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Adult Health Nursing II

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1 Adult Health Nursing II
Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring , part 2 Module: 2.3

2 Cardiovascular--- EKG’s / Cardiac Monitoring
Dynamic Presentation Static Presentation Note: A Power Point Presentation is designed for active viewing (or at least, this one is!). This presentation was not designed to be the template for a handout to be printed on paper. It is designed for viewing in the “Slide Show” Mode. Lead II Part II Block Module 2.3 Digitalis pupurea (Foxglove)

3 At the conclusion of this class (and after some practice)
the nurse will be able to: 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 Trace electrical conduction through the cardiac conduction system and correlate to the EKG Tracing. 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 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 Block Module 2.3

4 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 Module 2.3

5 Concept Map: Selected Topics in Cardiovascular Nursing
ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation Cardiac Monitoring Lab Monitoring PHARMACOLOGY Cardiac Glycosides ACE Inhibitors Alpha Blockers Beta Blockers Antiarrhythmics Catecholamines Anticoagulants 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 Raynaud’s Phenomenon Arrhythmias / Dysrhythmias Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more… Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary Block Module 2.3

6 Cardiac Output! * REMEMBER:
At the ‘end of the day,’ IT’S ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R Cardiac Output! * * Tissue perfusion of vital organs…and everything else…. Block Module 2.3

7 “It’s all about cardiac output.
An Affirmation “It’s all about cardiac output. Boy, don’t I know it now.” Block Module 2.3

8 Cardiac Output It’s All About… Cardiac Output = HR X SV What Factors
Affect Cardiac Output ? It’s All About… Cardiac Output Medications Sympathetic Nervous System Medications Baroreceptors Cardiac Output = HR X SV Blood Volume Chemoreceptors Preload, Afterload C.O. = Heart Rate x Stroke Volume Condition Of Myocardium And, Many more factors ! It’s All About Cardiac Output ! Condition of Cardiac Conduction System* Viscosity Of Blood Condition of Heart Valves Parasympathetic Nervous System Blood Volume Block Module 2.3

9 Example of Multiple Factors in Cardiac Output
Chemoreceptors Baroreceptors The SinoAtrial Node: impulses / minute Sympathetic Effects: Parasympathetic Effects: Block Module 2.3

10 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:_________ ________” conductivity, contractility, automaticity, refractoriness Sa= (atrial m. =60-100) av node = ventricle 20-40 SA node>>intratrial & internodal pathways>>AV node>>Bundle of His>> R & L bundle branches>>Purkinje fibers PRI= secs QRS=< 0.12 sec QT = CO = HR x SV BP = CO x SVR “Cardiac Output” Block Module 2.3

11 Superior Vena Cava Block 7.0 Module 2.3 R & L Common Carotid Arteries
Left Subclavian Artery Superior Vena Cava Lungs Lungs LUNGS Block Module 2.3

12 Cardiac Conduction Pathways
SA Node >> Inter nodal & Intra atrial pathways (Bachmann’s Bundle)>> AV Node >> Bundle of His >> Right & Left Bundle Branches >> Purkinje Fibers SA node Block Module 2.3

13 Intrinsic Rates… “automaticity”
Sino Atrial Node (SA Node) ipm Atrial Muscle ~ 60 ipm Atrio-Venticular Node (AV Node) 40 – 60 ipm “Rate & Rhythm” Ventricular Muscle 20-40 ipm Block Module 2.3

14 “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 = i.p.m. Block Module 2.3

15 Conduction Pathways and rough correlation to the ECG Waveform
SA Node Internodal & Intra-atrial Pathways AV Node Bundle of His (R) & (L) Bundle Branches Purkinje Fibers QRS : < 0.12 seconds T Wave Baseline Block Module 2.3 PRI: seconds

16 SA node Block Module 2.3

17 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 Block Module 2.3

18 Block Module 2.3

19 Rhythm Identification Each Has Specific Criteria…
POTENTIALLY LETHAL 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: 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 Terminology: Bradyarrhythmias versus tachyarrhythmias Wide-complex tachycardia versus narrow-complex tachycardia Block Module 2.3

20 Cardiac Output! * REMEMBER:
At the ‘end of the day,’ IT’S ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R Cardiac Output! * * Tissue perfusion of vital organs…and everything else…. Block Module 2.3

21 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 Module 2.3

22 The “Stepwise” Method Block Module 2.3

23 EKG PAPER Block Module 2.3

24 TIME EKG PAPER Small Block = 0.04 sec
5 Small Blocks = 1 Large Block = 0.20 sec 5 Large Blocks = 1 second EKG PAPER TIME Note: Standard EKG Machines “run” at 25 mm/sec “Amplitude” Or Strength of Electrical Impulse Block Module 2.3

25 “Standard” Limb Leads Lead II “universal”-- Most useful
Block Module 2.3

26 “ Chest Leads “ (for 12-Lead ECG)
Block Module 2.3

27 The ECG Complex, Wave forms, Intervals, Segments
Block Module 2.3

28 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 Block Module 2.3

29 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 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 (1st – 2nd- 3rd degree) PRI’s should all be ~ equal Block Module 2.3

30 QRS Complex 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 seconds, indicates “trouble,” i.e., a conduction delay in the ventricles Block Module 2.3

31 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 Module 2.3

32 Block Module 2.3

33 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 Block Module 2.3

34 “U” WAVES Potassium Effect HYPOKALEMIA Fairly Rare…. 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! Block Module 2.3

35 Block Module 2.3

36 Repetition—Repetition--Repetition
Overview— Develop Your Method Practice IT & Follow IT ! Repetition—Repetition--Repetition Apply findings and observations to CRITERIA 1. General Overview of strip 2. Rate 3. Rhythm 4. P Waves 5. P-R Interval (PRI) 6. QRS Interval 7. Q-T Interval Block Module 2.3

37 Cardiac Output! * REMEMBER:
At the ‘end of the day,’ IT’S ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R Cardiac Output! * * Tissue perfusion of vital organs…and everything else…. Block Module 2.3

38 Measuring Time and Events…
P P Baseline or Isoelectric line Block Module 2.3

39 Three Methods for rate determination…
120 start 300 150 100 60 Easy Way: 12 x 10 (almost 11)= 120’s Accurate if the rhythm is REGULAR 75 Memorize…. OR divide 300 By # of Big Boxes Between QRS complexes…or divide 60 by # seconds between qrs’s Block Module 2.3

40 Discussion … Measuring PRI & QRS
Block Module 2.3

41 Rates…Intervals… Remember the “normals”:
PRI= 0.12 – 0.20 seconds (SA Node to Ventricles) QRS = < 0.12 seconds Time Through the Ventricles Block Module 2.3

42 End of Cardiovascular Disease AH II Part 2 We Will Continue in a moment
But first…….. …..a word from our sponsors……. Block Module 2.3

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“P-P XL® helped me get my get my recommended 8 hours of sleep every day! Four hours at home, 1 hour in Pharmacology, two hours in Pedi, and 2 hours in Adult Health I ! I’ve never felt so refreshed! Wait—that adds up to eight, doesn’t it?” --Samantha Jones, Fictitious Nursing Student Indications: Powerful relief from NSRI* (Nursing School Related Insomnia) Power Point XL® is indicated for the treatment of chronic insomnia related to nursing school stress. With a starting dose of 50 slides per hour, P-P XL® is proven effective at hastening the onset of sleep in over 85% of nursing students. When combined with extremely boring material, the effect is even more pronounced* Warning: use cautiously with students with preexisting sleep apnea. ~END OF PRESENTATION~ GO TO THE NEXT PRESENTATION, Module 2.4 Block Module 2.3


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