Vitals & EKG Flashcards
What should you assess in tachycardic patients?
if they are febrile, dehydrated (nausea/vomiting/diarrhea?), perfusing (skin color, skin temperature and skin dryness), and always match the rate with a blood pressure.
What should you assess in bradycardic patients?
assess their alertness, medications, ask about any existing cardiac conditions or if the patient has passed out recently, and again always match the heart rate with a blood pressure
Is hypotension concerning?
According to the American Heart Association, hypotension isn’t concerning unless it is symptomatic.
Pre-hypertensive systolic blood pressure
between 120 and 129 mmHg with the diastolic blood pressure still being less than 80 mmHg.
Stage 1 Hypertension
SBP starts at 130 mmHg
DBP between 80-89 mmHg.
Stage 2 Hypertension
SBP 140 or higher
DBP higher than 90 mmHg.
Hypertensive Urgency
BP higher than 180/120 W/O any end organ failure.
Hypertensive Emergency
a BP higher than 180/120 mmHg WITH end organ failure
Neurological S/S of end organ failure include
Signs and symptoms of encephalopathy Altered LOC Dizziness Headache Stroke Seizures
Ophthalmology S/S of end organ failure include
Retinopathy
Papilloedema (optic disc swelling)
Retinal Hemorrhage
Cardiovascular S/S of end organ failure include
EKG changes
Chest pain
S3 and S4 heart sounds
Renal S/S of end organ failure include
Hematuria (blood in urine)
Oliguria
How is MAP calculated?
Normal values?
(SBP + (2xDBP) ) /3 = MAP
the heart spends twice as much time in diastole than systole.
Generally the goal for a MAP is between 60 and 100 mmHg.
What is pulse pressure?
Normal values?
a measurement of the difference between the systolic blood pressure and diastolic blood pressure. A normal pulse pressure is between 30-40 mmHg.
What is Pulmonary Wedge Pressure (PWP)?
Normal values?
- Pt would be in ICU*
- a measurement of left atrial pressure.
- a balloon to be placed in a patient’s pulmonary artery branch
- helps to diagnose left ventricular failure and is the gold standard for diagnosis of acute pulmonary edema
~systolic (normal range 15-30 mmHg) and diastolic (normal range 4-12 mmHg)
What signifies if a patient is positive for orthostatic hypotension?
If the SBP is greater or less than than 20 mmHg, the heart rate is greater or less than 20 BPM, or the patient is symptomatic (dizziness, lightheadedness, or fainting with position changes)
What can orthostatic hypotension indicate?
can indicate GI bleeding/blood loss, anemia, dehydration, etc. The first line of treatment, if appropriate, is to give fluids (orally if tolerated) and reassess orthostatics to eliminate dehydration. It is likely that the provider will want to also check for any blood in the stool as well as a CBC for the hemoglobin results.
If a patient is suspicious for an aortic dissection or aneurysm, how are VS assessed?
take the blood pressure in both arms and compare SBPs together and DBPs together. If the blood pressure is more than 20 mmHg of difference, there is a possibility that the patient is having a dissection. Check radial pulses at the same time and assess if they are equal in rate and intensity.
When do you hold cardiac medications?
systolic blood pressure is less than 90 mmHg or if the heart rate is less than 50 or 60 BPM
What is Cardiac Output (CO)?
Calulation?
- how much blood (in liters) the left heart is pumping out to the body per minute through the aorta
- calculated by multiplying how much blood is ejected with each cardiac contraction, which is called stroke volume (SV) multiplied by the number of heart beats per minute.
- In a “normal” patient, this number will be anywhere from 4-10 liters per minute.
What are sensitive indicators your patient is not getting the blood they need (perfusing)?
Skin signs such as a delayed capillary refill over 3 seconds, neuro signs such as altered mentation, and decreased urine output below 0.5mg/kg/hr or 30ml/hr minimum in an adult
Stroke Volume (SV)
the amount of blood in the left ventricle that ejects out with each contraction of the heart.
-arrhythmias like atrial fibrillation or premature beats can affect the ability of the left ventricle to completely fill on diastole and this will alter how much is being ejected.
What is a normal EF?
- A normal EF is 60-80%, and anytime you see the EF less than 50-55%, it is commonly referred to as systolic dysfunction and can be chronic, acute, or acute on chronic during a stressor.
- If you’ve got a patient who is in heart failure, the physician/advanced practice provider will typically order a transthroacic echocardiogram (TTE or “echo”) to evaluate the EF.
Things that can cause ST in patients?
Hypovolemia (dehydration) Fever Caffeine Stress Pain Hypotension Hyperthyroidism
What is happening during bradycardia? Symptoms?
- the time their heart spends in diastole in greatly increased and the cardiac output is decreased.
- Symptoms include:
Dizziness Weakness/Fatigue Altered Mental Status Shortness of Breath/Pulmonary Edema Hypotension
What are the expected interventions for symptomatic bradycardia?
If the patient is symptomatic, this is an urgent situation.
You may need to give the patient some oxygen and prepare for potential transcutaneous pacing by pulling the crash cart over and hooking the patient up to the electrode pads.
The 1st line treatment depends on if the patient has a heart transplant or not. If they do not have a heart transplant and it is their original heart, prepare for the doctor to order 0.5 mg of Atropine. Atropine can be repeated every 3-5 minutes and has a max dose of 3 mg (6 doses of 0.5 mg). If the patient has had a heart transplant, the first line treatment is isoproterenol (Isuprel).
If the first line doesn’t work, second line is transcutaneous pacing. If transcutaneous pacing is not available, the doctor might order an IV drip of epinephrine or dopamine.
questions for you to answer to help identify if the ECG is normal sinus rhythm or not
P wave
Is there a P wave?
Is the P wave happening regularly?
Does every P wave have a QRS complex following it?
Do all the P waves look the same?
PR interval
Is the PR interval between 0.12-0.2 seconds?
Does the interval time stay the same or vary?
QRS complex
Is the QRS interval between 0.08-0.1 seconds?
Are they the same height?
Is the R wave to R wave consistent?
T wave
Is there a T wave?
Does it follow a QRS complex?
How tall is the wave?
QT interval
Is the interval less than 0.44 seconds?
ST segment
Is the line flat and inline with the isoelectric line?
If your patient is having PACs, what should you monitor for?
PACs can lead to Atrial Fibrillation or Atrial Flutter
What is a PAC?
Premature Atrial Contractions (PAC)
the atria contract prematurely/early. The P wave can be irregularly shaped, occurring with or without a QRS complex following it, and this will make the rhythm irregular.
Sometimes, the PAC can contract during the same time the ventricles are repolarizing (AKA the T wave). If this happens the wave will have a camel hump appearance. This is important to note because it might seem like there isn’t a P wave, but there is.
Premature Junctional Contraction (PJC)
originating from the lower part of the atria the P wave will be inverted and the PR interval will be very short (less than 0.12 seconds).
What does Paroxysmal mean?
sudden onset
Supraventricular Tachycardia (SVT)
covers all tachycardias originating from above the ventricles
It occurs when an electrical impulse has found another pathway and enters back into the atrial cycle sending another set of signals much quicker than it is supposed to. The rate will likely be regular and P waves may be lost in the T waves.
What classifies Afib w/ RVR?
An uncontrolled afib rate above 100 BPM
What is occurring in the heart with Afib?
the signals in the atria are chaotic, causing the atria to quiver. A clear contraction of the atria does not occur, thus the P wave will be absent. In place of the P wave, there will be erratic scribbles. The ventricles receive confusing signals for when to contract so they contract irregularly.
The biggest problem with atrial fibrillation is the blood pooling in the atria causing blood clots to form and then sent into the bloodstream throughout the body.
What is occurring in the heart with A-flutter?
the conduction path from the sinoatrial node to the atrioventricular node (AV node) is spiral in nature and no longer the smooth direct pathway. The impulse still reaches the AV node causing the ventricles to contract and the QRS complex to appear at a regular interval.
How are junctional rhythms identified?
Due to the short distance that the signal will be traveling, the PR interval is shortened (less than 0.12 seconds) and the P wave is usually inverted.
tend to be between 40-60 BPM since they originate from the AV node
If the rate is between 60-100 BPM, it is called an Accelerated Junctional Rhythm.
If the rate is between 100-200 it is called Junctional Tachycardia.
Where do the most dangerous arrhythmias come from and why?
The ventricles.
The ventricles send blood all over the body and if the ventricles are not working the body/organs/tissues/cells are not getting blood.
If a pt has 3 or more PVCs in a row, what is it called?
V-tach, life threatening and need to notify MD
What causes PVCs?
could be electrolytes K, Mg levels out of whack
occur when the ventricles receive an impulse prematurely, having them contract before they are supposed to, interrupting the cardiac electrical cycle. They can be harmless and common, however, they can also spark an electrical chaos within the heart that can be harmful.
