Skills 3- ng tube and EKG Flashcards
uses of ng tube
e f
m a
d
post
long
Enteral feedings
Medication administration
Decompression
Post-op placement – bowel rest
long term continuous feedings
Insertion of a NG Tube: Assessment
verify
patient
assess/ and
hh
check
review
assess
Verify order
Patient identifiers
Assess patients knowledge and educate as needed
Hand hygiene
Check nare patency
Review medical history
Assess mental status, ability to actively participate in insertion directions
Planning and Implementation ng
explain
hand
position
apply
drape
measure
prepare
insert/tuck
advance
aspirate
fasten
confirm
hand
Explain the procedure- be honest and concise
Hand Hygiene
Position High Fowlers
Apply pulse oximeter/Capnography
Drape patients chest
Measure length of tube Tip of nose, xyphoid process to sternum
Prepare fixation dressing
Insert tube, tuck chin once tube has passed nasopharynx
Advance until desired length is reached
Aspirate gastric pH
Fasten tube as appropriate
Confirm with x ray (Facility policy)
Hand hygiene, dispose of equipment, document
never
due to
Things to know…Gastric surgery
NEVER withdraw a NG or place a NG on patients with recent gastric surgery
due to possible hemorrhage with suture lines
if
need to
things to know cough/choking
If cyanosis is present with coughing and choking NG is in airway
need to withdraw NG during insertion
checked how often
remember
whats needed
things to know ng
Placement should be checked every 8 hours or according to protocol
Remember I & O (including when you remove the NG)
Frequent oral hygiene is needed along with nasal hygiene
can place
wait for/look for
things to know ng tube
Can place to suction- need to be at low intermittent- nebver continuous
Wait for order to remove- look for passing flatus and tolerating clear liquids
Removing NG
complications ng tube
most common
FV
post
if/check
MC- aspiration
FVD
post op bleeding
if nausated- assess patency of tube
NG flush
before/after what
how often in ongoing feeding
before/after what
Before and after NG feeding
Ongoing feedings
Flush every eight hours (usually with 20-30mls) unless protocol specifies
Before and after enteral medication administration
NG flush
intermittent feedings
continuous feedings
Intermittent feedings need to have tube flushed first
Continuous feedings- checking placement usually every shift
how know if absorbed
to check what
ng flush
To know if feeding is absorbed you must check residual
To check patency and effectiveness of tube for bowel rest or decompression purposes
Right side of heart
receives
sends
receives blood from body
sends to lungs
left side of heart
receives
sends
receives 02 rich blood from lungs
sends to body
placement of leads- look at opposites
middle
lowerr right
upper right
lower left
upper left
brown in middle
lowerr right- green
upper right-white
lower left -red
upper left- black
lowest number of electrodes
most normal
why a 12 lead
dont do what in a 12 lead
Lowest number of electrodes that can be used is 3-
most normal is 5.
12 lead ekg to identify subtle changes – used for diagnostics like in mi
Don’t leave 12 lead on for too long- then go back onto 5
ecg
p
q
r
s
t
p- small hump at begging before qrs
q-small down bump in qrs
r- big up in qrs
s- going back to baseline from neg in qrs
t- small hmup after wrs
P wave:
represents
known as
represents atrial depolarization
(contraction)
QRS complex:
represents
known as
represents ventricular depolarization (
contraction
T wave:
represents
known as
represents ventricular repolarization
(relaxation)
Normal sinus rhythm
has
hr between
Has a normal p qrs t all within normal limits
Hr between 60-100
BPM
p qrs t
Sinus bradycardia
Less then 60 bpm
Normal p qrs t wave just slow
l
d
h
v
s
Decreased hr causes decreased cardiac output-
S/s
Sinus bradycardia
lightheaded,
dizziness,
hypotension,
vertigo,
syncopy
non cardiac problems causes
h
increased
h
h
s
Sinus bradycardia
hyperkalemia,
increased intercranial pressure,
hypothyroidism,
hypothermia
sleep
Can happen from cardiac disorders like
m
d t
Sinus bradycardia
mi/
drug tocixity-beta blockers, digoxin
Sinus bradycardia
slow hr leads to
atrial junction
ventricular ectopic rythms
first line of treaetmtn in sinus bradycardia
recommend
placing pt on 02 if symptomatic
recommend atropine
sinus tachycardia
BPM
harmless except
Normal rate greater then 100 bpm
Usually harmless except in heart disease when it increases oxygen demand
what causes sinus tachycardia
response
seen in
Response to stress or compensation mechanism to increase co in fight/flight
also seen in fever
external causes like
c
s d
use
m
tachycardia
caffeine,
sleep deprivation,
smoking/ nicotine use
,meds
s/s sinus tachy
asymtpmatic
treatment sinus tachycardia
identify
assess
use what meds
Identify and treat underlying cause,
assess/trat pain,
use olol to lower hr- beta blocker
What ECG looks like in
NSR
Bradycardia
Tachycardia
NSR- has a regular p qrs t
B- has a regular p qrs t just is <60
T- has a regular p qrs t just is >100
Atrial flutter
atrail rate of
rate
rarely seen
Atrial rate of 200-350 bpm
Rate is regular
Rarely seen In healthy heart
Atrial flutter
caused by
I
what disorder
c
c
h
c
m
what med
ischemia,
valve disorders,
copd,
chf,
hypertrophy,
cardiomypotathy,
mi,
dig toxiciy
Intervention- atrial flutter
assess
aim
treat
consider
assess pt,
aim to control ventricular rate,
treatment depends on symtoms,
consider anticoauglation,
meds to control ventriclular rate in artial flutter
a
b
c
amiodarone,
beta blockers olols,
Calcium channel blocker like dilitizem/ digoxin
Atrial flutter
risk for
use
Risk for potential clots-
herpain enoxaparin, warfarin,
atrial fluter
what meds slows
look for
Digoxin slows ventrilaur rate
Dig toxicity- hypotension, confusion, visual changes
What ECG looks like on A flutter
regular rhythm
regular p qrs t
just has a lot of waves/ lots of p’s in between the qrs
A fib
atrial
most
Atrial activity is completely chaotic-
Most common arrythmia
A fib Casued by
I
h
vd
c
m
c
c
med
ischemia,
hypertrophy,
valve disoerds,
cardiomypotahy,
mi,
chf
, copd
dig toxicity
A fib
assess what
give what
aim is what
Assess pt, vitals,
give 02 if needed
Aim is to control ventricular rate
A fib meds
a
c
b
d
Amiodarone,
ccb, - diltiazem
bb, -olols
digoxin
A fib why use anticoagulation
Anticagulation used because blood is pooling in atria
A fib Planned sycnronixed cardioversion
same
excpet
shock
-same as defibrillation
except shock is less powerful
shock is given with paitents r wave
A fib what before procedure
rules out
Echoogardigram is used before procedure
rule out any clots
What A fib looks like on ECG
what rhythm
what qrs
main idefitfies
cant get
irregular rythm
has a normal qrs
but time in between looks scribbly
cant get a proper p pr t
Supraventricular tachycardia (SVT)
what is it
Generic term for any tahcy cardia that occurs above ventricles-a flutter, a tcah
Supraventricular tachycardia (SVT)
Caused by
f
s
h
cd
u
fever
, stress
, hypovolemia,
conduction disturbances,
unknown
Goal
treat
try what
Supraventricular tachycardia (SVT)
Goal is to treat underlying cause-
treat with adenosine-
but try Valsalva manuever before
If s/s of decreased cario output-
do what
Supraventricular tachycardia (SVT)
do cardioversion to convert back to normal rhythm
what drug
does what
half life
give how/hold
Supraventricular tachycardia (SVT)
Adenosine is most common drug-
vasodilation and increasing blood flow up to 400%-
hl of less then 10 seconds-
give very fast and hold patient arm up to give
Supraventricular tachycardia (SVT) put what on pt
Ecg onpaitent
pt feels
pt will
Supraventricular tachycardia (SVT)
Patient may also feel doom and gloom for a few seconds
– pt will flatline for a few seconds
What does SVT looks like on ECG
very
will not
Very narrow- high on tachycardia
will have a barely visible p or t wave
what area
seen in
indicates
Premature Ventricular Contraction (PVC)
Irritable area with anywhere in the ventricle that causes premature firing
Seen in anyone on and off
indicates myocardial irritiblity
Premature Ventricular Contraction (PVC) on ECG
wil have
but then
that look like what
Will have NSR most of time
but them occasional wide and bizarre one
wide/ bizzare goes down and looks inverted
Frequently caused by
I
h
h
med
h
a
seen in
Premature Ventricular Contraction (PVC)
ischemia,
hypokalemia,
hypoglycemia,
med toxicity,
hypoxemia,
acidosis,
seen in stress or caffeine use
assess
assess what labs
get what
get what
remove
Premature Ventricular Contraction (PVC)
Assess pt, oxygen,
assess k, ca, mg-replete if low,
get dig level,
get glucose,
remove irritants,
give what if patent is symptomatic
a
l
p
Premature Ventricular Contraction (PVC)
amiodarone
lidocaine
procanimide
Ventricular Arrythmias
are what
3 types
Ventricular Tachycardia (V tach)
Ventricular Fibrillation (V fib)
Asystole
ventricle is
ventricular rate
what is happening
Ventricular Tachycardia (VT)
Ventrical is irritated and sends out at a rapid rate
V Rate will be 100-250
Atrium and ventricles are beating independeatly
Ventricular Tachycardia (VT)
qrs
pvc
Qrs is wide and bizzare,
3 or more pvc in a row
Ventricular Tachycardia (VT)
can become
leads to
Can become vfib
lead to sudden death
Ventricular Tachycardia (VT)
assess/check
to do what
Assess pt and check pulse,
to determain course of action and repsosinvess
stable vtach- s/s
Ventricular Tachycardia (VT)
not experiencing serious s/s- of cardiac output,
stable vtach-
give
establish
consider
order
Ventricular Tachycardia (VT)
give 02
, establish iv,
consider antiartymics,
order electrolyte like k or mg,
stable vtach
notify
anticipate
keep pt
notify pt-
anticipate cardioversion-
keep pt hooked up to cardiac monitor
unstable vtach – s/s
Ventricular Tachycardia (VT)
serious s/s of decreased cardiac output
unstable vtach –
call
still
administer
establish
Ventricular Tachycardia (VT)
/ call code/
still have a pulse/
administer 02,
establish iv,
unstable vtach –
prepare for
consider what
consider
order
notify
Ventricular Tachycardia (VT)
prepare for synronized carioverison
consider sedation for that with versate,
consider antiarythmic,
order electrolyte,
notify md
pulseless-
call
what asap
start
Ventricular Tachycardia (VT)
call a code,
dfib asap,
start cpr immedialty and follow acls guidelines-
pulsless
have
what meds
Ventricular Tachycardia (VT)
have a continuous infusion of whatever drug works-
vasopressin, epinephrine, amiodarone
what does v tach look like on ECG
Big M’s
a lot of big m’s
Torsades de Pointes (TdP)
what type of v tach
what qt/ qrs
Polymorphic v tach- all over place- stems from different areas
Prolonged qt interval- qrs changes shape and will twist around line
Torsades de Pointes (TdP)
is what
if pulseless
life threatening,
if pulseless call a code-
defribrilate adap and do cpr,
Torsades de Pointes (TdP)
if not pulseless
check
notify
treat -
check s/s of decreased co,
notify physician,
treat with meds, -give magnesium sulfate iv, may use lidocaine as well
Torsades de Pointes (TdP)
rate
not
call
Rate is rapid, irregular, no definitive parts,
not combative with life-
call code
Damage to cardiac muscle causes this,
c
acute
acure
c
h
Torsades de Pointes (TdP)
- cad,
acute coronary syndrome ,
acute mi,
cardiomypothaty,
hypoxia
Asses pt- for what
if truly in fib they will be
Torsades de Pointes (TdP)
assess rhythm to make sure rythmm is legit,
if truly in vfib they will be pulseless, apnic and unresponsive
what is only treatment
Torsades de Pointes (TdP)
Dfib is only treatemtns and begin bls
what does torsades look like on ECG
looks like vtach but it will go up and down more and look a lot smaller
nut will follow a line, just get smaller and upper
Asytole
what is it
what look like-always do what
Flatlined- without contractions
Pulsless, always cinfirm asystole in another lead
asystole
cannot
have to do what
Cannot shock because no electrical activity
Cpr and give epi
5 h’s Asystole
Hypoxia
,hypovolemia,
hypothermia,
hydrogen ions,
hypo/per kalemia
5 t’s Asystole
Tablets,
tamponade,
tension pnieonthorax,
thrombus cariac
, thrombus pe
Asystole
assess
call
start
confirm
Assess pt,
call code,
start cpr,
confirm rythmm for tru asytotle,
measurements of the ecg
5 large boxes equals
each small box
5 large boxes = 1 second
Each small box is 0.04 seconds
Six Steps to Interpreting Rhythms
determine
determine
analyze
measure
measure
determine
- Determine heart rate
- Determine if rate is regular or irregular
- Analyze the P wave
- Measure the P-R interval
- Measure the QRS duration
- Determine the rhythm
1 Determine heart rate
at a glance – too fast or too slow or appear normal?
Determine HR
each mark is how ling
we look at what
count number
multiply by
Each mark across the top represents 3 secs,
we typically look at 6 seconds,
and count the number of QRS complexes,
and multiply it by 10 and this will give you the rate.
- Determine whether the rhythm is regular or irregular
measure with
Calipers
Visualize
- Analyze the P waves
is there
is there
Is there a P for every QRS wave
is there a QRS for every P wave
- Measure the PR interval
normal
from the beginning
Normal = 0.12-0.2
From the beginning of the P to the beginning of the QRS
- Measure the QRS duration
from what
normal is
From beginning of the Q wave (if present) to the end of the S wave
Normal is less than 0.12 seconds.
When can you defibrillate x3
pulseless pt
pulsless vtach
vfib
when can you synchronized cardioverison x4
afib
a flutter
vtach w pulse
svt
when do you external pacing
severe bradycardia w pulse
