Adult Health Nursing II Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring, part 2 Module:...
Transcript of Adult Health Nursing II Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring, part 2 Module:...
Adult Health Nursing IIBlock 7.0
Topic: Cardiovascular Nursing & EKG Monitoring , part 2Module: 2.3
Block 7.0 Module 2.3
Cardiovascular--- EKG’s / Cardiac Monitoring
Digitalis pupurea (Foxglove)
Lead II
Dynamic Presentation
Static Presentation
Part II
Block 7.0 Module 2.3
At the conclusion of this class (and after some practice) the nurse will be able to:
1. State the four characteristics of cardiac muscle, and relate these characteristics to cardiac output. 2. Trace the flow of blood through the heart & lungs, naming all associated
structures3. Trace electrical conduction through the cardiac conduction system and
correlate to the EKG Tracing.4. State the intrinsic rates of SA node, atria, AV node, and Ventricles5. Identify waveforms, landmarks on the EKG tracing: P, QRS, T, U, baseline
6. Identify and measure P-R Interval (PRI), QRS duration, ST Segment
7. Using an EKG tracing, Calculate heart rate and rhythm
8. Using data from EKG analysis, determine name of cardiac rhythm
9. Based upon identified cardiac rhythm, correlate & determine rhythm’s effect on cardiac output.
10. Identify NSR, SB, ST, SVT, A-fib, A-flut, 1st-2nd-3rd degree AV Blocks, PVC’s, PAC’s, V-Tach, V-Fib, Toursades, Asystole, PEA
11. Identify nursing actions related to cardiac monitor readings and care of the cardiac patient.
12. Be familiar with the following medications and their effect on the cardiac output: Alpha Blockers, Beta Blockers, Ca Channel Blockers, Atropine, Lidocaine, amiodarone, epinephrine, digoxin
13. Nursing care of the cardiac patient, including considerations related to all aspects of physical assessment, including cardiac monitoring, activities of daily living, diet, and medications.
Block 7.0 Module 2.3
Concept Map: Selected Topics in Cardiovascular Nursing
PATHOPHYSIOLOGYMyocardial InfarctionAcute Coronary SyndromeValvular Heart DiseasePacemakersCABGAbdominal Aortic AneurysmPericarditisPeripheral Vasc Disease (PVD)Fem-Pop Bypass GraftShock / Fluid DeficitRaynaud’s PhenomenonArrhythmias / Dysrhythmias
PHARMACOLOGYCardiac GlycosidesACE InhibitorsAlpha BlockersBeta BlockersAntiarrhythmicsCatecholaminesAnticoagulants
ASSESSMENTPhysical Assessment Inspection Palpation Percussion AuscultationCardiac MonitoringLab Monitoring
Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
Block 7.0 Module 2.3
Block 7.0 Module 2.3
REMEMBER:At the ‘end of the day,’
IT’S ALL ABOUT
CardiacOutput!
C.O. = H R & R x S V
B.P. = C.O. X P V R S V R
*
* Tissue perfusion of vital organs…and everything else….
An Affirmation
“It’s all about cardiac output. Boy, don’t I know it now.”
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It’s All About…
Cardiac Output = HR X SVC.O. = Heart Rate x Stroke Volume
SympatheticNervousSystem
ParasympatheticNervous System
BloodVolume
BloodVolume
Baroreceptors
Chemoreceptors
Medications
Medications
Preload,Afterload
Condition ofCardiac ConductionSystem* Condition of
Heart Valves
ConditionOfMyocardium
It’s AllAboutCardiac Output !
ViscosityOf Blood
And,Many more factors !
What FactorsAffectCardiac Output ?
Block 7.0 Module 2.3
Example of Multiple Factors in Cardiac Output Chemoreceptors
Baroreceptors
The SinoAtrial Node:60-100 impulses / minute
Sympathetic Effects:
Parasympathetic Effects:
Block 7.0 Module 2.3
Recall / Quiz : 1. Distinguishing Characteristics of Cardiac
Muscle: C________, C________, A__________, R___________.
2. Intrinsic ‘Rates’ if Cardiac Tissue: SA Node =____; (Atrial Muscle=_____) AV
Node=_____; Ventricular Muscle =_____. 3. Conduction Pathways in the Heart:
____>_____+_____>_____>_____>______>_________ 4. “Interval Times,” i.e., how long it takes these
impulses to reach certain points within the conduction pathway:
P-R Interval=_____ QRS=_____ 5. FORMULA FOR CARDIAC OUTPUT:____________ 6. FORMULA FOR BP:_________________ 7. “IT’S ALL ABOUT:_________ ________”Block 7.0 Module 2.3
LUNGS
Superior Vena Cava
R & L Common Carotid Arteries
Left SubclavianArtery
Lungs
Lungs
Block 7.0 Module 2.3
Cardiac Conduction Pathways
SA Node >>Inter nodal & Intra atrial pathways
(Bachmann’s Bundle)>>AV Node >>Bundle of His >>Right & Left Bundle Branches >>Purkinje Fibers
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Intrinsic Rates… “automaticity”
Sino Atrial Node
(SA Node)
60-100 ipm
Atrial Muscle
~ 60 ipm
Atrio-Venticular Node
(AV Node)
40 – 60 ipm
Ventricular Muscle20-40 ipm
“Rate & Rhythm”Block 7.0 Module 2.3
“Automaticity”Intrinsic ratesSA Node = 60 – 100 i.p.m.Atrial Muscle = 60 i.p.m.AV Node = 40 – 60 i.p.m.Ventricular Muscle = 20 -40 i.p.m.
Block 7.0 Module 2.3
Conduction Pathways and rough correlation to the ECG Waveform
SA Node
AV Node
PRI: 0.12-0.20 seconds
QRS : < 0.12 seconds
Baseline
T Wave
Bundle of His
(R) & (L)Bundle Branches
PurkinjeFibers
Internodal & Intra-atrialPathways
Block 7.0 Module 2.3
Block 7.0 Module 2.3
Causes Of Dysrhythmias / Arrhythmias
1. Drugs (Medications & Others) Digoxin, quinidine, caffeine, nicotine,
alcohol, cocaine..others….2. Acid-Base & Electrolyte Imbalances: K+, Ca++, Mg+3. Marked Thermal Changes4. Disease & Trauma (Including
Surgery) 5. Stress
Block 7.0 Module 2.3
Block 7.0 Module 2.3
Rhythm IdentificationEach Has Specific Criteria…
Normal Sinus Rhythm (NSR)
Sinus Rhythm Sinus Bradycardia Sinus Tachycardia Sinus Arrhythmia
Atrial Flutter Atrial Fibrillation Junctional Rhythms Supraventricular
Tachycardia (SVT & PAT)
Heart Blocks: 1st, 2nd, 3rd
Ventricular Tachycardia Toursades de Pointes Ventricular Fibrillation Asystole Pulseless Electrical Activity
(PEA)
“Paced Rhythms”
Individual Ectopics: Premature Atrial Contractions Premature Junctional Contractions Premature Ventricular Contractions Artifact
POTENTIALLYLETHAL
Terminology:Bradyarrhythmias versus tachyarrhythmiasWide-complex tachycardia versus narrow-complex tachycardia
Block 7.0 Module 2.3
REMEMBER:At the ‘end of the day,’
IT’S ALL ABOUT
CardiacOutput!
C.O. = H R & R x S V
B.P. = C.O. X P V R S V R
*
* Tissue perfusion of vital organs…and everything else….Block 7.0 Module 2.3
An Important Caveat / Caution….
Cardiac Monitoring is a powerful diagnostic and patient care tool (only)
Correlate the monitor reading to the patient’s condition !
Check / Assess your patient for cardiac output!
The terms “EKG” and “ECG”ARE INTERCHANGEABLE
Block 7.0 Module 2.3
The “Stepwise” Method
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EKG PAPER
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EKG PAPER
“Amplitude”
Or Strength ofElectrical Impulse
TIMENote: Standard EKG Machines “run” at 25 mm/sec
Small Block = 0.04 sec5 Small Blocks = 1 Large Block = 0.20 sec5 Large Blocks = 1 second
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“Standard” Limb Leads
Lead II“universal”--
Most useful
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“ Chest Leads “ (for 12-Lead ECG)
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The ECG Complex, Wave forms, Intervals, Segments
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P Waves
Signal from the Sino Atrial Node (SA Node)“Normal Pacemaker of the heart”Should be upright ( Lead II )Should all look ~ alikeShould have 1:1 ratio with QRS ComplexesRhythms generated by this called “Sinus”, e.g., Sinus Rhythm, Normal Sinus Rhythm, Sinus Bradycardia, Sinus Tachycardia, Sinus Arrhythmia
Block 7.0 Module 2.3
P-R Interval (PRI)
Measure from beginning of P Wave to first deflection (up or down) from baseline to start QRS Complex
Time it takes for impulse to go from SA Node to ventriclesNormal time = 0.12 to 0.2 seconds ( 3-5 little blocks…)
(3 x 0.04= 0.12… 5 x 0.04= 0.20)Less than 0.12 sec PRI may indicate AV
Node--“junctional” problemGreater than 0.20 sec indicates AV Block
(1st – 2nd- 3rd degree) PRI’s should all be ~ equal
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General Overview: Are they narrow or wide?Electrical conduction through the ventricles
Ventricular Function ~ = Cardiac OutputAppearance is generally consistent with ventricular function
Normal = < 0.12 seconds“3 little boxes” (3 x 0.04 = 0.12 sec)
QRS should all be ~ same form / shapeIf greater than 0.12 seconds, indicates “trouble,”
i.e., a conduction delay in the ventricles
QRS Complex
Block 7.0 Module 2.3
S T Segment
Time from ventricular depolarization to ventricular repolarization
Frequently “speaks” of trouble within the ventricles
Elevated or depressed ST segment may indicate previous or ongoing ischemia or damage to ventricular myocardium
General rule of thumb: ST Depression ↓ = Ischemia ST Elevation ↑ = Infarction
?
Block 7.0 Module 2.3
Block 7.0 Module 2.3
T Waves
Represent repolarization of Ventricles, i.e., “preparing to beat again”
Should be upright (lead II)Should appear ~ same“Flipped or inverted T waves” may be
sign of prior or ongoing ventricular damage
Prolonged QT Interval may represent problems with ventricular repolarization— due to damage or medication effectBlock 7.0 Module 2.3
“U” WAVES
Potassium EffectHYPOKALEMIA Fairly Rare….
P QRS T U P QRS T U P QRS T U P QRS T U
TALL “TENT-LIKE” T WavesCaused by: K+ Hyperkalemia
Either One, if not corrected,Means that ventricular tachycardia,And / or ventricular fibrillationIS on the way!
Block 7.0 Module 2.3
Block 7.0 Module 2.3
Repetition—Repetition--Repetition
1. General Overview of strip2. Rate3. Rhythm4. P Waves5. P-R Interval (PRI)6. QRS Interval7. Q-T Interval
Overview— Develop Your Method Practice IT & Follow IT !
Apply findings and
observations to CRITERIA
Block 7.0 Module 2.3
REMEMBER:At the ‘end of the day,’
IT’S ALL ABOUT
CardiacOutput!
C.O. = H R & R x S V
B.P. = C.O. X P V R S V R
*
* Tissue perfusion of vital organs…and everything else….Block 7.0 Module 2.3
Measuring Time and Events…
Baseline orIsoelectric line
P P
Block 7.0 Module 2.3
Three Methods for rate determination…
300 150 100 60start
120
Easy Way:12 x 10 (almost 11)= 120’sAccurate if the rhythm is REGULAR
Memorize…. OR divide 300By # of Big Boxes Between QRS complexes…or divide 60 by # secondsbetween qrs’s
75
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Discussion …Measuring PRI & QRS
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Rates…Intervals…Remember the “normals”:
PRI= 0.12 – 0.20 seconds(SA Node to Ventricles)
QRS = < 0.12 secondsTime Through the Ventricles
Block 7.0 Module 2.3
End of Cardiovascular Disease AH II Part 2We Will Continue in a moment
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Block 7.0 Module 2.3
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Block 7.0 Module 2.3
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~END OF PRESENTATION~GO TO THE NEXT PRESENTATION,
Module 2.4