Week 1 Class 2 Rhythms Flashcards
Which part of the heart beat makes the P wave.
Both Atrium depolarization (contracting)
P wave begins at this location in the electric conduction system
SA node firing
PR segment on ECG comes from this area of electrical conduction system.
AV junction
- Define the time length a Small box on an ECG is.
- How many of these boxes make up a larger box.
- With a time frame is represented with the larger box…
- 0.04
- 5 × 5
- 0.20
Normal time intervals
P - R Interval (PRI) Or P - Q (PQI) ….
QRS Interval…
S-T Segment…..
Q - T Interval…..
P - R Interval (PRI) Or P - Q (PQI) ….
0.12 - 0.20 seconds
QRS Interval…
0.08 - 0.11 seconds
S-T Segment…..
No standard time. But usually 0.36 - 0.44
Q - T Interval…..
0.33 - 0.42 Seconds
Normal interval times
PR & PQ…
QRS….
ST….
QT…
PR & PQ: 0.12 - 0.20 or 3 small boxes - 1 large box
QRS: 0.08 - 0.11 or 2 - 3 small boxes
ST: No normal Generally 0.36 - 0.44 or 1 big box 4 small - 2 big box and 1 small
QT: 0.33 - 0.42 or 1 big box & 3 small - 2 big boxes
5 lead EKG placement
Right:
White: Right 2nd intercoast space (Right Side)
Brown: 4th intercoastal space Right sternal boarder
Green: 8th intercoastal space Right side. Near bottom of rib cage.
Left
Black 2nd intercoastal space Far left side
Red: 8th IC left hand side
Brown:
Purpose of the 5 color EKG leads..
What does eaxh color do…
White & black Record activity of arms
Red & Green: legs & ground (Green)
Brown: Chest activity
Bedside monitoring
Single lead shows…
Rate & Regularness
Time to conduct impulses
Describe Normal Sinus Rhythm
P wave & QRS complex
Time for waves…
P wave present befire each QRS complex
P = 0.12 - 0.20 or 3 small boxes - 1 large box
QRS = 0.06. - 0.10 OR 1.5 SMALL Boxes - 2.5 small boxes
PR interval
Measures…. (location on strip)
What it represents….
Beginning of P wave (Atrial depolarization/ Contraction) -
Beginning of QRS complex (Ventriclar depolarization/ Contraction)
0.12 - 0.20
PR interval represents: Time it takes impulse to travle through AV node, bundle of His, Purkinje Fibers. BEFORE reaching the Ventricles
This delay allows for ventricular filling of blood before contracting.
Prolonged PRI >0.20
- Indicates this problem…
- Seen with these conditions…
- Variable PRI times is this problem…
- 1st degree heart block - Least Serious- delay conduction through AV node.
- Conditions:
Ischemia (Reduction in blood) / Infarction (Death of tissue caused by lack of blood)
Meds: Beta-Blocker, CCB
Electrolyte imbalance Hyperkalemia
- Variable PRI times suggest
2nd or 3rd degree heart block
Mobitiz Type 1 (Wenckebach) Progressive lengthening of PRI until QRS is dropped.
Mobitz Type II: Fixed PRI with intermittent dropped QRS complex
Explain the difference between 2nd degree heart block :
Mobitz Type 1 (Wenckebach) & Mobitz II.
In relation to their appearance on an ECG…
Symptoms…
Mobitiz Type 1 (Wenckebach) Progressive lengthening of PRI until QRS is dropped.
Rhythm: Irregular
Usually asymptomatic possible dizziness
Cause: Vagal or meds
Mobitz Type II: Fixed PRI with intermittent dropped QRS complex
Symptoms: Fatigue, syncope, dizzy
More serious pathology & often requires a pacemaker.
- 3rd Degree aka…
- Cause….
- Describe appearance on EKG…
- Signs & Symptoms…
- Treatment….
- Complete heart block
- Electrical signals from atria isn’t making it to the ventricles
Congenital
Heart disease
MI
Meds Digoxin
Structure damage
Heart valve problem
- Fewer QRS complexes than P waves. “Missing P waves” Regular rate
(Ventriclar rate is lower than atrial rate)
- Low BP, Mental Status change, pale / clammy skin
- Activate Emergency Response
Atropine
Temporary Pace Maker / Permanent Pacemaker
Sinus Bradycardia
Rate…
Rhythm…
Pacemaker Site…
<60
Rhythm: Normal
Pacemaker Site: SA node
Sinus Tachycardia
Rate…
Rhythm…
Pacemaker site…
> 100
Rhythm: Regular
Pacemaker site: SA node
Sinus Dysrhthmias
Rate…
Rhythm…
Pacemaker site…
60 - 100 normal
Rhythm: Irregular
Pacemaker site: SA node
PR interval
How to measure…
What abnormalities suggest…
Start of P wave to Beginning of QRS complex.
Normal 0.12 - 0.20
Abnormalities
Prolonged:
1st degree heart block / conduction delays
2nd Degree Mobitz Type 1 Wenckebach
Progressive lengthening of PRI until QRS is dropped
2nd Degree Mobitz Type 2
PRI is normal QRS is dropped- More dangerous- Block at or below Bundle of His, Structural Abnormalities.
Can progress to Type 3 Total Heart block
Premature Atrial Contractions
Describe…
Causes…
Treatment…
Extra Heart beat originates from ectopic focus in the atria.
Typically benign
ECG
P wave Abnormal, maybe burried in the T wave / Close to QRS complex
PRI normal / Slightly prolonged
QRS Narrow
Causes:
Stress, fatigue, caffeine, alcohol, drug
Electrolyte imbalance
Hyperthyroidism
Hypertension
CAD
Atrial enlargement
Meds
Sympathomimetic
- bronchodilator
Digoxin toxicity
Treatment:
None normally- happens with stress & caffeine
Frequent >1 in 10 beats - further evaluation
Education: Avoid drugs & stress. If frequent notify HCP
Paroxysmal Supraventricular Tachycardia (PSVT)
Describe…
Rhythm….
P waves….
QRS complex…
Cuases…
Clinical Presentation….
Nursing interventions….
Stable / Unstable
Treatment….
Pacemaker site…
HR 150 - 250. Originates in atria / AV node due to abnormal electrical circuit.
BEGINS & ENDS SUDDEN (PAROXSYMAL)
Rhythm: Normal
P wave: Hidden in T wave or inverted if visible
QRS: Narrow <0.12, unless there is a bundle branch block.
Causes:
Stess, anxiety, fatigue
Caffeine, alcohol, drugs, smoking
Underlying conditions:
Congenital Heart conditions (Wolff-Parkinson-White Syndrome)
Hypokalemia
Structure disease/ ischemia
Digoxin
Presents:
Palpation
Dizzy
SOB
Chest discomfort (May resemble angina - Chest pain causes by lack of blood “Ischemia “
Fatigue
Nursing interventions
Stable:
Valsalva Maneuver
Notify HCP
Administer Adenosine if ordered
Unstable:
Prepare for synchronized Cardioversion
Oxygen if SpO² < 94%
Establish IV access
Treatment:
Adenosine IV push, may terminate rhythm
Beta Blockers/ CCB
Antiarrhythmic
For recurrent PSVT (amiodarone)
Longterm
Referred for Electrophysiologic Study
Ablation therapy for recurrent or severe cases
Pacemaker site: Atrial Outside the SA node
Which type of medication will you give for SVT & PSTV
This medication is given after less invasive interventions are tried ( Valsalva Maneuver)
Describe administration….
What scary side effect may happen…
Adenosine
Rapid IV push 1 - 2 seconds follow by saline flush.
6 mg, if no response 12 mg, follow by 12 mg if necessary
Scary SE
Asystole may is normal and expected before rhythm is restored.
Atrial Flutter
Rate (Atrial / Ventriclar)…
Rhythm….
Pacemaker….
P waves…
PRI…
QRS….
Rate (Atrial / Ventriclar)
Atrial 250 - 350
Ventricular Varies
Rhythm
Usually Regular
Pacemaker
Atrial Outside SA node
P waves
F (Flutter) Waves present
PRI Normal
QRS Normal
A Flutter has this appearance with the P waves…
Saw tooth
A Flutter
Associated Conditions…
Symptoms…
Treatment….
Associated Conditions:
Structure heart disease
Hyperthyroidism
Post-cardiac surgery
Symptoms:
Palpation
Dizzy
Fatigue
SOB
Chest discomfort
Maybe asymptomatic
Treatment:
Rate Control:
Beta Blockers / CCB
Rhythm Conversion:
Cardioversion or Antiarrhythmic drugs (Amiodarone)
Anticoagulantion:
To reduce stroke in persistent A Flutter
A Fibrillation
Rate…
Rhythm…
Pacemaker site…
P waves….
PRI….
QRS….
Rate:
Atrial 350 - 750
Ventricular Varies
Rhythm:
Irregularly Irregular
Pacemaker site:
Atrial Outisde SA node
P waves
None discernible F waves Present
PRI
None
QRS
Normal
A fib results in chaotic Atrial depolarization
Result:
Irregularly Irregular ventricular rhythm
Decreased cardiac output due to loss of Atrial Kick.
Sign & Symptoms…..
Complications…
Nursing Responsibilities…
Assessment…
Acute management…
Chronic management…
Signs
Palpation
Irregular pulse
Chest discomfort
Dizzy
SOB
Hypotension
STROKE Symptoms: Slurred Speech, Unilateral weakness, Confusion- due to embolism
Tjromboembolic Events: Blood statis in atria can lead to clot
Heart failure: Loss of Atrial Kick and rapid ventricle response can worsen heart function
Cardiomyopathy:
Chronic uncontrolled AF may lead to Atrial & Ventriclar remodeling
Nurse Responsibility
Assess:
BP, HR, OX Sat
Ask about palpation, fatigue, dizzy, chest discomfort
Monitor ECT
ACUTE MANAGEMENT
Beta-blockers (metoprolol)
CCB (Diltiazem)
Digoxin
MONITOR THESE MEDICATIONS FOR HYPOTENSION & BRADYCARDIA
Rhythm Control:
Adminster Antiarrhythmic (Amiodarone)
Assist with Cardioversion if indicated
Anticoagulantion
Adminster Heparin, Warfarin, Apixaban
Most common Dysrhthmia….
Symptoms depende on….
A Fib
Ventricular rate
Amlodipine
Nifedipine
Felodipine
Nicardipine
Diltiazem
Verapamil
This type of medication…
What affect…
Conditions to use it in…
Calcium Channel Blockers
Slows down Cardiac Conduction, Contractility.
Dilation of coronary arteries.
Conditions it treats:
A fib, A Flutter, SVT
What conditions are a Contradictions for CCB.
hypotension, bradycardia, heart failure,
CHADS2 Score
Purpose….
Scoring:
C: Congestive heart failure (1 point)
H: Hypertension (1 point)
A: Age ≥75 years (1 point)
D: Diabetes mellitus (1 point)
S: Prior stroke or transient ischemic attack (2 points)
Purpose:
Estimates stroke risk in patients with AF.
CHADS2 is a scoring chart used to determine likely hood of stroke with A fib.
Describe….
C: Congestive heart failure (1 point)
H: Hypertension (1 point)
A: Age ≥75 years (1 point)
D: Diabetes mellitus (1 point)
S: Prior stroke or transient ischemic attack (2 points)
What is CHADS2 VASC2 Used for….
Describe…..
A more refined scoring system to determine Use of Anticoagulants in a patient with Afib to prevent stroke.
C: Congestive heart failure (1 point)
H: Hypertension (1 point)
A2: Age ≥75 years (2 points)
D: Diabetes mellitus (1 point)
S2: Prior stroke or TIA (2 points)
V: Vascular disease (e.g., PAD, MI, aortic plaque) (1 point)
A: Age 65–74 years (1 point)
Sc: Sex category (female) (1 point)
Total Range: 0–9
Vitamin K agonist
This medication…
Target IRN level for effective use…
Target IRN level for age >75…
Normal healthy IRN level…
Antidote for Vitamin K agonist Warfarin (Coumadin)
Normal IRN level
Warfarin (Coumadin)
Target IRN 2.0 - 3.0
>75 1.6 - 2.5
Normal healthy: 0.8 - 1.2
Antidote: Vitamin K Phytonadione or Phylloquinone.
Difference in use between Vitamin K agonist Warfarin (Coumadin) &
Heparin, Enoxaparin (Lovenox)
Heparin, Enoxaparin (Lovenox)
Acute situations requiring rapid anticoagulation (e.g., pulmonary embolism, deep vein thrombosis, myocardial infarction).
Bridging therapy before starting warfarin or before surgery.
Warfarin
When Used:
Long-term anticoagulation for conditions like atrial fibrillation, mechanical heart valves, or chronic DVT/PE.
Reason: Slower onset of action but ideal for chronic management.
PTT (Partial Thromboplastin Time):
Target PTT for Therapeutic Use with these medications….
60–80 seconds (1.5–2.5 times the normal value).
Normal PTT:
25–35 seconds.
Target therapeutic use for:
Heparin, Enoxaparin (Lovenox)
What is the target time at type of blood clotting value for
Heparin & Enoxaparin (Lovenox)…
Vitamin K agonist: Warfarin (Coumadin)
Heparin & Enoxaparin (Lovenox)
PTT:
80 seconds (1.5–2.5 times the normal value).
Normal PTT: 25–35 seconds.
Vitamin K agonist Warfarin (Coumadin)
INR 2 - 3 seconds unless >75 1.6 - 2.5 seconds
Antidote for Heparin or Enoxaparin (Lovenox)
Protamine Sulfate.
Direct Thrombin inhibitors
Dabigatran - Pradaxa has a specific antidote ______
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Antidote _____
Dabigatran
(idarucizumab)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
Andexanet alfa (Andexxa)
Which area of the heart is the primary source of blood clots in A Fib….
Treatment…
Atrial appendage
Atrial appendage closure
Ventricular Escape Complexes
Rate…
Rhythm….
Pacemaker site…
P waves…
PRI…..
QRS….
General appearance…
Rate 15 - 40
Rhythm Escape Complex Irregular/ Escape Rhythm, Regular
Pacemaker site Ventricle
P waves None
PRI None
QRS: Wide QRS, Bizarre
General appearance: Huge QRS with a peak on Left Side
Premature Ventriclar Contractions
Rate
Rhythm
Pacemaker site
P wave
PRI
QRS
General appearance
Rate Underlying rhythm
Rhythm Interupts regular underlying rhythm
Pacemaker site Ventricle
P wave None
PRI None
QRS >0.12,
General appearance: Wide QRS complexes, Irregularly spaced
V Tach
Rate
Rhythm
Pacemaker site
P waves
PRI
QRS
General appearance
Rate 100 - 250
Rhythm Usually regular
Pacemaker site Ventricle
P waves Usually absent, if present not associated with QRS
PRI None
QRS >0.12 Wide, Bizarre
General appearance Tombstone
V Fib
Rate
Rhythm
Pacemaker site
P waves
PRI
QRS
General appearance
Rate no organized Rhythm
Rhythm no organized Rhythm
Pacemaker site Numerous ventricular foci
P waves Usually absent
PRI NONE
QRS NONE
General appearance: Squiggly lines No P waves nor QRS
Asynchronous countershock depolarizes myocardium to allow ____ to regain control
Defibrillation
SA node
Pacemakers can be
Temporary
Transcutaneous
External
Epicardial
or
Permanent
Ventricular
Atrial- Ventricular
Biventricular
S-ICD
Precautions…. (4)
Incision care
Restricted arm motion for 1 - 2 months (Lead Displacement- hematoma)
Avoid electromagnetic fields
Regular follow up
1st degree block
Rate
Rhythm
Pacemaker site
P waves
PRI
QRS
General appearance
Rate Depends on underlying rhythm
Rhythm Usually regular
Pacemaker site SA node or Atrial
P waves Normal
PRI >0.20 sec
QRS Normal
General appearance. Regular rhythm but the PRI is consistently longer than 0.20
2nd degree type 1 AV block Winkebach
Rate
Rhythm
Pacemaker site
P waves
PRI
QRS
General appearance
Rate: Atrial Normal, Ventriclar Normal to Slow
Rhythm Atrial Regular Ventriclar Irregular
Pacemaker site SA node or Atrial
P waves Normal, sone P waves will not be followed by QRS complex
PRI Increases in length until a QRS is dropped
QRS Normal
General appearance Increasing PRI until a QRS is dropped
Type 2 second degee AV block
Rate
Rhythm
Pacemaker site
P waves
PRI
QRS
General appearance
Rate Atrial normal Ventriclar maybe slow
Rhythm maybe regular or irregular
Pacemaker site SA node or Atrial
P waves Normal some P waves not followed by QRS
PRI Constant >0.20
QRS Normal
General appearance. Constant >0.20 PRI with dropped QRS complexes
3rd Degree AV block
Rate
Rhythm
Pacemaker site
P waves
PRI
QRS
General appearance
Rate Atrial Normal Ventriclar 20-40-60
Rhythm Regular
Pacemaker site SA & AV node or Ventricle
P waves Normal with No Correlation to QRS
PRI No relationship to QRS
QRS >0.12
General appearance P & QRS are not dependent on eachother
________ life-threatening condition where fluid accumulates in the pericardial sac, exerting pressure on the heart and impairing its ability to fill and pump effectively.
Cardiac tamponade
How to treat Pulseless Electrical Activity…
Treat the cause.
Hypovolemia
Tension pneumothorax
Cardiac Tamponade
Hypoxia
SVT, 160 - 180 HR, 88/56 BP, SOB, Palpation, weakness
INITIAL REACTIONS…
Notify HCP - Hemodynamically unstable
Provide oxygen if <95%
Establish IV
Vagal maneuver
Adenosine (if ordered) 6 mg IV push 1 - 2 seconds, 20 mL saline flush. 2nd dose if ineffective
Prepare for synchronized Cardioversion
- consent
- Sedation- Versed
- Monitor patient response
Reassess
In which cases will the nurse give adenosine.
Severe Bronchospastic Disease: Asthma or COPD exacerbation risk.
Supraventricular Tachycardia (SVT): Narrow QRS tachycardia with a rate >150 bpm.
Regular, Stable Tachycardia: Symptomatic (e.g., palpitations, chest discomfort, SOB) and unresponsive to vagal maneuvers.
Second- or Third-Degree AV Block: Without a functioning pacemaker.
Sinus Node Dysfunction: Without a pacemaker.
Wide Complex Tachycardia (diagnostic): To distinguish SVT with aberrancy from ventricular tachycardia under physician direction.
Atrial Fibrillation/Flutter with Accessory Pathway (e.g., WPW syndrome): Risk of triggering ventricular fibrillation.
Supraventricular Tachycardia (SVT): Narrow QRS tachycardia with a rate >150 bpm.
Regular, Stable Tachycardia: Symptomatic (e.g., palpitations, chest discomfort, SOB) and unresponsive to vagal maneuvers.
Wide Complex Tachycardia (diagnostic): To distinguish SVT with aberrancy from ventricular tachycardia under physician direction.
When a Nurse Cannot Give Adenosine
Atrial Fibrillation/Flutter with Accessory Pathway (e.g., WPW syndrome): Risk of triggering ventricular fibrillation.
Second- or Third-Degree AV Block: Without a functioning pacemaker.
Sinus Node Dysfunction: Without a pacemaker.
Severe Bronchospastic Disease: Asthma or COPD exacerbation risk.
Which is the preferred treatment of reoccurring Symptomatic SVT
Diltiazem
CCB
When a coronary vessel is mostly originates completely occuleded, the cells that depend on the oxygen become Ischemic, then necrotic, and die.
This result is known as ….
MI
- Nitrates cause blood vessels to….
- Results in drop in PVR & BP and decreased venous return to the heart. These actions (Decrease / Increase ) myocardial workload and restore balamce to the heart’s Supply-and-demand ratio.
- Relax and dilate
- Decrease
Angina Pectoris occurs when…
SS….
Stable vs Unstable…
Myocardial oxygen demand cannot be meet
Pain, anxiety, SOB, Fatigue
Stable: Oxygen demand is meet when at rest.
Unstable: Oxygen demand may not be meet when at rest
Drug of choice for treating Acute Anginal Attack
Sublingual Nitroglycerin
Beta-Blockers work by…
Prevent activation of Sympathetic NS (which increases heart stuff)
Leading cause of death US & world wide
ASCVD
____ is the bais of our clot-dissolving system
Plasminogen
____ drugs are used to stop bleeding
Hemostatic
