Week Four Modules Flashcards
why would you perform an EKG on a patient pre-operatively?
if there is a rhythm change in the patient or if the patient is having chest pain
a normal electrical impulse begins in the _____ which is located in the _____ near the entrance of the vena cava
sinoatrial (SA) node; upper right atrium
the SA node is known as the ______ of the heart
pacemaker
what is happening during the “P-Wave”? of an ECG?
atrial depolarization (the two atria are contracting)
the ___ is the second pacemaker of the heart and can initiate a _____ if the SA node does not fire
atrioventricular (AV) node; heartbeat
the _____ transmit an electrical impulse to the ventricles causing them to ____ which is known as the ______
purkinje fibers; contract; QRS complex
p wave = _____
p-r interval = ______
qrs complex = ______
atrial depolarization;
represents the movement of the impulse through the atria, AV node, and bundle of His/Purkinje fibers
represents ventricular depolarization of both ventricles
st segment = _____
t wave = ______
qt interval = ______
represents time between ventricular depolarization and repolarization
represents time for ventricular repolarization
represents the time for the entire ventricular depolarization and repolarization
how long should the p-r interval last?
how long should the QRS complex last?
how long should the ST segment last?
.12-.20 seconds;
usually between .04-.06, but less than 0.12 seconds;
.12 seconds
how long does the T wave usually last?
.12 seconds
if the QRS complex is wide what might this suggest?
it’s important to remember that the ST segment should always be _____ (on the baseline)
right or left bundle branch block;
isoelectric
a prolonged QT interval could trigger a ________ also known as torsades de pointes
polymorphic ventricular tachycardia
what are the seven steps of rhythm analysis?
determine the rate; is the rhythm regular/irregular; analyze the p-waves; measure the PR interval; measure the QRS complex; measure the QT interval; then interpret the rhythm
how can you determine if the rate is regular/irregular in a ECG strip?
you can do this by counting the number of small boxes between the start of one R wave to the next R wave
for it to be considered “regular” the distance from one R wave to the other needs to be the same
what are the requirements for a patient who has a basic sinus rhythm?
hr is within normal limits, p wave is present, pr interval is within normal limits; qrs complex is within normal limits; and qt wave is within normal limits
what are the requirements that need to be met in order for the patient to have sinus bradycardia?
hr is <60 bpm, regular rhythm, p waves present, pr interval within normal limits, and qrs within normal limits
what are signs and symptoms of a patient who has bradycardia?
patient may have symptoms of inadequate perfusion like fatigue, dizziness, chest pain, hypotension, or syncope
something to remember is that some patients may have asymptomatic bradycardia if they are ____, who often “brady down” during sleep
trained athletes
bradycardia can also happen if the patient is taking a _____. if the patient is showing symptomatic signs of bradycardia due to the drug then their dosage may need to be ______
beta blocker; reduced
if you’re on the telemetry floor and you notice that your patient is is showing signs of symptomatic bradycardia what would you do?
assess the patient; go into the patient’s room and say “hi there. i came to see how you’re doing since your heart rate is a little low. are you feeling lightheaded or dizzy?”; afterwards, you’ll take a set of VS and if the BP is low/patient is experiencing symptoms, you’ll want to call the provider
if you’re on the telemetry floor and one of your patients is stable and asymptomatic but they are experiencing bradycardia what would you do?
text/page the provider and let them know what’s going, especially if this is a change from their normal heart rate.
what are some treatment options for bradycardia?
sometimes atropine is used to increase the HR if the patient is symptomatic
transcutaneous pacing, where there is an electrode that is placed on the patient’s skin which can capture the patient’s HR
it’s important to remember that transcutaneous pacing is a ______ until the patient can have a permanent pacemaker placed
temporary fix
what are the requirements the patient needs to meet in order to be diagnosed with sinus tachycardia?
HR is somewhere between 101 - 180, regular rhythm, p wave is within normal limits, pr is within normal limits, qrs is within normal limits
what are signs and symptoms of tachycardia?
fever, pain, hypotension, hypovolemia, or hypoglycemia
medications like _____ or ______ are also known to cause tachycardia
epinephrine; pseudoephedrine
tachycardia can also result from things like _____, _____, and ______
exercise; anxiety; fear
if the patient on your telemetry floor is experiencing sinus tachycardia what would you do?
go to the room and assess the patient; ask them if they’re feeling dizzy or short of breath; take a set of VS and call the provider
what are some treatment options for sinus tachycardia?
first thing first, you want to treat the underlying cause
for example, if the patient has a fever, place a cool cloth on their forehead, use ice bags, and look for a PRN order of acetaminophen (325-650mg)
sometimes, young _____ patients will have unexplained tachycardia and have a HR in the ___
why does this happen?
male trauma; 120s
because the patient is already in a hypermetabolic state as the body is trying to heal from its wounds
once all other causes have been ruled out in sinus tachycardia, only then will the doctors prescribe a medication such as _____, a _____ to help reduce the metabolic demand of a high heart rate
propranolol; beta blocker
premature atrial contractions are contractions that come from an ______ (a place other than the AV node) in the atrium _____ than ____
ectopic focus; sooner; expected
when looking at an ECG you’ll be able to see premature atrial contractions where?
premature atrial contractions will display themselves on the R waves
often times, you’ll see that each R wave will come earlier than expected
what are some signs and symptoms of premature atrial contractions?
PACs can result from emotional or physical stress, caffeine/nicotine use, or alcohol use
patients will often report feelings of palpitations or a “skipped” heart beat
what are some treatment options for premature atrial contractions?
withdrawal of stimulants such as caffeine can help to reduce PACs
use of beta blockers can also help decrease PACs
how are premature junctional contractions treated?
the same way as PACs are treated
withdrawing any stimulants or using medications such as beta blockers
what causes premature junctional contractions?
they happen due to the SA node not firing so the AV node has to become the pacemaker
what causes an atrial flutter?
atrial flutter is an atrial tachydysrhythmia that results from a single ectopic foci in the atrium
what are some signs and symptoms of atrial flutter?
this will typically occur in patients who have coronary artery disease, COPD, or cor pulmonale
can also happen if the patient is taking digoxin or quinidine
patient may complain of things like lightheadedness or low blood pressure
patients who have a-flutter are also at a high risk of developing _____ that form in the atria
blood clots
often times, patients with a-flutter will be prescribed _____ to prevent clot formation
warfarin/coumadin
what is the primary treatment goal for patients who have a-flutter?
slow down the ventricular rate by increasing the AV block
what kinds of medications are known to increase the AV block?
calcium channel blockers and beta blockers are known to increase the AV block
_____ tends to be the treatment of choice for a-flutter patients which involves inserting a ___ into the right atrium
a _____ of electricity is then used to “ablate” or destroy the ectopic foci
ablation; catheter
low voltage
what causes atrial fibrillation to occur?
results from total disorganization of atrial electricity activity from MULTIPLE ectopic foci
a-fib is one of the most _____ dysrhythmias
common
a-fib is an ____ rhythm
irregular
what are some underlying causes that can also cause atrial fibrillation to occur?
a-fib can also result due to things like heart disease, heart failure, electrolyte imbalances, and stress
what is considered “controlled” a-fibrillation?
what is considered “uncontrolled” a-fibrillation?
when the patient has a HR between 60 and 100
when the patient has a HR that is greater than 100
a-fib is similar to a-flutter as it results in loss of an atrial kick which can cause decreased cardiac output and can manifest itself as ______, _____, _____, and ____
hypotension, weakness, palpitations, and fatigue
patients who are prescribed coumadin/warfarin will need to have PT/INR drawn in order to titrate Coumadin
what is considered a “therapeutic level” of INR?
INR is considered to be therapeutic when it is between 2-3 seconds
can coumadin be prescribed to help treat patients with A-fib?
yes
what is one of the first treatment goals when it comes to treating a-fib?
control the HR, meaning the rate needs to decrease and be around 100 bpm
if a-fib is treated in the hospital, the patient may receive _____ for a total of 3 doses that are five minutes apart
5 mg IVP metoprolol
in order to receive metoprolol in the hospital, the patient must be on a ______
telemetry (heart) monitor
if a-fib is resistant to the med pushes of metoprolol and the heart rate remains high, the patient will then be placed on _____ or ______ drip, that will run continuously
amiodarone; diltiazem
what is the maximum dose of diltiazem that can be given?
20 mg/hr
remember: diltiazem _____ works; whereas, amiodarone _____ works
sometimes; almost always
if the patient is suffering from a-fib, vital signs should be done at least once every ____ hours
4
if the patient has decreased tolerance for medications, what would be the next best solution?
placing the patient on cardioversion or ablation
if none of these treatment plans work, the last resort would be to place the patient on an _____ such as _____
anticoagulant; warfarin
in a 1st degree AV block everything remains normal except there is a prolonged ______
PR interval
with the 1st degree AV block, the impulses that are conducted through the ventricles are _____ than usual
much slower
with a 1st degree AV block, the PR interval lasts about _____
0.4 seconds
what are some signs and symptoms of 1st degree AV block?
patients with 1st degree AV block tend to be asymptomatic
what kinds of comorbid conditions tend to put the patient at a high risk for developing 1st degree AV block?
old age, myocardial infarctions, coronary artery disease, hyperthyroidism, hypokalemia, and taking medications such as digoxin, beta blockers, and calcium channel blockers
is there a treatment plan for those who are diagnosed with 1st degree AV block?
no, there is no treatment for 1st degree AVB, but treatment for the comorbid/associated conditions may help
what are PVCs?
what are some signs/symptoms of PVCs?
premature ventricular contractions
there tends to be very little signs and symptoms but patients have reported feelings of fluttering in the chest, skipped heartbeats, or awareness of their heartbeat
PVCs are ____ and ___ with age
common; increase
what are some common causes of PVCs?
stress, nicotine or caffeine use, and surgery
what are some treatment options for PVCs?
resolve the underlying cause such as hypokalemia/hypomagnesemia
PVCs are not typically treated
if the patient complains of frequent PVCs after the underlying issue has been resolved then ______ will be prescribed to the patient
beta blockers
what are some signs and symptoms of ventricular tachycardia?
HR of 150-250 bpm and no p-wave present
what are treatment options for ventricular tachycardia?
treat the precipitating cause!!
if the patient is stable and the pulse is present, you’ll want to monitor the patient’s O2 and place them on an EKG
if the patient is suffering from ventricular tachycardia and their condition is unstable with no pulse what are some treatment options?
defibrillate, do CPR, or give antidysrhythmic medications such as amiodarone or magnesium sulfate
if your patient is suffering from ventricular fibrillation what are some signs and symptoms you’d expect to see?
the patient has no pulse, call a code blue
what are some treatment options for ventricular fibrillation?
get an AED/defibrillator, defibrillate the patient, do CPR, or use pharmacologic therapy such as epinephrine, amiodarone, vasopressin, or magnesium sulfate
cardioversion is to be used on a _____ basis
cardioversion is used to treat what kind of conditions?
what is the energy level of shock for cardioversion?
non emergency;
used to convert a-fib or treat ventricular/supraventricular dysrhythmias
50 joules
defibrillation is to be used in _____ situations of unstable ____ and _____
what is the energy level of shock for defibrillation?
emergency; v-tach; v-fib
anywhere from 150 - 360 joules
is defibrillation synched with an ECG?
is cardioversion synched with an ECG?
no, it is not synchronized
yes, it is synchronized with the R wave of the QRS complex
what causes heart failure?
heart failure occurs when the heart cannot provide enough blood to meet the oxygen needs of the organs and tissues
heart failure can cause the supply to be ____ than the demand resulting in ______ cardiac output
less; decreased
decreased cardiac output can lead to what types of problems?
decreased tissue perfusion, decreased function, impaired gas exchange, and fluid volume imbalance
heart failure is associated with things such as _____, ______, and ______
HTN, coronary artery disease, and myocardial infarction
long term treatment of _____ can reduce the incidence of heart failure by ____%
HTN; 50%
what are the four things that impact cardiac output?
preload; afterload; contractility; and HR
______: the amount of blood pumped out into the circulation per heart beat
stroke volume
what is preload?
the volume of blood in ventricles AT THE END of diastole
what is afterload?
FORCE that the ventricle has to overcome in order to push blood out into circulation
what causes an increase in afterload?
hypertension and vasoconstriction
what causes an increase in preload?
hypervolemia, heart failure, and regurgitation of cardiac valves
heart failure results in response to ______ and results in ______ cardiac function
myocardial injury; decreased
what is the most common form of heart failure?
what causes left-sided heart failure?
left-sided heart failure
l-sided heart failure results from inability of the ventricle to empty blood during contraction or from not filling up with enough blood BEFORE the contraction
left sided heart failure can have problems with either systole (which is during _____), or diastole (which is ____).
contraction; filling
what is systolic heart failure?
the inability to pump blood
what is diastolic heart failure?
inability to relax and fill during diastole
what is the ejection fraction?
the EF compares the amount of blood in the heart to the amount of blood that is being pumped out
what range (percentage wise) is considered “normal” ejection fraction?
50-70% of blood is pumped out during each contraction
what range (percentage wise) is considered “borderline” ejection fraction?
41-49% of blood is pumped out during each contraction
what range (percentage wise) is considered “reduced” ejection fraction?
40% or less of blood is pumped out during each contraction
with borderline ejection fraction are symptoms noticeable on the patient?
with reduced ejection fraction are symptoms noticeable on the patient?
symptoms might become noticeable but only during activity
symptoms may become noticeable even during periods of rest
how do you measure/find an individual’s ejection fraction?
you can find this through the use of an electrocardiogram
what is an electrocardiogram?
if your patient is receiving an electrocardiogram what is one helpful tip you can mention to them?
electrocardiogram is an ultrasound of the heart
you can remind the patient that this is painless procedure which can help reduce any anxiety
what is considered an “early sign” of heart failure?
fatigue following activities of daily living
what are the two “special” side effects of left-sided heart failure?
orthopnea and paroxysmal nocturnal dyspnea
what is orthopnea?
what is paroxysmal nocturnal dyspnea?
orthopnea is dyspnea that occurs when the patient is lying in recumbent position which causes the redistribution of fluid from the BLE to the lungs
paroxysmal nocturnal dyspnea is a sudden awakening at night due to shortness of breath, again which is caused by fluid accumulation in the lungs while patient is in supine position
how can you relieve orthopnea?
this can be relieved by having the patient sit upright
if a patient comes to you and says they wake up in the middle of the night and feel like they’re suffocating what is this a sign of?
paroxysmal nocturnal dyspnea
what are some other side effects related to left-sided heart failure?
oliguria during the DAY, fatigue, pallor, weak peripheral pulses, cool extremities, crackles in the lungs, angina & nocturia, and S3 Kentucky
what is the most common dysrhythmia that occurs with chronic heart failure?
atrial fibrillation
what are some side effects of right-sided heart failure?
systemic congestion, enlarged liver & spleen, jugular vein distention, dependent edema, swollen abdomen & hands, and polyuria at NIGHT
if one of your patients has a nursing diagnosis of impaired gas exchange, what is the treatment plan?
your initial goal is to increase oxygen supply, you can do this by: changing positioning, using oxygen, CPAP/BIPAP, or the use of medications
if one of your patients needs to decrease oxygen demands what would their treatment plan look like?
alternating rest periods and decreasing activity periods; plan for activities that reduce competition for oxygen, decrease preload through the use of medications or changes in the diet
if one of your patients has a nursing diagnosis of decreased cardiac output, what would be your treatment plan?
your initial goal would be to improve cardiac function by prescribing medications such as: diuretic inhibitors (lasix), vasodilator drugs (nitroglycerin), inotropes (digoxin), and ACEs (lisinopril)
if one of your patients has a nursing diagnosis of fluid volume excess, what would their treatment plan look like?
your initial goal would be to decrease the intravascular volume which can be done through the use of medications, changes in positioning, and placing the patient on a LOW SODIUM diet
According to the Core Measures, what are some guidelines/rules that must be met when providing care for a patient with heart failure?
before discharge, you’ll want to evaluate their left ventricular function (EF), have a ACEI/ARB prescribed at discharge, and provide specific discharge instructions that relate to diet, activity, weight monitoring, and s&s the patient must be on the look out for
when monitoring for complications, what are some signs of worsening heart failure?
rapid weight gain (3-5 lbs in one week or 1-2 pounds overnight), decrease in exercise tolerance, cough lasting more than 3-5 days, or excessive awakening at night to urinate
what are some signs and symptoms of digoxin toxicity?
confusion, irregular pulse, loss of appetite, N/V/D, vision changes
how does coronary artery disease occur?
what does angina do to blood flow?
it occurs when plaque builds up in the artery
it makes it harder for blood to get through to the artery
what causes a heart attack?
a heart attack happens when plaque build up cracks and forms a blood clot blocking the artery from receiving blood
what are some modifiable risk factors for coronary artery disease?
elevated serum lipids, hypertension, smoking, physical INactivity, obesity, and comorbid conditions
what is a major consequence of coronary artery disease?
angina imbalance of supply and demand
what things consist of the “supply”?
what things consist of the “demand”
heart rate, BP, O2 concentration, and coronary vessel diameter
basal requirements, HR, preload/afterload, and contractility
STABLE ANGINA
- is typically provoked by ______
- is usually ______
- only lasts about ___ to ____ minutes
- can be relieved by ___ and _____
exercise; reversible; 5-15; rest; NTG SL
STABLE ANGINA is usually associated with a _______
stable atherosclerotic plaque
in STABLE ANGINA, there is ___ change in frequency, ____ in duration, or any _____ in the preceding 60 days
no; no change; precipitation factors
UNSTABLE ANGINA
- typically occurs at ____ or _______
- has a duration greater than or equal to ___ minutes
- the frequency and intensity of the pain tend to _____
- usually have an _____ pattern
rest; awakens the patient from their sleep; 15 minutes; increase; unpredictable
how does chest pain present itself in MEN?
upper chest pain, substernal pain radiating to the neck and jaw, substernal pain radiating down LEFT ARM, epigastric pain, epigastric pain that radiates to the neck, jaw, and arms and interscapular pain
when it comes to chest pain presentation in WOMEN something to keep in mind is WOMEN tend to have symptoms more often when _____ or ______
resting; sleeping
what are some angina symptoms that occur in women?
most commonly reported symptom is chest pressure/”chest tightness”, unusual fatigue, SOB, N/V, diaphoresis, indigestion, and pain in one or both arms
what is a special symptom we should remember when it comes to angina symptoms in WOMEN?
takotsubo cardiomyopathy which occurs under extreme stress and emotional conditions
how can we assess chest pain?
determine the onset, location, duration, character (“what does it feel like?”), are there any aggravating/alleviating factors, and the timing and severity of pain
what are some nursing interventions you can perform when your patient is experiencing chest pain?
it’s important that you ASSESS THE PAIN FIRST; call a rapid response/call the provider for orders, grab a set of VS (especially the BP), perform an EKG, and give the patient meds such as sublingual nitroglycerin, morphine, or troponin I
when giving NTG SL, what is the dosing and how long do you wait between each dose?
you give the patient 0.04 mg under the tongue, 3 times, 5 minutes apart with VS and EKG in between each dosage
remember, with chest pain, you’ll only give your patient morphine if there has been _____ from the nitroglycerin
NO RELIEF
with UNSTABLE ANGINA what are some EKG changes you will notice?
ST depression and t-wave inversion which are both ISCHEMIC changes
with a STEMI, there is ____ segment ____
ST; elevation
what are some drugs that can be used to treat myocardial infarction?
morphine, nitrates, aspirin, heparin, beta blockers, ACE inhibitors, and lipid lowering drugs like statin medications
what happens in cath lab?
why is the cath lab considered an “emergency” situation?
pt is placed on emergency defibrillation while cardiologists try to open the coronary artery that is blocked
b/c cardiac cells are only viable for about 20 minutes during ischemic conditions
MORPHINE:
- helps with ____
- ____ O2 demand
- _____ preload
- ______ anxiety
pain relief; decreases; decreases; decreases
NITRATES:
- _____ smooth muscle
- _______ the coronary arteries
- ______ preload & afterload
relaxes; dilates; decreases
ACE INHIBITORS:
- what is an example of an ACE inhibitor?
- ____ afterload by ____ blood vessels
- _____ progression of heart failure and ventricular remodeling
lisinopril; decrease; dilating; slows
what is a CABG procedure?
who are some eligible patients for CABG procedure?
coronary artery bypass graft
pts. who have failed management, pts. who have left main coronary artery disease, pts. who have 3 vessel disease or more
what happens in a CABG procedure?
what arteries/veins tend to be used in a CABG procedure?
a CABG procedure uses placement of arterial or venous grafts to provide blood flow from the aorta
internal mammary artery, saphenous vein, or radial arteries tend to be used
what are some nursing interventions for CABG patients?
teach sternal precautions, monitor chest tubes, have continuous telemetry monitoring, encourage early ambulation and the use of TEDs to prevent DVTs, and provide wound care for the surgical incision
what are sternal precautions?
how long must the patient follow sternal precautions?
not lifting more than 5-8 lbs, no pushing or pulling with the arms, don’t reach arms overhead, and brace the sternum with a pillow while getting up
precautions must be followed for 6-8 weeks to allow proper healing
RULES OF DIGOXIN:
if the patient’s pulse is less than _____ you’ll want to hold the digoxin and call the provider
digoxin toxicity can cause ______ b/c it is known to bind to the ATP pump which can keep ______ in the periphery
less than 60 bpm
hyperkalemia; potassium
what are some signs and symptoms of HYPERKALEMIA?
what treatment is used to treat hyperkalemia?
spiked t waves on an EKG, severe palpitations, muscle weakness, and numbness
calcium gluconate
if you have a heart failure patient and they’re prescribed lasix what supplement should they be receiving to go with it?
the patient should be receiving a potassium supplement
what is the most common trigger of digoxin toxicity?
HYPOKALEMIA
what are some signs and symptoms of hypokalemia?
st wave depression on EKG, fatigue, and muscle cramping
