AV node - Bundle of Hiss - Perkenji Fibers
This type of conduction/ Wave
Ventricular Depolarization/ Contraction
QRS complex
P wave is a measurement of…
Atrial depolarization (contraction)
P - R segment (between P & QRS)
Demonstrates what?
Delay AV node creates
AV node is the Gatekeeper which slows down to allow Atria to Empty Fully
PR interval differs from the PR segment how?
PR interval = Demonstrates time it takes for electrical signals to go from Atria to AV node.
PR segment = Delay AV node created
PR interval is measured
PR segment is measured
PR interval = Beginning P wave - Beginning QRS complex
(Heart Block)
PR segment = Flat line between the end of the P-wave and the start of the QRS complex.
PR interval can be useful to determine if a patient has this problem…
Is measured where?
Heart Block
Time between atrial depolarization and ventricular depolarization
Measured:
Beginning P wave - beginning QRS
Ventricular depolarization (Contraction) Is represented by this wave…
QRS Complex
Atrial Repolarization (Relaxation) also happens
Represents completion of ventricular depolarization & beginning of ventricular Repolarization.
Should be flat. (Isoelectric)
S-T segment
Represents beginning of Ventricular Repolarization (Relax)
This wave
T wave
U wave may appear after T wave due too….
This is an abnormal wave / finding
Hypokalemia
This wave
Represents the time it takes for electrical signals to cause the ventricles to contract & then rest
Q-T intervals
Use an EKG strip that is atleast how long?
6 sec
30 squares
Count P waves in a 6 second strip and multiply by 10
Gives this value
HR, BPM
How to determine if a strip is Sinus Bradycardia.
What is Sinsu Bradycardia
Regular features on strip
Fewer than 6 P waves in 6 second strip
Sinus Bradycardia = Regular, Slow heart
SA node damage
Low thyroid hormone
Older adult
Weak/Damage heart
Raised ICP
Athletes
Toxicity (beta blockers, CCB, DIGOXIN)
Hyperkalemia
Vagal Response
Sinus Bradycardia
If patient has Sinus Bradycardia and is showing symptoms (Hypotension, chest pain, fatigue, Diaphoresis)
What is the treatment?
Active Rapid Response
Medications:
Atropine
Dopamine
Epinephrine
If no symptoms: Athlete / Older Continue Monitor
Can a temporary pace maker be given for Sinus Bradycardia
Yes or permanent
Rhythm strips is normal but has more than 10 P waves in a 6 second (30 boxes) strip
Sinus Tachycardia
Causes:
Temperature Elevated
Aerobics
Cardiac disease (MI CHF)
Hyperthyroidism
Pain
Hemorrhage/ Hypovolemic shock
Stress
Anemia
Respiratory conditions
Medication:( Albuterol, Atropine, Nicotine)
Sinus Tachycardia
A Fib
The Atrium are contracting how?
What negative effect
Fast, Irregular rate
Quivering instead of contract
Negative Effect:
Blood pools & can Clot
A Fib
The Atrium are contracting how?
Fast, Irregular rate
Quivering instead of contract
P waves not present before QRS complexes.
P waves are replaced by irregular Fibrillatiory Lines (Fine or Course)
A fib
What does QRS (Ventricular Rate) look like with A Fib
Irregular intervals
Normal to fast >100
A fib is characterized by lack of P waves, replaced by irregular fibrillatory waves
If QRS (Ventricular Rate) >100 during A Fib it’s called.
Possible outcomes
Uncontrolled A-fib
Heart failure
Causes
After heart surgery
Valve problem
MI, CAD
COPD
Sleep apnea
A fib
Treatment:
For A Fib
Controlled <100 QRS
Monitor
Uncontrolled >100 QRS
Anticoagulants, beta-blockers, calcium-channel blockers, or digoxin.
Synchronized Cardioversion
Ablation (removing muscle fibers in the heart that cause abnormal rhythms )
Uncontrolled A Fib Treatment
Before Cardioversion Shock
Patient may need this type of medication
This type of test can be preformed to see if medication is needed
Anticoagulants
Transesophageal echocardiogram
TEE
Post Cardioversion for Uncontrolled A Fib give patient this type of medication
Anticoagulants
Cardizem (Diltiazem) CCB
Adenosine - Antiarrhythmic
Amiodarone - Antiarrhythmic
- These medications can be given to an A Fib Patient to have which Treatment effect
- What are some other types of medications that can treat A-fib
- Cardioversion- Restore regular heart Rhythm
- Warfarin, beta blockers, CCB (Diltiazem)
If
Adenosine - Antiarrhythmic
Amiodarone - Antiarrhythmic
Beta Blockers
CCB
Anticoagulants
Don’t help A-fib or Atrial Flutter. what procedure maybe done?
Ablation
Destroys tissue in heart to prevent it from abnormal firing
How does A-fib & A-flutters appearance differ in the EKG
Atrial Flutter = No “P” wave, Saw-tooth like waves before QRS complex. Regular
A-Fib No “P” wave but several small little “bumps” in place of the “P” wave
Atrial Flutter Medications
Antiarrhythmic Amiodarone
Anticoagulants Warfarin
CCB (Diltiazem/Cardizem)
Beta Blockers
Digoxin (HF)
Same as A-fib
When to preform Cardioversion with Atrial Flutter / A-Fib
Unstable
More than 100 QRS in 60 secs
&
After TEE Transesophageal Echocardiogram to ensure no blood clots
If clots give Heparin & Warfarin
Hallmark
Wide QRS complex >0.12 secs with a bizarre appearance
V Tach
V Tach can have various presentations:
Monomorphic (All Same Size & Shape)
Polymorphic (Different size & shapes)
On variation of Polymorphic is…
Torsades de Pointes:
Looks like Tornado
Causes:
Hypokalemia
MI
Digoxin
CHF, CAD, Valve disease
V Tach
Monomorphic
Causes:
Medications that increase QT interval
Amiodarone, Sotalol, Procainamide
Low Calcium, Magnesium, Potassium levels
V- Tach Polymorphic
Torsade de pointes
This rhythm can lead to V Fib which can lead to death
V-Tach
Treatment for V Tach
Stable
Least invasive to most invasive
Amiodarone IV
Synchronized Cardioversion
Treatment
V Tach Unstable (Symptoms but has Pulse)
Hypotension, mental changes, weak pulse, cool / clammy, chest pain
Synchronized Cardioversion
Antiarrhythmic meds Amiodarone
Treatment
V Tach - No Pulse
CPR
Defibrillation
Epinephrine
Chaotic rapid rhythm that has no real organization to it
V Fib deadly
Causes
MI / heart disease
Low / High Potassium
Hypoxia
Drug OD
V fib
V Fib Treatment
Call code
Start CPR
D FIB
Epinephrine, Amiodarone, Lidocaine
Which do you do first in Asystole
CPR or Cardioversion
CPR
Causes
Hypothermia, hypovolemia, Hypoxia
Toxins, Thrombosis, tension pneumothorax
Asystole
Describe PEA rhythm
Pulseless electrical activity
P & QRS complexes may or may not be present.
Appears as a “Sinus” rhythm
PEA pulseless electric activity
Treatment
CPR
NON SHOCKABLE
Epinephrine
AV heart blocks
1st degree
2nd degree (Type 1 & 2)
3rd degree
Names
1st degree
2nd degree
Type 1 Wenckebach aka Mobitz Type 1
Type 2 Mobitz Type 2
3rd degree (Complete Heart Block)
How to ID a Type 1 Mobitz aka Winkiebach Heart Block on a Rhythm Sheet?
Appears as normal sinus rhythm but has a prolonged PR Interval (>5 small boxes)
Normal QRS size
<0.12 sec / 3 small boxes
This type of heart block
Electric signal from Atria to Ventricles is slowed down to the point doesn’t stimulate contraction.
Appearance on rhythm strips:
PR intervals = prolonged (gradually get longer)
Occasional missing QRS complex
2nd degree heart block
Mobitz type 1 or Wenckebach
Second degree heart block
Type 2 Mobitiz type 2
Dropped QRS complex
What is the difference between Type 1 (also Dropped QRS) & Type 2
Type 1 is a gradual lengthening of the PR interval
Type 2 PR interval stays consistent but then has missing QRS complex
PR interval (beginning of P - beginning QRS)
Prolonged PR Interval Indicates what heart problem?
Heart Block
P waves measures
<0.12 secs
< 3 squares
PR interval
(Start of P wave - Start QRS)
Measurement….
Longer than normal Measurement indicates….
0.12 - 0.20 Normal
3 - 5 boxes
> 0.20 = Possible Heart Block
QT interval
the time it takes for the ventricles to contract and then recover
Should be how long?
0.35 - 0.44
9 - 12 Boxesish
First-degree atrioventricular (AV) block is PR interval of greater than ____ without disruption of atrial to ventricular conduction.
0.20
During a premature ventricular contraction (PVC), the heartbeat is initiated by the 1.______ rather than the SA node.
Given that a PVC occurs before a regular heartbeat, there is a pause before the next regular heartbeat.
In patients with PVCs, the ECG may reveal other findings that include: electrolyte abnormalities (peaked 2. ___ waves, prolongation of3. ___);
left ventricular hypertrophy; with an old MI, one may see Q waves, loss of R waves, and/or a bundle branch block; and acute ischemia may present with ST-segment elevation/depression and/or T wave inversion.
- Purkinje fibers
- T
- QT
Healthy P waves associated with atrial depolarization (Discharge energy) and measure…
0.12 sec ( 3 small boxes)
Repolarization = Rest
It’s measured from the beginning of the P wave’s upslope to the beginning of the QRS wave
Time between atrial depolarization and ventricular depolarization.
Name this “wave form”
Normal measurement…
What does an abnormal measurement mean…
PR interval
Normal PR interval = 0.12 - 0.20 (3 - 5 small boxes)
> 0.20 heart block
QRS Complex represents ventricular depolarization, which is the beginning of systole and ventricular contraction.
What is the normal time on ECG
QRS Complex normal time = 0.12 ( 3 small boxes )
QT interval: ventricular Depolarization and Repolarization
Normal time
0.36 - 0.44
9 - 11 Lil boxes
ST segment after the QRS complex should be isoletric (flat)
What does elevated/ depressed ST segment mean?
Elevation / Depression: Total blockage of one of the heart’s main supply arteries - lack of oxygen ischemia
Before Cardioversion for Unstable A Fib >100 BPM & S/S ( Hypotension/ decreased cardiac output)
What is done?
Why?
Transesophageal Echocardiogram (TEE) “ - Gram = contrast dyes are used Mostly Iodine”
TEE checks for blood clots
If blood clots present give anticoagulant
low molecular-weight heparin (LMWH) and warfarin:
LMWH: Used as a bridge, 1 mg/kg twice daily
P wave not present
Replace by F waves
Irregular QRS intervals
<100 QRS per min
What is the heart condition
What are the Interventions
Stable / Controlled A Fib
If symptom free no Hypotension or decreased cardiac output
Monitor to ensure QRS stays <100 BPM
Causes
Post surgery
Mitral valve problems
CAD
MI
Pericardis
Name rhythm problem
Describe pattern
Level of seriousness & possible interventions
A Fib
Lack of P wave - replaced with R waves
Irregular QRS complexes
Can be serious if QRS >100 BPM
Interventions: Transesophageal Echocardiogram (TEE) looking for blood clots
Heprin & Warfarin if clots present
Synchronized Cardioversion on R wave after TEE & Anticoagulants
Only if QRS >100
Causes
Increase body temp
Cardiac disease
Hyperthyroidism
Pain
Hypovolemia
Anemia Respiratory Conditions
Name Rhythm
Describe
Possible interventions
Sinus Tachycardia
Normal rhythm wave features but >100 BPM
Interventions: Medications: beta blockers, Calcium channel blockers, Pain meds, Antipyretics
Cushing’s triad is a set of physiological signs that indicate a response to increased intracranial pressure (ICP) in the brain:
Widened pulse pressure: An increase in systolic pressure and a decrease in diastolic pressure
Bradycardia: A slow heart rate
Irregular respirations: Also known as Cheyne-Stokes breathing
Before giving Digoxin check…
Apical pulse
<60 hold Digoxin
Meds to give for Bradycardia
Atropine, Dopamine, Epinephrine
Unstable A Fib patients can be cardioverted via these medications
Cardizem (Diltiazem) - CCB & Antihypertensive
Adenosine - Antiarrhythmic
Amiodarone - Antiarrhythmic
____ is a procedure that may be done to the heart to help with A Fib.
Ablation: Destroy tissue in the heart to prevent abnormal firing
A Flutter will have this appearance in the rhythm strip
Give these medications to help
Saw tooth
CCB - Diltiazem/ Cardizem
Beta Blockers Propranolol
Digoxin - With heart failure
Antiarrhythmic- Amiodarone
Anticoagulants - Warfarin
Unstable A Flutter >100 QRS BPM
This intervention
Synchronized Cardioversion
V Tach has this defining charactistic
It is described as looking….
QRS Complex > .12 (3 boxes)
Bizarre
List medications that prolong QT interval
This can lead to Polymorphic V Tach Torsade de pointes
Also, low calcium, K, mag levels can too
Amiodarone
Sotalol
Procainamide
Is V Tach (Wide QRS >.12 “3 BOXES”) Always an emergency?
Yes, active rapid response
They will go into V fib
Stable V Tach (No symptoms, has pulse)
Which interventions will be expected
IV Amiodarone - Antiarrhythmic
If not effective Synchronized Cardioversion
V Tach (QRS Complex >.12) Bizarre looking wave
No Pulse
What are the Interventions
CPR First. Need a pulse to shock
- Pulse then, defibrillation
Then Epinephrine
Then amiodarone, lidocaine,
Polymorphic V-tach (Torsade de pointes)
Stable (has pulse): Interventions
Unstable: Interventions
Stable: Give Magnesium Sulfate STOP QT interval widening medication. Amiodarone or Procainamide
Unstable: treat like V fib. CPR & Defib. Once stable possible ICD (cardioverter defibrillator) Implantation
V Fibs rhythm is described how?
Chaotic, rapid rhythm with no real organization
With V Fib Patient will have no pulse.
What are the Interventions
Call a code
CPR
Defibrillation when pulse is present
Epinephrine
Amiodarone/ Lidocaine
Asystole. What is the first thing you do?
Check the patient for a pulse.
Always assess patient first then machine
Pulseless Electrical Activity: Describe
Causes…
Interventions
Rhythm shows Sinus Rhythm but patient has no pulse.
Causes: Hypoxia, Hypovolemia, Electrolyte imbalance, Thrombosis, Trauma, Cardiac Disease
Interventions:
Code Blue
CPR
Rhythm Checks
Non Shockable
Meds: Epinephrine
1st degree heart block
PR interval > 0.20 (5 small boxes) - Occurs regularly throughout the Rhythm
Other factors are the same as Sinus Rhythm
Interventions:
Interventions: If on CCB, Beta Blockers, Digoxin
Dosage may need to be adjusted
If symptoms like Bradycardia (atropine) & possible pacemaker insertion
2nd Degree- Type 1 heart block
(Wenckebach or Mobitz Type 1)
Causes: MI - due to ischemia depriving tissue of oxygen, Rheumatic fever, increased Vagal Tone
Treatment: Adjust CBC, Beta Blockers, Digoxin- Give Atropine/ Temp Pacing
Differs from
Mobitz Type 2
Causes: MI, CAD, CBC, Beta blockers, digoxin
Describe ECG appearance
Which is more serious
2nd Degree- Type 1 heart block
(Wenckebach or Mobitz Type 1) = Gradual lengthen of PR Interval & eventual missing QRS complex
Second Degree Type II
PR interval doesn’t get progressively longer. But does have missing QRS interval
Second degree Type II is more serious
P waves & QRS complexes = Regular
However, fewer QRS complexes than P waves
Describes this condition
3rd degree heart block
Most serious
ECG patient has sinus Bradycardia with rate of 52. What is your next nursing action
- Prepare to admin atropine IV push
- Set-up for Transcutaneous pacing
- Assess the patient
- Call rapid response
- Assess the patient
Always assess first. This patient maybe an athlete or elderly who normally have lower HR
V Fib Patient. CPR has already been started and Patient remains in V Fib. In addition to CPR what will next action be?
- Atropine
- Defibrillation
- Epinephrine
- Synchronized Cardioversion
- Defibrillation
V Fib = D Fib
First degree Heart Block is characterized by a PR interval >.20 seconds.
Which medication below can cause 1st degree heart block
A. Lisinopril
B. Diltiazem
C. Furosemide
D. Clopidogrel
B. Diltiazem (CBC)
Slow down conduction through AV node.
______ occurs when PR interval follows a pattern of gradual lengthen and absence of QRS complex.
_____ is a constant PR interval >.20 followed by occasional missing QRS complexes
Which is more serious
Second degree (Wenckebach/ Mobitz 1) occurs when PR interval follows a pattern of gradual lengthen and absence of QRS complex.
Second Degree (Mobitz Type 2) is a constant PR interval >.20 followed by occasional missing QRS complexes
Mobitz 2 is more serious
