Respiratory Assessment 2 Final Exam

An ECG is used to evaluate the-

electrical activity of the heart

Inherent Rates: Sinus node

60-100 bpm

Inherent Rates: AV junction

40-60 bpm

Inherent Rates: Ventricles

20-40 bpm

Pacemaker site with the fastest rate will generally-

control the heart

Irritability is a site along the conduction pathway

becomes-

irritable and speeds up, thus overriding higher pacemaking sites for control of the heart.

Escape Mechanism is the

normal pacemaker slows down or fails, and a lower pacing site assumes pacemaking responsibility

Autonomic Nervous System: Sympathetic

Affects the atria and ventricles

Increases:

-Heart rate

-Conduction

-Irritability

Autonomic Nervous System: Parasympathetic

Affects only the atria

Decreases:

-Heart rate

-Conduction

-Irritability

Electricity flowing toward positive electrode produces an

upright pattern

Electricity flowing toward negative electrode produces an

inverted pattern

What Voltage is measured by

Comparing the height of the spike to the horizontal lines on graph paper

What is Time measured by

Comparing the markings to the vertical lines on the graph paper

In order to analyze EKG rhythm strip you need to-

Use organized format to collect available clues

Compare information collected to rules for each arrhythmia

Calculating Heart Rate –Regular Rhythms: Count number of large squares between

Two R waves and divide into 300

Calculating Heart Rate –Regular Rhythms: Count number of small squares between

Two R waves and divide into 1500

Figuring Rates Based on the Number of QRS Complexes in a 6-Second Strip is where you

Count number of R waves in a 6-second strip and multiply by 10

Rhythm Strip Analysis Format

Regularity (Rhythm)

Rate

P Waves

PRI intervals

QRS Complexes

Mechanism of Normal Sinus Rhythm is when

sinus node initiates regular impulses at a normal rate. Each impulse is conducted normally to the ventricles

Rules for Normal Sinus Rhythm is when

Regularity: Regular

Rate: 60–100 bpm

P Wave: Uniform shape; one P wave in front of every QRS complex

PRI: 0.12–0.20 second and constant

QRS: Less than 0.12 second

Mechanism of Sinus Bradycardia is when

the sinus node is the pacemaker, firing regularly at a rate of less than 60 times per minute. Each impulse is conducted normally through to the ventricles

Rules for Sinus Bradycardia includes

Regularity: Regular

Rate: Less than 60 bpm

P Wave: Uniform shape; one P wave in front of every QRS complex

PRI: 0.12–0.20 second and constant

QRS: Less than 0.12 second

Mechanism of Sinus Tachycardia includes

the sinus node is the pacemaker, firing regularly at a rate of greater than 100 bpm. Each impulse is conducted normally through to the ventricles

Rules for Sinus Tachycardia includes

Regularity: Regular

Rate: Greater than 100 bpm (usually does not exceed 160 bpm)

P Wave: Uniform shape; one P wave in front of every QRS complex

PRI: 0.12–0.20 second and constant

QRS: Less than 0.12 second

Mechanism of Sinus Arrhythmia includes

the sinus node is the pacemaker, but impulses are initiated in an irregular pattern. The rate increases as the patient breathes in and decreases as the patient breathes out. Each impulse is conducted normally through to the ventricles

Rules for Sinus Arrhythmia includes

Regularity: Irregular

Rate: 60–100 bpm (usually)

P Wave: Uniform shape; one P wave in front of every QRS complex

PRI: 0.12–0.20 second and constant

QRS: Less than 0.12 second

Mechanism of Wandering Pacemaker includes

the pacemaker site wanders between the sinus node, the atria, and the AV junction. Although each impulse originates from a different focus, the rate usually remains within a normal range, but it can be slower or faster. Conduction through to the ventricles is normal

Rules for Wandering Pacemaker includes

Regularity: Slightly irregular

Rate: Usually normal, 60–100 bpm

P Wave: Morphology changes from one complex to the next

PRI: Less than 0.20 second; may vary

QRS: Less than 0.12 second

Mechanism of Premature Atrial Complex includes

the pacemaker is an irritable focus within the atrium that fires prematurely and produces a single ectopic beat. Conduction through to the ventricles is normal. This is a single beat, not an entire rhythm; the underlying rhythm also must be identified.

Rules for Premature Atrial Complex are

Regularity: Depends on the underlying rhythm;

regularity will be interrupted by the PAC

Rate: Depends on the underlying rhythm

P Wave: P wave of early beat differs from the sinus P waves; can be flattened or notched; may be lost in the preceding T wave

PRI: 0.12–0.20 second; can exceed 0.20 second

QRS: Less than 0.12 second

Mechanism of Atrial Tachycardia includes

the pacemaker is a single irritable site within the atrium that fires repetitively at a very rapid rate. Conduction through to the ventricles is normal

Rules for Atrial Tachycardia includes

Regularity: Regular

Rate: 150–250 bpm

P Wave: Atrial P wave; differs from sinus P wave; can be lost in T wave

PRI: 0.12–0.20 second

QRS: Less than 0.12 second

Mechanism of Atrial Flutter includes

a single irritable focus within the atria issues an impulse that is conducted in a rapid, repetitive fashion. To protect the ventricles from receiving too many impulses, the AV node blocks some of the impulses from being conducted through to the ventricles. Those that do get through are conducted normally

Rules for Atrial Flutter includes

Regularity: Atrial rhythm is regular; ventricular rhythm is usually regular but can be irregular if there is variable block

Rate: Atrial rate 250–350 bpm; ventricular rate varies

P Wave: Characteristic sawtooth pattern

PRI: Unable to determine

QRS: Less than 0.12 second

Mechanism of Atrial Fibrillation includes

the atria are so irritable that a multitude of foci initiate impulses, causing the atria to depolarize repeatedly in a fibrillatory manner. The AV node blocks most of the impulses, allowing only a limited number through to the ventricles.

Rules for Atrial Fibrillation includes

Regularity: Grossly irregular

Rate: Atrial rate greater than 350 bpm; ventricular rate varies greatly

P Wave: No discernible P waves; atrial activity is referred to as fibrillatory waves (f waves)

PRI: Unable to measure

QRS: Less than 0.12 second

Inverted P Wave includes

The P wave precedes the QRS complex if the atria are depolarized before the ventricles. In this case, the PRI will be less than 0.12 seconds

Inverted P Wave (Hidden) is if the

Atria and the ventricles are depolarized simultaneously, there will be no visible P wave, since it is hidden within the QRS complex

In the a inverted P wave, the P wave will

Follow the QRS complex if the ventricles are depolarized before the atria

Mechanism of Premature Junctional Complex includes

the pacemaker is an irritable focus within the AV junction that fires prematurely and produces a single ectopic beat. The atria are depolarized via retrograde conduction. Conduction through the ventricles is normal. This is a single beat, not an entire rhythm; the underlying rhythm also must be identified

Rules for Premature Junctional Complex includes

Regularity: Depends on regularity of underlying arrhythmia

Rate: Depends on rate of underlying arrhythmia

P Wave: Will be inverted; can fall before, during, or after the QRS complex

PRI: Can be measured only if the P wave precedes the QRS complex; if measurable, will be less than 0.12 second

QRS: Less than 0.12 second

Mechanism of Junctional Escape Rhythm includes

when higher pacemaker sites fail, the AV junction is left with pacemaking responsibility. The atria are depolarized via retrograde conduction. Conduction through the ventricles is normal

Rules for Junctional Escape Rhythm includes

Regularity: Regular

Rate: 40–60 bpm

P Wave: Will be inverted: can fall before or after the QRS complex or can be hidden within the QRS complex

PRI: Can be measured only if the P wave precedes the QRS complex; if measurable, will be less than 0.12 second

QRS: Less than 0.12 second

Mechanism of Accelerated Junctional Rhythm includes

an irritable focus in the AV junction speeds up to override the SA node for control of the heart. The atria are depolarized via retrograde conduction. Conduction through the ventricles is normal

Rules for Accelerated Junctional Rhythm includes

Regularity: regular

Rate: 60–100 bpm

P Wave: will be inverted; can fall before or after the QRS complex or can be hidden within the QRS complex

PRI: can be measured only if the P wave precedes the QRS complex; if measurable, will be less than 0.12 second

QRS: less than 0.12 second

Mechanism of Junctional Tachycardia includes

A very rapid irritable focus in the AV junction overrides the SA node for control of the heart. The atria are depolarized via retrograde conduction. Conduction through the ventricles is normal

Rules for Junctional Tachycardia includes

Regularity: Regular

Rate: 100–180 bpm

P Wave: Will be inverted; can fall before or after the QRS complex or can be hidden within the QRS complex

PRI: Can be measured only if the P wave precedes the QRS complex; if measurable, will be less than 0.12 second

QRS: Less than 0.12 second

Supraventricular Tachycardia is a phrase used to describe a-

rapid, regular supraventricular arrhythmia when more accurate identification is impossible because P waves aren’t visible and rate is common to other arrhythmias

SVTs with Overlapping Rate Ranges:

Sinus Tachycardia

Atrial Tachycardia

Atrial Flutter

Junctional Tachycardia

Mechanism of First Degree Heart Block includes

AV node holds each impulse longer than normal before conducting it to the ventricles. Each impulse is eventually conducted

Rules for First Degree Heart Block

Regularity: Depends on underlying rhythm

Rate: Depends on underlying rhythm

P Wave: Upright and uniform; each P wave will be followed by a QRS complex

PRI: Greater than .20 seconds; constant across strip

QRS: Less than .12 seconds

Mechanism of Type II Second Degree Heart Block including

The AV node selectively conducts some beats while blocking others. Those that are not blocked are conducted through to the ventricles, although they may encounter a slight delay in the node. Once in the ventricles, conduction proceeds normally

Rules for Type II Second Degree Heart Block includes

Regularity: If the conduction ratio is consistent, the R–R interval will be constant, and the rhythm will be regular. If the conduction ratio varies, the R–R will be irregular

Rate: The atrial rate is usually normal (60–100 bpm). Since many of the atrial impulses are blocked, the ventricular rate will usually be in the bradycardia range (< 60 bpm), often one-half, one-third, or one-fourth of the atrial rate

P Waves: P waves are upright and uniform. There are always more P waves than QRS complexes

PRI: The PRI on conducted beats will be constant across the strip, although it might be longer than a normal PRI measurement

QRS: The QRS complex measurement will be less than 0.12 second

Mechanism of Wenckebach (Type I Second-Degree Heart Block) are

As the sinus node initiates impulses, each one is delayed in the AV node a little longer than the preceding one, until one impulse is eventually blocked completely. Those impulses that are conducted travel normally through the ventricles

Rules for Wenckebach

Regularity: Irregular; R-R interval changes as PR interval gets longer; characteristic grouped beating

Rate: Usually slightly slower than normal

P Wave: Upright and uniform; some P waves not followed by QRS complexes

PRI: Progressively lengthens until one P wave is not conducted

QRS: Less than .12 seconds

Mechanism of Complete Heart Block (CHB) includes

The block at the AV node is complete. The sinus beats cannot penetrate the node and thus are not conducted through to the ventricles. An escape mechanism from either the junction or the ventricles will take over to pace the ventricles. The atria and ventricles function in a totally dissociated fashion

Rules for Complete Heart Block

Regularity: Regular

Rate: AR—usually normal (60–100 bpm) VR—40–60 if focus is junctional; 20–40 if focus is ventricular

P Waves: Upright and uniform; more P waves than QRS complexes

PRI: No relationship between P waves and QRS complexes; P waves can occasionally be found superimposed on the QRS complex

QRS: Less than 0.12 second if focus is junctional; 0.12 second or greater if focus is ventricular

Mechanism of Premature Ventricular Complex includes

A single irritable focus within the ventricles that fires prematurely to initiate an ectopic complex. This is a single beat, not an entire rhythm; the underlying rhythm also must be identified

Rules for Premature Ventricular Complex includes

Regularity: Ectopics will disrupt regularity of underlying rhythm

Rate: Depends on underlying rhythm and number of ectopics

P Waves: Will not be preceded by a P wave; dissociated P wave may be seen near PVC

PRI: Since the ectopic comes from a lower focus, there will be no PRI

QRS: Wide and bizarre; 0.12 seconds or greater; T wave is usually in opposite direction from R wave

Ectopic A exhibits R on T phenomenon;

Ectopic B

does not

Mechanism of Ventricular Tachycardia includes

An irritable focus within the ventricles fires regularly at a rapid rate to override higher sites for control of the heart

Rules for Ventricular Tachycardia includes

Regularity: Usually regular; can be slightly irregular

Rate: 150–250 bpm; can exceed 250 bpm if the rhythm progresses to Ventricular Flutter; may occasionally be slower than 150 bpm, in which case it is called slow VT

P Waves: Will not be preceded by P waves; dissociated P waves may be seen

PRI: Since the focus is in the ventricles, there will be no PRI

QRS: Wide and bizarre; 0.12 second or greater; T wave is usually in opposite direction from R wave

Mechanism of Ventricular Fibrillation includes

Multiple foci within the ventricles become irritable and generate uncoordinated, chaotic impulses that cause the heart to fibrillate rather than contract

Rules for Ventricular Fibrillation

Everything is totally chaotic with no discernible waves or complexes

Mechanism of Idioventricular Rhythm includes

In the absence of a higher pacemaker, the ventricles initiate a regular impulse at their inherent rate to take control of the heart

Rules for Idioventricular Rhythm

Regularity: usually regular

Rate: 20–40 bpm; can drop below 20 bpm

P Waves: none

PRI: none

QRS: Wide and bizarre; 0.12 seconds or more

Mechanism of Asystole includes

The heart has lost its electrical activity. There is no electrical pacemaker to initiate electrical flow

Rules for Asystole includes

Everything being a straight line indicates no electrical activity

Epinephrine is administered first

during resuscitation with asystole

Atropine and Epinephrine can be given

IV and via ETT

ACLS recommended dosage for Adenosine is

6 mg rapid IVP follow with 20 ml flush

ACLS recommended dosage for epinephrine is:

1mg IV/ET every 3-5 minutes

Epinephrine is given for

pulseless Vtach

Racemic epinephrine for

stridor

Polysomnography is the

the study of sleep. This is the testing used to diagnose sleep disorders.

To meet the definitive criteria for sleep apnea there needs to be

10 seconds of air flow cessation during sleep

must be documented

The first sign of sleep disordered breathing is

Snoring

What rhythms do you shock

Ventricular Fibrillation and Ventricular Tachycardia

What rhythms do you cardiovert

Ventricular Tachycardia (VT)

Atrial Fibrillation

Atrial Flutter

Supraventricular Tachycardia (SVT)

Atrial Fibrillation may cause or lead

to CHF

When would you have a dull percussion note

Pneumonia

Pleural effusion

Atelectasis

Tumor

When would you have a hyper-resonant percussion note

Pneumothorax

Emphysema / COPD

What is leukopenia

an abnormally low number of white blood cells (WBCs) in the blood, typically defined as falling below <4,000 cells per microliter

What is leukocytosis

an elevated white blood cell (WBC) count in the blood

What is a normal WBC

4,000 to 11,000 cells per microliter (mcL) of blood

Patients receiving corticosteroids are at risk for thrush- also called oral candida. Which medications contain these corticosteroids

Budesonide

Fluticasone

Beclomethasone

Ciclesonide

The affinity between carbon monoxide and hemoglobin is

240 times stronger than the affinity between hemoglobin and oxygen

According to the O₂Hb-dissociation curve, under normal conditions,

a PaO₂ of 60 mm Hg correlates to an SpO₂ of 90%

Calculate minute ventilation

Minute ventilation (VE)= Tidal volume (VT) × Respiratory rate (RR)

ETCO2 is measured at the peak of the curve on

the capnography tracing

What is this ETCO2 waveform

Dislodged tube

What is this ETCO2 waveform

rebreathing CO2

What is this ETCO2 waveform

Hypoventilation

What is this ETCO2 waveform

bronchospasm

What is this ETCO2 waveform

Patient breathing around ET tube

In Junctional Rhythms, if conduction to the atria occurs simultaneously with conduction to the ventricles, the p waves will be

inverted, and lost within the QRS complex