T2 Cardiac Dysrhythmias

Question 1

The ability of the body to deliver nutrients and oxygen via the blood through arteries and capillaries, organs

and in turn picking up cellular waste and carbon dioxide from the cells via the veins
Cardiac dysrhythmias decrease perfusion and can lead to organ failure

Answer 1

Perfusion

Question 2

Gas exchange vs perfusion?

Cardiac arrythmias can decrease?

Answer 2

Perfusion- how the blood gets there or is able to carry to end point

Has exchange- exchanging of oxygen and carbon dioxide across capillary and aveolli

Perfusion

Question 3

Perfusion assessment

Answer 3

Recognize indicators of adequate and inadequate perfusion*

Central perfusion: assess HR and BP

Cerebral tissue: patients mental status

Peripheral tissue: extremity temp, color, pulse, cap refill

Low bp and confusion, fever, bounding, threads pulse capillary refill more than 3seconds= perfusion issue

Central= organs , heart

Question 4

How does heart rhythm affect perfusion ?

Answer 4

Body receives more blood oxygen demand with a faster/more beats

Question 5

Pacemaker of heart

Answer 5

SA node (top left)

Question 6

Cardiac conduction system

Answer 6

SA node (right atrium) travels to AV node in middle - travels down bundle of His, bundle branch , fibers which causes ventricular contraction 
This shows QRS complex 

SA node stimulates P wave -> QRS -> T wave

AV node stimulates PR segment

The length of time it takes for electricity to come back to normal, repoloarize and be able to receive electrical stimulation again.

Question 7

Electrical impulses 60 to 100 beats/min
P wave on ECG

Alterations in HR occur here first*

If something wrong see what?

How it connects to EKG waveforms?

Answer 7

Sinoatrial node *

Elevated or decreased heart rate or dysrhythmias

Affected by sympathetic and parasympathetic nerves that increase or decrease the heart rate

Atrial depolarization(contraction) and P wave on ECG

Question 8

beats 40-60 beats/min
Contraction known as “atrial kick”

If SA node stopped working - AV works as back up but only 40-60 bpm so may need assistance (pacemaker) or may have decreased perfusion

How it connects to EKG waveforms?

Answer 8

Atrioventricular Node -AV node

Below right atrium

PR segment and contraction through AV node and bundle of His which allows atrium to contract and ventricles to fill before ventricular contraction

Atrial kick contributes to additional blood volume for greater cardiac output

Question 9

Right bundle branch system
Left bundle branch system
(beats 20-40 beats/min)

Causes ventricles to contract

Not enough on its own to give proper perfusion

How it connects to EKG waveforms?

Answer 9

Bundle of His

Stimulates ventricles

Ventricular depolarization = QRS on ECG

Question 10

Conduction begins in SA node, located in right atrium
SA node is pacemaker of the heart, effected by sympathetic and parasympathetic nerves which increase or decrease heart rate
Impulses travel through SA node resulting in atrial depolarization (contraction) and p wave on ECG

AV node beneath right atrium, impulse slows through AV node before proceeding to ventricles
AV junction is PR segment and includes conduction through AV node and Bundle of His, allows atrium to contract and ventricles to fill before ventricular contraction
Atrial kick contributes additional blood volume for greater cardiac output

Bundle of His= right and left bundle to stimulate ventricles
End of bundle branches are purkinje fibers.
Ventricular depolarization = QRS on ECG

Answer 10

Yes

Question 11

Within the cardiac condition system there are Specialized myocardial cells

Characteristics of the cells include:

Answer 11

Automaticity: able to spontaneously generate an electrical impulse

Excitability: capable of being activated and reacting to electrical stimuli

Conductivity: able to conduct electricity

Contractility: form a contraction and strength of the hearts contraction during systole

Question 12

ECG waveforms are measured in what??

Isoelectric, positive deflection and negative deflection

One small block =_____? seconds.

Five small blocks equal one large block=____seconds

Five large blocks =1 second and 30 large blocks =6 seconds

Left to right- measure time

Top to bottom- measures voltage and amplitude (how much voltage is conducted)

Measure how long each waveform should be

Answer 12

amplitude (voltage) and duration (time).

One small block = 0.04 seconds.

Big-0.2 seconds

Question 13

Each segment between the dark lines (above the monitor strip) represents 3 seconds (15 large boxes). To estimate the ventricular rate, count the QRS complexes in a 6-second strip and then multiply that number by 10 to estimate the rate for 1 minute. In this example, there are 9 QRS complexes in 6 seconds. Therefore the heart rate can be estimated to be 90 beats/min.

Answer 13

Look at rate - count qrs x by 10 (6 seconds is 15 boxes)

There are 9 QRS x 10= 90 bpm

Question 14

_____wave is usually positive deflection that represents atrial depolarization. Every beat has a this wave hopefully. First thing will see.

Answer 14

P wave

Question 15

____segment/interval is isoelectric line from end of P wave to QRS represents time traveled between SA and AV node .12-.20 or 3-5 little squares.

Answer 15

PR segment

Question 16

____complex represents ventricular depolarization .04-.12 seconds

Answer 16

QRS complex

Question 17

______ is first negative deflection after p wave and isn’t always present (can mean myocardial necrosis)

Answer 17

Q wave

Question 18

______duration is time it takes impulse to travel through Bundles and cause contraction

Answer 18

QRS

Question 19

_____ represents early ventricular repolarization (becoming ready to be stimulated again) isoelectric line

Answer 19

ST segment

Question 20

______follows ST segment and represents full ventricular repolarization, usually positive and rounded but can be tall, peaked, inverted, or flat

Answer 20

T wave

Question 21

_____ is not normally seen and may represent electrolyte abnormality (hypokalemia)

Answer 21

U wave

Question 22

____interval varies with age, gender, and heart rate.

Answer 22

QT

Question 23

How to analyze an ECG?

Should be what?

Answer 23

Determine heart rate
Determine heart rhythm
Analyze P waves
Measure PR interval
Measure QRS duration
Examine ST segment
Assess T wave and QT interval
Interpret rhythm

**Should be systematic and consistent
Rate=speed
Rhythm=consistency
P wave= are p waves present, are p waves consistent (PR interval)

Question 24

Simplified rhythm analysis ?

4 steps

Answer 24

Determine heart rate-bmp

Determine heart rhythm- is the hr even and rhythmic/regular

Assess P wave
Present and consistent- one for each QRS and they look the same

Interpret rhythm- use above info to interpret this

Question 25

What type of heart rhythm? . Both atrial and ventricular rhythms are essentially regular (a slight variation in rhythm is normal). Atrial and ventricular rates are both 80 beats/min. There is one P wave before each QRS complex, and all the P waves are of a consistent morphology, or shape. The PR interval measures 0.18 second and is constant; the QRS complex measures 0.06 second and is constant

Answer 25

Normal sinus rhythm

Question 26

Must be within these ranges for this rhythm Rate: 60 to 100 beats/min Rhythm: Regular P waves: Present, consistent configuration, one P wave before each QRS complex PR interval: 0.12 to 0.20 second and constant-normal QRS duration: 0.04 to 0.10 second and constant- normal

Answer 26

Normal sinus rhythm

Question 27

Variant of NSR (normal sinus rhythm) Results from changes in intrathoracic pressure during breathing inhalation Exhale beat goes back up

Answer 27

Sinus arrhythmia

Question 28

Common dysrhythmias

Answer 28

Premature complexes - Bigeminy - Trigeminy - Quadrigeminy Bradydysrhythmias - hr slower than normal Tachydysrhythmias- hr faster than normal

Question 29

Premature complexes are early rhythm complexes. can be atrial or ventricular ______exists when normal complexes and premature complexes occur alternately _______exists when normal and premature beats occur in a three beat pattern _______is four beat pattern PVCs- how frequent they are happening

Answer 29

Bigeminy Trigeminy Quadrigeminy

Question 30

Causes of dysrhythmias

Answer 30

``` May occur for many reasons Myocardial infarction Electrolyte imbalances Hypoxia Drug toxicity Hypovolemia Drugs-illegal substances ``` Electrolytes: potassium and magnesium Drugs: cocaine, nicotine, alcohol, caffeine Also stress and fear

Question 31

Care for clients with dysrhythmias? What to check with ABCs? Teach patient to check what? How?

Answer 31

Ensure ABC’s are intact* Check Perfusion, hr, Bp, cap refil, mentation Assess vital signs Determine if symptomatic* Administer medications as prescribed and monitor response Monitor appropriate lab values Teach patient to monitor their pulse regularly* rate and regular

Question 32

S/s of symptomatic dysrhythmias?

Answer 32

Low bp Poor mentation SOB Chest pain/pressure/discomfort Restlessness/anxiety Dizziness Syncope - loc r/t low bp Weakness fatigue Pale/diaphoresis

Question 33

Monitor which labs with dysrhythmias

Answer 33

Potassium and magnesium

Question 34

On 6 second strip determine what?

Answer 34

Rate - bpm Rhythm - regular? P wave - present and consistent? Tx- monitor, treat underlying causes

Question 35

Major concern in patients with CAD, increases work load on the heart (sinus tachycardia) Coronary Perfusion decreases due to decrease in diastolic time (coronary perfusion occurs during diastole) May remain adequate Symptoms include:? Symptoms of heart failure:?

Answer 35

Symptoms include: palpitations, chest discomfort, restlessness, anxiety, pale cool skin, syncope (from possible hypotension), can lead to heart failure Symptoms of heart failure: dyspnea, lung crackles, JVD, fatigue, and weakness

Question 36

What Can cause increased heart rate in sinus tachycardia ?

Answer 36

Fever , pain, anxiety, dehydration Treat underlying cause first The may need beta blockers?

Question 37

Rate: 100-180 beats per minute Rhythm: regular P Wave: present, consistent Treatment*: monitor, treat underlying causes

Answer 37

Sinus tachycardia

Question 38

40 bpm Regular rhythm P wave for every QRS - present and consistent What type of rhythm is this?

Answer 38

Sinus bradycardia rhythm

Question 39

Sinus Bradycardia musts Rate? Rhythm? P wave? Tx? If symptomatic? Common symptoms-?

Answer 39

Rate: < 60 beats per minute Rhythm: regular P wave: present and consistent Treatment: first monitor, treat underlying causes If symptomatic*: atropine, oxygen, increase IV fluids, temporary pacing Hypoxia and dehydration are common symptoms - treat with oxygen and IV fluids

Question 40

Sinus Bradycardia Myocardial oxygen demand is less (can be beneficial) perfusion may remain adequate Forms of bradycardia include________ degree blocks Symptomatic= __________????? Tx?

Answer 40

2nd and 3rd degree blocks Symptomatic= syncope, dizziness, weakness, confusion, hypotension, shortness of breath, chest pain, dehydration, hypoxia Atropine 0.5 mg IV

Question 41

Temporary pacing—two different types invasive and noninvasive Invasive wires go into chest Noninvasive- pads on chest and machine on outside of body to stimulate hr ————— Permanent pacemakers Safety considerations*: Temporary:

Answer 41

Keep cell phones 6 inches away Avoid electromagnetic fields (MRI) Carry identification card or wear bracelet Teach patient to monitor for pulse lower than pacemaker has it set at Temporary-external pass or invasive wires to external pacemaker

Question 42

Pacemaker spikes If see it before p wave- atrial paced Before QRS- ventrical paced Know what the spike means? Know where it is? Know which part of the heart it’s stimulating?

Answer 42

Know what the spike means? vertical signals that represent the electrical activity of the pacemaker.

Question 43

Rapid stimulation of atrial tissue occurs at rate of 180 to 280 beat/min (adults) P waves may not be visible/ because heart is beating so fast May occur in healthy people (women more prone) Paroxysmal supraventricular tachycardia rhythm is intermittent, terminated suddenly with or without intervention (comes and goes) 200 bpm, regular- t wave covers up p wave - slow HR down first

Answer 43

Supraventricular tachycardia SVT

Question 44

SVT May be asymptomatic Symptoms (if symptomatic) include: *? Treatment:? If symptomatic:

Answer 44

Symptoms (if symptomatic) include: chest pain, palpitations, shortness of breath, fatigue, restlessness, hypotension, altered mental status* Treatment: fix as soon as possible, perfusion is greatly reduced being this fast ,first line tx is vagal maneuvers (bear down or blow/push/blow through straw)- can kick hr back into normal Adenosine 6 or 12 mg ** (slow down heart and may stop for brief amt of time. May feel impending doom and anxiety. Wears off very quickly..goal is normal rhythm when starting back up..if doesn’t work- if that doesn’t work then sync cardioversion (deliver shock to patient and reset heart) If symptomatic: synchronized cardioversion* 2nd line Mexican tx to control HR- Beta and calcium channel blockers can also be given to treat SVT. Long term may need ablation

Question 45

Most common dysrhythmia Most common dysrhythmia- especially in elderly (May be normal beat for them) High risk for morbidity (disability)and mortality (death) Clotting can lead to stroke or PE** asses for signs Many atria foci depolarize in a disorganized manner (not a clear atrial contraction) - so blood may pool and form a clot- can push into ventricles and release clot into other parts of body such as brain or lungs =stroke risk No clear p waves, no atrial contraction, irregular ventricular response Associated with underlying cardiac disease

Answer 45

Atrial fibrillation

Question 46

No clear P waves HR 100 Irregular Electricity Shivering causing fibrillation What is this?

Answer 46

Atrial fibrillation

Question 47

Assessment of atrial fibrillation? Signs of poor perfusion Irregular palpated pulse Anxiety 12 lead ECG Complications* ? Goals*? Teach patient what??

Answer 47

Potential for embolus formation Potential for heart failure PE; VTE Goals* Preventing embolus formation Preventing heart failure Teach to check pulse - rate and rhythm

Question 48

Interventions for atrial fibrillation? Goal?

Answer 48

Medications* Antidysrhythmic drugs to slow rate or convert Electrical cardioversion Maze procedure Radiofrequency catheter ablation Bi-ventricular pacing Goal: restore regular blood flow, correct rhythm, control heart rate Medications: calcium channel blockers (diltiazem), or antiarrhythmics (amiodarone), beta blockers (metoprolol) for rate control add info about beta blockers…slow the HR Medications also include anticoagulation- prevent clots Risks of cardioversion (May not want to for someone that doesn’t know when rhythm started) May jolt clot Maze procedure: open chest surgical technique, place “maze” of sutures in various locations to try to impede electrical impulses Ablation: abolish irritable focus with scar tissue

Question 49

Ventricular dysrythmias : Premature ventricular complexes Ventricular tachycardia Ventricular fibrillation Ventricular asystole Lethal rhythms - important to identify quickly Are more what?

Answer 49

More life-threatening than atrial dysrhythmias Because Left ventricle pumps oxygenated blood through the body to perfuse vital organs and other tissues

Question 50

Also called V tach—repetitive firing of irritable ventricular ectopic focus, usually at 140 to 180 beats/min

Answer 50

Ventricular tachycardia

Question 51

V tachycardia tx?

Answer 51

Treatment: assess patient*, fix ASAP if pulse -antiarrhythmics and monitor, if no pulse start CPR Sustained ventricular tachycardia at a rate of 166 beats/min. Antiarrhythmic: amiodarone

Question 52

V-tach strip - what it looks like?

Answer 52

A bunch of Wide QRS in a row

Question 53

Also called — result of electrical chaos in ventricles No clear contraction - quivering Treatment ?* Lethal rhythm - no counting Coarse ventricular fibrillation

Answer 53

V fib-Ventricular fibrillation Will never have a pulse, start CPR and defibrillate ASAP* Tx Interupt electricity in heart, stop and reset heart

Question 54

Also called ventricular standstill—complete absence of any ventricular rhythm Ventricular asystole with one idioventricular complex Firing of random electricity but not enough for a pulse. Treatment??

Answer 54

Ventricular asystole Can not defibrillate, can do CPR and ACLS medications to get them back to a point where we can defibrillate Check for artifacts if patient is sitting up and talking to you and appears normal If unresponsive- start chest compressions stat!

Question 55

How to manage cardiac arrest Most important thing ?

Answer 55

CPR, Cardiopulmonary resuscitation Start high quality chest compressions (most important thing)* Maintain patent airway Ventilate with mouth-to-mask device Defibrillate as needed Advanced cardiac life support

Question 56

Asynchronous countershock that depolarizes critical mass of myocardium simultaneously to stop re-entry circuit and allow sinus node to regain control of heart Goal is to reset electrical activity of the heart*

Answer 56

Defibrillation

Question 57

Automated external defibrillation AEDs create an opportunity for laypersons to respond to cardiac arrest AEDs analyze the rhythm and shocks are delivered for ventricular fibrillation or pulseless ventricular tachycardia only Safe use of AED*:

Answer 57

Safe use of AED*: Avoid puddles - pull out of water and dry off chest as best as possible- doesn’t need to be completely dry Remove medication patches- avoid or remove , quick wipe and put AED on Avoid pacemakers- never out on top of pacemaker Hair removal- some come with shavers- avoid hair or shave spot. If no shaver- can try to rip hair off with AED pads and the. Use new ones after if available. Anyone can use - turn it on and it walks you through the steps It decides if patient needs to be defibrillated or continue CPR

Question 58

The nurse working in the outpatient setting identifies which dysrhythmia as the most commonly diagnosed? A.Atrial fibrillation Sinus tachycardia Sinus bradycardia Ventricular fibrillation

Answer 58

A. Atrial Fibrillation Rationale: Atrial fibrillation (AF) is the most common dysrhythmia seen in clinical practicel- especially in elderly. It is responsible for a third of hospitalizations for cardiac rhythm disturbances. Patients can live with this dysrhythmia, but most are treated with anticoagulation therapy to avoid possible blood clots.

Question 59

On a telemetry monitor, the nurse observes that a patient’s heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse’s first action? A.Synchronized cardioversion B.CPR and immediate defibrillation C.Administration of IV amiodarone (Cordarone) and dextrose D.Administration of oxygen and observation of the heart rhythm

Answer 59

D. Administration of oxygen and observation of the heart rhythm Current advanced cardiac life support (ACLS) guidelines recommend administration of oxygen and observation of heart rhythm first, followed by administration of an IV antidysrhythmic agent such as amiodarone mixed with dextrose 5%. Synchronized cardioversion would be the next step. CPR and immediate defibrillation would be used only to treat unstable VT.

Question 60

A patient is admitted to a telemetry unit with a new diagnosis of atrial fibrillation (AF). The patient states, “I feel fine, this rhythm won’t hurt me.” Which nursing response is appropriate? A.AF can cause clots to form from the irregular blood flow in the heart.” “B.It’s important to monitor the AF for 24 hours.” “C.AF leads the death of the heart muscle.” “D.AF can cause cardiac output to increase.”

Answer 60

A. AF can cause clots to form from the irregular blood flow in the heart.” Educate patient - Many times patients are found to have atrial fibrillation and they may be asymptomatic. While some patients do live with long-term atrial fibrillation, they need to be anticoagulated to decrease the risk of embolus formation due to the irregular cardiac rhythm. AF does not cause death of the heart muscle, nor does it cause the cardiac output to increase. Cardiac output will decrease due to the shortened filling time in the atria, which contributes to the development of heart failure due to altered conduction. While monitoring the patient is appropriate, it is not the best response to help educate the patient on the process of atrial fibrillation.

Question 61

Jaimie will Post - Practice websites Worksheet with strips to print off and assess Using calipers to identify rhythms Slideshow - blocks -1st degree, 2nd degree, 3rd degree heart rhythms Refer to book YouTube videos -registered nurse RN

Answer 61

Utilize these resources for practice