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Bonewit: Clinical Procedures for Medical Assistants, 8th Edition
Chapter 12: Cardiopulmonary Procedures
Content Outline
1. Electrocardiograph: instrument used to record the electrical activity of the heart
2. Electrocardiogram (ECG): graphic representation of the electrical activity of the heart
3. Cardiovascular disorders;
a. Can cause abnormal changes on ECG
4. Purpose of electrocardiography:
a. Evaluate the following symptoms:
 Chest pain
 Shortness of breath
 Dizziness
 Heart palpitations
b. Detect an abnormality in heart rate or rhythm (dysrhythmia)
c. Detect the presence of impaired blood flow to the heart muscle (cardiac ischemia)
d. Help diagnose damage to heart caused by myocardial infarction
e. Determine presence of hypertrophy of the heart
f. Detect myocarditis or pericarditis
g. Assess the effect on the heart of digitalis or other cardiac drugs
h. Determine the presence of electrolyte disturbances
i. Assess progress of rheumatic fever
j. Detect congenital heart defects
k. Performed before surgery to assess cardiac risk during surgery
l. As part of a complete physical examination
5. ECG cannot detect all cardiovascular disorders
a. Cannot always detect impending heart disease (e.g., MI)
6. ECG is taken with patient in resting state
a. Only records 10 seconds of heart’s activity
 If patient has an intermittent dysrhythmia
- May not occur during this brief time
b. Patient with angina pectoris
 Does not usually have symptoms in a resting state
- ECG may appear normal
7. To obtain a complete assessment of cardiac functioning
a. ECG must be used in combination with:
 Patient’s symptoms
 Health history
 Physical examination
 Other diagnostic and laboratory tests
8. MA responsible for running ECG, which includes
a. Preparation of patient
b. Operation of electrocardiograph
c. Identification and elimination of artifacts
d. Care and maintenance of electrocardiograph
9. ECG machine formats
Copyright © 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc.
Content Outline
a. Single-channel format: one lead recorded at a time
b. Three-channel format: three leads recorded at one time
 Most offices use
Structure of the Heart
1. Heart consists of four chambers
a. Small upper chambers
 Right atrium
 Left atrium
b. Large lower chambers
 Right ventricle
 Left ventricle
2. Pathway of blood through the heart
a. Blood enters right atrium: from superior and inferior vena cavae
 Brought back to heart after circulating in the body
 Deoxygenated: contains very little oxygen and high in CO2
b. Enters right ventricle
c. Pumped to the lungs
 By way of the pulmonary artery
- In lungs
(1) Picks up oxygen
(2) Gives off CO2
d. Returns to the left atrium of the heart
 Through pulmonary veins
e. Enters left ventricle
 Most muscular and powerful chamber of the heart
- Pumps blood to entire body
f. Pumped into the aorta to be distributed to the body
 Nourishes tissues with oxygen and nutrients
g. Coronary arteries
 Consist of two small arteries that branch off the aorta
- Innervate the heart
- Have numerous smaller branches that supply the heart with oxygen
Conduction System of the Heart
1. Sinoatrial (SA) node
a. Located in upper portion of right atrium
 Just below opening of superior vena cava
b. Consists of knot of modified myocardial cells
 Able to send out an electrical impulse
- Without an external nerve stimulus
c. Initiates and regulates heartbeat
 Known as “pacemaker” of the heart
d. Normal individual
 Generates impulse at rate of 60–100 times per minute
2. Path of impulse from SA node
a. Electrical impulse discharged by SA node
b. Impulse distributed to right and left atria: causes atria to contract
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Content Outline
 Blood forced through cuspid valves and into ventricles
c. Impulse picked up by atrioventricular (AV) node
 Knot of modified myocardium
- Located at base of right atrium
d. AV node delays impulse momentarily
 Allows for:
- Complete contraction of atria
- Filling of ventricles with blood from atria
e. Impulse transmitted to bundle of His
 Bundle of His is divided into right and left bundle branches
f. Bundle branches: relay impulse to the Purkinje fibers
g. Purkinje fibers: distribute impulse evenly to right and left ventricles
 Causes ventricles to contract
- Forces blood out of ventricles
(1) From right ventricle: blood is forced into pulmonary artery
(2) From left ventricle: blood is forced into aorta
(a) Causes BP and pulse to be produced
h. Entire heart relaxes momentarily
i. New impulse initiated by SA node
j. Cycle repeats
Cardiac Cycle
1. Represents one complete heartbeat
2. Consists of
a. Contraction of atria
b. Contraction of ventricles
c. Relaxation of entire heart
3. ECG: records electrical activity that causes cardiac cycle to occur
4. ECG cycle: graphic representation of cardiac cycle
Waves
1. P wave
a. Represents electrical activity associated with contraction of the atria
b. Known as atrial depolarization
2. QRS complex (consists of Q, R, S waves)
a. Represents electrical activity associated with contraction of ventricles
 Known as ventricular depolarization
b. Ventricles are larger than atria
 Requires a stronger electrical stimulus to depolarize ventricles
- Causes R wave to be taller than P wave
3. T wave
a. Represents electrical recovery of the ventricles
 Known as ventricular repolarization
b. Muscle cells are recovering in preparation for another impulse
c. Atrial repolarization (electrical recovery of the atria)
 Occurs following P wave
 Occurs at same time as ventricular depolarization (QRS complex)
- Causes it to be masked by the QRS complex
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- Therefore does not appear as a separate wave on ECG cycle
4. U wave
a. Occasionally follows T wave
b. Small wave
c. May be associated with repolarization
Baseline, Segments, and Intervals
1. Baseline
a. Flat, horizontal line that separates various waves
b. Heart is at rest (polarized)
c. No electrical activity occurring in the heart
d. Electrocardiograph does not have anything to record
This is why the baseline is flat
e. Waves deflect either upward or downward from baseline
 Positive deflection: wave deflects upward
 Negative deflection: wave deflects downward
2. ECG: divided into segments and intervals between the P wave and T wave
a. Purpose: interpretation and analysis of ECG
3. Segment: portion of the ECG between two waves
a. P-R segment
 Time interval from the end of atrial depolarization to the beginning of ventricular
depolarization
- Represents time needed for impulse:
(1) To be delayed at the AV node
(2) Then travel through bundle of His and Purkinje fibers to ventricles
b. S-T segment
 Time interval from the end of ventricular depolarization to the beginning of repolarization
of the ventricles
4. Interval: length of a wave or length of wave with a segment
a. P-R interval
 Time interval from the beginning of atrial depolarization to the beginning of ventricular
depolarization
b. Q-T interval
 Time interval from the beginning of ventricular depolarization to the end of repolarization
of the ventricles
5. Baseline (after T wave or U wave)
a. Period when entire heart returns to resting or polarized state
Electrocardiograph Paper
1. Paper divided into two sets of squares
a. Small square: 1 mm high and 1 mm wide
b. Large square: 5 mm high and 5 mm wide
 Each large square is composed of 25 small squares
2. Physician uses graph to manually measure various waves, intervals, and segments
a. Determines if ECG is within normal limits
3. Heart disease
a. Can trigger abnormal changes on ECG cycle
Causes results to fall outside normal limits
Copyright © 2012, 2008, 2004, 2000, 1995, 1990, 1984, 1979 by Saunders, an imprint of Elsevier Inc.
Content Outline
- Example:
(1) Cardiac ischemia (due to CAD)
(a) Can cause depressed S-T segment and inverted T wave
(2) Myocardial infarction
(a) Can cause larger than normal Q wave and elevated S-T segment
4. Paper contains a thermosensitive coating
a. Black or red graph printed on top of coating
5. Thermal print head
a. Produces ECG tracing
Generates heat in a prescribed pattern
6. Thermosensitive paper
a. Comes in contact with heated print head
Coating of paper turns black where it is heated
- Produces ECG tracing
7. Paper also is pressure sensitive
a. Handle carefully to avoid making impressions
 May interfere with proper reading of ECG
Standardization of the Electrocardiograph
1. Electrocardiograph must be standardized for every recording
a. Quality control measure
 Ensures an accurate and reliable recording
 Also means ECG run on one electrocardiograph compares in accuracy
- With a recording run on another machine
2. Normal standardization mark
a. Height: 10 mm (10 small squares)
b. Width: approximately 2 mm wide (2 small squares)
3. Three-channel machine: automatically records standardization marks on recording
a. One mark is recorded at the beginning and end of each ECG strip
4. If standardization mark is more or less than 10 mm high
a. Must be adjusted
b. Consult operating manual for adjustment information
Electrocardiograph Leads
1. Consists of 12 leads
a. Lead: a tracing of the electrical activity of the heart between two electrodes
2. Each lead:
a. Provides an electrical “photograph” of the heart’s activity from a different angle
b. Results in 12 “photographs” of the heart
 Facilitates thorough interpretation of the heart’s activity
3. Electrode
a. Made of a substance that is a good conductor of electricity
b. Picks up electrical impulses given off by the heart
 Conducts impulse into the machine by lead wires
4. Amplifier: device located in the machine that amplifies the electrical impulses
a. Electrical impulses given off by the heart are very small (0.0001 to 0.003 volt)
 Must be made larger (amplified)
5. Galvanometer: changes amplified voltages into mechanical motion
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Content Outline
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6. Thermal print head
a. Records heart tracing on ECG paper
7. Ten lead wires
a. Attached to patient
 Used to take 12 electrical “photographs” of the heart
8. Four limb lead wires
a. Right arm (RA)
b. Left arm (LA)
c. Right leg (RL): ground
 Not used for recording
 Serves as an electrical reference point
d. Left leg (LL)
9. Chest lead wires
a. Abbreviated V
b. Uses six chest lead wires
Electrodes
1. Used to record a resting 12-lead electrocardiogram
2. Contain a thin layer of a metallic substance
a. Good conductor of electricity
3. Square in shape
a. Tab extends from one end
 Allows for firm attachment of alligator clip
4. Electrolyte gel combined with an adhesive
a. Located on back of electrode
 Electrolyte: a substance that facilitates the transmission of the heart’s electrical impulse
b. Skin is a poor conductor of electricity
 Electrolyte must be used when recording an ECG
c. Adhesive: allows for firm adherence of electrode to skin
 No adhesive on tab
- Allows for attachment of alligator clip
d. Applied to the skin
 Held in place with adhesive backing
 Thrown away after use
e. Available on cards containing 10 electrodes
f. Foil-lined pouch
 Holds 10 cards of electrodes (100 electrodes per pouch)
 Preserves moisture
- Prevents electrolyte from drying out
g. Expiration date
 Stamped on each electrode pouch (and box containing the pouches)
 Always check expiration date before applying
Electrolyte gel on outdated electrodes may be dried out

- Unable to transmit a good ECG signal
h. Store properly to prevent electrolyte drying
 Cool area (less than 75°F or 24°C)
 Away from sources of heat
i. After opening electrode pouch
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Content Outline


Seal by folding over the end of it
Place pouch in a zip-lock plastic bag
- To preserve moisture.
Bipolar Leads
1. Leads I, II, III
2. Each bipolar lead: uses two limb electrodes to record the electrical activity of the heart
a. Lead I: records electrical current traveling between right arm and left arm
b. Lead II: records electrical current traveling between right arm and left leg
c. Lead III: records electrical current traveling between left arm and left leg
3. Lead II: shows heart’s rhythm more clearly than other leads
a. Rhythm strip: longer recording (12 inches) of lead II
 Often requested by the physician
Augmented Leads
1. aVR (augmented voltage—right arm)
a. Records electrical current traveling between
 Right arm electrode and a central point between left arm and left leg
2. aVL (augmented voltage—left arm)
a. Records electrical current traveling between
 Left arm electrode and a central point between right arm and left leg
3. aVF (augmented voltage—left leg or foot)
a. Records electrical current traveling between
 Left leg electrode and a central point between right arm and left arm
4. Leads I, II, III, aVR, aVL, and aVF
a. Provide electrical photograph of heart’s activity
 From side to side and from top to bottom of heart
Chest Leads
1. V1, V2, V3, V4, V5, and V6
a. Record heart’s voltage from front to back of the heart
 From a central point “inside” the heart: to a point on the chest wall
- Where each chest electrode is placed
2. Leads must be properly located by palpating the patient’s chest
a. To ensure an accurate and reliable recording
b. Example:
 If V1 and V2 are placed in the third (instead of fourth) intercostal space
- Changes can occur to P and T waves that falsely indicate heart disease
3. When first learning to locate electrode sites
a. Helps to mark location on chest
 With a felt-tipped pen
4. Normally ECG is recorded with paper moving at speed of 25 mm/sec
Patient Preparation
1. Minimal preparation required for an ECG
2. Purpose
a. Facilitate placement of electrodes
b. Ensure good adhesion of the electrodes to the skin
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3. Instruct patient in the following:
a. Do not apply body lotion, oil, or powder on the day of test
 May make it more difficult to apply electrodes
c. Wear comfortable clothing
d. Wear a shirt or blouse that can easily be removed
e. Women should not wear full-length hosiery (e.g., panty hose or tights)
Maintenance of the Electrocardiograph
1. Casing
a. Clean frequently
 Use a soft cloth slightly dampened with a mild detergent
- To remove dust and dirt
 Do not use solvents or abrasives
- Can damage finish of casing
2. Patient cable, lead wires, and power cord
a. Clean periodically with a cloth moistened with a disinfectant
3. Never immerse cables in cleaning solution
a. Could damage them
4. Inspect cables frequently for cracks or fraying
a. Replace if needed
5. Check metal tip of each lead wire for adhesive/electrolyte gel residue
a. Can interfere with transmission of a good ECG signal
 Remove residue with alcohol wipe using pressure and friction
6. Reusable alligator clips
a. Clean thoroughly with alcohol wipe after patient use
b. Should fit snugly on metal tip of each lead wire
Electrocardiographic Capabilities
Three-Channel Recording Capability
1. Records electrical activity of heart through three leads simultaneously
a. Single-channel: records only one lead at a time
2. Advantage
a. ECG can be run in less time
3. Leads recorded simultaneously
a. I, II, III
b. aVR, aVL, aVF
c. V1, V2, V3
d. V4, V5, V6
4. Electrocardiograph automatically labels each lead
a. With its appropriate abbreviation
5. Requires three-channel recording paper (81⁄2 by 11 inch)
a. Printout: fits easily into a paper-based medical record
6. Most have copy capability
a. Quickly produces duplicate copy of an ECG just recorded
7. Some have memory storage
a. Specific number of ECGs can be stored
 For later retrieval
b. Misplaced ECG can be retrieved and printed out again
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Content Outline
Teletransmission
1. Transmits recording electronically over phone line
 To ECG data interpretation site
2. Recording interpreted by cardiologist
a. Along with a computer analysis
3. Interpretation and ECG recording
a. Electronically transmitted to sending office the same day
Interpretive Electrocardiograph
1. Built-in computer program
a. Analyzes recording as it is being run
2. Provides immediate information on the heart’s activity
a. Leads to earlier diagnosis and treatment
3. Patient data: must be entered into electrocardiograph before running
a. Patient age
b. Sex
c. Height
d. Weight
e. Medications
4. Patient data and analysis printed at top of recording
a. Along with reason for interpretation
5. Results reviewed and interpreted further by the physician
EMR (Electronic Medical Record) Connectivity
1. Allows electrocardiograph to be linked with office computer
a. Either wirelessly or through a USB port
2. Digital image of ECG sent to computer
a. Displayed on screen of computer
3. Software also analyzes ECG
a. Displays this information on screen
 Along with reason for each interpretation
4. Copy of ECG can be printed out (if needed)
5. ECG report is reviewed and interpreted further by the physician
6. ECG stored electronically in patient’s EMR
Artifacts
1. Important to produce a clear and concise ECG
a. Can be read and interpreted by computer and physician
2. Occasionally artifacts appear in the recording
a. Artifact: additional electrical activity picked up by the electrocardiograph
 Interferes with the normal appearance of ECG cycles
3. Affects quality of recording
 Makes it difficult to manually measure ECG cycles
4. May cause a false-positive ECG on ECGs analyzed by a computer
5. Artifacts must be identified and corrected by the MA
6. Most common artifacts
a. Muscle
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Content Outline
b. Wandering baseline
c. 60-cycle interference (Ac artifact)
7. If unable to correct artifacts: machine may be broken
a. Contact service technician with the following information
 What has already been done to locate and correct the problem
 Leads in which artifact occurs
 Sample of the artifact
Muscle Artifact
1. Characterized by
a. Fuzzy, irregular baseline
2. Due to
a. Involuntary muscle movement (somatic tremor)
b. Voluntary muscle movement
3. Caused by
a. Apprehensive patient
 To correct
- Reduce apprehension, which relaxes muscles
(1) Explain the procedure
(2) Reassure patient that ECG is painless
b. Patient discomfort
 To correct
- Make patient more comfortable
(1) Ensure table is wide enough to support patient’s arms and legs
(2) Place pillow under patient’s head
(3) Ensure room temperature is comfortable for the patient
(a) Patient has removed clothing: may be cold
• Can cause shivering
c. Patient movement
 To correct
- Instruct patient to lie still and not to talk
d. Physical condition
• Nervous system disorder may prevent relaxation (e.g., Parkinson’s disease)
- Patient trembles continuously
• Difficult to obtain an ECG free of artifacts
• To reduce artifacts
- Have patient put hands under buttocks with palms facing downward
Wandering Baseline Artifact
1. Caused by
a. Loose electrodes
 Results in poor transmission of the electrical impulse
 To correct:
- Ensure electrodes are attached firmly to patient’s skin
 If electrode pulls loose:
- Reattach with tape
- Replace with a new electrode
 Ensure alligator clips are firmly attached to electrode tabs
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 Ensure patient cable is well supported on patient’s abdomen or table
- To prevent pulling of lead wires on electrodes
(1) Can cause electrodes to pull away from skin
 Do not allow patient cable to dangle
b. Dried-out electrolyte on electrode
 Prevents good adhesion of electrodes to skin
 To correct:
- Replace it with a new electrode
 Check expiration date stamped on electrode pouch (or box)
- To make sure electrodes are within their expiration date
c. Body creams, oils, or lotions on skin at electrode application site
 To correct:
- Remove by rubbing with alcohol using friction
d. Excessive movement of the chest wall during respiration
 To correct:
- Encourage patient to relax and breathe more calmly
60-Cycle Interference Artifact
1. Also known as AC artifact
2. Caused by electrical interference
3. Electric current can leak out
a. From power used by electrical appliances in room
 May be picked up by patient and carried into machine
- Results in 60-cycle interference artifact
4. Appearance of 60-cycle interference artifact
a. Small straight spiked lines that are consistent
 Causes baseline to be thick and unreadable
5. Caused by
a. Lead wires not following body contour
 Dangling lead wires pick up electric current
 To correct:
- Arrange lead wires to follow body contour and to lie flat
b. Other electrical equipment in room: may leak electric current
 To correct
- Unplug nearby electrical equipment (lamps, autoclave, electrically powered
examining table)
 Jewelry and watches
- Do not interfere with recording
- Not necessary to remove
(1) Unless they interfere with placement of electrodes
c. Wiring in walls, ceiling, and floors
 To correct
- Move patient’s table away from walls
d. Improper grounding of electrocardiograph
 Machine is automatically grounded when plugged in (by three-prong plug)
 Check plug: to make sure prongs are not loose or damaged
 Ensure plug is securely in wall outlet
 RL electrode picks up electric current from patient and carries it into machine
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- Electric current is carried away by grounding system of machine
Interrupted Baseline Artifact
1. Caused by
a. Metal tip of lead wire becoming detached
 To correct
- Reattach lead to alligator clip
b. Frayed or broken patient cable
 To correct
- Replace patient cable
Holter Monitor Electrocardiography
1. Portable ambulatory monitoring system
2. Continuously records electrical activity of heart for 24 hours or more
3. Also known as ambulatory electrocardiographic monitor (AEM)
4. Detects cardiac abnormalities
a. That occur while patient is engaged in normal daily routine
5. Holter system designed so that
a. Patient is able to maintain daily activities
 With minimal inconvenience
6. Similar to a resting 12-lead ECG
a. Electrical impulses given off by heart are picked up by electrodes
 Transmitted through lead wires to a recording device
b. Different than a resting 12-lead ECG
 Only about 10 seconds of the heart’s activity are recorded with a 12-lead ECG
 Holter monitor records heartbeat continuously for an extended period of time
7. Purpose
a. Used to diagnose cardiac rate, rhythm, and conduction abnormalities
b. Most frequently used to:
 Assess the rate and rhythm of the heart during daily activities
 Evaluate patients with unexplained chest pain, dizziness, or syncope (fainting)
 Discover intermittent cardiac dysrhythmias not picked up on a routine resting 12-lead
ECG
- Resting ECG: only records between 40 to 50 heartbeats
- Holter monitor: records approximately 100,000 heartbeats in a 24-hour period
 Detect myocardial ischemia
 Assess the effectiveness of antidysrhythmic medications
- Examples: digitalis and antianginal medications
 Assess the effectiveness of a pacemaker
Digital Holter Monitor
1. To document heart’s activity, uses either:
a. External (removable) memory card
b. Internal (nonremovable) memory card
- To document the heart’s activity
2. Lightweight and battery powered
3. Can be:
a. Clipped onto a belt around waist
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Content Outline
b. Held in a protective pouch
 Hung around patient’s neck with a lanyard
4. Continuously records electrical activity of heart:
a. For 24 hours, 48 hours, or 72 hours
 Most physicians order a 24-hour recording
b. Stores it on the memory card
5. LCD screen displays the date and time
a. Along with the remaining recording time
6. Automatically stops recording after monitoring period is completed
7. Medical office may have a Holter monitor
a. Medical assistant is responsible for:
 Preparing the patient
 Applying and removing the monitor
 Instructing patient in
- Preparation requirements
- Guidelines to follow during the monitoring period
Patient Preparation
1. Take a shower or bath before coming to the medical office
a. Will not be able to shower or bathe again until monitor is removed
2. Do not apply body lotion, oil, or powder to chest before or during the test
a. May make it more difficult to apply electrodes
3. Take usual medications (unless physician specifies otherwise)
4. Wear loose, comfortable clothing
a. Shirt or blouse that buttons down front:
 For easier application of electrodes
 To prevent electrodes from rubbing against clothing
- May become loose
Electrode Placement
1. Holter monitor electrodes
a. Pick up electrical impulses given off by heart
 Impulses are transmitted through lead wires and patient cable to monitor
b. Consist of foam
c. Are round or rectangular in shape
 With an electrode plate and a snap
- For attaching a lead wire
d. Adhesive backing
e. Central sponge pad
 Contains an electrolyte gel
f. Disposable
- Discarded after use
2. Newer Holter monitors are three-channel recording systems
a. Can record three leads at one time
b. Use between four and seven electrodes (depending on brand of monitor)
 Placed at various locations on chest
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
Number of electrodes and location
- Diagramed in an electrode placement chart (included in operating manual)
 Electrodes typically placed over bone (sternum and ribs)
- To reduce artifacts during the recording period
 Electrodes must be properly placed
- To ensure an accurate recording
 When first learning to place electrodes
- Helps to mark location on patient’s chest with felt-tipped pen
c. Check monitor’s effectiveness after hooking up patient
 To ensure a clear signal is being relayed
- From electrodes to monitor
 To perform check
- Access Lead Status screen on LCD screen (on the monitor)
- Quality of ECG signal for each lead is displayed on screen
- Signal should be clear and strong
- If signal is “noisy”
(1) Electrode may not have good connection with skin
(2) Apply gentle pressure to each electrode
(a) To improve contact with skin
- If problem still exists
(1) Monitor may be malfunctioning and in need of repair
Patient Diary
1. All activities and emotional states must be documented
a. Along with time of occurrence
2. Physical symptoms experienced during activity
 Must be indicated next to each activity
3. Dysrhythmia or abnormal ECG change recorded by Holter monitor compared with diary
a. To determine if an activity, emotional state, or symptom triggered the ECG abnormality
Holter Monitor Patient Guidelines
1. Most routine activities can be performed
a. Except those that can:
 Damage the monitor
 Cause artifacts
- May cause false-positive results on a computer-analyzed ECG
2. Guidelines to ensure an accurate and reliable recording:
a. Participate in normal everyday activities
 Purpose of Holter monitoring:
- To determine how heart functions during usual daily activities
 Avoid engaging in activities that cause excessive sweating (e.g., vigorous physical
exercise)
- May cause electrodes to become loose or fall off
b. Do not shower, bathe, or swim
 Water can damage monitor
 Can loosen electrodes
 Sponge bath can be taken
c. Check periodically to make sure:
 Indicator light is still on
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Content Outline
 All electrodes and lead wires are still attached to chest
d. Do not touch or move electrodes or lead wires
- To prevent artifacts
e. If a lead wire detaches from an electrode:
 Snap it back onto the electrode (ASAP)
 Record this information in the patient diary
f. If an electrode comes loose:
 Press down around edges of the electrode
 Apply tape to the electrode to restore contact
 Record information in patient diary
 If an electrode comes off and cannot be replaced
- Contact medical office
g. Do not handle monitor or take it out of pouch
h. While wearing monitor, do not use:
 Electric blanket
 Hair dryer
 Electric shaver
 Heating pad
 Microwave oven
 Electric toothbrush
i. Avoid the following, which can cause electrical interference artifacts:
 Magnets
 Metal detectors
 Areas with high-voltage electrical wires
j. Record activities in patient diary (along with time of occurrence)
 Physical exercise associated with daily activities
- Walking
- Housework
- Gardening
- Employment-related activities
 Walking up or down stairs
 Periods of inactivity (e.g., sitting in a chair, lying on a couch)
 Driving
 Smoking
 Urination
 Bowel movements
 Meals (including alcohol and caffeinated beverages)
 Sexual intercourse
 Medications consumed
 Sleep periods (including naps)
k. Record emotional states in patient diary (along with time of occurrence):
 Anger
 Excitement
 Anxiety
 Fear
 Laughter
l. Record physical symptoms experienced during each activity
 If nothing abnormal is experienced
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- Leave symptom space blank
 Examples of physical symptoms:
- Shortness of breath
- Chest pain
- Neck, arm, or face pain
- Heart palpitations
- Nausea
- Dizziness
- Faintness
Event Marker
1. Some Holter monitor models have an event marker button
a. Used along with patient diary for evaluation
2. When event marker button is pressed
a. Beep may sound as audible feedback
3. Patient should be instructed to:
a. Depress the button momentarily when experiencing a symptom
b. Record time and nature of symptom in the diary
4. Depressing button:
a. Places electronic signal on recording
 Highlights recording where symptom occurred
b.When patient data are analyzed by a computer
 Time of the event along with an ECG event-strip
- Will be included in ECG report
Evaluating Results
1. At end of monitoring period
a. Holter monitor removed from patient
2. Memory card information uploaded to computer
3. Specialized ECG software:
a. Performs calculations on the data
b. Prepares an ECG summary report
 Displayed on screen of computer
4. Computer-generated ECG report
a. Summarizes information about:
 Patient’s heart rate and rhythm
 Any abnormalities that occurred during the monitoring period
b. Includes selected samples of patient’s cardiac activity:
 Patient event-strips
 Any abnormal cardiac activity (e.g., dysrhythmias)
c. Results reviewed and interpreted further by physician
d. Physician also reviews patient’s diary
 To correlate patient’s activities, emotional states, or symptoms
- With ECG abnormalities
e. Report can be:
 Printed out and stored in PPR (patient-based paper record)
 Stored electronically in patient’s EMR (electronic medical record)
Maintenance of Holter Monitor
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1. At end of the recording period:
a. Remove battery from monitor and discard
b. Leaving battery in monitor could result in corrosion
 Could damage monitor
2. Clean casing of monitor frequently
a. Using a soft cloth moistened with a mild disinfectant
 To remove dust and dirt
b. Avoid use of commercial solvents and abrasives
 Could damage finish of casing
3. Clean patient cable and lead wires periodically
a. Using a cloth moistened with a mild disinfectant
b. Never immerse in cleaning solution
 Could damage them
c. Clean snap of each lead wire
 With alcohol and a small brush
- To eliminate any electrolyte gel
d. Store monitor in a dry, dust free area
Cardiac Dysrhythmias
1. Normal ECG: consists of P wave, QRS complex, and T wave
a. Repeats in a regular pattern
2. Normal sinus rhythm: ECG that is within normal limits
a. Waves, intervals, segments, and cardiac rate fall within normal range
3. Normal heart rate range: 60 to 100 beats/min
4. Sinus bradycardia: less than 60 beats/min
5. Sinus tachycardia: greater than 100 beats/min
6. Cardiac dysrhythmia: abnormal electrical activity in the heart causing an irregular heartbeat
a. Most are harmless
b. Some can be serious (even life-threatening)
7. Categories of cardiac dysrhythmias:
a. Extra beats
b. Abnormal rhythm
c. Abnormal heart rate
8. MA should be able to identify dysrhythmias on ECG
a. Alert the physician
Premature Atrial Contraction
1. Description
a. Beat that comes before next normal beat is due
b. P wave has a different shape from P wave of normal beat
c. Normal QRS complex and T wave
2. Clinical significance
a. Common in healthy individuals
b. Often caused by intake of stimulants (caffeine, tobacco)
c. Also can be associated with
 Serious atrial dysrhythmias
 Structural heart disease
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Content Outline
Paroxysmal Atrial Tachycardia
1. Description
a. Abrupt episode of tachycardia
b. Heart rate: 150 to 250 beats/min
c. Sudden onset and termination
d. Lasts only a few seconds, then heart rate returns to normal
e. ECG cycles are very close together
 As a result of increased heart rate
f. Patient experiences
 Sudden pounding or fluttering of chest
 Weakness and breathlessness
 Acute apprehension
 Occasionally may experience syncope
2. Clinical significance
a. One of most common rhythm disorders
b. Often occurs in healthy patients
 Especially young adults with normal hearts
c. Also can occur in patients with organic heart disease
Atrial Flutter
1. Description
a. Rapid regular fluttering of the atrium
b. Heart rate: 250 to 350 beats/min
c. More than one P wave precedes QRS complex
 Can range from 1 to 8
d. P wave appears as saw-toothed spikes between QRS complexes
e. QRS complexes are normal
f. T wave usually lost in P waves
2. Clinical significance
a. Rarely occurs in healthy individuals
b. Found in patients with underlying heart disease
c. Can occur in patients with
 Mitral valve disease
 Coronary artery disease
 Acute myocardial infarction
 Chronic lung disease
 Hypertensive heart disease
 Pulmonary emboli
 Patients who have undergone cardiac surgery
Atrial Fibrillation
1. Description
a. P waves have no definite pattern or shape
 Appear as irregular, wavy undulations between QRS complexes
b. QRS complexes are normal, but do not have a definite pattern
c. Atria contract 400 to 500 times per minute
d. Ventricular rate may be normal or rapid (150 to 180 beats/min)
2. Clinical significance
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a. Common dysrhythmia that occurs in healthy individuals
 Caused by stress, excessive alcohol consumption, vomiting
b. Can occur in patients with heart disease
 Individuals younger than 50 years: may be caused by
- Congenital heart disease
- Rheumatic heart disease with mitral valve involvement
 Individuals older than 50 years: may be caused by
- Coronary artery disease
- Mitral valve disease
- Hypertension heart disease
Premature Ventricular Contraction (PVC)
1. Description
a. Most common rhythm disturbance seen on ECG
b. Beat comes early in the cycle
 Not preceded by a P wave
c. Wide and distorted QRS complex
 Easily stands out on ECG
d. T wave opposite in direction to R wave
e. Baseline distance after PVC: usually longer than normal
 Means PVC is followed by a pause before next normal beat
2. Clinical significance
a. Seen in normal individuals in all age groups
b. Caused by
 Anxiety
 Smoking
 Caffeine
 Alcohol
 Certain medications (e.g., epinephrine)
c. Also can occur with any type of heart disease
d. Seen most often with
 Hypertensive heart disease
 Ischemic heart disease
 Lung disease with hypoxia
 Digitalis toxicity
 Mitral valve prolapse
Ventricular Tachycardia
1. Description
a. Series of three or more consecutive PVCs
 Occur at a rate of 150 to 250 beats/min
b. May occur suddenly and last for a short time
 Or may last for a long time
c. QRS complexes are bizarre and widened
d. No P waves present
e. Sustained VT: life-threatening
 Prevents adequate filling time for heart
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 May degenerate into ventricular fibrillation and cardiac arrest
2. Clinical significance
a. Usually seen in patients with acute or chronic heart disease
b. Runs of VT indicate coronary artery disease
c. Also occurs as a complication of myocardial infarction
Ventricular Fibrillation (V-fib)
1. Description
a. Most serious dysrhythmia
b. Ventricles do not beat in a coordinated manner
 Instead they twitch or fibrillate
c. Virtually no blood is ejected into systemic circulation
d. Appears as irregular, chaotic undulations of baseline
e. No recognizable P waves, QRS complexes, or T waves
f. No effective ventricular pumping action
g. Must be treated STAT
h. Can lead to sudden death
2. Clinical significance
a. Most common cause: acute myocardial infarction
b. Also can occur in patients with
 Organic heart disease
 Cardiac dysrhythmias
c. May be preceded by PVCs or ventricular tachycardia, or may occur spontaneously
Pulmonary Function Tests
1. Purpose of PFT: to assess lung functioning
2. Assists in detection of pulmonary disease
3. PFT tests include
a. Spirometry
b. Lung volumes
c. Diffusion capacity
d. Arterial blood gas studies
e. Pulse oximetry
f. Cardiopulmonary exercise tests
Spirometry
1. Noninvasive screening test often performed in the medical office
2. Spirometer: computerized electronic instrument
a. Measures
 Amount of air that is expelled from the lungs
 Rate at which air is expelled
b. Report printed out as a table and graph
3. Considered a screening test
a. Abnormal results require:
- Additional PFT tests
- Possibly a CT scan
4. Indications for performing spirometry
a. Patients who exhibit symptoms of lung dysfunction (e.g., dyspnea)
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b. Individuals at high risk for lung disease due to:
 Smoking
 Exposure to environmental pollutants
- Coal dust
- Asbestos
- Exhaust fumes
c. Patients with lung disease
 Asthma
 Chronic bronchitis
 Emphysema
d. Patients who are to undergo surgery
 To assess probable lung performance during an operation
e. Patients who need to be evaluated for lung disability or impairment

For a compensation program (e.g., coal miner)
Spirometry Test Results
1. Spirometry: provides numerous measurements to assess lung function
2. Forced vital capacity (FVC): maximal volume of air that can be expired when patient exhales as
forcefully and rapidly as possible for as long as possible (measured in liters)
a. FVC breathing maneuver
 Patient takes a deep breath until lungs are completely full
 Patient blows all air out of lungs into a mouthpiece
- As hard and fast as possible
- Until no more air can be expelled
 To be considered an adequate test
- Patient must forcibly blow out all air and continue smooth, continuous exhaling
for 6 seconds
 Minimum of three acceptable efforts must be obtained
 Some patients have trouble performing breathing maneuver due to:
- Physical impairment
- Poor motivation
- Do not understand instructions
 Be patient and work with patient to help perform the maneuver
 If unable to perform the maneuver after eight attempts: discontinue testing
- Fatigue may affect accuracy of results
3. Forced expiratory volume after 1 second (FEV1): volume of air that is forcefully exhaled
during first second of the FVC breathing maneuver
a. Automatically determined by the spirometer
 From FVC maneuver
4. FEV1/FVC ratio: comparison of FEV1 with FVC
a. Patient with healthy lungs: 70% to 75% of air (FVC) is exhaled
 In the first second (FEV1) of breathing maneuver (expressed as a percentage)
- Example: patient with healthy lungs may have a ratio of 85%
- Means that 85% of exhaled air was exhaled during the first second of the
breathing maneuver
b. Patients with COPD: ratio is less than 70% to 75%

Patient unable to move exhaled air out of lungs during first second
- Because of an obstruction to the airflow
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- Examples: inflammation, damaged lung tissue
c. Categories of airflow obstruction
 Mild obstruction: 61% to 69%
 Moderate obstruction: 45% to 60%
 Severe obstruction: less than 45%
5. Evaluation of results
a. Demographic factors used to evaluate results entered into the machine
 Age
 Sex
 Weight
 Height
b. Based on demographic factors: spirometer automatically calculates predicted values
 Predicted value: what the results should be for a patient with healthy lungs
c. When test is run: physician compares measured values with predicted values
 Values are printed out on the spirometry report
 Assists physician in detecting pulmonary disease
6. Patient preparation
a. Do not eat a heavy meal for 8 hours before test
 Full stomach: interferes with performing breathing maneuver
b. Stop smoking at least 8 hours before test
c. Do not take bronchodilators 4 hours before test
d. Do not engage in strenuous activity 4 hours before test
e. Wear loose, nonrestrictive clothing: keeps chest area free
 Easier to perform breathing maneuver
7. Calibration of the spirometer
a. Perform each day the machine is used
b. Known quality of air injected into spirometer
c. 3-L spirometry syringe: used to inject 3 L of air into machine
d. Output should read 3 L
e. Reading should not vary more than 3%
f. If not calibrated properly: adjust machine (consult operating manual)
Postbronchodilator Spirometry
1. Ordered when results of spirometry indicate an obstruction
2. How performed
a. Patient inhales a bronchodilator
b. Spirometry test is run 10 to 15 minutes later
3. Purpose: informs physician how treatment would work in patients with obstructed airway
a. If FVC or FEV1 increases by at least 15%:
 Result is reported as positive for bronchodilator responsiveness
- Means the obstruction may be reversible or partially reversible with medications
Peak Flow Measurement
Asthma
1. Chronic lung disease
a. Affects small airways of lungs
2. Trachea divides into right and left primary bronchi
a. After primary bronchi enter lungs
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Branch into smaller bronchi (secondary and tertiary bronchi)
- Then into smaller passages: bronchioles
b. Bronchioles continue to branch
 Finally lead into microscopic alveolar ducts
- Terminate in clusters of tiny air sacs: alveoli
3. Asthma affects smaller bronchi and bronchioles
4. Can occur at any age (but more common in children and young adults)
a. Affects:
 Boys more frequently before puberty
 Girls more frequently after puberty
5. Characteristics of asthma:
a. Chronic inflammation of the small airways
b. Recurrent attacks of:
 Coughing
 Chest tightness
 Shortness of breath
 Wheezing
- Wheezing: a continuous, high-pitched, whistling, musical sound heard particularly during
exhalation and sometimes during inhalation
c. Asthma attack usually followed by a symptom-free period
d. Can be controlled by:
 Recognizing warning signs and symptoms of an attack
 Treating symptoms when they first occur
e. Failure to treat asthma
 Can lead to serious complications
- Example: Permanent lung damage
f. Cause of asthma: not known
 Thought to be caused by:
- Genetics
- Certain childhood respiratory infections
- Contact with allergens
- Exposure to certain viral infections in infancy or early childhood.
Asthma Attack
1. Varies in frequency and severity
2. May come on suddenly or gradually
3. May last for only 10 to 15 minutes
a. Or for hours or even days
4. Normal individual
a. Airways to lungs are fully open
 Allows air to move easily in and out of lungs
5. Patient with asthma
a. Airways are always inflamed
b. Airways are hypersensitive to certain stimuli known as asthma triggers
 Can “trigger” an asthma attack
6. Asthma triggers
a. Vary from one patient to another
b. May vary from one season to the next
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c. Common allergens that may trigger an asthma attack
 House dust
 Pollens
 Molds
 Animal danders, and cockroaches
d. Environmental irritants, activities or events:
 Air pollutants
 Tobacco smoke
 Chemical fumes (e.g., perfume, paint, gasoline)
 Vigorous physical exercise
 Upper respiratory viral infections
 Exposure to cold
 Emotional stress
e. Sometimes it is difficult to determine what specific triggers cause a patient’s asthma attack
7. Reaction that occurs when airways of patient are stimulated by a trigger
a. Bronchial tubes begin to constrict and swell
 Causes patient to experience asthma symptoms
b. Symptoms may be mild and go away
 On their own, or with minimal treatment with medication
c. Symptoms may lead to a full-blown asthma attack
d. During a severe asthma attack:
 Bronchial tubes continue to constrict and swell
 Become clogged with mucus
 Results in less air moving in and out of lungs
- Leads to a decrease in oxygen available to the body
 Causes patient to experience:
- Coughing
- Chest tightness
- Shortness of breath
- Wheezing
e. Important to treat symptoms when they first occur
 Prevents them from getting worse
- Could cause a severe asthma attack (may require emergency care)
Diagnosis and Treatment
1. Diagnosed through a careful and detailed medical history
a. Of particular importance:
 Patient’s symptoms
 Family history of asthma
 Home and work environment
 Living habits
2. Physician also performs a thorough physical examination
a. To detect symptoms resulting from asthma (e.g., wheezing)
3. Laboratory and diagnostic tests usually ordered:
a. May include:
 Pulmonary function tests (e.g., spirometry)
 Allergy testing
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 Arterial blood gas studies
Asthma is a chronic disease with no cure
a. Most patients are able to lead a normal life
 Through proper management and treatment
5. General treatment of asthma
a. Identifying and avoiding asthma triggers (if possible)
b. Preventing and alleviating symptoms through drug therapy
6. Long-term control medication
a. Helps relieve bronchial inflammation
b. Prevents symptoms from occurring
c. Helps the patient have fewer and milder asthma attacks
d. Typically taken every day
e. Examples:
 Corticosteroids (Flovent, Azmacort, Vanceril, and AeroBid)
 Singulair
 Accolate
 Serevent
 Alupent
 Advair.
7. Quick-relief medication (also called rescue medication)
a. Opens the airways quickly
 By dilating bronchial tubes
b. Taken when patient is experiencing symptoms
 To prevent or control an asthma attack
c. Examples:
 Fast-acting bronchodilators (Proventil, Ventolin, and Xopenex)
8. Many asthma medications are delivered through an inhaler
a. Allows medication to go directly to lungs
9. Nebulizer: breathing machine used to treat an asthma attack at home
a. May be used with quick-relief medications
10. Some asthma medications: administered orally
a. Take longer to work
 Must first travel through digestive and circulatory systems before reaching the lungs
4.
Peak Flow Meter
1. Portable, handheld manual or digital device
2. Used to measure a breathing maneuver
3. Manual peak flow meter
a. Consists of a plastic tube with a sliding indicator
 Indicator manually moves along a scale of numbers
- When patient performs the breathing maneuver
4. Digital peak flow meter
a. Automatically measures breathing maneuver
b. Displays measurement digitally on a screen
5. Measures how quickly air flows out of the lungs
a. When patient exhales forcefully
6. Frequently used by patients with asthma
a. Recommended for patients with moderate to severe asthma
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7. Measurements obtained from peak flow meter
a. Not as accurate as those obtained by spirometry
8. Peak flow meter: can be used easily by a patient at home
9. Peak flow measurements
a. Provide patient with important information
 When to take medication
 Severity of asthma attack
10. Different brands of peak flow meters are available
a. Peak flow measurements between brands may vary
b. If more than one meter is purchased
 Always buy the same brand
11. Available in two ranges:
a. Low range
 Ranges from 0 to 300
 Used by young children and some older patients
b. Full range
 Ranges from 0 to 800
 Used by older children, teenagers, and adults
 Adult has much larger bronchial tubes than a child
- Needs the wider range
Peak Flow Rate
1. Maximum volume of air measured in L/min (liters per minute)
a. That can be exhaled when the patient blows into a peak flow meter
 As forcefully and as rapidly as possible
2. Patient performs a breathing maneuver
a. Takes a deep breath until the lungs are completely full
b. Blows all the air out of the lungs and into a mouthpiece
 As hard and as fast as possible
c. Causes sliding indicator to move up the scale of the meter
d. Indicator stops and remains at patient’s peak flow rate (PFR)
3. To obtain most accurate PFR
a. Patient should perform three acceptable breathing maneuvers
b. Record the highest of three measurements
c. The three measurements should be about the same
 Shows an acceptable breathing maneuver was performed each time
 Especially important when evaluating a child’s peak flow measurement
4. MA often responsible for:
a. Instructing patient in procedure for using a peak flow meter at home
b. Obtaining peak flow rate of a patient with asthma at the medical office
Schedule of Use
1. Should be used by patients with moderate to severe asthma
a. To determine how well asthma is being controlled
2. Physician determines schedule of use based on:
a. Severity and frequency of asthma symptoms
3. Most physicians recommend use of peak flow meter:
a. At least once a day
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 Preferably in the morning
 Before taking asthma medication
b. When patient is having symptoms
c. Twice a day for patient with more severe form of asthma
 Morning and evening
4. Peak flow measurements
a. Usually recorded on a peak flow chart
 Can track changes in lung function over a period of time
 Consists of graph paper with a range of peak flow numbers
- Usually from 50 to 800 L/min
 Patient indicates date and time at top of chart
 Dot is placed across from peak flow number in appropriate column
Purpose of Peak Flow Measurements
1. Used to monitor changes in patient’s airflow
a. To determine how well asthma is being controlled
2. High number
 Air is moving easily out of the patient’s lungs
3. Low number
 Airways are narrowed
 Air cannot move easily through them
- Results in a decrease in oxygen available to the body
4. Use of peak flow measurements:
a. Monitor how well the asthma is being controlled
• Assists physician in knowing what medications to prescribe
b. Change or adjust medication
• If patient is doing well (indicated by high peak flow measurements)
- Physician may be able to:
(a) Lower dosage of patient’s medication
(b) Discontinue certain medications altogether
5. Recognize early changes before symptoms occur
a. Peak flow measurements may show changes before patient feels them
 PFR may drop hours or even days before asthma symptoms occur
b. Patient can take medication before symptoms occur
 May be possible to stop attack quickly
- To avoid a severe asthma attack
6. Determine the severity of an asthma episode
a. Allows patient to decide when to use quick relief medication
b. If necessary: when to seek emergency care
c. Patient can determine response to treatment during an asthma attack
 By measuring PFR before and after taking quick-relief medication
7. Assist in identifying asthma triggers
a. Can sometimes identify asthma triggers by measuring PFR
 Before and after exposure to a trigger suspected of causing the asthma
Care and Maintenance
1. MA should instruct patient in proper care of (manual) peak flow meter
a. Dirt collecting on meter
 May result in inaccurate measurements
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2. To clean meter:
a. Wash weekly with warm soapy water
b. Rinse thoroughly with warm water
c. Remove excess water by gently shaking meter
d. Air dry completely before use
3. Many peak flow meters can be cleaned
a. By placing them in the dishwasher (on top shelf)
 Check manufacturer’s instructions for this information
4. Inspect peak flow meter periodically for damage
a. Cracks: could cause air to leak out of the meter
 Leads to inaccurate readings
5. With proper care
a. Should last 2 to 3 years
Home Oxygen Therapy
1. Oxygen
a. Colorless, odorless, and tasteless gas
b. Vital to human body
c. Transported by blood to tissues
 Oxygen taken into cells
- Combines with glucose to produce energy
(1) Necessary for carrying out metabolic processes that sustain life
(a) Breathing
(b) Beating of heart
2. When lungs cannot deliver enough oxygen to body
a. Reduction in amount of oxygen in blood
 Results in hypoxemia
- Hypoxemia: a decrease in the oxygen saturation of the blood
(1) Leads to hypoxia
(a) Hypoxia: a reduction in the oxygen supply to the tissues of the body
3. Failure to maintain adequate blood oxygen level
a. Can result in progressive deterioration of the patient
 Death of cells
 Organ failure
 Body system failure
 Death
4. Prescription for home oxygen therapy may be written for:
a. Conditions that reduce amount of oxygen in the body (hypoxemia)
 Example: severe chronic obstructive pulmonary disease (COPD)
5. Oxygen therapy
a. Administration of supplemental oxygen at concentrations greater than room air
 To treat or prevent hypoxemia
b. Increases oxygen supply to lungs
 Raises blood oxygen to normal levels
- Increases availability of oxygen to the tissues
c. Helps to alleviate effects of low oxygen levels:
 Shortness of breath and fatigue
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d. Helps patient have better quality of life and live longer
e. Most commonly prescribed for
 Patients with severe COPD
- Caused by smoking
f. Also prescribed for:
 Asthma
 Occupational lung disease
 Lung cancer
 Cystic fibrosis
 Congestive heart failure
Oxygen Prescription
1. Need for oxygen therapy determined through:
a. Clinical observation of patient
b. Measuring oxygen level of patient’s blood
2. Clinical signs of hypoxemia:
a. Cyanosis
b. Dyspnea
c. Tachypnea
d. Tachycardia
e. Anxiety
3. Oxygen level of the blood measured by:
a. Arterial blood gas (ABG) analysis
 Normal individual: 75 to 100 mm Hg
 Warrants use of oxygen therapy: less than or equal to 55 mg Hg
b. Pulse oximetry
 Normal individual: above 94%
 Warrants use of oxygen therapy: less than or equal to 88%
4. Goal of oxygen therapy:
a. Maintain blood oxygen level of :
 65 mm Hg (measured through ABG analysis)
 90 to 93% (measured through pulse oximetry)
5. Prescription for oxygen therapy
a. Filled by a home medical supply company
b. Prescription includes:
 Amount and duration of oxygen needed
- Based on severity of patient’s condition
 Recommended oxygen delivery system
 Administration device (e.g., nasal cannula)
6. Flow rate:
a. Number of liters of oxygen per minute (L/min)
 That come out of an oxygen delivery system
b. Example:
 If patient has been prescribed 2 L/min
- Each minute: 2 L of oxygen flows from oxygen delivery system into tubing and into
patient’s upper airway.
c. Most people with COPD:
 Start with flows rate of 1 to 2 L/min
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As COPD worsens over time
- Flow rate might increase to 3 to 6 L/min
7. Duration of oxygen therapy
a. Number of hours per day oxygen therapy is administered
b. Varies from a few hours a day up to 15 hours or more per day
 Depending on patient’s lung function
c. Some patients:
 Only need oxygen when sleeping or exercising
d. Patients with more severe hypoxemia
 May require continuous oxygen therapy
- Continuous oxygen therapy: use of oxygen for more than 15 hours a day
8. Once oxygen therapy is initiated
a. Periodic assessment of blood oxygen level required
 To make sure patient still requires oxygen therapy
 Amount and duration of oxygen is adequate
- To meet patient’s oxygen needs
Oxygen Delivery Systems
1. Type prescribed based on:
a. Patient’s condition
b. Patient’s personal preference
c. Ease of equipment use
d. Cost
2. Can be used alone
a. Or in combination with another system
 To meet oxygen needs of patient
Compressed Oxygen Gas
1. Oxygen gas compressed under high pressure
a. Then stored in a container
 Referred to as a cylinder or tank
2. Compressed oxygen cylinders
a. Vary in size
 Large stationary cylinder
- Used at home by patient
 Small portable cylinder
- Placed in a carrying device (e.g., shoulder bag)
(1) When the patient goes outside the home
3. Regulator and flow meter
a. Control flow rate of oxygen
b. Flow of oxygen out of the cylinder is constant
4. Oxygen-conserving device may be attached to system
a. Conserves oxygen and avoids waste
 Releases oxygen gas only when patient inhales
- Cuts off release of oxygen when patient exhales
5. Advantages:
a. Less expensive than liquid oxygen
6. Disadvantages:
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a. Must be refilled frequently
b. Cannot be taken on a commercial airliner
Liquid Oxygen
1. Oxygen gas subjected to extremely cold temperature
a. Changes from gas to very cold liquid
2. Stored in insulated tank
a. Lining similar to a thermos
3. Takes up less space than compressed oxygen gas
a. Example: 1 L of liquid oxygen is equal to 860 L of compressed oxygen gas
b. Container of liquid oxygen
 Lasts four times longer than compressed oxygen gas of the same weight
4. Liquid oxygen system consists of:
a. Large stationary tank: primary oxygen reservoir of oxygen
b. Small portable tank used outside the home
 Filled from large primary tank for use outside the home
 Hung over shoulder or pulled on a roller cart
5. Liquid oxygen released from its tank
a. Changes into a gas
 Patient breathes it in
6. Advantages:
a. Takes up less space than compressed oxygen gas
 Preferred by individuals with an active life
7. Disadvantages:
a. More expensive than compressed oxygen gas
b. Contents of tank evaporate
 Must refill tank often
c. Portable tank cannot be taken on a commercial airliner
Oxygen Concentrator
1. Electrically powered device
a. Weighs about 35 pounds
b. Size of a large suitcase
2. Works by:
a. Separating oxygen out of the air
b. Concentrating it
c. Storing it for use by patient
3. Equipped with a built-in flow meter
a. Allows the prescribed flow rate to be set
4. Portable battery-powered systems have recently been developed
a. Weigh about 10 pounds
b. Can provide patient with oxygen for 8 hours
 At a flow rate of 2 L/min
c. Have replaced liquid oxygen or compressed gas cylinders for mobility
5. Advantages:
a. Do not need to be resupplied with oxygen from a supply company
b. Less expensive and safer than oxygen cylinders
c. Battery powered systems offer greater freedom and mobility
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 Than other oxygen delivery systems
d. Some portable concentrators
 Have been approved by FAA for use on commercial airlines
6. Disadvantages:
a. Concentrators use electricity
 If power goes out
- Patient must have an oxygen gas cylinder as back-up
Oxygen Administration Devices
1. Device used to administer oxygen to upper airway
a. From the delivery system
2. Device used depends on:
a. Expected duration of therapy
b. Personal preference and needs of patient
3. Nasal Cannula
a. Most frequently used
b. Consists of soft plastic tubing
 With a two-pronged device
- Inserted into patient’s nose
c. Tubing loops over patient’s ears and secured under chin
 Connects to oxygen delivery system
d. Advantage of nasal cannula
 Does not interfere with ability to talk, eat, or drink
e. Concentration of oxygen inhaled by patient
 Depends on flow rate prescribed by physician
f. Can deliver oxygen at a flow rate between 0.25 and 6 L/min
 Flow rate greater than 4 L/min: can dry out nasal passages
- To prevent: use humidifier to provide moisture
g. Wash cannula once or twice a week using liquid soap and water
 Rinsed thoroughly
 Allow to air dry
h. Replace cannula every 2 to 4 weeks
4. Face Mask
a. Consists of plastic
b. Fits over patient’s nose and mouth
c. Face mask strap
 Tightened around head to ensure secure fit
d. Oxygen tubing
 Used to connect face mask to oxygen delivery system
e. Not used as frequently as nasal cannula because:
 It is bulky
 Must be removed:
- For eating or drinking
- To communicate effectively
f. Often used for patients who need a high flow of oxygen
 Can deliver oxygen at a flow rate between 5 and 15 L/min
g. Wearing nasal cannula for extended period:
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 Can cause irritation of nose
- To reduce irritation
(1) Wear nasal cannula during the day and face mask at night
h. Face mask may also be preferred
 When patient has nasal congestion (e.g., cold)
i. Care
 Wash once or twice a week using liquid soap and water
 Rinse thoroughly
 Dry
j. Replace with new one every 2 to 4 weeks
 Sooner if it becomes cracked or discolored
Oxygen Guidelines
a. Home medical supply company
 Provides specific instructions on safe use, care, and maintenance of equipment
b. Oxygen is a safe gas as long as it is used properly
 Not flammable nor will it explode
 Greatly increases combustion rate of a fire
- If something catches fire
(1) Will make flame hotter: causes it to burn faster and more vigorously
(a) Result: fire involving oxygen can appear explosive-like
c. General usage guidelines:
 Contact physician if symptoms of low blood oxygen level occur:
- Frequent headaches, anxiety, cyanosis of the lips or fingernails, drowsiness,
confusion, restlessness, or slow, shallow, difficult, or irregular breathing
 Keep oxygen delivery system clean and free from dust
 Do not change oxygen flow rate
- Unless directed to do so by physician
 Do not use alcohol or take any other sedating drugs
- Will slow breathing rate
 Order more oxygen from home medical company in a timely manner
 To prevent cheeks or skin behind ears from becoming irritated from tubing
- Tuck some gauze under tubing
 For persistent redness under nose: contact physician
 Oxygen therapy dries out inside of nose and mouth
- Use water-based lubricants (e.g., K-Y Jelly) on lips or nostrils
(1) To relieve drying effect
- Do not use oil-based products (e.g., petroleum jelly)
 Do not use more than 40 to 50 feet of tubing (to avoid bending or twisting of tubing)
- Ensures unobstructed oxygen flow
 Not allowed to bring compressed oxygen cylinders or liquid oxygen tanks
- On board an airplane
(1) Many airlines provide oxygen
(a) If notified 48 to 72 hours in advance
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d. General safety guidelines:
 Store oxygen in clean, dry, well-ventilated room
- If kept in closed area (e.g., closet)
(1) Small amount of oxygen gas that is continually vented from unit
(a) Can accumulate in a confined space and become a fire hazard
 Oxygen cylinders and liquid oxygen tanks must remain upright at all times
- Secure to a fixed object or place in a stand
 Never smoke while using oxygen
- Post “No Smoking: Oxygen in Use” signs where oxygen is kept
 Keep oxygen supply at least 6 to 8 feet away from open flames
- Examples: gas stoves, lighted fireplaces, and candles
 Keep oxygen supply at least 6 to 8 feet away from intense heat
- Examples: radiators, furnaces, and space heaters
 Keep oxygen supply away from flammable products
- Examples: cleaning fluid, paint thinner, and aerosol sprays
 Do not lubricate oxygen equipment with oil or grease
- These substances are flammable
 Be sure to have functioning smoke detectors in the home
 Buy a fire extinguisher
- Be familiar with how to use it
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