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NURS362 - Practice of Nursing III > Week 10: Cardiac Rhythm Disorders > Flashcards

Week 10: Cardiac Rhythm Disorders Flashcards

1
Q

What are the 2 major phases of the cardiac cycle

A
  1. Contraciton (Depolarization)

2. Relaxation (repolarization)

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2
Q

Chronotrophy

A

Heart Rate

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3
Q

Ionotrophy

A

Contraction Force

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4
Q

Dromotrophy

A

Conduction Speed

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5
Q

Path of Cardiac Conduction

A

SA Node –> AV Node –> Bundle of His –> Right and Left Bundle Branch –> Purkinje Fibers

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6
Q

Depolarization

A

when Na moves into a cell and K moves out

activity causes electrical activity which causes cardiac muscle movement

as one cell depolarizes it makes the next do so as well and causes a chain reaction

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7
Q

Repolarization

A

occurs when the cell returns to its resting or baseline state

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8
Q

SA Node

A

Sinus Node / Sinoatrial Node

Main pacemaker of the heart

Stimulates 60-100 BPM through depolarization

Located high in the right atrium

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9
Q

What part of the heart conduction pathway can a right sided MI destroy

A

the SA node –> this leads to bradycardia and hypotension

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10
Q

Tx when a Right Sided MI occurs

A

IV fluids!!!

Nitroglycerin

Patient to cath lab

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11
Q

AV Node

A

atrioventricular Node

Gatekeeper of the heart

fires if the SA node rate is too low at an intrinsic rate of 40-60 BPM

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12
Q

What does the AV node allow for

A

it allows the atria to contaract and empty by slowing impulses from the SA node

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13
Q

Where is the AV node located

A

small group of cells in the lower right atrium

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14
Q

Bundle of HIS

A

short bundle of fibers at the bottom of teh AV node

they are specialized electrical cells that travel in the septum and spread to both sides of the heart in both ventricles

leads into the bundle branches

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15
Q

The Bundle Branches

A

Left and Right

Rapidly conduct impulses to the left and right ventricles after the Bundle of HIS

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16
Q

The Purkinje Fibers

A

Terminal point in the conduction system in the ventricles

they are hair like fibers spreading out from the bundle branches along the endocardial surface of the ventricles

rapidly conduct the impulse to the ventricular cells

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17
Q

The Purkinje Fibers are capable of causing impulses at ___-___ BPM

A

20-40

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18
Q

P Wave

A

a normally small smooth and rounded bump at the start of the impulse

indicated atrial contraction / atrial depolarization

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19
Q

PR Interval

A

Conduction from the atrium to Purkinje fibers depolarizing

Measured from start of P wave to the tip of the R

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20
Q

How long is the PRI usually

A

normally less than 1 large (or 5 small) blocks so less than 0.2 seconds

So usually 0.12-.20 seconds

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21
Q

Each small box on the EKG is ___ s

A

0.04 seconds

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22
Q

Each large box on the EKG is ___ s

A

0.2 seconds

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23
Q

5 of the large boxes (25 small boxes) on the EKG is ___ s

A

1 second

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24
Q

QRS Complex

A

Occurs with ventricular contraction/depolarization

Q is the first down, R is the first up, and S is the negative deflection after r

Usually less than 2.5 small boxes (0.1 s) –> 0.06-0.1 s

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25
Q

T Wave

A

Follows the QRS

Indicated ventricular repolarization

heart resting period

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26
Q

What wave indicates a vulnerable period of the heart where if there is an issue something lethal can occur

A

T Wave

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27
Q

Different deflections from baseline of the PQRS complex indicates..

A

different views or LEADS of hearts conduction patterns (lead 2-3 may look different)

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28
Q

When Assessing EKGs it is important to look at what 2 things

A
  1. Rhythm - regular/irregular - the origin of beat

2. Rate - number of ventricular contractions per minute

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29
Q

We should check the EKG first to see if there is a…

A

P wave

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30
Q

We can check rhythm by

A

measuring distance between P-P2 R-R2 waves and comparing peaks

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31
Q

What are the 3 methods of calculating rate off an EKG

A
  1. # Small boxes Between QRS Complexes / 1500
  2. # Large boxes between QRS complexes / 300
  3. 6 Second Method - number of peaks x 10
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32
Q

What are the things to ask when evaluating the P wave and PR Interval

A

Does the rhythm originate in the atrium

Are P waves regular

Are P waves followed by QRS

Is the Pr normal .12-.2 in length or is it longer than .2

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33
Q

What are the things to ask when evaluating QRS complex

A

Is it normal duration of .06-.1 or is it higher

Do the QRS complexes look the same - wide ones can indicate ventricular arrhythmias

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34
Q

What are the thigns to ask when evaluating ST Segments

A

Is T Wave height less than 1/2 the QRS height

Is ST elevation above or depression below isometric line - indicates ischemic changes or MI

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35
Q

Raised ST increases threshold which can…

A

cause a heart attack

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36
Q

What are some other unusual findings on EKGs to see

A

ST Depression

Q Waves - scar from MI

Ectopic Beats - originate from abnormal pathways

Abnormal Herat Rhythms

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37
Q

Sinus rhythm

A

normal rhythm

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38
Q

Premature Rhythm

A

complex earlier than expected

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39
Q

Compensatory rhythm

A

pause in the beat occurring after a premature beat

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40
Q

Junctional rhythm

A

at or below AV node, above ventricle

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41
Q

Normal Sinus Rhythm

A

Rate 60-100 BPM

Regular R to R Interval

Normal PR Interval

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42
Q

Sinus Bradycardia

A

Rate < 60 BPM

Regular R to R interval

Normal PR Interval

P Wave

Beats are initiated in SA node

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43
Q

Sinus Tachycardia

A

Rate >100 BPM

Regular R to R Interval

P Wave Present

Normal PR Interval

Beat Initiated in SA Node

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44
Q

Sinus Arrhythmia on EKG

A

Rate 60-100 BPM

IRREGULAR R-R INTEVAL

P wave present and Normal PRI

Beat initiated in SA Node

BPM increases with inhalation and decreases with exhalation!!!

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45
Q

Dysrhythmias

A

disorders of formation or conduction (or both) of electrical impulses within heart

potentially alters blood flow, causes hemodynamic changes

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46
Q

Dysrhythmias can cause disturbances of…

A

rate

rhythm

both rate and rhythm

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47
Q

Dysrhythmias are diagnosed by …

A

analysis of electrographic waveform

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48
Q

Dysrhythmias can be ___ or ___ in origin

A

supraventricular (above - SA/AV node)

Ventricular (bundle branches/perkinje)

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49
Q

What are the 3 most common Supraventricular Rhythms

A

Junctional Rhythms

A Fib

A Flutter

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50
Q

What are the 3 most common Ventricular Rhythms

A

PVC

VT

VF

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51
Q

What is more deadly supraventricular or ventricular rhythms?

A

Ventricular Rhythms

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52
Q

Premature Atrial Contraction (PAC)

A

Abnormal P Wave that comes early and fuses with T wave

There is then a pause after it occurs

Lots of people have this occur

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53
Q

What can cause PAC

A

caffeine

Nicotine

stress

ischemia (big problem)(

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54
Q

Atrial Fibrillation

A

Rate: 400-600 BPM atrial; Ventricular rate varies but can be high as 110-160

R to R is irregular

No P WAVES!!!

QRS appears normal usually

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55
Q

What is the most common rhythm seen next to normal sinus rhythm (NSR)

A

A fib

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56
Q

If A Fib has a rapid ventricular rate as well…

A

this may cause reduced cardiac output

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57
Q

A Fib may lead to …

A

Mural Thrombi

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58
Q

In A Fib what is lost and can lead to heart failure

A

atrial kick

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59
Q

Tx for A Fib

A

Watch for CO (BP, UO, LOC, Color)

Meds - variety used to control rate or restore normal rhythm (digozin, verapamil, beta blockers)

ASA - anticoagulants

Watchman

Cardioversion or pacemaker may be necessary if unstable

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60
Q

Watchman

A

Device that is like a coffee filter surgically implanted into the inferior vena cava/major vessel/vessel that catches the clots if you were prone to clots

61
Q

Atrial Flutter

A

Regular R-R Rhythm!!!

Similar to A Fib but has no P Waves - rate is still high (fast though)

Saw Tooth Pattern P Waves

Atrial rate usually 200-300 and ventricular rate usually normal

62
Q

In A Flutter the patient shows s/s of

A

Decreased CO

63
Q

What may form in A Flutter

A

Mural Thrombi

64
Q

Persistent atrial flutter converts…

A

to sinus rhythm or atrial fib by itself or in response to meds

65
Q

What is A Flutter treatment like

A

A Fib Treatment

66
Q

Junctional Rhythms

A

Rate 40-60
R-R Regular
No P Wave or Inverted P Wave

Occurs above ventricle and at the AV node or Bundle of HIS

67
Q

What is Junctional Rhythm like

A

treat underlying causes: pacemaker, drug toxicity

tx s/s!

68
Q

Where is the junctional rhythm issue occurring?

A

Below SA Node but above the ventricle

69
Q

PVC (Premature Ventricular Complexes)

A

Normal QRS, Flipped T Wave - looks like wide bizarre QRS complexes that come in early and have a pause after

70
Q

What may cause PVCs to happen

A

Premature Depolarization in Ventricular Myocardium:

Hypoxia
Myocardial Ischemia
Hypokalemia
Acidosis
Exercise
Increased Digoxin Level
Increase with Aging
More common with CHD

Not dangerou w/ normal hearts; higher mortality with heart disease

71
Q

PVCs may indicate what serious problems occurring

A

MI

Digoxin Toxicity

Hypoxia

Electrolyte Imbalance (Potassium)

Associated with Acute MI

72
Q

PVC are dangerous when…

A
  1. more than 6 per minute
  2. its near a T wave
  3. In couplets or triplets or more in a row
  4. Multifocal
  5. when associated with acute MI
73
Q

Treatments for PVC

A

Acute - IV Lidocaine

Treat Cause: Hypokalemia

Other agents for long term control ex: Cortisol - amiodarone (push slow)

If ischemic problem - nitrates (vasodilates) and O2

74
Q

Bigeminy

A

normal sinus beat interspersed with PVC

75
Q

Trigeminy

A

2 sinus beats interpersed with PVC

76
Q

Causes of Bigeminy/Trigeminy

A

MI, CHF, Digoxin Toxicity

77
Q

Treatments for Bigeminy and Trigeminy PVC

A

Long term problems: Antiarrhythmics, Procan SR, Pronestyl

78
Q

V-Tach

A

Ventricular Tachycardia

No P Waves

Wide Bizarre QRS Complex - VTach Mountains

Ventricular Rate of 150-200+ BPM

rhythm - Regular

79
Q

How lethal is V Tach

A

can be very lethal - pulseless V Tach even needs defibrillation or CPR as it means no perfusion (its just electrical activity)

80
Q

What is the first thing to do when a patient enters V Tach

A

check patient and talk to them and feel for a pulse

81
Q

Causes for V Tach

A

similar to PVCs but this is considered more dangerous because of decreased cardiac output and its ability to degenrate further

82
Q

What is V Tach called based on if its 30 seconds or longer

A

If less than 30 seconds = Nonsustained VT

If more than 30 sec = Sustained VT

83
Q

V Tach is a precursor to…

A

ventricular fibrillation

84
Q

What can occur with V Tach for the patient

A

inadequate perfusion leading to loss of consciousness

85
Q

V Tach Treatment

A

IV lidocaine or amiodarone

Cardioversion (Sync Shock)

Treat Underlying Cause: MI, K Imbalance, Chornic - may need implantable defibrillator

86
Q

What can be assumed is low if K is low

87
Q

Ventricular Fibrillation

A

No P Waves, No QRS Complex, Rhythm is Irregular and Chaotic, rate is rapid and uncoordinated and ineffecteive

No CO = No pulse

Fatal if not treated

88
Q

During V Fib what will be absent

A

A pulse is definitely absent

89
Q

V Fib is ___ if not treated

90
Q

V Fib is a cause of…

A

sudden cardiac death

91
Q

Treatment of V Fib

A

Defibrillation (Immediate!) and or CPR!!!!!!!!

Use ACLS protocols for defibrillation

Antiarrhythmic drugs may be used as well

92
Q

Cardioversion and Defibrillation

A

treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial cells - when cells repolarize, sinus node usually able to recapture role as heart pacemaker

93
Q

What happens in Cardioversion

A

current delivery synchronized with the patients ECG

94
Q

What happens in defibrillation

A

current delivery is not synchornized with the patient EKG

you often have to do this first when you cannot sync and then do cardioversion after

95
Q

Safety Measures for Cardioversion and Defibrillation

A

Assure good contact between skin, pads, or paddles

PLace paddles so they do not touch bedding or clothing and are not near mediation patches or o2 flow

If cardioverting turn sync on

if defibrillating turn sync off

no wet or metal surface

dont touch patient when attached

96
Q

A user of Defibrillation must be ___ ____

A

ACLS trained

97
Q

What has to be used when a user is not ACLS certified

A

AED - Automatic Defibrillation

98
Q

Asystole

A

No rate
No Rhythm
P waves can be present if SA or AV is fxning
QRS Complex gone

No CO, Pulse, very poor prognosis

NEEDS IMMEDIANT TREATMENT

Check pt first then monitor

No pulse here

99
Q

When do you shock in asystole

A

never - thats only done in movies

theres nothign to shock

100
Q

Tx for Aystole

A

Must be Immediate:

EP
Atropine
Pacemaker (External, Temp internal, CPR (do this first))

101
Q

Pacemaker

A

electronic device that provides electrical stimuli to heart muscle

102
Q

Types of Pacemakers

A

Permanent

Temporary

103
Q

What situations indicate Pacemakers

A

sick sinus syndrome

heart blocks

post op cardiac surgery

post MI with heart block

104
Q

Heart Block

A

dissociation between SA node to AV to bundle branches

communication between top or bottom of the heart

105
Q

What shows a pacemaker is in use on the EKG

A

a pacemaker spike before the QRS (and a slightly wider QRS)

106
Q

ICD Implantable Defibrillators

A

Senses and converts V Tach and V Fib

Similar to a pacemaker with similar teaching

Medic alert bracelet

Battery check every 6 months

typically sits on left side

107
Q

Complications of Pacemaker/Defibrillator Use

A

infection

bleeding or hematoma formation

dislocation of lead

skeletal muscle or phrenic nerve stimulation

cardiac tamponade

malfunction of pacemaker/defibrillator

108
Q

Cardiac Tamponade

A

Bleeding into the pericardial sac leading to tamponade which restricts the heart and can lead to cardiogenic shock

109
Q

Nursing Interventions for pts with Pacemakers

A

Monitor cardiac rhythm - sensing and capturing

Note pacemaker rate, MA (milliamps), and Mode

Patient response to pacing

110
Q

Care of the patient with an ICD - assessment

A

device function : ECG

cardiac output

hemodynamic stability

incision site

coping

patient and family knowledge

PAIN

111
Q

Patient teaching on Pacers and Defibrillators should involve

A

regular pacemaker monitoring

taking heart rate

avoiding magnets like in an MRI

wearing medi bracelet or having the card

112
Q

Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias

A

Electrophysiologic Studies (EPS)

Cariac Conduction Surgery: Maze Procedure or Catheter Ablation Therapy

113
Q

Ablation

A

An a fib treatment

burning off or ablating the area causing the A Fib

114
Q

Potential s/s of Cardiovascular Problems

A

Fatigue

Fluid Retention

Irregular Heartbeat

Dyspnea

Pain

Syncope or Near Syncope

Leg Pain

115
Q

What is included in a cardiac health assessment

A 
medication
nutrition
elmiination
activity and exercise
sleep adn rest
self perception and self concept
roles and relationships
sexuality and reproduction
coping and stress tolerance
prevention strategies
116
Q

Important Risk Factors for CV Disease

A

elevated serum lipid

HTN

tobacco use (Smoking and chewing)

sedentary lifestyle

obesity DM II

stressful lifestyle

117
Q

Why do we keep an arm at the level of the heart during BP

A

if elevated it lowers pressure

if dependent it raises pressure

118
Q

Pulse Pressure

A

Systolic - Diastolic

Not significant alone but in the wider picture it is

usually 30-40 mmHg

Drop can indicate heart failure, shock, hypovolemia

Increase seen with increased stroke volume likeatherosclerosis anemia hyperthyroid or pregnancy

119
Q

Normal Response to Postural BP

A

transient increase of 5-20 BPM

drop in systolic of <10 mmHg

AND

increase in diastolic of 5 mmHg

120
Q

Orthostatic or Postural hypotension can be accompanied by

A

dizziness
lightheadedness
syncope

121
Q

3 most common causes of postural hypotension

A

intravascular volume depletion

inadequate vasoconstrictor mechanisms

autonomic insufficiency

122
Q

When does Orthostatic BP (orthostasis) occur

A

when there is a drop in systolic of 20 mmHg or more, a drop in diastolic of at least 10 mmHg and a pulse rise greater than or equal to 20 bpm

123
Q

Is posutral BP change from lying to sitting food enough for orthostasis diagnosis?

A

no but it can be a screening test

124
Q

Allen Test

A

occlusion of radial and ulnar pulse test

125
Q

Amplitude Scale

A

Absent = 0 = Need doppler

Diminished = +1

Normal = +2

Mod Increased = +3

Markedly Increased = +4

126
Q

Other than pulses what other pulse should we check

A

the abdomen aorta for aneurysms

127
Q

Pulsus Alterans

A

regular alteration of weak and strong beats w.o changes in cycle length

from heart failure or pericardial effusion

128
Q

Bruits

A

a blowing sound that occurs with turbulent blood flow - suggests partial obstruction to blood flow

a palpable thrill

arteries are normally silent is why this is bad

129
Q

Jugular Venous Pulse

A

can give information about right hear hemodynamics

while in semi fowlers you observe pulsations of right internal jugular vein and the measure of cm above sternal angle - if above 3 cm thats abnormal

may indicate heart failure or fluid overload

130
Q

Where are the Aortic, Pulmonic, Tricuspid, and Mitral areas

A

Aortic - 2nd ICS on RSB

Pulmonic - 2nd ICS on LSB

Tricuspid - 4th ICS on LSB

Mitral - 5th ICS on LSB

131
Q

Stethoscope diaphragm for ___ pitch sounds like ___ and ____

A

high; S1 and S2

132
Q

Stethoscope bell for ___ pitched sounds like ___ and ___ and ____

A

low; S3 S4 murmurs

133
Q

S1

A

first heart sound

closure of mitral and tricuspid valves

onset of systole

loudest at apex

134
Q

S2

A

second heart sound

closure of aortic and pulmonic valves

beginning of diastole

loudest over pulmonic area

135
Q

S3

A

third heart sound

physiologically normal in children, fit athletes and well exercised

pathologic in new onset or found after age 40

sounds like Lub Dup Ta

Gallop Rhythm / Sloshing In

136
Q

S4

A

least common fourth heart sound

HTN and stiff walls from cardiovascular damage causes this

Ta Lub Dup - precedes S1

Best heart with bell like S3

Can mean aortic stenosis scarring or HTN

137
Q

Murmurs

A

Are sound produced by abnormal turbulance:

bruit within a vessel

murmur across a valve

location of murmur tells what valve is troubles

can sound like whoosh, click, mechanical

138
Q

Murmurs are classified by…

A

timing in cardiac cycle

pitch (low medium high)

location - apex, sternum

quality - soft blowing harsh mechanical

duration - throughout cycle or at the beginning

intensity - scale of I to VI

139
Q

If a murmur is heard at apex between S1 and S2 then it is a ___ murmur and PROBABLY is ____

A

systolic; mitral valve

140
Q

Cardiac Markers

A

CPK - creatine kinase

CRP

Troponin T and I

Homocysteine

141
Q

What level should HDL be

142
Q

What does LDL <160, 130, and 100 mean

A

<160 - primary prevention, 1 or no risk factors

<130 primary prevention, 2 or more risk factors

<100 secondary prevention, person with known CAD

143
Q

Medications for cholesterol are only used for…

A

high levels of LDL cholesterol

144
Q

A client with angina asks the nurse “What information does the EKG
provide?” The nurse would respond that the EKG primarily gives information
about the:

  1. Electrical conduction of the myocardium.
  2. Oxygenation and perfusion of the heart
  3. Contractile status of the ventricles
  4. Physical integrity of the heart muscle.
A
  1. electrical conduction of the myocardium
145
Q 
Which of the following are tests used to specifically evaluate the
function of the heart? (Select all that apply)
1. EEG
2. TEE
3. BUN
4. CK-MM fractions
5. Holter monitor
6. Cardiac catheterization
A
  1. TEE
  2. Holter Monitor
  3. Cardiac Catheterization
146
Q 
When discussing the patient's
elevated LDL and lowered HDL
levels, the patient shows an
understanding of the significance
of these levels by the statement:
A. “Increased LDL and decreased HDL
increase my risk of coronary artery
disease.”
B. “Increased LDL and decreased HDL
decrease my risk of coronary artery
disease.”
C. “The decreased HDL level will increase
the amount of cholesterol moved away
from the artery walls.”
D. “The increased LDL will decrease the
amount of cholesterol deposited on the
artery walls.”
A

A. Increased LDL adn decreased HDL increase my risk of CAD

147
Q

In preparation for a transesophageal
echocardiography, the nurse must:
A. Have the patient drink 1 liter of water
before the test.
B. Heavily sedate the patient.
C. Inform patient that blood pressure (BP)
and electrocardiogram (ECG) will be
monitored throughout the test.
D. Inform the patient that an access line
will be initiated in the femoral artery.

A

C. Inform patient that blood pressure (BP)
and electrocardiogram (ECG) will be
monitored throughout the test.

148
Q 
Which of the following indicates a
positive result of an exercise stress
test?
A. Chest pain
B. Drop in BP and pulse
C. Target heart rate reached
D. ST segment depression
A

A. Chest Pain

149
Q

In teaching the client to avoid orthostatic
hypotension, the nurse should emphasize
which of the following instructions? (select all
that apply).
1. Plan regular times for taking medications
2. Arise slowly from bed
3. Avoid standing still for long periods
4. Avoid excessive alcohol intake
5. Avoid Hot baths

A
  1. Arise slowly from bed

3. Avoid standing still for long periods

NURS362 - Practice of Nursing III (13 decks)

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