Week 3 - EKG Flashcards
ECG placement mnemonic
White on the right
clouds over grass
smoke over fire
I <3 chocolate
P wave - ___________ of atria in response to SA node triggering
depolarization
T wave - _________ ___________
ventricular repolorization
ST segment - beginning of ventricular repolarization - should be _____
flat
QRS complex - ____________ of ventricles, triggering main pumping contractions
depolarization
PR interval - delay of AV node to allow ___________
filling of ventricles
1st degree heart block - _______________________
prolonged PR interval - >0.20s
V-Fib - pulseless rhythm - immediate ______
CPR
V-Tach - With or w/o pulse. First thing to do is _____________
check pt’s pulse!
A-Flutter - ________ pattern
sawtooth
Chest tube complications
___________: Usually minor, but may require surgery if extensive
___________: Likelihood increases the longer the chest tube is in place
Subcutaneous ___________: Characterized by swelling in face, neck, and chest; crackles on palpation
Bleeding: Usually minor, but may require surgery if extensive
Infection: Likelihood increases the longer the chest tube is in place
Subcutaneous emphysema: Characterized by swelling in face, neck, and chest; crackles on palpation
Chest tubes - Nursing Considerations
Monitor vital signs
Assess breath sounds bilaterally (check for SQ emphysema, crepitus)
Assess the insertion site
Encourage the patient to TCDB
Make sure connections are taped securely
Keep collection apparatus below the level of the patient’s chest; don’t allow tubing to touch floor
Monitor vital signs
Assess breath sounds bilaterally (check for SQ emphysema, crepitus)
Assess the insertion site
Encourage the patient to TCDB
Make sure connections are taped securely
Keep collection apparatus below the level of the patient’s chest; don’t allow tubing to touch floor
Chest tube - more Nursing Considerations
Check suction control and water seal chambers frequently
Assess drainage for color, amount
Measure drainage every 8 hours or more often depending on patient’s condition
Document assessment
Report: drainage greater than 200 mL in the first hour, development of subcutaneous emphysema, or any signs and symptoms of respiratory distress
Check suction control and water seal chambers frequently
Assess drainage for color, amount
Measure drainage every 8 hours or more often depending on patient’s condition
Document assessment
Report: drainage greater than 200 mL in the first hour, development of subcutaneous emphysema, or any signs and symptoms of respiratory distress
Can remove chest tube when:
*There’s little to no drainage
*Air leak is gone
*Patient is breathing normally without respiratory distress
*Fluctuations in water seal chamber stopped
*Chest X-ray shows lung re-expansion with no residual air or fluid
*There’s little to no drainage
*Air leak is gone
*Patient is breathing normally without respiratory distress
*Fluctuations in water seal chamber stopped
*Chest X-ray shows lung re-expansion with no residual air or fluid
What should the nurse measure to determine whether there is a delay in impulse conduction through the patient’s ventricles?
A. P wave
B. Q wave
C. PR interval
D. QRS complex
D. QRS complex
The QRS complex represents ventricular depolarization. The P wave represents the
depolarization of the atria. The PR interval represents depolarization of the atria,
atrioventricular node, bundle of His, bundle branches, and the Purkinje fibers. The Q wave is the first negative deflection following the P wave and should be narrow and short.
The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, PR interval not measurable, ventricular rate of 162, R-R interval regular, QRS complex wide and distorted, and QRS duration of 0.18 second. How should the nurse interpret this cardiac rhythm?
A. Atrial flutter
B. Sinus tachycardia
C. Ventricular fibrillation
D. Ventricular tachycardia
D. Ventricular tachycardia
The absence of P waves, wide QRS, rate greater than 150 beats/min, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration
A patient has a sinus rhythm and a heart rate of 72 beats/min. The nurse determines that the PR interval is 0.24 seconds. What action should the nurse take?
A. Notify the health care provider immediately.
B. Document the finding and monitor the patient.
C. Give atropine per agency dysrhythmia protocol.
D. Prepare the patient for temporary pacemaker insertion.
B. Document the finding and monitor the patient.
First-degree atrioventricular block is asymptomatic and requires ongoing monitoring
because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary.
A patient who was admitted with a myocardial infarction has a 45-second episode of
ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/min. Which action should the nurse take next?
A. Immediately notify the health care provider.
B. Document the rhythm and continue to monitor the patient.
C. Prepare for synchronized cardioversion per agency protocol.
D. Prepare to give IV amiodarone per agency dysrhythmia protocol.
D. Prepare to give IV amiodarone per agency dysrhythmia protocol.
The burst of sustained ventricular tachycardia indicates that the patient has significant
ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Cardioversion is not indicated given that the patient has returned to a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation.
20-yr-old patient has a mandatory electrocardiogram (ECG) before participating on a
college soccer team. The patient is found to have sinus bradycardia, rate 52 and blood pressure (BP) 114/54 mm Hg. The student denies any health problems. What action by the nurse is appropriate?
A. Allow the student to participate on the soccer team.
B. Refer the student to a cardiologist for further testing.
C. Tell the student to stop playing immediately if any dyspnea occurs.
D. Obtain more detailed information about the student’s family health history
A. Allow the student to participate on the soccer team.
In an aerobically trained individual, sinus bradycardia is normal. The student’s normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family’s health history. Dyspnea during an aerobic activity such as soccer is normal
Which finding from a newly admitted adult patient’s electrocardiogram (ECG) requires further investigation by the nurse?
A. Isoelectric ST segment
B. PR interval of 0.18 second
C. QT interval of 0.38 second
D. QRS interval of 0.14 second
D. QRS interval of 0.14 second
Because the normal QRS interval is less than 0.12 seconds, the patient’s QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The PR interval and QT interval are within normal range and ST segment should be isoelectric (flat).
Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?
A. Blood glucose of 243 mg/dL
B. Serum chloride of 92 mEq/L
C. Serum sodium of 134 mEq/L
D. Serum potassium of 2.9 mEq/L
D. Serum potassium of 2.9 mEq/L
Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular
tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values are also abnormal, they are not likely to be the cause of the patient’s PVCs and do not require immediate correction.
A patient is apneic and has no palpable pulses. The heart monitor shows sinus tachycardia, rate 132. What action should the nurse take next?\
A. Perform synchronized cardioversion.
B. Start cardiopulmonary resuscitation (CPR).
C. Give atropine per agency dysrhythmia protocol.
D. Apply supplemental O2 via non-rebreather mask.
B. Start cardiopulmonary resuscitation (CPR).
The patient’s manifestations indicate pulseless electrical activity, and the nurse should
immediately start CPR. The other actions would not be of benefit to this patient.
FUNCTIONAL PROPERTIES OF CARDIAC CELLS
- Automaticity – spontaneous depolarization (electrical)
- Excitability – ability to be stimulated or respond to an electrical impulse (electrical)
- Conductivity – ability to transmit an electrical impulse to adjoining cells (electrical)
- Contractility - ability of cardiac muscle cells to contract in response to an electrical stimulus (mechanical)
- Automaticity – spontaneous depolarization (electrical)
- Excitability – ability to be stimulated or respond to an electrical impulse (electrical)
- Conductivity – ability to transmit an electrical impulse to adjoining cells (electrical)
- Contractility - ability of cardiac muscle cells to contract in response to an electrical stimulus (mechanical)
FUNCTIONAL PROPERTIES OF CARDIAC CELLS
- Refractoriness – time when cardiac cells cannot respond to a stimulus.
- Depolarization – electrical excitation of the cell membrane, normally followed my mechanical contraction
- Repolarization – return of cell membrane to its resting state, normally followed by mechanical relaxation.
- Refractoriness – time when cardiac cells cannot respond to a stimulus.
- Depolarization – electrical excitation of the cell membrane, normally followed my mechanical contraction
- Repolarization – return of cell membrane to its resting state, normally followed by mechanical relaxation.
SA node rate
60 - 100 bpm
AV junction rate
40 - 60 bpm
ventricles rate
20 - 40 bpm
Waveforms of ECG represent the _____________ produced by the movement of charged ions across membranes of heart cells
Waveforms of ECG represent the electrical activity produced by the movement of charged ions across membranes of heart cells
TELEMETRY MONITORING
Observation of pt’s HR and rhythm
Helps identifies dysrhythmias, ischemia or infarction.
Observation of pt’s HR and rhythm
Helps identifies dysrhythmias, ischemia or infarction.
A patient in the coronary care unit develops ventricular fibrillation. The first action the nurse should take is to:
a. perform defibrillation.
b. initiate cardiopulmonary resuscitation.
c. prepare for synchronized cardioversion.
d. administer IV antidysrhythmic drugs per protocol.
b. initiate cardiopulmonary resuscitation.
Normal PR interval
0.12 - 0.20 sec
Normal QRS duration
0.08 - 0.10 sec
Normal QT interval
0.4 - 0.43 sec
Normal R-R interval
0.6 - 1 sec
Identify
A-FIB
identify
A-Flutter
identify
1st Degree Heart Block
identify
V-Fib - pulseless- start CPT
identify
V-Tach
What happens at the QRS complex.
the heart’s electrical signal spreads through the ventricles, causing them to depolarize and contract
Know how to count the PR interval and what the normal range is.
Unless using an monitor, your measurements may vary by 0.01-0.05
To count the PR interval:
Find the start of the P wave (where it begins to rise).
Locate the start of the QRS complex (usually the start of the downward Q wave or the upward R wave).
Count the small boxes between these two points on the ECG.
Multiply the number of small boxes by 0.04 seconds (each small box represents 0.04 seconds on a standard 25 mm/s ECG).
Normal PR interval range:
0.12–0.20 seconds (3–5 small boxes).
If using a monitor, slight variation by 0.01–0.05 seconds is acceptable due to differences in measurements.
PVCs
What are they and what do they look like. What do you do.
What are they? Early beats from the ventricles disrupting normal rhythm.
What do they look like?
Wide, bizarre QRS (>0.12 sec).
No P wave before PVC.
Compensatory pause after the PVC.
tX: β-blockers, treat causes, lidocaine, or amiodarone.
Know rates and rhythms for SR, SB, and ST
Sinus Rhythm (SR):
Rate: 60-100 beats per minute (bpm)
Rhythm: Regular
P waves: Present, uniform, and one P wave for every QRS complex
PR Interval: 0.12-0.20 seconds
QRS Complex: Normal, 0.06-0.10 seconds
Sinus Bradycardia (SB):
Rate: <60 bpm
Rhythm: Regular
P waves: Present, uniform, and one P wave for every QRS complex
PR Interval: 0.12-0.20 seconds
QRS Complex: Normal, 0.06-0.10 seconds
Sinus Tachycardia (ST):
Rate: >100 bpm
Rhythm: Regular
P waves: Present, uniform, and one P wave for every QRS complex
PR Interval: 0.12-0.20 seconds
QRS Complex: Normal, 0.06-0.10 seconds
What happens during 1st degree heart block
-The heart’s wiring is slow to send electrical signals.
-All of the signals pass through the heart successfully. There is no actual blockage. But the signal from the atria to the ventricles is slowed or delayed.
A-fib/A-flutter rhythms and interventions
β-blockers, cc blockers,
amiodarone, cardioversion,
coumadin, ablation
At what point is synchronized cardioversion warranted.
sinus tachycardia
SUPRAVENTRICULA
R TACHYCARDIA
(SVT)
A-Fib / A-flutter
V-Tach rhythm and interventions
Rhythm: Regular or Irregular
Tx: treat the cause, ACLS
V-Fib rhythm and interventions
irregular, chaotic
immediate CPR
5 Steps of ECG Analysis
- Determine regularity
- R-R consistency, p-wave for every qrs?
- Calculate HR
- Number of R waves in specific timeframe
- Examine PQRST waves
- Uniform? Consistent? Present/Absent?
- Measure intervals
- PR normal: 0.12-0.20 s
- QRS normal: 0.04-0.10 s
- Identify rhythm
- Put the pieces together
- Determine regularity
- R-R consistency, p-wave for every qrs?
- Calculate HR
- Number of R waves in specific timeframe
- Examine PQRST waves
- Uniform? Consistent? Present/Absent?
- Measure intervals
- PR normal: 0.12-0.20 s
- QRS normal: 0.04-0.10 s
- Identify rhythm
- Put the pieces together
Things to Know (Box Counting)
- One large square = __ small boxes (5 mm) = 0.20 s
- 1 small box = 1 mm
- 1 small box = 0.04 seconds
- 30 large squares = 150 small boxes = __ seconds
- We review 6 second strips
- One large square = 5 small boxes (5 mm) = 0.20 s
- 1 small box = 1 mm
- 1 small box = 0.04 seconds
- 30 large squares = 150 small boxes = 6 seconds
- We review 6 second strips
Normal Sinus Rhythm (NSR)
Rhythm: _________
Rate: _________ bpm
P-waves: ______ (present for each beat)
PR interval: _________
QRS complex: _________
Treatment: _________
Rhythm: regular
Rate: 60-100 bpm
P-waves: sinus (present for each beat)
PR interval: 0.12-0.20
QRS complex: 0.04-0.10
Treatment: N/A
Sinus Bradycardia
Rhythm: Regular
Rate: <___ bpm
P-waves: _______ (present for each beat)
PR interval: _______ (0.12-0.20 s)
QRS: _______ (0.04-0.10 s)
Treatment: ________________
Rhythm: Regular
Rate: <60 bpm
P-waves: sinus (present for each beat)
PR interval: normal (0.12-0.20 s)
QRS: normal (0.04-0.10 s)
Treatment: atropine, pacemaker
Sinus Tachycardia
Rhythm: __________
Rate: >_____ bpm
P-waves: ______ (present for each beat)
PR interval: __________(0.12-0.20 s)
QRS: __________ (0.04-0.10 s)
Treatment: _____ blockers, CCB, pain meds, antipyretics, rest/stop exercise
Rhythm: Regular
Rate: >100 bpm
P-waves: sinus (present for each beat)
PR interval: normal (0.12-0.20 s)
QRS: normal (0.04-0.10 s)
Treatment: beta blockers, CCB, pain meds, antipyretics, rest/stop exercise
Atrial Flutter
Rhythm: Usually ________
Rate: atrial (____ but regular) and ventricular (variable)
P-waves: _____, replaced by flutter waves
PR interval: not measurable
QRS: normal (0.04-0.10 s)
QT also not measurable
Treatment: calcium channel blockers, beta blockers, digoxin,
amiodarone, synchronized cardioversion, anti-coagulants
Rhythm: Usually regular
Rate: atrial (fast but regular) and ventricular (variable)
P-waves: absent, replaced by flutter waves
PR interval: not measurable
QRS: normal (0.04-0.10 s)
QT also not measurable
Treatment: calcium channel blockers, beta blockers, digoxin,
amiodarone, synchronized cardioversion, anti-coagulants
Atrial Fibrillation
Rhythm: ________
Rate: atrial (too _____ to measure) and ventricular (irregular)
P-waves: absent, replaced by fibrillary waves
PR interval: not measurable
QRS: normal (0.04-0.10 s)
Treatment (if symptomatic): synchronized __________, diltiazem, adenosine, amiodarone, anticoagulants
Rhythm: Irregular
Rate: atrial (too fast to measure) and ventricular (irregular)
P-waves: absent, replaced by fibrillary waves
PR interval: not measurable
QRS: normal (0.04-0.10 s)
Treatment (if symptomatic): synchronized cardioversion, diltiazem, adenosine, amiodarone, anticoagulants
Premature Ventricular Contractions (PVCs)
Rhythm: irregular due to _______ beats; underlying rhythm may be regular or irregular
Rate: variable
P-waves: not present
PR interval: not measurable
QRS: wide >0.12s, ______
Treatment: treat underlying cause, amiodarone
Rhythm: irregular due to early beats; underlying rhythm may be regular or irregular
Rate: variable
P-waves: not present
PR interval: not measurable
QRS: wide >0.12s, bizarre
Treatment: treat underlying cause, amiodarone
Ventricular Tachycardia (V-Tach)
Rhythm: regular, sometimes slightly irregular
Rate: > 100 bpm (up to ____)
P-waves: not present
PR interval: not measurable
QRS: _____ and bizarre
Treatment: If have pulse (Stable)–> synchronized ___________ + O2
No pulse (Unstable) –> ____+ defib + drugs: epi, lidocaine, amiodarone
*More than 3-5 PVCs in a row = V-Tach
Rhythm: regular, sometimes slightly irregular
Rate: > 100 bpm (up to 250)
P-waves: not present
PR interval: not measurable
QRS: wide and bizarre
Treatment: If have pulse (Stable)–> synchronized cardioversion+ O2
No pulse (Unstable) –> CPR + defib + drugs: epi, lidocaine, amiodarone
*More than 3-5 PVCs in a row = V-Tach
Ventricular Fibrillation (V-Fib)
Rhythm: _________ and irregular
Rate: not measurable
P-waves: not seen
PR interval: not measurable
QRS: not seen
Treatment: __________!
CPR + defibrillation + drugs: epi, lidocaine, amiodarone
Rhythm: Chaotic and irregular
Rate: not measurable
P-waves: not seen
PR interval: not measurable
QRS: not seen
Treatment: EMERGENCY!
CPR + defibrillation + drugs: epi, lidocaine, amiodarone
Asystole (ventricular stand still)
Rhythm: may or may not be regular as organized electrical activity is absent
Rate: atrial rate is possibly normal, ventricular rate is ______
P-waves: possibly present
PR interval: not measurable
QRS: not present
Treatment: ____ & drugs
Do not shock asystole
Rhythm: may or may not be regular as organized electrical activity is absent
Rate: atrial rate is possibly normal, ventricular rate is absent
P-waves: possibly present
PR interval: not measurable
QRS: not present
Treatment: CPR & drugs
Do not shock asystole
Pulseless Electrical Activity (PEA)
No pulse but yes electrical activity
ID the ______ to reverse the problem
_____ + Drugs
No pulse but yes electrical activity
ID the cause to reverse the problem
CPR + Drugs
First Degree AV Block
Delay rather than block
Rhythm: regular
Rate: normal or slow
P-waves: present and normal
PR interval: _________ but consistent (>0.20 s)
QRS: normal (0.04-0.10 s)
Treatment: symptom-based
Delay rather than block
Rhythm: regular
Rate: normal or slow
P-waves: present and normal
PR interval: prolonged but consistent (>0.20 s)
QRS: normal (0.04-0.10 s)
Treatment: symptom-based
Defibrillation is the preferred treatment for
V-fib
Pulseless V-Tach
