chap 8 cardiovascular monitoring

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 8Advanced Cardiovascular

Monitoring Skills

Chapter 8Advanced Cardiovascular

Monitoring Skills


Automatic Blood Pressure Monitoring Automatic Blood Pressure Monitoring


Arterial Pressure Monitoring Arterial Pressure Monitoring

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Observations to Report to the Nurse ImmediatelyObservations to Report to the Nurse Immediately

• The dressing the insertion site is loose, wet, or soiled

• redness, swelling, drainage, or bleeding

• blood in the tubing

• Tubing disconnected

• change in the position of the patient or the bed (in other words, the transducer needs to be leveled and zeroed)

• change in the waveform or pressure reading on the monitor

• patient C/O pain, numbness, or tingling in the hand

• patient’s hand is pale, blue, or cold


Heart AnatomyHeart Anatomy• Location:

– Mid chest

– Base

• Top of heart

– Apex

• Bottom of heart – near diaphragm

– PMI

• Strongest pulse – 5 ICS, MCL


Layers of heart wallLayers of heart wall

• Pericardium

– Outermost layer

• Myocardium

– Muscular portion heart

• Endocardium

– Inner surface of heart


Chambers of heartChambers of heart


• Diastole

– Ventricles at rest, fill c blood

• Systole

– Ventricles contract, force blood into aorta / lungs


Pulse sitesPulse sites• Apical

• Temporal

• Carotid

• Brachial

• Radial

• Femoral

• Popliteal

• Pedal

• Posterior tibial


TelemetryTelemetry


Myocardial CellMyocardial Cell


Electrical PathwaysElectrical Pathways

• SA node

– Pacemaker of heart

• AV node

• Bundle of HIS

• Right and left bundle branches

• Purkinje fibers


EKG ComplexEKG Complex

• P Wave

• PR Interval

• QRS Complex

• T wave


P waveP wave

• First waveform – which represents impulse that causes atria to contract

• Represents atrial depolarization


PRIPRI

• Time required for impulse to travel from SA node to AV node


QRS ComplexQRS Complex

• Represents ventricular depolarization

– Journey AV node thru purkinje fibers


T waveT wave

• Repolarization of the heart

– Cell recharge selves for another impulse


Isoelectric lineIsoelectric line

No electrical activity

baseline


EKG Records:EKG Records:

• 1. amount of voltage generated by ht – vertical scale

• 2. time required for voltage to travel thru ht – horizontal scale


Review:Review:

• Which wave form represents?

– Ventricular depolarization?

– Atrial depolarization?

– Repolarization of the heart?


Answers:Answers:

• Ventricular depolarization = QRS complex

• Atrial depolarization = P wave

• Repolarization of the heart = T wave


EKG Interpretation: 5 criteriaEKG Interpretation: 5 criteria

• 1. What is the rate?

– Quick estimate:

• Count # R waves in a 6 second strip x 10

• 6 second strip = 3 “tic” marks


• 2. Is rhythm regular or irregular?

– Measure distance between RR interval

– Measure throughout full 6 second strip


• 3. Are P waves present?

– Should be 1:1


Abnormal rhythms with P wavesAbnormal rhythms with P waves


4. What is the PR Interval? PRI4. What is the PR Interval? PRI

• Normal .12 - .20

• Beginning of P wave to beginning of QRS complex


5. What is the width of QRS complex?5. What is the width of QRS complex?

• Normal .12 or < (less)


Interpretation of Rhythm:Interpretation of Rhythm:

• What is the rhythm?

– Use information from 5 previous slides– 1. rate =

– 2. P waves =

– 3. PRI =

– 4. QRS =

– 5. Interpretation =


Set up “cheat sheet”- Sinus RhythmsSet up “cheat sheet”- Sinus Rhythms

Interpretation Sinus Rhythm (SR)

Sinus Brady (SB)

Sinus Tach (ST)

Sinus (SA) Arrhythmia

Regularity

Rate

P waves

PRI

QRS


Sinus Rhythms: Impulse originates in SA node – normal pacemaker site

Sinus Rhythms: Impulse originates in SA node – normal pacemaker site

• Normal Sinus Rhythm - NSR:– Regularity – regular

– Rate - 60 – 100 / minute

– P waves = 1:1

– PRI = .12 - .20

– QRS = .12 or <


QuestionQuestion

What is a dysrhythmia?

A. Irregular rate only

B. Irregular rhythm only

C. Irregular rate and rhythm

D. Can be either or both irregular rate or rhythm


AnswerAnswer

D. Can be either or both irregular rate or rhythm

A dysrhythmia is an irregular heart rate, rhythm, or both. Remember that for the heart to be an effective pump, it must contract in two coordinated phases (atrial systole/ventricular diastole, followed by ventricular systole/atrial diastole). Rhythms that are irregular or rates that are too fast can affect the ventricles’ ability to fill with an adequate amount of blood or pump strongly enough to send the blood out of the heart.


Sinoatrial Node (Sinus) Dysrhythmias Sinoatrial Node (Sinus) Dysrhythmias

• Sinus bradycardia: the SA node fires electrical impulses at a rate that is slower than normal (that is, less than 60 impulses per minute)

• Sinus tachycardia: the SA node fires electrical impulses at a rate that is faster than normal (that is, greater than 100 impulses per minute)


Sinus Bradycardia - SBSinus Bradycardia - SB

• Regularity – regular

• Rate – less than 60 / min

• P waves – 1:1

• PRI - .12 - .20

• QRS - .12 or less


Sinus Tachycardia - STSinus Tachycardia - ST

• Regularity – regular

• Rate - > 100 / min

• P waves = 1:1

• PRI = .12 - .20

• QRS = .12 or <


Sinus Arrhythmia - SASinus Arrhythmia - SA

• Caused by a variety of factors: anxiety, stimulants, fever, exercise, medical conditions

• Regularity – irregular

• Rate – anything; freq. in normal rate of 60 – 100 / min

• P waves – 1:1

• PRI - .12 - .20

• QRS - .12 or <


Sinus Rhythms: Sinus Rhythms:

Interpretation SR SB ST SA

Regularity Regular Regular Regular Irregular

Rate 60 – 100/ min < 60 min > 100 min Could be any rate, usually between 60 - 100

P waves 1:1 1:1 1:1 1:1

PRI .12 - .20 .12 - .20 .12 - .20 .12 - .20

QRS .12 or < .12 or < .12 or < .12 or <


Atrial Dysrhythmias Atrial Dysrhythmias

• Atrial flutter: in atrial flutter, atrial contraction (represented by the P waves on the ECG) is regular but faster than normal (250 to 400 times per minute)

• Atrial fibrillation: is caused by rapid, uncoordinated twitching of the myocardium of the atria; in atrial fibrillation, the P waves are irregular and small, and they occur at a rapid rate all along the ECG


Atrial Fibrillation : A FibAtrial Fibrillation : A Fib


Atrial Flutter : A FlutterAtrial Flutter : A Flutter


Question:Question:

The person with atrial fibrillation may feel which of the following?

A. Light-headed with palpitations

B. Unconscious

C. Nothing because there are no symptoms

D. Muscle movements may be uncoordinated


AnswerAnswer

A. Light-headed with palpitations

The ventricular rhythm is usually very irregular, and the rate of ventricular contraction is high (usually between 120 and 200 times per minute). When the ventricular rate is so rapid, the ventricles are not able to fill adequately with blood between beats. As a result, the maximum amount of blood is not sent out to the body with each beat. The person may feel light-headed and complain of chest palpitations (awareness that the heart is beating).


Atrioventricular Junction DysrhythmiasAtrioventricular Junction Dysrhythmias

• Junctional rhythm: occurs if the SA node fails to fire and send an electrical impulse through to the AV node or if the SA node fires the impulse too slowly


Junctional rhythmsJunctional rhythms


P wave after QRS - junctionalP wave after QRS - junctional


Ventricular DysrhythmiasVentricular Dysrhythmias

• Premature ventricular contraction

• Ventricular tachycardia

• Ventricular fibrillation


Cheat Sheet-Ventricular DysrhythmiasCheat Sheet-Ventricular Dysrhythmias

Interpretation PVC – premature ventricular contraction

VT – Ventricular Tachycardia

VF – Ventricular Fibrillation

Asystole

Regularity

Rate

P waves

PRI

QRS


Premature Ventricular Contraction: PVCPremature Ventricular Contraction: PVC

• Ectopic beat – dangerous if occurs often

• Regularity – may interrupt the regularity of underlying rhythm

• Rate – depends on underlying rhythm

• P wave – will not be one before ectopic beat

• PRI – none in ectopic beat – measure underlying rhythm

• QRS – ectopic beat – wide and bizarre, also look at underlying rhythm


Ventricular Tachycardia - VTVentricular Tachycardia - VT

• Medical Emergency – most pts will be unconscious & can’t feel pulse

• Regularity – usually regular, can be slightly irregular

• Rate – 150 – 250 / min

• P waves – none

• PRI – none

• QRS - >.12


Ventricular Fibrillation - VFVentricular Fibrillation - VF

• Start CPR!!

• Regularity – baseline totally chaotic

• Rate – can’t determine

• P waves - ?

• PRI - ?

• QRS - ?


AsystoleAsystole

• No electrical activity

• Start CPR


Cheat Sheet – Ventricular DysrhythmiasCheat Sheet – Ventricular Dysrhythmias

Interpretation PVC – premature ventricular contraction

VT – Ventricular Tachycardia

VF – Ventricular Fibrillation

Asystole

Regularity The underlying rhythm can be regular or irregular

Usually regular, can be irregular

Baseline totally chaotic

No electrical activity, only a flat line

Rate Determined by underlying rhythm

150 – 250Per min.

Can’t be determined

P waves Ectopic not preceded by a P wave

none No discernible P waves

PRI Ectopic comes from lower focus, no PRI

none none

QRS Wide and bizarre >.12

Wide and bizarre >.12

No discernible QRS complex


Atrioventricular BlocksAtrioventricular Blocks

• First-degree atrioventricular block

• Second-degree atrioventricular block

* Type I - Wenckebach rhythm

* Type II - Mobitz type I rhythm

• Third-degree atrioventricular block (Mobitz type II rhythm)


Observations to Report to the Nurse ImmediatelyObservations to Report to the Nurse Immediately

• The PR interval is longer than earlier

• The QRS complex changed shape or widened

• The ECG shows a new dysrhythmia that was not there before

• C/O chest pain or discomfort

• C/O shortness of breath

• C/O dizziness

• Person unconscious


Artifacts Can Be Caused by:Artifacts Can Be Caused by:

• Electrical interference from other electrical equipment (such as an electric razor) or monitoring devices in the area

• Loose electrodes, especially if the person is diaphoretic (sweating) or recently repositioned

• Electrodes dried out

• Electrodes placed over an excessively hairy area

• Defective monitor or lead wires

• Patient movement (for example, from shivering or brushing the teeth)


Artifact:Artifact:


12 Lead EKG:12 Lead EKG:

• Prepare equipment

• Bed at comfortable working height

• Adjust patient’s clothing to expose chest; provide privacy

• Determine correct position for each electrode

– If excessive hair, remove with shaver

– Clean with alcohol pad to remove oils if needed

– Ask patient to lay still and obtain tracing


12-Lead EKG Placement:12-Lead EKG Placement:


Lead Placement: Limb leadsLead Placement: Limb leads


12-lead EKG Placement12-lead EKG Placement

• RL & LL

• RA & LA

• Chest leads:

– V1 – 4th ICS, R of sternum

– V2 – 4th ICS, L of sternum

– V4 – 5th ICS, MCL

– V3 – between V2 and V4

– V5 – 5th ICS, anterior axillary line

– V6 – 5 ICS, mid axillary line


12-Lead Tracing:12-Lead Tracing:


QuestionQuestion

What are abnormal ECG tracings that do not represent the heart’s electrical activity?

A. AV block

B. Dysrhythmia

C. Artifact

D. Bundle of His


AnswerAnswer

C. Artifact

Artifact can be caused by electrical interference from other electrical equipment (such as an electric razor) or loose electrodes, especially if the person is diaphoretic (sweating) or has recently been repositioned.


Question:Question:

In a 12-lead ECG, how many electrodes are placed on the body?

A. 12

B. 4

C. 10

D. 3


AnswerAnswer

C. 10

A 12-lead ECG is used to diagnose a heart condition. A 12-lead ECG uses 10 electrodes.


Scenario: Scenario:

• Mrs. Spencer is an elderly patient who has been admitted to your unit, 2A, after having abdominal surgery. She has been placed on telemetry to monitor her heart. Since her surgery, Mrs. Spencer has become a bit confused and has pulled off her telemetry leads three times already today. As you pass the station where the telemetry monitoring screens are, you notice that Mrs. Spencer’s rhythm is again looking irregular. You are really busy, and she has already pulled her leads off so many times today. What should you do?


Scenario: Scenario:

• Mrs. Jacobs is an elderly patient who has just been admitted to your unit with pneumonia. Her doctor has written an order for telemetry monitoring. What will some of your responsibilities be regarding Mrs. Jacobs’ telemetry?

chap 8 cardiovascular monitoring

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