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ECG - is a series of waves and deflections recording the hearts electrical activity from a certain view.
Heart Conduction
act as back-up
pacemaker Rate: 40 60 bpm Purkinje Fiber can act as back-up pacemaker Rate: 20 40 bpm
isoelectric line
From the beginning of
QRS Complex
ventricular depolarization Impulse from the Bundle
T wave
Ventricular
repolarization
Resting phase of the
cardiac cycle
upright & round
U wave
Purkenji fiber
repolarization
Etiology: hypokalemia
Electrode application
White to right Red to ribs Black over the red.
LEAD II
monitoring
Step I: rhythm
Regular
irregular
Step II:
Rate
Method I
For regular rhythm:
Count the number of large boxes between
Method II
For fast heart rate:
count the number of small boxes between two
Remember:
5 small boxes/large box 300 large boxes/min
300 x 5 = 1500
Method III
For irregular rhythm:
Method IV:
Find the R wave that fall on a large box line. Level the next large box line a rate of 300 150 100 75 60 50 43 37 33 & 30, until the next R wave.
Step 3 P wave
configuration: round and upright
To ask: Are P wave present? Do they look the same? Is there P before every QRS?
Step 4: PR interval
From the start of Atrial depolarization to the beginning of
ventricular depolarization
Location: beginning of P wave to beginning of Q wave Duration: .12 - .20 sec Amplitude: not measured Configuration: P wave followed by isoelectric line To ask? Are all P-R intervals consistent?
to ask? Are there QRS? Do they look the same? Do they come after the P wave? Are the R R intervals equal?
Configuration
T wave
Ventricular repolarization
ST segment
End of ventricular depolarization to the beginning of
ventricular repolarization Location: end of S wave to beginning of T wave Amplitude: isoelectric Duration: not measured Configuration: nearly isoelectric
Configuration
Isoelectric
QT interval
Location: beginning of Q wave to end of T wave
U wave
Purkinje fiber repolarization
31.
ARTIFACTS
ARTIFACTS
Four Common Causes:
Patient Movement
Loose or defective electrodes Improper grounding Faulty ECG apparatus
SINUS RHYTHMS
1.
ECG characteristics
Rhythm: regular Rate: normal (60 100 bpm) P wave: normal / 1 per QRS complex PR interval: normal (.12 - .20 sec) QRS complex: normal (.04 - .12 sec) ST segment: not elevated or depressed T wave: normal
disease.
Mechanism:
conduction 2.
Sinus Bradycardia
Etiology: sleeping; young, athletic individuals Excessive vagal tone (straining, vomiting, intubation) Sick sinus syndrome, MI Digoxin toxicity, Sedative Hyperkalemia Trauma to conductive system
Clinical signs: low CO low perfusion lethargy, mental status change, anxiety, poor capillary refill, mottled skin, low UO syncope
Bradycardia
Nursing action: (if symptomatic)
Document rhythm & notify MD
Apply O2 & consider atropine Prepare for external pacing If with PVCs dont treat with lidocaine (this is the hearts
Maximum dose: 3 mg
Do not give < 0.5 mg may worsen the bradycardia Do not push slow
ECG characteristics: all normal Rate: 101 160 bpm P wave: normal or merge to T wave
Sinus tachycardia
Etiology: a natural response to environmental stimuli pain, fever, exercise, emotion, dehydration Drugs, caffeine, alcohol, Hyperthyroidism, shock, CHF, hypoxia Clinical signs: Increased workload of the heart decrease CO low perfusion angina, SOB, anxiety, hypotension, low UO Nursing action: if symptomatic Document rhythm & notify MD Apply O2 Treat underlying cause May consider vagal maneuver cough, bear down, blow through straw try blowing plunger off the syringe
Mechanism: reflux vagal tone inhibition associated with respiration. (rate increases with inspiration & drops with exhalation) 4.
Sinus Arrhythmia
Etiology: Normal phenomenon with inspiration (esp, in infant) Digitalis toxicity, MI, increased ICP Fever, anxiety, shock Nursing action: Document rhythm & notify MD if symptomatic No treatment
Sinus pause / block - Basic rhythm resumes after a pause ECG Characteristics: Rhythm: irreg Rate: normal or < 60 Other waves: Normal except during pause or arrest
Sinus pause/arrest/block
Etiology: High vagal tone or increased vagal stimulation Drug toxicity (esp. digoxin) MI, s/p cardiac surgery, SA node trauma lupus, metabolic disorders Clinical signs: If HR is <50 decreased CO hypotension, changes in
ATRIAL DYSRHYTHMIAS
(PAC)
Mechanism: (early P) premature beat originate from the Atria 7.
ECG characteristics:
Rhythm: irreg during the beat
Rate: varies
P wave: different from normal P wave PRI: varies during the beat QRS com / ST seg: Normal
Clinical signs:
>10 PACs = CHF Palpitations
Nursing Action:
Document Treat underlying cause
AF
Mechanism: Atrial quiver with ventricular response (> 100 = RVR (rapid) / 60 =100 CVR (controlled)) blood clots
8.
ECG Characteristics: Rhythm: irreg Rate: Atria: 350-600 / Ventricle: varies P wave: none ( F wave) QRS comp: Normal Others: not measurable
Atrial Fibrillation
Etiology: Atrial enlargement due to AV valve disorders Hpn, CAD, COPD, CHF, MI Hypoxia, drugs, digitoxicity, tobacco Clinical signs: Irregular pulse, palpitation, anxiety, SOB CHF
shock
Nursing Action: Document rhythm & inform MD Apply O2 Possible Synchronize cardioversion Anticoagulant therapy
ECG characteristics: Rhythm: irreg / regular Rate: Atria: 250-350 / ventricle: varies QRS comp: Normal Others: not measurable
Atrial Flutter
Etiology: Related to underlying heart disease Hyperthyroidism, alcoholism Clinical signs: decreased CO hypotension, mental status change,
PAT / SVT
Mechanism: impulse originate above the ventricle, due to rapid
10.
ECG characteristics: Rhythm: regular Rate: 140 250 bpm P wave: hidden in T wave QRS comp: normal PRI: not measurable
decreased perfusion myocardia ischemia Nursing Action: Treat the cause Valsalva maneuver or carotid massage
JUNCTIONAL DYSRHYTHMIAS
11.
ECG characteristics: Rate: 40 60 bpm P wave: inverted or none or retrograde PRI: shortened QRS comp: normal Others normal unless distorted by the P wave
Junctional tachycardia
13.
Junctional rhythm
Etiology: SA node failure due to vagal stimulation, IHD, valve
Mechanism: conduction defect at the bundle branches Shows RSR wave or notched QRS complex rabbit ear
14.
ECG characteristics: QRS comp: >.20 sec. ST segment: maybe depressed T wave: maybe inverted Others: normal
AV HEART BLOCKS
It is a delay or failure of the impulse across the AV node
ECG characteristics: All normal except for Prolonged PRI (>.20 sec)
Etiology: Drugs quinidine, digitalis, beta blockers, calcium channel blockers, procainamide Acute inferior wall MI, Increase vagal tone, Hyperkalemia Tx: none
junction
16.
Rate: Depends on rate of underlying rhythm Rhythm: Irregular P Waves: Normal (upright and uniform) PR Interval: Progressively longer until one P wave is
Mobitz I
Clinical Tip: This rhythm may be caused by medication
such as beta blockers, digoxin, and calcium channel blockers. Ischemia involving the right coronary artery is another cause.
Mechanism:
Damage of the AV junction below the bundle of HIS SA or AV
17.
ECG characteristics: P wave 2 or more P wave for every QRS complex PRI normal or prolonged QRS: normal or wide
Mobitz II
Etiology: AMI, ischemia, s/p cardiac surgery, CAD, degenerative dis of conductive system Drug toxicity
independently P Waves: Normal (upright and uniform); may be superimposed on QRS complexes or T waves PR Interval: Varies greatly QRS: normal
VENTRICULAR RHYTHM
(PVC)
Ectopic beats that originate in the ventricle abnormal QRS complex.
19.
ECG characteristics: Rhythm: regular / becomes irreg with PVC Rate: within normal P wave: none associated with PVC PRI: not measureable QRS: wide & bizarre T wave: in opposite direction of the wide QRS
PVCs: bigeminy
20.
PVCs: trigeminy
21.
22.
23.
PVCs: quadrigeminy
24.
PVCs: couplets
25.
amplitude.
26.
The QT interval is normal or long. Rate: 100250 bpm Rhythm: Regular or irregular P Waves: None or not associated with the QRS PR Interval: None QRS: Wide (0.10 sec), bizarre appearance
possible etiology.
Rate: 2040 bpm Rhythm: Regular P Waves: None PR Interval: None QRS: Wide (0.10 sec), bizarre appearance
Rate: 41100 bpm Rhythm: Regular P Waves: None PR Interval: None QRS: Wide (0.10 sec), bizarre appearance Clinical Tip: Idioventricular rhythms appear when supraventricular pacing sites are depressed or absent. Diminished cardiac output is expected if the heart rate is slow.
Torsade de pointes
The QRS reverses polarity and the strip shows a spindle effect. This rhythm is an unusual variant of polymorphic VT with
Rate: 200250 bpm Rhythm: Irregular P Waves: None PR Interval: None QRS: Wide (0.10 sec), bizarre appearance
Torsade de pointes
In French the term means twisting of the points.
or asystole. Clinical Tip: Frequent causes are drugs that prolong QT interval and electrolyte abnormalities such as hypomagnesemia.
depolarization or contraction.
30.
P Waves: None
PR Interval: None QRS: None
Clinical Tip: There is no pulse or cardiac output. Rapid intervention is critical. The longer the delay, the less the chance of conversion. ECGs
Rate: None Rhythm: None P Waves: None PR Interval: None QRS: None Clinical Tip: Always confirm asystole by checking the ECG in two different leads. Also, search to identify underlying ventricular fibrillation.