Unit D1

The nursing student learning on a cardiac unit asks the instructor why loss of the "atrial kick" causes a decrease in cardiac output, because the ventricles are still contracting. What is the nursing instructor's best response? "The atrial contraction fills the ventricles and accounts for nearly one-third of the volume ejected during ventricular contraction." "Loss of the atrial kick does not affect cardiac output; cardiac output remains the same, with or without it." "The atrial kick is only helpful if the ventricles are failing." "The atrial kick is never lost; there is always some atrial kick present."

"The atrial contraction fills the ventricles and accounts for nearly one-third of the volume ejected during ventricular contraction."

While teaching a CPR class, a student in the class asks what the difference is between cardioversion and defibrillation. What would be the nurse's best response? "Cardioversion is done on a beating heart; defibrillation is not." "The difference is the timing of the delivery of the electric current." "Defibrillation is synchronized with the electrical activity of the heart; cardioversion is not." "Cardioversion is always attempted before defibrillation because it is not as dangerous."

"The difference is the timing of the delivery of the electric current."

The nursing student asks the nurse how to tell the difference between ventricular tachycardia and ventricular fibrillation on an electrocardiogram strip. What is the best response? "Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes." "The two look very much alike; it is difficult to tell the difference." "The QRS complex in ventricular fibrillation is always narrow, while in ventricular tachycardia the QRS is of normal width." "The P-R interval will be prolonged in ventricular fibrillation, while in ventricular tachycardia the P-R interval is normal."

"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes."

A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in the left chest. The client is planning to go rifle hunting. How should the nurse respond? "Enjoy your hunting trip." "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." "Being that close to a rifle might make your ICD fire." "You'll need to take an extra dose of your antiarrhythmic before you shoot."

"You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site."

Lidocaine

-PVC -Vtach -Vfib

Adenosine

-SVT -paroxysmal push quickly, follow with saline flush give at room temperature

Epinephrine

-Vfib -Asystole -IVP q3-5m -used during cardiopulmonary arrest

Defibrillation

-Vfib -pulseless Vtach -asystole -do not use on pt with pulse or conscious -following defibrillation, CPR started immediately -clear: don't touch pt -pt may have burns after -after 2x then epi IVP

Procainamide

-afib -aflutter -PVC -Vtach -Vfib *can cause drug-induced lupus syndome*

All medications

-can cause more serious or new dysrrthmias -check apical/radial pulse 1 min before admin -hold med is HR <50, notify HCP -teach pt to take own pulse

S/S of decreased cardiac output

-change in LOC -decreased EF -anxious, distressed -pt may complain in chest pain d/t ischemia

PVC treatment

-correct cause: hypokalemia, hypomagnesemia, hypoxia -BB's, CCB;s -amiodarone

Cardioversion

-delivery of electrical current is synchronized with pt's intrinsic rhythm *"timed"* -during vent. depolarization, *QRS complex* *-never used during repolarization, t wave, will l/t Vtach or Vfib* *-pt must be on anticoagulant for 4-6w prior, TEE first* *-no Digoxin 48h before* -no food/drink 4h before *-check s/s of emboli: SOB, neurologic changes*

implantable cardioverter defibrillator (ICD)

-detects and terminates life-threatening tachycardia or fibrillation -implanted *-automatically charges and delivers charge* *-magnet will deactivate* -can interrogate device

electrophysiology study (EPS)

-evaluate and tx dysrhythmia -type of cardiac cath, uses contrast -not painful -NPO 8h before -lay still on table -don't bend at waist, strain, lift 24h after -no tub -check bleeding, swelling, temp -check contrast induced renal failure - increase hydration, I/O

V-tach treatment

-if no pulse: CPR/defibrillation -if pulse: amiodarone, BB, cardioversion -most important: assess pt, pulse, BP, mental status -can l/t v. fib

Second degree AV block Mobitz Type I Wenckebach treatment

-if no s/s: monitor -if s/s from decreased HR: atropine or pacemaker

pacemaker box settings

-rate -output -capture: will see P or QRS wave after firing -sensitivity: should sense pt's own rhythm, fire when needed

atrial flutter treatment

-rate control: BB's, CCB's, digoxin -rhythm control: amiodarone -anticoagulant -TEE to confirm no clots -cardioversion

A-fib treatment

-rate control: BB's, CCB's, digoxin -rhythm control: amiodarone -anticoagulant -TEE: confirm no clots -cardioversion

sinus bradycardia treatment

-remove meds that decrease HR (BB's, CCB's, digoxin) -atropine -pacemaker

sinus tachycardia treatment

-remove pain, fever, hypoxia, ischemia -BB's, CCB's, digoxin

ICD pt teaching

-routine telephone checks -take arrhythmia meds -no MRI, airport wand, generator, etc. -if ICD fires, call HCP ASAP -if ICD fires and feel sick, call 911 ASAP -wear bracelet -carry card -if energy too high, hiccups

permanent pacemakers

-single chamber: R atrium or vent. -dual chamber: R atrium and R vent. -biventricular: R atrium and R&L vent. - cardiac resynchronization

pacemaker pt teaching

-to change settings on pacer (interrogate): use special monitor. can also see hx -maintain pacer surveillance checks via phone transmission -no MRI -no high output electric generator -no contact sports -no heavy lifting 2 months -do not stand next to anti-theft device -no screening want at airport -carry pacer card -if HR <50, notify HCP. check daily -ok to use garage door opener and microwave

Types of temporary pacemakers

-transcutaneous -transvenous -epicardial

SVT treatment

-vagal stimulation (bear down, cough) -adenosine: IV push fast, then saline flush -BB's, CCB's -cardioversion if none of above works

universal classification system used to communicate

-when chamber is paced -which chamber is sensed -what prevents/triggers a paced beat

EKG: 5 small blocks/1 big block is how many seconds?

.20

EKG: each small block is how many seconds?

0.04

What is normal PRI?

0.12-0.20 seconds

atrial flutter 3 problems

1) clots 2) rate control 3) decreased CO

A-fib 3 problems:

1) clots 2) rate controls 3) decreased CO

Ventricular fibrillation (V-fib)

1) rhythm: irregular 2) rate: ? 3) P wave: none 4) PRI: none 5) QRS: ? 6) ectopic beats? yes 7) cm: no pulse, apenic

Atrial Fibrillation (A-Fib)

1) rhythm: irregular 2) rate: vent. rate (R-R)- <100 is controlled, >100 is uncontrolled. atrial rate (P-P)- 300-400 3) P wave: fibrillatory waves 4) PRI: cannot determine 5) QRS: narrow 6) ectopic beats? no 7) cm: pulse may be irregular, s/s decreased CO

First degree AV block

1) rhythm: regular 2) rate: 60-100 3) P wave: present 4) PRI: prolonged >0.2 5) QRS: narrow 6) ectopic beats? no 7) cm: none

Supraventricular Tachycardia (SVT)

1) rhythm: regular 2) rate: >100 3) P wave: cannot visualize 4) PRI: cannot determine 5) QRS: narrow (impulse generated above vent.) 6) ectopic beats? no 7) cm: palpitations, s/s decreased CO

Premature Atrial Contraction (PAC)

1) rhythm: regular except early beat(s) 2) rate: 60-100 3) P wave: present. P wave of PAC may look different 4) PRI: 0.12-0.2 5) QRS: narrow 6) ectopic beats? yes, early beats 7) cm: irregular pulse, PAC will produce pulse

premature ventricular contraction (PVC)

1) rhythm: regular except early beat(s) 2) rate: follows underlying rhythm 3) P wave: no P wave before PVC 4) PRI: none with the PVC 5) QRS: PVC has wide/distorted QRS, others narrow 6) ectopic beats? yes, early beat(s) 7) cm: PVC does not produce pulse, generally no s/s

atrial flutter

1) rhythm: regular or irregular 2) rate: vent. rate (R-R)- <100 is controlled >100 is uncontrolled. atrial rate (P-P)-220-350 3) P wave: saw-toothed flutter waves 4) PRI: cannot determine 5) QRS: narrow 6) ectopic beats? no 7) cm: may have irregular pulse, s/s decreased CO

Strip Assessment steps

1) rhythm: regular or irregular. use index card 2) rate: fast or slow. reg-count blocks irreg-count QRS's 3) P wave: P in front of QRS's, no extras 4) PRI: norm of 0.12-.02 5) QRS: narrow-impulse above vent. wide-impulse in/below vent. 6) ectopic beats? 7) tolerance: assess pt

ventricular couplet

2 PVCs in a row

conduction system: ventricles bpm

20-40

Ventricular tachycardia (V-tach)

3+ PVC's in a row 1) rhythm: regular 2) rate: 100-250 3) P wave: cannot visualize 4) PRI: cannot determine 5) QRS: wide, distorted 6) ectopic beats? yes 7) cm: s/s decreased CO, may or may not have pulse

conduction system: AV node bpm

40-60

conduction system: SA node bpm

60-100

A client is admitted to the emergency department reporting chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph monitor. The nurse counts 9 RR intervals on the client's 6-second rhythm tracing. The nurse correctly identifies the client's heart rate as

90 bpm

The nurse is working on a telemetry unit, caring for a client who develops dizziness and a second-degree heart block, Mobitz Type 1. What will be the initial nursing intervention? Administer an IV bolus of atropine. Send the client to the cardiac catheterization laboratory. Prepare to client for cardioversion. Review the client's medication record.

Administer an IV bolus of atropine. Atropine 0.5 mg given rapidly as an intravenous bolus every 3 to 5 minutes to a maximum total dose of 3.0 mg is the medication of choice in treating symptomatic second-degree heart block. The client may need to be sent to the cardiac catheterization lab for a temporary pacemaker, but atropine should be tried first. Cardioversion is used to treat a fast heart rate. Reviewing the medication record will not help the client initially.

The nurse explains to the patient with PACs that there are many causes, some of which are modifiable. Select all that apply. Hyperkalemia Hypoxemia Atrial ischemia Hypovolemia Alcohol Anxiety

All of these causes stimulate or increase electrical impulses in the heart except for hyperkalemia.

The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart? Altered patterns frequently turn into life-threatening arrhythmias. Altered patterns frequently produce neurological deficits. Altered patterns frequently cause a variety of home safety issues. Altered patterns frequently affect the heart's ability to pump blood effectively.

Altered patterns frequently affect the heart's ability to pump blood effectively.

The emergency department nurse is caring for a patient who has gone into cardiac arrest. The nurse is performing external defibrillation. Which of the following is a vital step in the procedure?

No one is to be touching the patient at the time shock is delivered.

A nurse is caring for a client who has had an automatic cardiac defibrillator implanted. What instructions should the nurse provide to the client? Avoid devices with a magnetic field. Use digital cellular telephones. Avoid driving for at least 3 months. Avoid using microwave ovens.

Avoid devices with a magnetic field.

The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client? Select all that apply. Avoid handheld screening devices in airports Refrain from walking through antitheft devices Check pulse daily, reporting sudden slowing or increase Avoid the usage of microwave ovens and electronic tools Wear a medical alert, noting the presence of a pacemaker

Avoid handheld screening devices in airports Check pulse daily, reporting sudden slowing or increase Wear a medical alert, noting the presence of a pacemaker Handheld screening devices used in airports may interfere with the pacemaker. Patients should be advised to ask security personnel to perform a hand search instead of using the handheld screening device. With a permanent pacemaker, the client should be instructed initially to restrict activity on the side of implantation. Clients also should be educated to perform a pulse check daily and to wear or carry medical identification to alert personnel to the presence of the pacemaker. Client should walk through antitheft devices quickly and avoid standing in or near these devices. Client can safely use microwave ovens and electronic tools.

V-fib treatment

CPR, defibrillation, epinephrine

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

P wave

PAC vs PVC

PAC: P wave before extra beat, narrow QRS PVC: no P wave before extra beat, wide QRS

with heparin, always check

PTT and platelets

R on T phenomenon

PVC on second half of T-wave can l/t v. fib

What is the absolute refractory period?

QRS

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle?

QRS complex

Amiodarone is not given for which dysrrthmia?

SVT

SVT vs VT

SVT: narrow QRS VT: wide QRS

transcutaneous pacemaker

Temporary; most commonly used as an emergency pacer large pacing pads placed on pt's chest and back *may cause significant discomfort, skin irritation bc of increased electricity. check for burns*

The nurse is assessing a patient with a probable diagnosis of first-degree AV block. The nurse is aware that this dysrhythmia is evident on an ECG strip by what indication? Variable heart rate, usually fewer than 90 bpm Irregular rhythm Delayed conduction, producing a prolonged PR interval P waves hidden within the QRS complex

Delayed conduction, producing a prolonged PR interval

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. The nurse knows elective cardioversion prevents what? Disrupting the heart during the critical period of atrial repolarization. Disrupting the heart during the critical period of ventricular repolarization. Disrupting the heart during the critical period of ventricular depolarization. Disrupting the heart during the critical period of atrial depolarization.

Disrupting the heart during the critical period of ventricular repolarization.

A nurse evaluates a client with a temporary pacemaker. The client's ECG tracing shows each P wave followed by the pacing spike. What is the nurse's best response? Document the findings and continue to monitor the client Reposition the extremity and turn the client to left side Obtain a 12-lead ECG and a portable chest x-ray Check the security of all connections and increase the milliamperage

Document the findings and continue to monitor the client Capture is a term used to denote that the appropriate complex is followed by the pacing spike. In this instance, the patient's temporary pacemaker is functioning appropriately; all Ps wave followed by an atrial pacing spike. The nurse should document the findings and continue to monitor the client. Repositioning the client, placing the client on the left side, checking the security of all connections, and increasing the milliamperage are nursing interventions used when the pacemaker has a loss of capture. Obtaining a 12-lead ECG and chest x-ray are indicated when there is a loss of pacing-total absence of pacing spikes or when there is a change in pacing QRS shape.

A client has been living with an internal, fixed-rate pacemaker. When checking the client's readings on a cardiac monitor the nurse notices an absence of spikes. What should the nurse do? Double-check the monitoring equipment. Do nothing; there is no cause for alarm. Suggest the need for a new beta-blocker to the doctor. Measure the client's blood pressure.

Double-check the monitoring equipment. One of the reasons for lack of pacemaker spikes is faulty monitoring equipment.

How is PR interval measured?

From the *beginning* of P to the beginning of QRS

with heparin, watch for

HIT (check platelets)

If QRS is narrow, impulse generated?

above ventricles

afib, SVT, vtach with pulse treatment

amiodarone, adenosine, and verapamil, cardioversion

P wave represents?

atrial depolarization (contraction)

PP interval represents?

atrial rate and rhythm

If there is a P wave know impulse originated in?

atrium

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia?

atropine

Second degree AV block Mobitz Type II treatment

atropine or pacemaker

bradycardia treatment

atropine, pacemaker

Which postimplantation instruction must a nurse provide to a client with a permanent pacemaker?

avoid sources of electrical interference

A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for? Insertion of an ICD Insertion of a permanent pacemaker Catheter ablation therapy Maze procedure

catheter ablation therapy

Pulseless Electrical Activity (PEA)

condition in which electrical activity is present on an electrocardiogram, but there is not an adequate pulse or blood pressure on the patient

How to calculate irregular rate?

count # of QRS's on strip, multiple x10

How to calculate regular rate?

count # of small blocks between R waves and divide by 1500

Digoxin

decreases HR -afib -aflutter check for bradycardia hold if HR <50, notify HCP check s/s of toxicity: GI upset, confusion, vision changes.

vtach without pulse, vfib treatment

defibrillation, epinephrine

pulse deficit

difference between the apical and radial pulse rates

pacemaker complications: most common

dislodgement of pacing electrode -if temp electrode: do not move extremity -if permanent: do not move extremity for 24h, in sling. restrict activity on side of implant for 2-4w. do not raise arm above shoulder 2-4w -minimize activity *-if dislodged: would see on monitor - pacer spikes with no firing*

epicardial pacemaker

done with open heart surgery, wires attached on epicardium, box attached

The nurse and student nurse are observing a cardioversion procedure completed by a physician. At which time is the nurse most correct to identify to the student when the electrical current will be initiated?

during ventricular depolarization NOT: during QRS complex The electrical current is initiated at the R wave when ventricular depolarization occurs. The electrical current completely depolarizes the entire myocardium with the goal of restoring the normal pacemaker of the heart. The other options focus on an incorrect timing that will not restore the normal electrical conduction.

intrinsic rhythm

electrical activity from heart itself

Ventricular bigeminy

every other beat is a PVC

Second degree AV block Mobitz Type II

extra P's at consistent interval - some without QRS 1) rhythm: R-R (vent)- regular or irregular. P-P (atrium)-regular 2) rate: may be reduced 3) P wave: present, extra assigned 4) PRI: constant for all conducted beats, none for unassigned 5) QRS: may be prolonged, no QRS attached to some P's 6) ectopic beats? none 7) cm: s/s of decreased CO

if pacer spike and no QRS after, then

failure of capture

A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that don't precede a beat. Which condition should the nurse suspect?

failure to capture

PAC treatment

generally benign -no stimulants -may use BB's

capture

heart's electrical response to pacer generated electrical stimulus. appropriate complex after pacing spike pacer spike, then should see complex (ie ORS) - means capture occurred

A-fib causes

hypertension, CHF, CAD, rheumatic heart disease, cor pulmonale, pericarditis, alcohol, illegal drug use

The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia? hypovolemia vagal stimulation hypothyroidism digoxin

hypovolemia

What is the treatment of choice for ventricular fibrillation?

immediate bystander CPR

The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?

immediate defibrillation

If QRS is wide, impulse generated?

in/below ventricles

Prolonged QT interval can lead to?

increased risk of vfib, death

Atropine

increases HR, given if bradycardic (AV block or sinus bradycardia) -anticholinergic -don't give to glaucoma patient -check BPH, urinary retention

transvenous pacemaker

lead or leads are threaded to the right atrium and/or right ventricle and attached to the external power source

A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia?

magnesium and potassium

Aystole

no electrical impulse no pulse (mechanical)

First degree AV block treatment

no treatment; changes to potentially causative situations

if pacer spike and QRS after, then capture

occured

Third degree AV block treatment

pacemaker

pacemaker firing

pacer electrical stimulus bc of absence of intrinsic stimulus pacer fires bc no internal beat

if pacer pt has hiccups:

pacer is pacing diaphragm

sensing

paver will detect whether or not heart has its own intrinsic rhythm to determine if it needs to fire -if no sense then it will not fire when needed

heparin antidote

protamine sulfate

Third degree AV block

random P's, inconsistent PRI, wide QRS, reduced HR 1) rhythm: R-R (vent) regular 2) rate: 20-60 3) P wave: present, unassigned extra 4) PRI: cannot determine 5) QRS: usually prolonged 6) ectopic beats: no 7) cm: s/s of decreased CO

Metoprolol (BB)

rate control. decreases HR and BP -afib -aflutter -PVC -sinus tachycardia do not stop abruptly check hypotension, bradycardia, HF *hold if HR less <50*

Diltiazem (CCB)

rate control. decreases HR and BP -afib -aflutter -SVT -sinus tachycardia check bradycardia, hypotension, HF check apical pulse/radial pulse 1 min. before admin hold is HR <50

Amiodarone

rhythm control -afib -aflutter -PVC -Vtach -Vfib can cause pulmonary toxicity, vision changes, liver dysfunction, photosensitivity, bluish skin

Multifocal PVCs

runs of PVCs - danger of decreased cardiac output - risk of V-tach or V-fib

The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter?

sawtooth

Second degree AV block Mobitz Type I Wenckebach

short, long, drop QRS. more P's than QRS's 1) rhythm: R-R (vent.)-irregular, P-P (artium)-regular 2) rate: may be reduced 3) P wave: present, extra unassigned 4) PRI: progressive prolongation of PRI until QRS is dropped 5) QRS: narrow 6) ectopic beats? no 7) cm: irregular pulse, s/s of decreased CO

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of dysrhythmia would the cardiologist likely diagnose?

sinus tachycardia

pacemaker spike

slash when pacer fires

modes of pacing

synchronous: demand mode asynchronous: fixed rate

The nurse is analyzing a rhythm strip. What does the nurse look at to identify ventricular repolarization?

t wave

The nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation for what important reason?

the defibrillator won't deliver a shock if the synchronizer is turned on. NOT: the delivered shock must be synchronized with the client's QRS complex. The nurse needs to check the synchronizer switch to ensure the switch is turned off. The defibrillator won't deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on. The synchronizer switch should be turned on when attempting to terminate arrhythmias that contain QRS complexes, such as rapid atrial fibrillation that's resistant to pharmacologic measures. A synchronized shock should occur with the QRS complex, not the T wave, to avoid inducing ventricular fibrillation and allow for a lower shock dose.

When no atrial impulse is conducted through the AV node into the ventricles, the client is said to be experiencing which type of AV block?

third degree NOT: first degree In third degree heart block, two impulses stimulate the heart, one impulse stimulates the ventricles and other stimulates the atria. In first degree heart block, all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. In second degree AV block, type I, all but one of the atrial impulses are conducted through the AV node into the ventricles. In second degree AV block, type II, only some of the atrial impulses are conducted through the AV node into the ventricles.

QRS represents?

ventricular depolarization (contraction)

RR interval represents?

ventricular rate and rhythm

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?

warfarin