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Jerry Carley RN, MSN, MA, CNE University of Southern Nevada Summer2010 Cardiovascular--- EKGs / Cardiac Monitoring Digitalis pupurea (Foxglove) Lead II Dynamic Presentation Static Presentation Part II Slide 2 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 structures 3.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 Ventricles 5. 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 rhythms effect on cardiac output. 10. Identify NSR, SB, ST, SVT, A-fib, A-flut, 1 st -2 nd -3 rd degree AV Blocks, PVCs, PACs, 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 Slide 3 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. Slide 4 Concept Map: Selected Topics in Cardiovascular Nursing PATHOPHYSIOLOGY Myocardial Infarction Acute Coronary Syndrome Valvular Heart Disease Pacemakers CABG Abdominal Aortic Aneurysm Pericarditis Peripheral Vasc Disease (PVD) Fem-Pop Bypass Graft Shock / Fluid Deficit Raynauds Phenomenon Arrhythmias / Dysrhythmias PHARMACOLOGY Cardiac Glycosides ACE Inhibitors Alpha Blockers Beta Blockers Antiarrhythmics Catecholamines Anticoagulants ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation Cardiac Monitoring Lab Monitoring Care Planning Plan for client adls, Monitoring, med admin., Patient education, more Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary Slide 5 REMEMBER: At the end of the day, ITS ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R * * Tissue perfusion of vital organsand everything else. Slide 6 An Affirmation Its all about cardiac output. Boy, dont I know it now. Slide 7 Its All About Cardiac Output = HR X SV C.O. = Heart Rate x Stroke Volume Sympathetic Nervous System Parasympathetic Nervous System Blood Volume Blood Volume Baroreceptors Chemoreceptors Medications Preload, Afterload Condition of Cardiac Conduction System* Condition of Heart Valves Condition Of Myocardium Its All About Cardiac Output ! Viscosity Of Blood And, Many more factors ! What Factors Affect Cardiac Output ? Slide 8 Example of Multiple Factors in Cardiac Output Chemoreceptors Baroreceptors The SinoAtrial Node: 60-100 impulses / minute Sympathetic Effects: Parasympathetic Effects: Slide 9 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. ITS ALL ABOUT:_________ ________ Slide 10 LUNGS Superior Vena Cava R & L Common Carotid Arteries Left Subclavian Artery Lungs Slide 11 Cardiac Conduction Pathways SA Node >> Inter nodal & Intra atrial pathways (Bachmanns Bundle)>> AV Node >> Bundle of His >> Right & Left Bundle Branches >> Purkinje Fibers Slide 12 Intrinsic Rates automaticity Sino Atrial Node (SA Node) 60-100 ipm Atrial Muscle ~ 60 ipm Atrio-Venticular Node (AV Node) 40 60 ipm Ventricular Muscle 20-40 ipm Rate & Rhythm Slide 13 Automaticity Intrinsic rates SA 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. Slide 14 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 Purkinje Fibers Internodal & Intra-atrial Pathways Slide 15 Slide 16 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 Changes 4. Disease & Trauma (Including Surgery) 5. Stress Slide 17 Slide 18 Rhythm Identification Each 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: 1 st, 2 nd, 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 POTENTIALLY LETHAL Terminology: Bradyarrhythmias versus tachyarrhythmias Wide-complex tachycardia versus narrow-complex tachycardia Slide 19 REMEMBER: At the end of the day, ITS ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R * * Tissue perfusion of vital organsand everything else. Slide 20 An Important Caveat / Caution. Cardiac Monitoring is a powerful diagnostic and patient care tool (only) Correlate the monitor reading to the patients condition ! Check / Assess your patient for cardiac output! The terms EKG and ECG ARE INTERCHANGEABLE Slide 21 The Stepwise Method Slide 22 EKG PAPER Slide 23 Amplitude Or Strength of Electrical Impulse TIME Note: Standard EKG Machines run at 25 mm/sec Small Block = 0.04 sec 5 Small Blocks = 1 Large Block = 0.20 sec 5 Large Blocks = 1 second Slide 24 Standard Limb Leads Lead II universal-- Most useful Slide 25 Chest Leads (for 12-Lead ECG) Slide 26 The ECG Complex, Wave forms, Intervals, Segments Slide 27 P Waves Signal from the Sino Atrial Node (SA Node) Normal Pacemaker of the heart Should be upright ( Lead II ) Should all look ~ alike Should have 1:1 ratio with QRS Complexes Rhythms generated by this called Sinus, e.g., Sinus Rhythm, Normal Sinus Rhythm, Sinus Bradycardia, Sinus Tachycardia, Sinus Arrhythmia Slide 28 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 ventricles Normal 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 problem Greater than 0.20 sec indicates AV Block (1 st 2 nd - 3 rd degree) PRIs should all be ~ equal Slide 29 General Overview: Are they narrow or wide? Electrical conduction through the ventricles Ventricular Function ~ = Cardiac Output Appearance 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 / shape If greater than 0.12 seconds, indicates trouble, i.e., a conduction delay in the ventricles QRS Complex Slide 30 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 ? Slide 31 Slide 32 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 effect Slide 33 U WAVES Potassium Effect HYPOKALEMIA Fairly Rare. P QRS T UP QRS T UP QRS T U P QRS T U TALL TENT-LIKE T Waves Caused by: K+ Hyperkalemia Either One, if not corrected, Means that ventricular tachycardia, And / or ventricular fibrillation IS on the way! Slide 34 Slide 35 RepetitionRepetition--Repetition RepetitionRepetition--Repetition 1. General Overview of strip 2. Rate 3. Rhythm 4. P Waves 5. P-R Interval (PRI) 6. QRS Interval 7. Q-T Interval Overview Develop Your Method Practice IT & Follow IT ! Practice IT & Follow IT ! Apply findings and observations to CRITERIA Slide 36 REMEMBER: At the end of the day, ITS ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R * * Tissue perfusion of vital organsand everything else. Slide 37 Measuring Time and Events Baseline or Isoelectric line P P Slide 38 Three Methods for rate determination 300 15010060 start 120 Easy Way: 12 x 10 (almost 11)= 120s Accurate if the rhythm is REGULAR Memorize. OR divide 300 By # of Big Boxes Between QRS complexesor divide 60 by # seconds between qrss 75 Slide 39 Discussion Measuring PRI & QRS Slide 40 RatesIntervals Remember the normals: PRI= 0.12 0.20 seconds (SA Node to Ventricles) QRS = < 0.12 seconds Time Through the Ventricles Slide 41 End of Cardiovascular Disease AH II Part 2 We Will Continue in a moment But first.. ..a word from our sponsors. 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