Critical care exam I

Normal Sinus Rhythm

1st degree AV block

• PR interval is longer than 0.20 secs, but P:QRS ratio 1:1

• Usually regular

2nd degree AV block type I (Weckenbach)

• PR interval gets longer & longer, than a QRS is dropped

• Think: “longer, longer, drop”

• 
  

  

2nd degree AV block type II

• PR interval stays constant, but QRS complexes are suddenly dropped

• More serious; may require pacing

• 
  

  

3rd degree/complete ❤ block

• P waves & QRS complexes have no relationship to each other

• Atria & ventricles beat independently

• 
  

  

NSR - story and rhyme

The P & QRS are dating & never leave eachothers side 🙂

1st degree AV block - story and rhyme

• The P & QRS got into an argument & are keeping their distance

• Rhyme: “If the R is far from the P, then you have a 1st degree”

2nd degree AV block type I AKA weckenbach - story and rhyme

The P & QRS are in a cycle of breaking up & getting back together, repeat

Rhyme: “longer, longer, longer, DROP. Then you have a WECKENBACH!”

2nd degree AV block type II AKA mobitz II - story & rhyme

• The P & QRS work it out but QRS is still upset & decides to go out

• Rhyme: “If some QRS don’t get through, then you have a mobitz II”

• 
  

  

3rd degree AV block - story & rhyme

• The QRS catches P cheating so they separate & live single lives

• Rhyme: “If P’s & Q’s don’t agree, then you have a 3rd degree”

• PACEMAKER NEEDED

• 
  

  

Asymptomatic bradycardia tx

Assess & monitor

Symptomatic / hemodynamically unstable bradycardia tx

• May require atropine, pacing, or other interventions

• Always assess the whole pt, not just the monitor

QT interval

• Start of QRS —> end of T

• The QT interval represents ventricular depolarization & depolarization

• A prolonged QT interval increases the risk for dangerous/life threatening dysrhythmias

Atrial Flutter

• Characteristic “sawtooth” pattern

• Atrial rate is typically very fast

• Ventricular rhythm may be regular or irregular

• 
  

Atrial fibrillation

• Irregularly irregular rhythm

• No clearly identifiable normal P waves

• High risk of thrombus / stroke

• 
  

Afib tx concepts/common goals of tx

• Rate control

• Anticoagulation when indicated to decrease thromboembolic risk

Catheter Ablation

• A procedure used to treat certain abnormal ❤ rhythms

• A catheter is advanced through a blood vessel, commonly from the femoral area, toward the ❤

• The provider identifies abnormal areas of cardiac electrical activity & uses

  • Heat (radio frequency)

  • OR freezing (cyroablation)

• To destroy / isolate the abnormal tissue

• Remember= Ablation = eliminate abnormal electric pathways

❤ failure common manifestations

• Dyspnea

• Fatigue

• Fld retention

• Peripheral edema

• Pulmonary edema

• Pulmonary crackles

• Cough

• Decreased appetite

Left sided HF

• LEFT = LUNGS

• Possible findings:

  • Dyspnea

  • Pulmonary edema

  • Crackles

  • Cough

  • Orthopnea

Right sided HF

• RIGHT = Rest of body

• Possible findings:

  • Peripheral edema

  • Increased abdominal girth

  • Ascites

  • Weight gain

  • JVD

Ejection Fraction

• Ejection fraction measures the %age of blood pumped out of the ventricles with each contraction

  • Normal/preserved EF = 50—>70%

• Low EF= reduced pumping function

HF diagnostics - Echocardiogram

• Evaluates cardiac structure & function

• Helps determine EF

HF diagnostics - BNP

Helps evaluate for HF

HF diagnostics - CXR

Can show pulmonary congestion/edema

HF diagnostics - ECG

Evaluates cardiac rhythm & electrical activity

Coronary Artery Disease (CAD) - Modifiable RF

• HTN

• Diabetes

• Smoking

• Obesity

• Physical inactivity

• Unhealthy diet

• Increased cholesterol

Coronary Artery Disease (CAD) -- Non modifiable RF

• Age

• Family history/heredity

Atherosclerosis & thrombus formation

1. Adhesion

   1. Platelets attach / bind to injured vessel wall

   2. “I stick to the injury”

2. Activation

   1. Platelets change shape & become activated

   2. “Something is wrong! Get more platelets” Think like activation of an alarm to signal more platelets to come

3. Aggregation

   1. Platelets clump together

   2. “Everyone pile on!”

4. Easy memory trick:

   1. A-A-A

   2. Adhesion —> Activation —> Aggregation

Angiography & Angioplasty

The procedure may include:

• Cardiac catheterization

• Contrast dye

• Angiography = visualization of coronary blood vessels

• Angioplasty = the balloon fix

• Stent placement (KEEP IT OPEN)

  • Stent = a small mesh tube used to help keep a coronary artery open

• Important difference:

  • Angioplasty/stent is NOT the same as a CABG

  • CABG is open ❤ surgery using a blood vessel graft to create a new route

Post Angiography nursing care

Immediately following the procedure, monitor for:

• Bleeding

• Hematoma

• Changes in cardiac rhythm

• VS changes

• Neurovascular status of the affected extremity

The pt may need bed rest & restrictions on movement