EKG Code Lab

1
EKG / Code Lab

• NURS 228
• Janie Best, RN, MSN, ACNS-BC

2
Objectives

• Apply appropriate nursing interventions for
  selected dysrhythmias.
• Analyze professional and legal dimensions that
  guide a nurses responsibilities during a code,
  including DNR status

3
Types of Cardiac Cells

• Myocardial cells
• Working or mechanical cells
• Contain contractile filaments
• Pacemaker cells
• Specialized cells of the electrical conduction
  system
• Responsible for the spontaneous generation and
  conduction of electrical impulses

4
Properties of Cardiac Cells

• Excitability
• Muscle cells can respond to outside stimulus
• Automaticity
• Pacemaker cells spontaneously initiate an
  electrical impulse without being stimulated from
  another source
• Conductivity
• Cardiac cells can receive an electrical stimulus
  and conduct it to adjacent cardiac cell
• Contractility
• Muscle contraction in response to electrical
  stimulus

5
Cardiac Conduction
6
Skin Preparation

• Clean skin where electrodes will be applied
• Rub electrode site with alcohol
• Removes oil, lotion, powder from skin
• Shave any hair from electrode site
• Improves conductivity
• Electrodes remove easier
• Can apply skin prep to site
• Protects skin site in fragile skin
• Apply electrode
• Remove electrodes after use
• Use adhesive remover or moist cloth

7
Lead Placement 5 lead system
From Basic ECG Module - AACN
8
ECG Paper

• ECG paper is graph paper made up of small and
  larger, heavy-lined squares
• Smallest squares are 1 mm wide and 1 mm high
• 5 small squares between the heavier black lines
• 25 small squares within each large square

9
What Does the ECG Measure?
V O LTAGE
T I M E
10
ECG Complex
11
FIGURE 27-3. E Smeltzer Brunner, 11th Ed. p.
827.
12
PR Interval
Normal P wave small, round, upright PR
Interval Begins with the onset of the P wave and
ends with the onset of the QRS complex Normally
measures 0.12 to 0.20 seconds 5 small boxes
13
QRS Complex

• A QRS complex normally follows each P wave
• Consists of Q wave, R wave, and S wave
• Represents the spread of electrical impulse
  through the ventricles (ventricular
  depolarization)
• Normal - 0.04 0.12 seconds

14
ST segment T wave

• T wave - Represents ventricular repolarization
• The beginning of the T wave is identified as the
  point where the slope of the ST segment appears
  to become abruptly or gradually steeper
• The T wave ends when it returns to the baseline

• ST Segment - Begins with the end of the QRS
  complex and ends with the onset of the T wave and
  is on the same line as the PR interval
• ST segment depression of more than 1 mm is
  suggestive of myocardial ischemia
• ST segment elevation of more than 1 mm is
  suggestive of myocardial injury or
  Pericarditis

15
ST Segment

• The ST segment is considered
• Elevated if the segment deviates above the
  baseline of the PR segment
• Depressed if the segment deviates below it

16
From Basic ECG Module - AACN
17
ECG and the Cardiac Cycle
ST Segment
Isometric line
18
ECG Practice Strips

• Identification of the waveforms

19
Steps of Rhythm Analysis

• What is the rate?
• Ventricular
• Atrial
• Is the rhythm regular or irregular?
• Is there 1 P wave before each QRS?
• Is the PR interval WNL (.12-.20)?
• Is the QRS narrow or wide (.04-.10)?
• Interpret the rhythm
• Is the rhythm clinically significant?

• Also look at
• ST segment
• T wave

20
Determining the Rate

• 1500 of small boxes within an RR interval
  (regular rhythms)
• 10 x of R complexes in 6 seconds

21
Rhythm Regular / Irregular

• Distance between the R waves

22
Normal Sinus Rhythm

• Ventricular rate 60-100 Regular rhythm
• Atrial Same as ventricular
• P consistent shape always positive
• P-R interval 0.12-0.20
• QRS complex 0.04-0.10
• 1 P wave for every QRS

23
Dysrhythmias

• Disorders of electrical impulse
• Formation
• Conduction
• Named by
• Site of origin of impulse
• Mechanism of formation or conduction involved

24
Dysrhythmias

• Site of origin
• SA node
• Bradycardia, Tachycardia
• Atrial tissue
• Flutter, fibrillation
• AV node
• Blocks
• Junctional
• Ventricular tissue
• Tachycardia, fibrillation

25
Dysrhythmias

• Mechanism of formation or conduction
• Normal
• Bradycardia
• Tachycardia
• Flutter
• Fibrillation
• Premature complexes
• Conduction blocks

26
Tachy-dysrhythmias

• Rate gt 100 bpm (beats per minute)
• Coronary artery blood flow occurs during diastole
  (aortic valve closed)
• Shorter diastolic time ? coronary artery
  perfusion time
• ? workload of heart, ? myocardial O2 demand
• CAD (? blood flow)

27
Sinus Tachycardia

• Etiology
• ? CNS response Anxiety Pain Fever Anemia
  Meds Compensatory hypovolemia
• Is client symptomatic?
• Interventions
• Identify cause, Select best Treatment
• Goal ? HR to normal levels
• ASA, ß-blockers, ACE Inhibitors
• Meds of concern

28
Sinus Tachycardia

• Ventricular rate gt 100 (up to180) Regular
  rhythm
• Atrial Same as ventricular
• P consistent shape
• P-R interval Normal
• P wave for every QRS
• QRS complex Normal

29
Paroxysmal Supraventricular Tachycardia (PSVT)
Paroxysmal supraventricular tachycardia is a
term used to describe SVT that starts and ends
suddenly
30
Bradydysrhythmias

• HR lt 60 bpm
• ? myocardial O2 demand
• Prolongs diastole
• Coronary perfusion pressure may ? if HR too slow
  to provide adequate CO BP
• If BP adequate, will tolerate slow rate
• If BP not adequate, symptomatic (may lead to
  myocardial ischemia, MI, HF)

31
Sinus Bradycardia

• Ventricular ratelt 60 regular rhythm
• Atrial same as ventricular
• P consistent shape
• P-R interval Normal
• P wave for every QRS
• QRS complex Normal

32
Sinus Bradycardia

• Etiology
• PNS dominant Excessive vagal (Valsalva)
  stimulation to the heart (? SA node discharge ?
  HR, ? conduction)
• Is client symptomatic?
• Interventions
• Atropine Tx of choice
• Volume replacement
• Pacemaker placement

33
Flutter and Fibrillation
34
Atrial Flutter

• Etiology
• AV node selectively blocks impulses that reach
  ventricles (protective mechanism)
• Rheumatic Heart disease, CHF, AV valve disease,
  post cardiac surgery
• Clinical manifestations dependent upon
  ventricular response
• Interventions
• O2
• Meds amiodarone, Cardizem, verapamil (older and
  seldom used drug choice)

35
Atrial Flutter

• Ventricular rate Variable, Regular rhythm
• Atrial 250-300/minute, Regular rhythm
• P shape sawtooth formation
• P-R interval Absent
• No P wave
• QRS complex
• Normal

36
Atrial Fibrillation

• Etiology
• Most common dysrhythmia in US
• Aging, MI, HF, MS, Cardiomyopathy
• Multiple, rapid impulses many atrial foci Atrial
  depolarization disorganized and chaotic
• No atrial contraction, Irregular ventricular
  response
• Can lead to formation of multiple thrombi in
  cardiac chambers

37
Atrial Fibrillation

• Symptoms
• SOB
• Fatigue
• Weakness,
• Distended neck veins
• Anxiety
• Syncope
• Palpitations
• Chest discomfort
• Irregular pulse

• Commonly seen after cardiac surgery (transient)
• Can be intermittent or chronic

38
Atrial Fibrillation

• Interventions
• If initial Atrial fib lt 48 hrs the treatment is
  aimed to ? ventricular response convert to NSR
• ß-blockers, Ca channel blockers
• Antiarrhythmics (conversion to NSR)
• Cardioversion synchronized countershock
• If in atrial fib gt 48 hrs
• Anticoagulant therapy

39
Atrial Fibrillation

• Ventricular rate lt 100 (controlled), irregular
• Atrial Unable to determine (lt 350)
• No P waves (fibrillatory waves)
• P-R interval Absent
• QRS complex Normal

40
Atrial Fibrillation
41
Premature Ventricular Contractions

• Etiology
• Early ventricular complexes, followed by pause
• Ventricular contraction originating in an ectopic
  focus outside ventricles
• Aging, MI, HF, Caffeine, ? K
• Assessment
• Asymptomatic or Symptomatic
• Palpitations, Chest Pain (lack of perfusion)
• Can be warning (onset of VT, VF, R on T
  phenomenon) AMI

42
Premature Ventricular Contractions

• Interrupts basic rhythm
• Occurs early in the R-R cycle
• No P wave w/ PVC
• QRS wide and unusual

PVC
43
Premature Ventricular Contractions

• Interventions
• If symptomatic
• Identify eliminate cause
• O2, Antiarrhythmics (lidocaine)
• MONA
• Morphine
• Oxygen
• Nitroglycerine
• ASA

44
PVCs
Unifocal PVCs
Multi-focal PVCs
45
Refractory The extent to which a cell is able
to respond to a stimulus

• Absolute refractory period
• Onset of QRS complex to approximately peak of T
  wave
• Cardiac cells cannot be stimulated to conduct an
  electrical impulse, no matter how strong the
  stimulus
• Relative refractory period
• Corresponds with the downslope of the T wave
• Cardiac cells can be stimulated to depolarize if
  the stimulus is strong enough

46
R on T phenomenon

• Appearance of PVC on T wave of preceding normal
  beat
• Can lead to Ventricular Fibrillation
• May see with MI

47
Ventricular Tachycardia

• Etiology
• Repetitive firing of an irritated ventricular
  ectopic focus
• Intermittent (NSVT)
• Sustained gt 15-30 sec
• SA node discharges independently (atria
  depolarize, not the ventricles AV dissociation)
• P waves seldom seen in sustained V Tach
• AMI, CAD, K imbalance, gt QT interval, Cardiac
  surgery, Digoxin toxicity

48
Ventricular Tachycardia

• Assessment
• Depends on ventricular rate
• Slower rates better tolerated
• Interventions Treat cause
• Sustained
• O2, ECG, Antiarrhythmics (amiodarone)
• Elective cardioversion
• Unstable
• Emergency cardioversion, O2, antiarrhythmics
• Pulseless
• Defibrillation

49
Ventricular Tachycardia (V Tach)

• Unable to determine rhythm
• Regular ventricular rate (100-250)
• No P waves present
• QRS complex gt 0.10 sec

50
V Tach
Indicates defibrillation
51
Ventricular Fibrillation

• Chaotic electrical activity
• No discernable P-QRS-T complexes
• Cardiac arrest
• Etiology
• Ventricles quiver, consume lots of O2, No
  cardiac output, no perfusion
• AMI, ? K, ? Mg
• Rapidly fatal (3-5 min)

52
Ventricular Fibrillation

• Assessment
• LOC, Absence of Pulse
• Apnea
• Seizures
• Development of respiratory metabolic acidosis
• Treatment
• CPR (ACLS)
• Defibrillation
• Drug of choice Amiodarone, Lidocaine, Magnesium
  Sulfate (for hypomagnesemia or torsades de
  pointes)

53
Ventricular Fibrillation (V Fib)
Coarse
Fine
54
Asystole

• Ventricular standstill
• Complete absence of any ventricular rhythm
• Etiology
• No electrical impulses, No depolarization
• No cardiac output, VS
• No impulses reach ventricles if SA fires
• Cardiac arrest, Unresponsive
• Intervention ACLS
• Make sure not in Fine V Fib

55
Cardioversion / Defibrillation

• Cardioversion
• timed electrical current
• Synchronizes with the ECG so that electrical
  impulse discharges during ventricular
  depolarization (QRS complex) causing a momentary
  delay in discharge of current once the unit is
  charged
• Defibrillation
• Treatment of choice for pulseless VT and V fib
• Electrical current is not timed (no QRS complex
  is present)
• Current discharges immediately when charged

56
Heart Blocks

• Occur when there is a delay in the conduction of
  the impulse through the AV node
• PR is gt 0.20 seconds
• SA node function is normal

57
Heart Block Overview

• 1st degree
• PR interval gt 0.20 seconds
• All impulses reach the ventricles
• 2nd degree (2 types)
• Mobitz I each impulses takes longer to conduct
  until 1 is blocked and a QRS complex is dropped
  and a pause occurs then cycle repeats
• Mobitz II Impulses are blocked at a regular
  interval causing dropped QRS complexes
• 3rd degree
• None of the atrial impulses reach the ventricles
• Activity of the atria and ventricles is
  divorced
• Results in inadequate cardiac output
• Requires pacemaker

58
1st degree
2nd degree Type 1
59
2nd degree Type II
3rd degree
60
Pacemakers
61
Ventricular pacemaker
Atrial Ventricular pacemaker
62
Atrial Pacing

• A pacing electrode is placed in the right atrium
• Produces a pacemaker spike followed by a P wave
• May be used when the SA node is diseased or
  damaged but conduction through the AV junction
  and ventricles is normal

63
Ventricular Pacing

• A pacing electrode is placed in the right
  ventricle
• Produces a pacemaker spike followed by a wide
  QRS, resembling a ventricular ectopic beat

64
Pacemakers
65
Pacemaker Malfunction

• Loss of capture
• Undersensing
• Oversensing
• Loss of pacing

66
Failure to Capture

• Recognized on the ECG by visible pacemaker spikes
  not followed by P waves (if electrode in atrium)
  or QRS complexes (if electrode in right ventricle)

67
Failure to Sense (Undersensing)

• Recognized on the ECG by pacemaker spikes that
  follow too closely behind the patients QRS
  complexes

68
(No Transcript)
69
Activity Intolerance r/t Ineffective / decreased
myocardial function
Patient / Family Education Medication
regime Safety precautions
Fear r/t Unknown Deficient knowledge regarding
dysrhythmia Threat to health with fear of death
Dysrhythmia
Decreased cardiac output r/t Altered cardiac
rate / rhythm Dysfunctional electrical
conductivity or cardiac cells Ineffective /
decreased myocardial function
Deficient knowledge r/t New onset of disease Lack
of information of disease treatment
70
Nursing Interventions

• Monitor and manage the dysrhythmia
• Minimize anxiety
• Teach self-care

71
Evaluation

• Expected Patient Outcomes
• Maintains cardiac output
• Experiences reduced anxiety
• Expresses understanding of the dysrhythmia and
  its treatment

72
Case Study 9Coronary Artery Disease

• Assessment
• Telemetry
• Diagnosis
• Nursing diagnosis
• Collaborative problems / potential complications
• Planning and Goals
• Nursing Interventions

73
NCLEX Questions

• The client show ventricular fibrillation on the
  telemetry at the nurses station. Which action
  should the telemetry nurse implement first?
• Administer epinephrine IVP
• Prepare to defibrillate the client
• Call a STAT code
• Start cardiopulmonary resuscitation

74
NCLEX Questions

• The client has chronic atrial fibrillation.
  Which discharge teaching should the nurse discuss
  with the client?
• Instruct the client to use a soft-bristle
  toothbrush
• Discuss the importance of getting a monthly PTT
• Teach the client about signs of pacemaker
  malfunction
• Explain to the client the procedure for
  synchronized cardioversion

75
NCLEX Questions

• The client that is one day postoperative coronary
  artery bypass surgery is exhibiting sinus
  tachycardia. Which intervention should the nurse
  implement?
• Assess the apical heart rate for 1 full minute
• Notify the clients cardiac surgeon
• Prepare the client for synchronized cardioversion
• Determine if the client is having pain.

76
References

• Aehlert, B. 1995). ECGs made easy. Mosby
  Yearbook, Inc. St. Louis, MO.
• Geiter, H.B. (2007). E-Z ECG Rhythm
  Interpretation. F.A. Davis, Philadelphia.
• LeMone, P., Burke, K. (2008). Nursing Care of
  Clients with coronary heart disease. In
  Medical-Surgical Nursing Critical Thinking in
  Client Care, 4th Ed., pp. 957-1020.
• Smeltzer, S.C., Bare, B.G. (2008). Management of
  patients with dysrhythmias and conduction
  problems. In Brunner Suddarths Textbook of
  Medical Surgical Nursing, 11th ed. Pp.
  822-857.