35: Dysrhythmias
first-degree block details
- atrial rate - regular, P-P is regular, 60-100 bpm - ventricular rate - regular, R-R is regular, 60-100 bpm - P wave - before every QRS - PR interval - >0.20 seconds - QRS interval - <0.12 seconds
second-degree (type 2) block details
- atrial rate - regular, P-P is regular, rate is variable - ventricular rate - regular until QRS is dropped, rate is less than atrial rate - P wave - more P waves than QRS complexes - PR interval - 0.12-0.20 seconds where they can be measured - QRS interval - variable
Third degree block
-Occasionally congenital, advanced age, acute MI, myocarditis, cardiac surgery, dig toxicity -transverse pacemaker, atropine, isproproteronol, pace maker
Ventricular Fibrillation
-Watch for PVCs and treat as ordered -CPR and defibrillate ASAP -may have Implatable Cardioverte Defibrillator
The nurse is doing discharge teaching with the patient and spouse of the patient who just received an implantable cardioverter-defibrillator (ICD) in the left side. Which statement by the patient indicates to the nurse that the patient needs more teaching? "I will call the cardiologist if my ICD fires." "I cannot fly because it will damage the ICD." "I cannot move my left arm until it is approved." "I cannot drive until my cardiologist says it is okay."
"I cannot fly because it will damage the ICD." The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that informing TSA about the ICD can be done because it may set off the metal detector and if a hand-held screening wand is used, it should not be placed directly over the ICD. The other options indicate the patient understands the teaching.
atrial flutter
- 250-350 atrial beats / 100 ventricular beats - PR not measurable - sawtooth P waves - normal QRS
normal sinus rhythm detail
- 60-100 bpm - atrial and ventricular rates are regular - PR interval - 0.12-0.20 seconds - QRS interval - <0.12 seconds
sinus bradycardia details
- <60 bpm - atrial and ventricular rates are regular - PR interval - 0.12-0.20 seconds - QRS interval - <0.12 seconds
sinus tachycardia details
- >100 bpm - atria and ventricular rate is regular - PR interval is 0.12-0.20 seconds - QRS interval is <0.12 seconds
causes for premature atrial contraction (PAC)
- AMI - CMF - anxiety - cigarette smoking - caffeine or alcohol intake - hypervolemia - hypokalemia - treatment usually not required
treatment for pulseless electrical activity
- CPR - epinephrine - identify possible causes (H&T)
treatment for sinus tachycardia
- alleviate underlying cause - administer IV fluids for hypovolemia - administer antipyretics for fever - synchronized cardioversion for hemodynamic instability
atrial flutter details
- atrial - regular rate, 250-400 bpm - ventricular - R-R intervals are regular or irregular based on fixed or variable block, 60-150 bpm - P waves are not discernible, has "sawtooth" appearance - PR interval - not measureable - QRS interval - <0.12 seconds
premature atrial contraction (PAC) details
- atrial and ventricular rates are regular but shortened - P wave is premature - PR interval is 0.12-0.20 seconds - QRS interval is <0.12 seconds
asystole details
- atrial rate - absent - ventricular rate - absent - P waves - absent - QRS - absent - PR and QRS intervals - absent
ventricular fibrillation details
- atrial rate - absent - ventricular rate - absent - P waves - absent - QRS - absent - PR interval and QRS interval - absent
premature ventricular contraction details
- atrial rate - absent/dissociated - ventricular rate - R-R is shorter with ectopic (premature or irregular) beat - P wave - absent/dissociated from the ectopic beat - QRS - widened or bizarre - PR interval - absent - QRS interval - ≥0.12 seconds
atrial fibrillation details
- atrial rate - no P-P interval, rate cannot be measured - ventricular rate - R-R intervals are irregular, rate is variable - no P wave - PR interval cannot be measured - QRS interval - <0.12 seconds
polymorphic ventricular tachycardia details
- atrial rate - obscured - ventricular rate - irregular and chaotic, 250-350 bpm - P wave - obscured - QRS - variable, wide and bizarre, not identical - PR interval - absent - QRS interval - ≥0.12 seconds
monomorphic ventricular tachycardia details
- atrial rate - obscured - ventricular rate - regular, R-R is regular, >150 bpm - P waves - obscured - PR interval - absent - QRS interval - ≥0.12 seconds
supraventricular tachycardia details
- atrial rate - regular, P-P interval is regular if it can be identified, 150-250 bpm - ventricular rate - regular, R-R is regular, 150-250 bpm - P waves - difficult to detect or hidden because of fast HR - PR intervals - not measureable - QRS intervals - <0.12 seconds
second-degree (type 1) block details
- atrial rate - regular, P-P is regular, 60-100 bpm - ventricular rate - R-R intervals decrease progressively until QRS drops, rate is variable - P wave - more P waves than QRS complexes - QRS - dropped in a cyclic pattern - PR intervals - increases with each beat - QRS - <0.12 seconds
third-degree block/complete block
- atrial rate - regular, PP is regular is underlying rhythm is sinus, 60-100 bpm, can be variable (afib) - ventricular rate - regular, R-R is regular ≤60 bpm (40 to 60 bpm if junctional, 15 to 40 bpm if ventricular) - P waves - more P waves than QRS complexes (complete A-V dissociation) - PR interval - increases with each beat - QRS interval - variable, but usually >0.12 seconds
pulseless electrical activity
- atrial rate - variable - ventricular rate - variable - P waves - may be present or absent - QRS - variable - PR interval - may be present or absent - QRS interval - variable
causes of ventricular fibrillation
- cardiac arrest - untreated or unsuccessfully treated ventricular tachycardia - cardiomyopathy - valvular heart disease - avid-base and electrolyte imbalance - electrical shock
treatment of heart block
- determine whether patient is stable or unstable - discontinue drugs if indicated and continue to monitor - pacemaker may be necessary
causes of heart block
- digitalis - beta-blockers - calcium channel blockers - increased vagal tone - hyperkalemia - myocarditis - rheumatic fever - degeneration of normal conductive pathways as associated with aging
treatment of atrial flutter
- goal is to convert to sinus rhythm - beta-blockers, digitalis, calcium channel blockers - if hemodynamically unstable, immediate cardioversion - anticoagulation prophylaxis - long term treatment - ablation
treatment of atrial fibrillation
- goal is to convert to sinus rhythm - diltiazem - if hemodynamically unstable, immediate cardioversion - anticoagulants prophylaxis - beta-blockers and digitalis
causes of atrial flutter
- hyperthyroidism - ischemic heart disease or AMI - cardiomyopathy - pericarditis - CHF - post-operative cardiac surgery - valvular disease - HTN - pulmonary disease - myocarditis - SSS
causes of pulseless electrical activity
- hypo/hyperkalemia - hypo/hyperglycemia - hypo/hyperthermia - hypoxemia - hypovolemia - trauma - toxins - tamponade - tension pneumothorax - thrombus
treatment of ventricular fibrillation
- immediate defibrillation - CPR - epinephrine - titrate to patient response - vasopressin as alternative to epinephrine
treatment of polymorphic ventricular tachycardia
- immediate defibrillation - precordial thump - CPR if pulseless - epinephrine - amiodarone - lidocaine
causes of supraventricular tachycardia
- nicotine or caffeine intake - stress/anxiety - hypoxemia - underlying CAD or cardiomyopathy
causes of premature ventricular contraction
- nicotine, caffeine, alcohol intake - cardiac ischemia or infarction - increased cardiac workload - digitalis toxicity - hypoxia - acidosis - hypokalemia
treatment for sinus bradycardia
- not necessary unless pt is symptomatic - discontinue medications - have patient cough to decrease vagal tone - atropine - pacemaker may be necessary
what can cause sinus bradycardia?
- parasympathetic nervous stimulation - ischemic SA node - some medications (digoxin, propranolol, barbiturates)
causes of polymorphic ventricular tachycardia
- same as PVCs - low ejection fractions - deadly rhythm with no perfusion although could have a pulse
what can cause sinus tachycardia?
- sympathetic nervous system stimulation - pain - anxiety or fear - drugs (caffeine, nicotine, amphetamine, cocaine, ecstasy, aminophylline, atropine) - hypoxia - hypovolemia - left ventricular failure, shock, or extension of infarct
treatment of premature ventricular contraction
- treated with amiodarone if persistent or frequent
causes of atrial fibrillation
- valvular disease - CHF - sick sinus syndrome (SSS) - cardiomyopathy - pulmonary disease - ischemic heart disease - post-operative cardiac surgery - hyperthyroidism - congenital disease
treatment for supraventricular tachycardia
- vasovagal maneuver (carotid sinus massage, gag, breath-holding, immerse face in cold water, blow in sealed syringe) - administer adenosiney - calcium channel blocker - cardioversion
Ventricular Tachycardia
-150-250 bpm -MI, Dig toxicity, Drug abuse, Electrolyte imbalance. -no pulse in this rhytm treat as v-fib and start CPR
couplet
-2 PVCs together (PVC, PVC, sinus, PVC, PVC, sinus, etc)
triplet
-3 PVCs together (PVC, PVC, PVC, sinus, PVC, PVC, PVC, sinus, etc)
Junctional Rhythm
-40-60 -underlying heart disease -if asymptomatic no treatment -if symptomatic treat with atropine, o2, transcutaneous pacing)
Atrial Flutter
-Atrial rate greater than 230 -r/t underlying cardiac causes -No treatment if flutter if venticular response is WDL, if not - diltiziem, magnesium, beta blockers
Atrial Fibrillation
-Controlled (70-90) -uncontrolled (110-180) -Usually started from PAC (decreased cardiac output) TREATMENT 1. control HR- diltiazem,BB, magnesium 2. convert to NSR: amiodaron, Ibultilide 3. Prvent stroke -cardioversion (if less than 48 hrs, if after admin anticoagulants for 3-4 weeks and then attempt)
non-ST-segment elevation MI (NSTEMI)
-ECG shows ST segment depression or prominent T wave inversion and/or positive biomarkers of necrosis (rise in troponin)
ST-segment elevation MI (STEMI)
-ECG shows ST segment elevation -occurs when thrombus completely blocks coronary artery -causes: acute MI, pericarditis, injury, LV aneurysms, broken heart syndrome (more common in elderly women)
First degree heart block
-Found in all agres with normal and diseased hearts, may be caused by meds -none, usually well tolerated -symptomatic treatment- atropine and pacemaker
Normal Sinus Rhythm with PVC
-No P wave -if infrequent no treatment -if frequent treat with antiarrhytmics, check K+ and dig levels, treat underlying cause: give 02, decrease pain, electrolyte balance.
Supraventricular Tachycardia
-atria and ventricular rates = 150-300 BPM -hidding t waves -asymptomatic if episodes are short, if sustained they cause dyspnea, dizziness, palpitation, hypotension, syncope, anxiety or chest pain. -TREAtMENT- O2, IV access, vagal maneuver, adnosine, calcium channel blockers and beta blockers to slow the heart
Dopamine
-beta receptors in the heart increases CO, and renal perfussion
ventricular fibrillation
-chaotic quivering of ventricles -grossly irregular electrical activity -unable to recognize ANY waveforms -results in CV COLLAPSE :( -causes: drugs that inc QT, ischemia, electrolyte abnormalities, reduces EF <30% -tx: CALL CODE (CPR, defib, epi, amiodarone) -think of Greys (VFIB, PUSH ONE OF EPI)
Second degree block Mobitz II
-damage to ventricular septum (MI) -may progress to third degree block -transvaneous pacing, atropine, epi
P Wave
-depolarization of the atria or contraction of the atria -No longer than 0.12 seconds
QRS Complex
-depolarization of the ventricular muscle -less than 0.12 seconds
bigeminy
-every other beat is PVC (PVC, sinus, PVC, sinus, etc)
asystole
-flatline -absence of electrical activity -result of prolonged cardiac arrest -successful resuscitation not likely -PEA: pulseless electrical activity (rhythm present but NO pulse) -tx: compressions, EPI, oxygenate, fluid challenge, find cause!! -causes (H/T): hypoxemia, hypovolemia, hypothermia, hypo/hyperkalemia, hydrogen ion (acidosis), tamponade, tension pneumothorax, toxins (drugs), thromboembolism (pulmonary or coronary)
Sinus Tachycardia
-greater than 100 BPM -usually harmless if less than 150 bpm but cause needs to be identified -S/sx- dizziness, hypotension -TREATMENT- eliminate cause
second degree heart block
-grouped beatings -PR interval gets progressively longer followed by a QRS complex -inferior MI or dig toxicity, may be normal -no treatment except check drug levels
Sinus Bradycardia
-heart rate is less than 60 bpm -no treatment if asymptomatic -if symptomatic- atropine and oxygen, transcutaneous pacing, dopamine, epinepherine.
Normal Sinus Rhythm
-hr 60-100 bpm
P-R Interval
-impulse that passes from the SA node, through the atria and AV node to the ventricles -0.12-0.20 seconds
Sinus Arrest
-in elderly pt with disease of SA node -results from med intoxication -acute MIs -Treatment-- look for cause, discontinue drugs that may cause the problem, may need to use atropine or pacer
Epinephrine
-increases contraction, HR, CO, and vasoconstriction
a-fib
-irregular R-R interval -no P waves -fibrillatory waves -SA node no longer in control of heart -impulses coming from everywhere in atria -no ventricular rate (HR can be slow or fast) -causes: CHF, HTN, valve disorder, CMP, MI, fluid overload, pericarditis, hyperthyroidism, idiopathic -emboli can develop -tx: rate and rhythm control, radio-frequency ablation, anticoagulation
Asystole
-lack of firing throughout the heart -check pt first -cpr -check another lead -epi, atropine, pacemaker
Normal Sinus Rhythm with Premature Atrial Contractions
-may occur in normal people - if healthy heart no treament, depends on symptoms -Treatment- sedation and removal of exciting cause, may admin digoxin, propanolol, quinindine -monitor so it doesn't progress to a-fib
Sinus Dysrhythmias
-normal in young personw tih respirations -may indivate disaeas of SA node in the elderly -may be by meds -usually not treated
sinus bradycardia
-rate <60 bpm -causes: hyperkalemia, vagal stimulation, hypoxia/sleep apnea, athlete, dec blood flow, hypothyroid, inc ICP, meds
ventricular tachycardia
-rate >100 bpm -WIDE QRS -AV dissociation (atria and ventricles no longer working together, ventricles took over) -causes: electrolyte imbalance, ischemia, acute MI, CAD, CHF, reduced EF -tx: determine if pulse or pulseless, correct electrolytes, cardioversion *PULSE: state 12 lead EKG, VS, vagal maneuvers, drug therapy *PULSELESS: call CODE, CPR, defib, epi, amiodarone
sinus tachycardia
-rate >100 bpm (adults) -sx: fatigue, weakness, SOB, orthopnea, dec SpO2, dec BP -tx: maybe none, treat underlying cause
T Wave
-recovery phase after ventricular contraction. -antyhing that interferes with repolarization can invert the t waves.
atrial flutter
-regular flutter waves (rapid and regular) -ventricular rate irregular -unlike a fib, can have regular ventricular response -rate of atrial 140-150 -worse than a fib bc results in faster HR and cont to pump blood -most common adult arrythmia -causes: CHF, HTN, valve disorder, CMP, MI, fluid overload, pericarditis, hyperthyroidism, idiopathic -tx: rate and rhythm control, radio-frequency ablation, anticoagulation
ST Segment
-time period between completion of depolarization and the beginning of repolarization
QT interval
-ventricullar depolarization and repolarization. -0.36-0.44
premature ventricular complexes (PVCs)
-wide, bizzare QRS -BEAT, not rhythm (can have PVC w sinus rhythm) -premature complex -not associated w/P waves (P are atrial) -originate from ventricles -can have sinus rhythm, sinus brady, or sinus tachy w/PVC -bigeminy, triplet, couplet -worry if EF <30%, >6 PVCs/min, >2PVCs together, polymorphic -causes: ischemia/injury, drugs or electrolyte imbalance, invasive lines -tx: determine frequency, assess for cause and treat that, DO NOT routinely give drugs to suppress bc pt can die, can be ablated if excessive and symptomatic
how many seconds in small box?
.04 seconds
PR interval length
0.12 - 0.2 seconds
QRS interval length
0.12 seconds or less
how many seconds in large box?
0.2 seconds
When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be 60 beats/min. 75 beats/min. 100 beats/min. 150 beats/min.
100 beats/min. Since each small block on the ECG paper represents 0.04 seconds, 1500 of these blocks represents 1 minute. By dividing the number of small blocks (15, in this case) into 1500, the nurse can calculate the heart rate in a patient whose rhythm is regular (in this case, 100).
Atrial Flutter
250-300 bpm regular, recurring, saw-tooth flutter waves that originate from single ectopic foci in the right atrium high ventricular rates of over 100 bpm and the loss of the atrial kick (in the p wave) can decrease CO and cause chest pain/ HF increased risk for stroke catheter ablation is the treatment of choice causes: CAD, hypertension, mitral valve disorders, pulmonary emboli, drugs ect..
atrial fibrillation
350-500 atrial beats/min and irregular - PR not measurable - fast undefined P wave - QRS normal
Physiological Integrity COMPLETION 1. When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.
50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30. DIF: Cognitive Level: Remember (knowledge) REF: 789-790 TOP: Nursing Process: Assessment MSC:
Ventricular Tachycardia
>100 BPM Rhythm usually regular but may be slightly irregular If P wave present that usually bear no relation to the QRS complexes sometimes appearing randomly as notches in between the ventricular complexes. PR interval absent QRS complex wide bizarre shape >0.12 sec; similar shape and points in one direction-monoform V tach; When QRS complexes gradually changes direction and twist around the electrical axis-torsade de pointes
Physiological Integrity 25. Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin? a. Instruct the patient to call for assistance before getting out of bed. b. Explain the association between various dysrhythmias and syncope. c. Educate the patient about the need to avoid caffeine and other stimulants. d. Tell the patient about the benefits of implantable cardioverter-defibrillators.
A A patient with fainting episodes is at risk for falls. The nurse will plan to minimize the risk by having assistance whenever the patient up. The other actions may be needed if dysrhythmias are found to be the cause of the patient's syncope, but are not appropriate for syncope of unknown origin. DIF: Cognitive Level: Apply (application) REF: 807 TOP: Nursing Process: Planning MSC:
Physiological Integrity 9. A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about a. anticoagulant therapy. b. permanent pacemakers. c. electrical cardioversion. d. IV adenosine (Adenocard).
A Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant treatment for 3 weeks before attempting cardioversion. This is done to prevent embolization of clots from the atria. Cardioversion may be done after several weeks of anticoagulation therapy. Adenosine is not used to treat atrial fibrillation. Pacemakers are routinely used for patients with bradydysrhythmias. Information does not indicate that the patient has a slow heart rate. DIF: Cognitive Level: Apply (application) REF: 796 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC:
avoid standing near anti theft devices in doorways
A patient with a sinus node dysfunction has a permanent pacemaker inserted. Before discharge, what should the nurse include when teaching the patient?
an increase in infarct size
A patient with an acute MI has sinus tachycardia of 126 bpm. The nurse recognizes that if this dysrhthymia is not treated, the patient is likely to experience?
ST segment elevation
A with patient with chest pain that is unrelieved by nitroglycerin is admitted to the coronary care unit for observation and diagnosis. While the patient has continuous ECG monitoring, what finding would most concern the nurse?
Physiological Integrity OTHER 1. When preparing to defibrillate a patient. In which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patient's chest. e. Check the location of other staff and call out "all clear."
A, C, D, E, B This order will result in rapid defibrillation without endangering hospital staff. DIF: Cognitive Level: Analyze (analysis) REF: 802 TOP: Nursing Process: Implementation MSC:
A. Atrial fibrillation B. Atrial Flutter
A. top B. bottom
Ventricular Fibrillation
No rate Grossly irregular rhythm P wave absent PR interval absent QRS complex irregularly shaped, rounded or pointed and markedly dissimilar fibrillation (f) waves. May be coarse >3mm or fine if <3mm. Absence of pulse is best way to distinguish from artifact.
Second-degree AV block Type I
Rate and rhythm- Atrial: normal and regular, Ventricular: slower and regular. P Wave- Normal PR interval-Progressive lengthening QRS complex- Normal QRS width, with pattern of one nonconducted (blocked) QRS complex
Third Degree Heart Block
signal is blocked completely multiple escape beats from the ventricles because they are not receiving any impulse from the AV node symptoms: chest pain, dyspnea, syncope
Second-degree AV block Type II
Rate and rhythm- Atrial: usually normal and regular, Ventricular: slower and regular or irregular. P Wave- More P waves than QRS complexes. PR interval- Normal or prolonged QRS complex- Widened QRS, preceded by >= P waves, with nonconducted (blocked) QRS complex.
First-degree AV block
Rate and rhythm- Normal and regular P Wave- Normal PR interval- >0.20 sec QRS complex- Normal
Ventricular fibrillation
Rate and rhythm- Not measurable and irregular. P Wave- Absent. PR interval- Not measurable. QRS complex- Not measurable.
Premature ventricular contraction
Rate and rhythm- Underlying rhythm can be any rate, regular or irregular rhythm, PVCs occur at variable rates. P Wave- Not usually visible, hidden in the PVC. PR interval- Not measurable QRS complex- Wide and distorted.
there is electrical activity with no mechanical response
After defibrillation, the advanced cardiac life support nurse says that the patient has pulseless electrical activity, what is most important for the nurse to understand about this rhythm?
Premature Ventricular Contraction (PVC)
Rate of underlying rhythm Irregular rhythm when early PVCs interrupt underlying rhythm P wave absent or appearing as notches after QRS in ST segment or T wave. Compensatory pause usually present. PR interval absent QRS complex > 0.12; wide with bizarre shape; determine if PVCs are identical they are called uniform; PVCs with different shape are called multiform
SVT
SA node uncontrolled firing, HR greater than 150, pwave present
induce dysrhythmias that may require cardioversion or defibrillation to correct
the nurse plans close monitoring for the patient during electrophysiologic testing because this test
Safe and Effective Care Environment 23. A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first? a. Obtain a 12-lead electrocardiogram (ECG). b. Notify the health care provider of the change in rhythm. c. Give supplemental O2 at 2 to 3 L/min via nasal cannula. d. Assess the patient's vital signs including oxygen saturation.
C Because this patient has dyspnea and chest pain in association with the new rhythm, the nurse's initial actions should be to address the patient's airway, breathing, and circulation (ABC) by starting with oxygen administration. The other actions also are important and should be implemented rapidly. DIF: Cognitive Level: Apply (application) REF: 793 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
Atrial Flutter
Atrial rate 240-360 BPM (usually 300); Ventricular rate can vary from 60-150 BPM Regular or irregular rhythm Identical jagged, saw tooth repetitive waves; "F" or flutter waves; picket fence in appearance. One flutter wave is usually buried in the QRS. No PR interval; P:QRS conduction ratio may be 2:1, 3:1, 4:1 QRS complex usually narrow and normal
Atrial Fibrillation
Atrial rate 350-600 BPM; Ventricular rate 60-100 (controlled) > 100 (uncontrolled) Irregularly irregular ventricular rhythm Wavy undulating baseline; "f" or fibrillation waves that are irregularly shaped, rounded, or pointed and dissimilar. Coarse if "f" waves are large (greater than or equal to 1 mm). Fine if "f" waves are less than or equal to 1 mm. PR interval absent QRS complex usually normal
Physiological Integrity 21. A 19-year-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).
B In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the patient has coronary artery disease, and this should not be the first question the nurse asks. The patient is hemodynamically stable, so there is no indication that the patient needs to be seen in the ED or that oxygen needs to be administered. DIF: Cognitive Level: Apply (application) REF: 799 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
Physiological Integrity 15. When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n) a. isoelectric ST segment. b. P-R interval of 0.18 second. c. Q-T interval of 0.38 second. d. QRS interval of 0.14 second.
D Because the normal QRS interval is 0.04 to 0.10 seconds, the patient's QRS interval of 0.14 seconds indicates that the conduction through the ventricular conduction system is prolonged. The P-R interval and Q-T interval are within normal range, and ST segment should be isoelectric (flat). DIF: Cognitive Level: Apply (application) REF: 791 TOP: Nursing Process: Assessment MSC:
Physiological Integrity 6. A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to a. notify the health care provider immediately. b. give atropine per agency dysrhythmia protocol. c. prepare the patient for temporary pacemaker insertion. d. document the finding and continue to monitor the patient.
D First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block. The rate is normal, so there is no indication that atropine is needed. Immediate notification of the health care provider about an asymptomatic rhythm is not necessary. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Implementation MSC:
Physiological Integrity 22. The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first? a. A patient who is in a sinus rhythm, rate 98, after having electrical cardioversion 2 hours ago b. A patient with new onset atrial fibrillation, rate 88, who has a first dose of warfarin (Coumadin) due c. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating d. A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due
D The frequent firing of the ICD indicates that the patient's ventricles are very irritable, and the priority is to assess the patient and administer the amiodarone. The other patients may be seen after the amiodarone is administered. DIF: Cognitive Level: Analyze (analysis) REF: 803 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Implementation MSC:
Third degree block
No communication between the atria and ventricles; P will fire different from QRS
Pulseless Electrical Activity
ECG shows a normal heart rhythm that does not produce a pulse
A patient in asystole is likely to receive which drug treatment? Epinephrine and atropine Lidocaine and amiodarone Digoxin and procainamide β-adrenergic blockers and dopamine
Epinephrine and atropine Normally the patient in asystole cannot be successfully resuscitated. However, administration of epinephrine and atropine may prompt the return of depolarization and ventricular contraction. Lidocaine and amiodarone are used for PVCs. Digoxin and procainamide are used for ventricular rate control. β-adrenergic blockers are used to slow heart rate, and dopamine is used to increase heart rate.
sinus tachycardia
HR above 100
sinus bradycardia
HR below 40
the procedure will destroy area of the conduction system that are causing rapid heart rhythms
Important teaching for the patient scheduled for a radiofrequency catheter ablation procedure includes explaining that
Ventricular Tachycardia
Monomorphic P wave - not usually visible PR interval - not measurable QRS - wide and distorted
The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment depression and T-wave inversion. What should the nurse know that this indicates? Myocardia injury Myocardial ischemia Myocardial infarction A pacemaker is present.
Myocardial ischemia The ST depression and T wave inversion on the ECG of a patient diagnosed with ACS indicate myocardial ischemia from inadequate supply of blood and oxygen to the heart. Myocardial injury is identified with ST-segment elevation. Myocardial infarction is identified with ST-segment elevation and a widened and deep Q wave. A pacemaker's presence is evident on the ECG by a spike leading to depolarization and contraction.
Asystole
Nothing
Paroxysmal superventricular tachycardia
P wave - abnormal shape, may be hidden in preceding T wave PR interval - Normal or shortened QRS complex - normal
Ventricular Fibrillation
P wave - absent PR interval - not measurable QRS - not measurable
Atrial Fibrillation
P wave - fibrillatory waves PR interval - not measurable QRS - normal
Atrial Flutter
P wave - flutter waves sawtooth pattern; more flutter waves than QRS complexes; occur in 2:1, 3:1, 4:1 PR interval - not measurable QRS - normal
First-Degree AV Block
P wave - normal PR interval - >.20 secs QRS - normal
is an emergency, no shocking
PEA
Second Degree AV block: Type 1
PR interval gets progressively longer until a p-wave is blocked completely cyclic lengthening no ventricular stimulation- there is a dropped beat symptoms: lightheadedness, dizziness, syncope
First degree block
PR interval greater than .20 seconds; toxicity in digoxin is most common reason
first degree AV block
PR interval is longer than 0.2 second, p wave is separated from QRS complex
Hypokalemia can cause these heart rhythms
PVCs, bradycardia, blocks, ventricular tachycardia, inverted T waves and ST depression
Hyperkalemia can cause these heart rhythms
PVCs, vfib, peaked T waves, widened QRS
Torsades de Pointes
Polymorphic VT P wave - not usually visible PR interval - not measurable QRS - wide and distorted, alternates size and shape, prolonged QT interbal
PAC- premature atrial beat
Pre-cursor to A Fib; Cardioversion: controlled; shock to regulate the rate; Cardizem
A patient has sought care following a syncopal episode of unknown etiology. Which nursing action should the nurse prioritize in the patient's subsequent diagnostic workup? Preparing to assist with a head-up tilt-test Preparing an IV dose of a β-adrenergic blocker Assessing the patient's knowledge of pacemakers Teaching the patient about the role of antiplatelet aggregators
Preparing to assist with a head-up tilt-test In patients without structural heart disease, the head-up tilt-test is a common component of the diagnostic workup following episodes of syncope. IV β-blockers are not indicated although an IV infusion of low-dose isoproterenol may be started in an attempt to provoke a response if the head-up tilt-test did not have a response. Addressing pacemakers is premature and inappropriate at this stage of diagnosis. Patient teaching surrounding antiplatelet aggregators is not directly relevant to the patient's syncope at this time.
wenckebachs phenomena
QRS complex goes missing , or spaced out.
Which ECG characteristic is consistent with a diagnosis of ventricular tachycardia (VT)? Unmeasurable rate and rhythm Rate 150 beats/min; inverted P wave Rate 200 beats/min; P wave not visible Rate 125 beats/min; normal QRS complex
Rate 200 beats/min; P wave not visible VT is associated with a rate of 150 to 250 beats/min; the P wave is not normally visible. Rate and rhythm are not measurable in ventricular fibrillation. P wave inversion and a normal QRS complex are not associated with VT.
Sinus Tachycardia
Rate and rhythm- 101-200 bpm and regular P Wave- Normal PR interval- Normal QRS complex- Normal
The patient has atrial fibrillation with a rapid ventricular response. The nurse knows to prepare for which treatment if an electrical treatment is planned for this patient? Defibrillation Synchronized cardioversion Automatic external defibrillator (AED) Implantable cardioverter-defibrillator (ICD)
Synchronized cardioversion Synchronized cardioversion is planned for a patient with supraventricular tachydysrhythmias (atrial fibrillation with a rapid ventricular response). Defibrillation or AEDs are the treatment of choice to end ventricular fibrillation and pulseless ventricular tachycardia (VT). An ICD is used with patients who have survived sudden cardiac death (SCD), have spontaneous sustained VT, and are at high risk for future life-threatening dysrhythmias.
assessing the patient response to the dysrhythmia
The ECG monitor of a patient in the cardiac care unit after an MI indicates ventricular bigeminy with a rate of 50 beats/min. The nurse would anticipate?
Sinus rhythm with a depressed ST segment
The nurse is monitoring the ECG of a patient admitted with ACS, which ECG characteristics would be most suggestive of Myocardial ischemia
Patients should be sedated if cardioversion is done on a non emergency basis
The nurse prepares a patient for synchronized cardioverion knowing that cardioversion differs from defibrillation in that
tachydysrhythmias
The use of catheter ablation therapy to "burn" areas of the cardiac conduction system is indicated for the treatment of
The nurse is seeing artifact on the telemetry monitor. Which factors could contribute to this artifact? Disabled automaticity Electrodes in the wrong lead Too much hair under the electrodes Stimulation of the vagus nerve fibers
Too much hair under the electrodes Artifact is caused by muscle activity, electrical interference, or insecure leads and electrodes that could be caused by excessive chest wall hair. Disabled automaticity would cause an atrial dysrhythmia. Electrodes in the wrong lead will measure electricity in a different plane of the heart and may have a different wave form than expected. Stimulation of the vagus nerve fibers causes a decrease in heart rate, not artifact.
For which dysrhythmia is defibrillation primarily indicated? Ventricular fibrillation Third-degree AV block Uncontrolled atrial fibrillation Ventricular tachycardia with a pulse
Ventricular fibrillation Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used (as long as the patient has a pulse). Pacemakers are the treatment of choice for third-degree heart block.
always pulsesless
Vfib
Lead placement for V1 includes one lead each for right arm, right leg, left arm, and left leg with the 5th lead on the 4th intercoastal space of the right of the sternal border.
What accurately describes ECG monitoring?
call the cardiologist
While providing discharge instructions to the patient who has had an implantable cardioverter-defibrillator inserted, the nurse teaches the patient that if the ICD fires,he or she should do what?
marked bradycardia and hypotension
a 54 year old patient who has no structural heart disease has an episode of syncope. An upright tilt table test is performed to rule out neurocardiogenic syncope. The nurse explains to the patient that is neurocardiogenic syncope is the problem, the patient will experience?
Begin CPR
a patient on the cardiac telemetry unit goes into ventricular fibrillation and is unresponsive. Following initiation of the Emergency call system (code blue), what is the next priority for the nurse in caring for this patient?
atropine
blocks vagal effects andi ncreases heart rate
pulse vtach patient awake
cardioversion, have crash cart ready
Vfib
chicken scratch looking
BBBs
conduction delay or block within one of the two main bundle of HIS branches
Atrial Tachycardia
rate is usually 160-240 beats a type of Supraventricular Tachycardia- generation of impulse outside the SA node can be a result of drug toxicity (digitalis)
atrial flutter
see regular QRS complex, p waves "flutter"
First Degree AV Block
delay in conduction of electrical impulse in the AV node but it still makes it to the ventricles Regular p-wave long P-R interval usually no symptoms but may be caused by lyte imbalance or medicine
Atrial Fibrillation
disorganization of atrial electrical activity from multiple ectopic foci can be paroxysmal or persistent (7 days or more) 350-600 bpm ventricular response of 60-100= controlled, ventricular response >100= uncontrolled results in decreased CO because of ineffective atrial contractions can cause thrombi from blood pooling and lead to strokes treatment: decrease ventricular response, CCB (diltiazem), BB, Digoxin (lanoxin), dronedarone
pulseless vtach you do..
get defibrillator, call code, CPR
premature arterial complexes
impulse fires before next sinus impulse, no pwave.
Second Degree AV block: type 2
intermittent drop in beats that happens randomly R-waves are irregular (dropped QRS complexes) usually occurs in an anterior MI (blocked bundle branch)
ventricular arrhythmias
more common in ADULTS (cause of ped arrest is usually respiratory)
afib
no clear p wave, no atrial contraction, irregular ventricular response
Pulseless electrical activity (PEA)
no palpable pulse, but shows electrical activity
third degree block
no regular p wave exist "buried",
normal sinus rhythm
p wave is present consistent and preceding each QRS complex, heart beat 60-100bpm
second degree AV block type 2
p waves randomly not conduct, usually no lengthening of PR interval before missing QRS
Premature Atrial Contraction (PAC)
p-wave followed by a normal QRS can be caused by caffeine, alcohol, drugs, electrolyte imbalance, COPD usually not treated...maybe BB p-wave can look like its part of the T wave
Wandering Atrial Pacemaker
pacemaker site shifts from the SA node to the AV node Rate is still 60-100 p-waves vary in size/shape P-R intervals are normal to short 1:1
shockable rhythms
pulseless Vtach and Vfib
Supraventricular tachycardia (SVT)
rapid rhythm over 100 generated outside of the ventricles symptoms: palpitations, lightheadedness, dizziness treatment: BB, CCB, antiarrythmics
Hypokalemia and hypomagnesemia can cause this heart rhythm
torsades; can be the result of prolonged QT; often ends in vfib
cannot be defibrillated only CPR
ventricular asystole
Wolff- Parkinson- White (WPW)
ventricular pre-excitation presence of delta wave
vtach
wide complex, patient may or may not have pulse
automaticity
What describes the SA node ability to discharge an electrical impulses spontaneously
applying gel pads to the patient chest
What is included in the nurse's responsibilities in preparing to administer defibrillation?
chest pain and decreased mentation
in the patient with a dysrhythmia, which assessment indicates decreased cardiac output
ST segment Elevation
the patient is brought to the ED with acute coronary syndrome. What changes should the nurse expect to see on the ECG is only myocardial injury has occurred?
Hypocalcemia can cause these heart rhythms
prolonged QT and prolonged ST interval
Safe and Effective Care Environment 27. Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias? a. Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia b. Obtains the defibrillator and quickly brings it to the bedside of a patient whose monitor shows asystole c. Turns the synchronizer switch to the "on" position before defibrillating a patient with ventricular fibrillation d. Gives the prescribed dose of diltiazem (Cardizem) to a patient with new-onset type II second degree AV block
A Adenosine must be given over 1 to 2 seconds to be effective. The other actions indicate a need for more education about treatment of cardiac dysrhythmias. The RN should hold the diltiazem until talking to the health care provider. The treatment for asystole is immediate CPR. The synchronizer switch should be "off" when defibrillating. DIF: Cognitive Level: Analyze (analysis) REF: 795 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Evaluation MSC:
Physiological Integrity 8. After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective? a. Increase in the patient's heart rate b. Increase in strength of peripheral pulses c. Decrease in premature atrial contractions d. Decrease in premature ventricular contractions
A Atropine will increase the heart rate and conduction through the AV node. Because the medication increases electrical conduction, not cardiac contractility, the quality of the peripheral pulses is not used to evaluate the drug effectiveness. The patient does not have premature atrial or ventricular contractions. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Evaluation MSC:
Physiological Integrity 14. A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate? a. Allow the student to participate on the soccer team. b. Refer the student to a cardiologist for further diagnostic testing. c. Tell the student to stop playing immediately if any dyspnea occurs. d. Obtain more detailed information about the student's family health history.
A In an aerobically trained individual, sinus bradycardia is normal. The student's normal BP and negative health history indicate that there is no need for a cardiology referral or for more detailed information about the family's health history. Dyspnea during an aerobic activity such as soccer is normal. DIF: Cognitive Level: Apply (application) REF: 793 TOP: Nursing Process: Implementation MSC:
1. To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's a. P wave. b. Q wave. c. P-R interval. d. QRS complex.
A The P wave represents the depolarization of the atria. The P-R interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers. The QRS represents ventricular depolarization. The Q wave is the first negative deflection following the P wave and should be narrow and short. DIF: Cognitive Level: Understand (comprehension) REF: 791 TOP: Nursing Process: Assessment MSC:
Physiological Integrity 12. Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs? a. The nurse assists the patient to do active range of motion exercises for all extremities. b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID. c. The nurse gives amiodarone (Cordarone) to the patient without first consulting with the health care provider. d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.
A The patient should avoid moving the arm on the ICD insertion site until healing has occurred in order to prevent displacement of the ICD leads. The other actions by the new nurse are appropriate for this patient. DIF: Cognitive Level: Apply (application) REF: 803 TOP: Nursing Process: Evaluation MSC:
Physiological Integrity 18. A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first? a. Perform immediate defibrillation. b. Give epinephrine (Adrenalin) IV. c. Prepare for endotracheal intubation. d. Give ventilations with a bag-valve-mask device.
A The patient's rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the initial action should be to defibrillate. If a defibrillator is not immediately available or is unsuccessful in converting the patient to a better rhythm, the other actions may be appropriate. DIF: Cognitive Level: Apply (application) REF: 801 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
The nurse is watching the cardiac monitor, and a patient's rhythm suddenly changes. There are no P waves. Instead there are fine, wavy lines between the QRS complexes. The QRS complexes measure 0.08 sec (narrow), but they occur irregularly with a rate of 120 beats/min. The nurse correctly interprets this rhythm as what? Sinus tachycardia Atrial fibrillation Ventricular fibrillation Ventricular tachycardia
Atrial fibrillation Atrial fibrillation is represented on the cardiac monitor by irregular R-R intervals and small fibrillatory (f) waves. There are no normal P waves because the atria are not truly contracting, just fibrillating. Sinus tachycardia is a sinus rate above 100 beats/minute with normal P waves. Ventricular fibrillation is seen on the ECG without a visible P wave; an unmeasurable heart rate, PR or QRS; and the rhythm is irregular and chaotic. Ventricular tachycardia is seen as three or more premature ventricular contractions (PVCs) that have distorted QRS complexes with regular or irregular rhythm, and the P wave is usually buried in the QRS complex without a measurable PR interval.
Physiological Integrity 16. A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6
B Leads II, III, and AVF reflect the inferior area of the heart and the ST segment changes. Lead II will best capture any electrocardiographic (ECG) changes that indicate further damage to the myocardium. The other leads do not reflect the inferior part of the myocardial wall and will not provide data about further ischemic changes in that area. DIF: Cognitive Level: Analyze (analysis) REF: 806 TOP: Nursing Process: Implementation MSC:
Physiological Integrity 24. A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take? a. Perform synchronized cardioversion. b. Start cardiopulmonary resuscitation (CPR). c. Administer atropine per agency dysrhythmia protocol. d. Provide supplemental oxygen via non-rebreather mask.
B The patient's clinical manifestations indicate pulseless electrical activity and the nurse should immediately start CPR. The other actions would not be of benefit to this patient. DIF: Cognitive Level: Apply (application) REF: 800 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
Physiological Integrity 5. The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm? a. Ventricular couplets b. Ventricular bigeminy c. Ventricular R-on-T phenomenon d. Multifocal premature ventricular contractions
B Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking. Pairs of wide QRS complexes are described as ventricular couplets. There is no indication that the premature ventricular contractions (PVCs) are multifocal or that the R-on-T phenomenon is occurring. DIF: Cognitive Level: Apply (application) REF: 799 TOP: Nursing Process: Assessment MSC:
Safe and Effective Care Environment 13. Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg? a. Turn the synchronizer switch to the "off" position. b. Give a sedative before cardioversion is implemented. c. Set the defibrillator/cardioverter energy to 360 joules. d. Provide assisted ventilations with a bag-valve-mask device.
B When a patient has a nonemergency cardioversion, sedation is used just before the procedure. The synchronizer switch is turned "on" for cardioversion. The initial level of joules for cardioversion is low (e.g., 50). Assisted ventilations are not indicated for this patient. DIF: Cognitive Level: Apply (application) REF: 802 TOP: Nursing Process: Implementation MSC:
The nurse obtains a 6-second rhythm strip and charts the following analysis: Tab 1 Atrial data Rate: 70, regular Variable PR interval Independent beats Tab 2 Ventricular data Rate: 40, regular Isolated escape beats Tab 3 Additional data QRS: 0.04 sec P wave and QRS complexes unrelated What is the correct interpretation of this rhythm strip? A. Sinus arrhythmias B. Third-degree heart block C. Wenckebach phenomenon D. Premature ventricular contractions
B. Third-degree heart block Third-degree heart block represents a loss of communication between the atrium and ventricles from AV node dissociation. This is depicted on the rhythm strip as no relationship between the P waves (representing atrial contraction) and QRS complexes (representing ventricular contraction). The atria are beating totally on their own at 70 beats/min, whereas the ventricles are pacing themselves at 40 beats/min. Sinus dysrhythmia is seen with a slower heart rate with exhalation and an increased heart rate with inhalation. In Wenckebach heart block, there is a gradual lengthening of the PR interval until an atrial impulse is nonconducted and a QRS complex is blocked or missing. Premature ventricular contractions (PVCs) are the early occurrence of a wide, distorted QRS complex.
Physiological Integrity 3. A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute. a. 15 to 20 b. 20 to 40 c. 40 to 60 d. 60 to 100
C If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will automatically discharge at the normal rate of 40 to 60 beats/minute. The slower rates are typical of the bundle of His and the Purkinje system and may be seen with failure of both the SA and AV node to discharge. The normal SA node rate is 60 to 100 beats/minute. DIF: Cognitive Level: Understand (comprehension) REF: 797 TOP: Nursing Process: Assessment MSC:
Physiological Integrity 10. Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter? a. The procedure will prevent or minimize the risk for sudden cardiac death. b. The procedure will use cold therapy to stop the formation of the flutter waves. c. The procedure will use electrical energy to destroy areas of the conduction system. d. The procedure will stimulate the growth of new conduction pathways between the atria.
C Radiofrequency catheter ablation therapy uses electrical energy to "burn" or ablate areas of the conduction system as definitive treatment of atrial flutter (i.e., restore normal sinus rhythm) and tachydysrhythmias. All other statements regarding the procedure are incorrect. DIF: Cognitive Level: Apply (application) REF: 805 TOP: Nursing Process: Implementation MSC:
Safe and Effective Care Environment 28. A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as a. junctional escape rhythm. b. accelerated idioventricular rhythm. c. third-degree atrioventricular (AV) block. d. sinus rhythm with premature atrial contractions (PACs).
C The inconsistency between the atrial and ventricular rates and the variable P-R interval indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs will have a normal rate and consistent P-R intervals with occasional PACs. An accelerated idioventricular rhythm will not have visible P waves. DIF: Cognitive Level: Apply (application) REF: 798 TOP: Nursing Process: Assessment MSC:
Physiological Integrity 29. A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next? a. Prepare to perform electrical cardioversion. b. Have the patient perform the Valsalva maneuver. c. Obtain the patient's vital signs including oxygen saturation. d. Prepare to give a -blocker medication to slow the heart rate.
C The patient has sinus tachycardia, which may have multiple etiologies such as pain, dehydration, anxiety, and myocardial ischemia. Further assessment is needed before determining the treatment. Vagal stimulation or -blockade may be used after further assessment of the patient. Electrical cardioversion is used for some tachydysrhythmias, but would not be used for sinus tachycardia. DIF: Cognitive Level: Analyze (analysis) REF: 793 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
Physiological Integrity 26. Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit? a. Decide whether a patient's heart rate of 116 requires urgent treatment. b. Monitor a patient's level of consciousness during synchronized cardioversion. c. Observe cardiac rhythms for multiple patients who have telemetry monitoring. d. Select the best lead for monitoring a patient admitted with acute coronary syndrome.
C UAP serving as telemetry technicians can monitor cardiac rhythms for individuals or groups of patients. Nursing actions such as assessment and choice of the most appropriate lead based on ST segment elevation location require RN-level education and scope of practice. DIF: Cognitive Level: Analyze (analysis) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:
The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which nursing intervention is most appropriate at this time? A. Reinforcing the pressure dressing as needed B. Encouraging range-of-motion exercises of the involved arm C. Assessing the incision for any redness, swelling, or discharge D. Applying wet-to-dry dressings every 4 hours to the insertion site
C. Assessing the incision for any redness, swelling, or discharge After pacemaker insertion, it is important for the nurse to observe signs of infection by assessing for any redness, swelling, or discharge from the incision site. The nonpressure dressing is kept dry until removed, usually 24 hours postoperatively. It is important for the patient to limit activity of the involved arm to minimize pacemaker lead displacement.
Which statement best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? A. The length of time it takes to depolarize the atrium B. The length of time it takes for the atria to depolarize and repolarize C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers D. The length of time it takes for the electrical impulse to travel from the SA node to the AV node
C. The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers The electrical impulse in the heart must travel from the SA node through the AV node and into the Purkinje fibers in order for synchronous atrial and ventricular contraction to occur. When measuring the PR interval (the time from the beginning of the P wave to the beginning of the QRS), the nurse is identifying the length of time it takes for the electrical impulse to travel from the SA node to the Purkinje fibers. The P wave represents the length of time it takes for the impulse to travel from the SA node through the atrium causing depolarization of the atria (atrial contraction). Atrial repolarization occurs during ventricular depolarization and is hidden by the QRS complex. The length of time it takes for the electrical impulse to travel from the SA node to the AV node is the flat line between the end of the P wave and the beginning of the Q wave on the ECG and is not usually measured.
Physiological Integrity 17. Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider? a. Blood glucose 243 mg/dL b. Serum chloride 92 mEq/L c. Serum sodium 134 mEq/L d. Serum potassium 2.9 mEq/L
D Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation. The health care provider will need to prescribe a potassium infusion to correct this abnormality. Although the other laboratory values also are abnormal, they are not likely to be the etiology of the patient's PVCs and do not require immediate correction. DIF: Cognitive Level: Apply (application) REF: 799 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
Atrial flutter
Rate and rhythm- Atrial 200-350 bpm and regular, Ventricular> or < 100 bpm regular or irregular. P Wave- Flutter (F) waves (sawtooth pattern) more flutter waves than QRS complexes; may occur in a 2:1, 3:1, 4:1 pattern. PR interval- Not measurable QRS complex- Normal usually
Atrial fibrillation
Rate and rhythm- Atrial 350-600 bpm and regular. P Wave- Fibrillatory (f) waves PR interval- not measurable QRS complex- Normal (usually)
Physiological Integrity 4. The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as a. atrial flutter. b. sinus tachycardia. c. ventricular fibrillation. d. ventricular tachycardia.
D The absence of P waves, wide QRS, rate >150 beats/minute, and the regularity of the rhythm indicate ventricular tachycardia. Atrial flutter is usually regular, has a narrow QRS configuration, and has flutter waves present representing atrial activity. Sinus tachycardia has P waves. Ventricular fibrillation is irregular and does not have a consistent QRS duration. DIF: Cognitive Level: Apply (application) REF: 794 TOP: Nursing Process: Assessment MSC:
Physiological Integrity 7. A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next? a. Immediately notify the health care provider. b. Document the rhythm and continue to monitor the patient. c. Perform synchronized cardioversion per agency dysrhythmia protocol. d. Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.
D The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes. The nurse should notify the health care provider after the medication is started. Defibrillation is not indicated given that the patient is currently in a sinus rhythm. Documentation and continued monitoring are not adequate responses to this situation. DIF: Cognitive Level: Apply (application) REF: 799 TOP: Nursing Process: Implementation MSC:
Third-degree AV block
Rate and rhythm- Atrial: Regular but may appear irregular due to P waves hidden in QRS complexes, Ventricular: 20-60 beats/min and regular. P Wave- Normal, but no connection with QRS complex. PR interval- Variable. QRS complex- Normal or widened, no relationship with P waves.
Premature atrial contraction
Rate and rhythm- Usually 60-100 bpm and irregular. P Wave- Abnormal shape PR interval- Normal QRS complex- Normal (usually)
Physiological Integrity 19. A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next? a. Place the transcutaneous pacemaker pads on the patient. b. Administer atropine sulfate 1 mg IV per agency dysrhythmia protocol. c. Document the patient's rhythm and assess the patient's response to the rhythm. d. Call the health care provider before giving the next dose of metoprolol (Lopressor).
D The patient has progressive first-degree atrioventricular (AV) block, and the -blocker should be held until discussing the medication with the health care provider. Documentation and assessment are appropriate but not fully adequate responses. The patient with first-degree AV block usually is asymptomatic, and a pacemaker is not indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no indication that this patient is symptomatic. DIF: Cognitive Level: Apply (application) REF: 798 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
Physiological Integrity 20. A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next? a. Recheck the heart rhythm and BP in 5 minutes. b. Have the patient perform the Valsalva maneuver. c. Give the scheduled dose of diltiazem (Cardizem). d. Apply the transcutaneous pacemaker (TCP) pads.
D The patient is experiencing symptomatic bradycardia, and treatment with TCP is appropriate. Continued monitoring of the rhythm and BP is an inadequate response. Calcium channel blockers will further decrease the heart rate, and the diltiazem should be held. The Valsalva maneuver will further decrease the rate. DIF: Cognitive Level: Apply (application) REF: 804 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:
Psychosocial Integrity 11. After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states a. "I will avoid cooking with a microwave oven or being near one in use." b. "It will be 1 month before I can take a bath or return to my usual activities." c. "I will notify the airlines when I make a reservation that I have a pacemaker." d. "I won't lift the arm on the pacemaker side up very high until I see the doctor."
D The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads. The patient should notify airport security about the presence of a pacemaker before going through the metal detector, but there is no need to notify the airlines when making a reservation. Microwave oven use does not affect the pacemaker. The insertion procedure involves minor surgery that will have a short recovery period. DIF: Cognitive Level: Apply (application) REF: 805 TOP: Nursing Process: Evaluation MSC:
Physiological Integrity 2. The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use? a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
D This is the quickest way to determine the ventricular rate for a patient with a regular rhythm. All the other methods are accurate, but take longer. DIF: Cognitive Level: Apply (application) REF: 789-790 TOP: Nursing Process: Assessment MSC:
The patient has hypokalemia, and the nurse obtains the following measurements on the rhythm strip: Heart rate of 86 with a regular rhythm; the P wave is 0.06 seconds (sec) and normal shape; the PR interval is 0.24 sec; the QRS is 0.09 sec. How should the nurse document this rhythm? First-degree AV block Second-degree AV block Premature atrial contraction (PAC) Premature ventricular contraction (PVC)
First-degree AV block In first-degree AV block there is prolonged duration of AV conduction that lengthens the PR interval above 0.20 sec. In type I second-degree AV block the PR interval continues to increase in duration until a QRS complex is blocked. In Type II the PR interval may be normal or prolonged, the ventricular rhythm may be irregular, and the QRS is usually greater than 0.12 sec. PACs cause an irregular rhythm with a different-shaped P wave than the rest of the beats, and the PR interval may be shorter or longer. PVCs cause an irregular rhythm, and the QRS complex is wide and distorted in shape.
Paroxysmal supraventricular tachycardia
Rate and rhythm- 150-220 bpm regular P Wave- Abnormal shape, may be hidden in the preceding T wave. PR interval- Normal or shortened QRS complex- Normal (usually)
Ventricular tachycardia
Rate and rhythm- 150-250 bpm and regular or irregular. P Wave- Not usually visible. PR interval- Not measurable QRS complex- Wide and distorted.
Accelerated idioventricular rhythm
Rate and rhythm- 40-100 bpm and regular. P Wave- not usually visible. PR interval- Not measurable. QRS complex- Wide and distorted.
Junctional dysrhythmias
Rate and rhythm- 40-180 bpm and regular P Wave- Inverted, may be hidden in QRS complex. PR interval- Variable QRS complex- Normal (usually)
Normal Sinus Rhythm
Rate and rhythm- 60-100 bpm P Wave- Normal PR interval- Normal QRS Complex- Normal
Sinus Bradycardia
Rate and rhythm- <60 bpm regular P Wave- Normal PR interval- Normal QRS complex- Normal
