ADVANCED MED SURG: CH. 22

atrial flutter

EKG: (sawtooth pattern)

Rate--> usually over 100 bpm

Rhythm--> regular

P waves--> absent

PR--> absent

QRS--> normal (usually evenly spaced)

S/S: low oxygen--> chest pain, anxiety, SOB, palpitations, dizziness, low BP, etc.

INTERVENTIONS: A- anticoagulants to prevent clots, B- BB's to slow HR, C- cardiac ablation, D- digoxin, E- electro cardioversion

atrial fibrillation

EKG:

Rate--> over 100 bpm

Rhythm--> irregular/unorganized

P waves--> absent/none

PR--> absent/none

QRS--> present but unevenly spaced

S/S: HUGE risk for clots (PE, DVT, or strokes), low cardiac output/oxygen out to body (SOB, chest pain, etc.)

INTERVENTIONS: A- anticoagulants such as warfarin (to prevent clots), B- beta blockers to slow HR, C- cardiac ablation to burn erratic cells, D- digoxin for a deeper contraction, or E- electro cardioversion for a "baby" shock to the heart

ventricular fibrillation

EKG:

Rate--> indistinguishable

Rhythm--> chaotic waveform

P waves, PR, and QRS--> all absent

S/S: loss of consciousness or signs of low cardiac output

INTERVENTIONS: defibrillation (super shock) to reset SA node, give epinephrine (if that doesn't work then lidocaine, amiodarone, or magnesium sulfate) and/or CPR

ventricular tachycardia

EKG: (tombstones)

Rate--> 100-250 bpm

Rhythm--> regularly spaced

P waves--> none

PR--> none

QRS--> wide/even (like tombstones)

S/S: low cardiac output--> chest pain, SOB, anxiety, low BP, lethargy, cyanosis, etc.

INTERVENTIONS: ASSESS FIRST (if patient has pulse, give amiodarone to stabilize rhythm); then cardioversion to give baby shock to reset SA node; if NO PULSE--> CPR

asystole

flat line/no electrical conductivity of the heart

CPR !!! (give epinephrine 1 mg IV, and vasopressin)

first degree AV block

EKG:

Rate--> 60-100 bpm

Rhythm--> regular

P waves--> present/consistent

PR--> greater than .20 seconds but consistently long

QRS--> present/normal

S/S: asymptomatic

INTERVENTIONS: no treatment; regular ECG monitoring

second degree type 1 (wenkebach) AV block

EKG: (longer, longer, longer, drop)

Rate--> variable

Rhythm--> irregular

P waves--> present but late

PR--> gradually gets longer

QRS--> normal but drops

S/S: low oxygen in body (cyanosis, chest pain, etc.)

INTERVENTIONS: STOP meds that decrease HR, give atropine/dopamine/and epinephrine, or pacemaker may be needed

Second Degree Type 2 AV Block

EKG: (if some P's don't get through, it's type 2)

Rate--> atrial rate is faster than ventricular (more P waves than QRS's)

Rhythm--> irregular

P waves--> too many

PR--> normal or prolonged

QRS--> usually wide

S/S: low oxygen (chest pain, SOB, low BP, dizziness, etc.)

INTERVENTIONS: STOP BB's or CCB's, give atropine/dopamine/epinephrine, or pacemaker last resort

third degree AV block

EKG: (P's and Q's don't agree, third degree)

Rate--> 40-60 bpm

Rhythm--> regular (but P waves/QRS contract independently)

P waves--> normal

PR--> varies

QRS--> normal or wide

S/S: low oxygen (SOB, cyanosis, low BP, palpitations, anxiety, etc.)

INTERVENTIONS: STOP beta blockers etc, give atropine, dopamine, and/or epinephrine, or pacemaker as last resort

defibrillation vs. cardioversion

Cardioversion:

- Synchronized shock

- Low energy shock (50-200 joules of electricity)

- Less damage to myocardium

- Used in most arrhythmias except vtach or vfib

Defibrillation:

- Unsynchronized shock

- High energy shock (200-360 joules)

- More damage to myocardium

- Used in pulseless Vtach or Vfib

pacemaker care/education after surgery:

immobilize the arm (do not raise arm over head for about 2 weeks post-op), monitor for infections, and inspect HR daily

-swimming/driving is OK after 2 WEEKS

-teach patient to keep ID card on them

-teach patient to report SOB/dizziness

-avoid contact sports, MRIs, microwaves, and metal detectors

normal conduction of the heart

SA node (60-100) --> AV node/backup pacemaker (40-60) --> bundle of His --> bundle branches --> lastly to the purkinje fibers

sinus arryhtmia

EKG:

Rate--> 60-100 bpm

Rhythm--> irregular

P waves, PR, and QRS--> normal/present

S/S: asymptomatic or signs of low oxygen

INTERVENTIONS: usually, no treatment required (just monitor symptoms/ECG)

normal sinus rhythm

RATE: 60-100 bpm

RHYTHM: regular (evenly spaced R waves)

P waves: consistent shape

PR interval: 0.12-.20 seconds

QRS: 0.6-0.12

sinus bradycardia

EKG:

Rate--> under 60 bpm

Rhythm--> regular

P waves, PR, and QRS--> present/normal

S/S: can be asymptomatic or have signs of low oxygen (SOB, chest pain, pale skin, cyanosis, ALOC, etc.)

INTERVENTIONS: Atropine (increase HR), administer oxygen if needed, and/or may need pacemaker

the P waves represent what?

atrial contraction (Depolarization)

QRS complex represents what?

ventricular contraction (depolarization)

what does the T wave represent?

ventricular repolarization (relaxation of ventricles)

sinus tachycardia

EKG:

Rate--> over 100 bpm

Rhythm--> regular

P waves, PR, and QRS--> present/normal

S/S: can be asymptomatic or signs of low oxygen (chest pain, pale skin, SOB, or ALOC)

INTERVENTIONS: vagal maneuver (bare down), administer oxygen if needed, give beta blockers, or calcium channel blockers

Premature Ventricular Contractions (PVCs)

EKG:

Rate--> varies

Rhythm--> irregular (when the PVC occurs)

P waves--> none before PVC occurs

PR--> none associated with PVC

QRS--> wide/bizarre

S/S: a skipped heartbeat, hypotension, and possibly pulse deficit

INTERVENTIONS: treat the causes (stress, stimulants, and/or sepsis), discontinue digoxin, correct hypokalemia, and give procainamide or amiodarone

how do you calculate the PR interval?

Count small boxes from the start of P wave to start of QRS then X that number by 0.04

how do you calculate the heart rate with a regular rhythm on an EKG strip?

count the small boxes between the R wavs and divide by 1500

(if irregular rhythm, count R waves and X by 10)