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CARDIOVASCULAR LEARNING ACTIVITY MODULE SOUTHEASTERN LOUISIANA UNIVERSITY DEPARTMENT OF NURSING NLAB 335 Developed by: M. Wafer, Fall, 1997 Revised by: L. Larsen, Spring, 1998; R. Rolling, Fall, 2000; Fall 2003, Fall 2005; Fall 2007 Landry/Vessel Spring 2008, TV Fall 2008, Landry/Guillot Spring 2009 Revised: D. Guillot, Fall 2013, Su 2014, Fall 2015, March 2017 1 LEARNING ACTIVITY MODULE EKG INTERPRETATION Purpose: The purpose of this learning activity module is to introduce students to the following: a. proper electrode placement for basic cardiac monitoring b. basic identification of an EKG rhythm strip c. how to defibrillate or perform synchronized cardioversion d. how to manage a cardiac arrest utilizing Sim-Man scenario Rationale: The ability to monitor a client’s cardiac status and to recognize and manage common abnormal rhythms is an essential skill for the nurse. Objectives: The learner will be able to: 1. 2. 3. 4. Demonstrate proper lead placement for 3 lead & 5 lead cardiac monitoring Analyze each component of an EKG wave form Utilize a 5-step method to interpret a EKG rhythm strip Identify the following dysrhythmias: 5. 6. 7. normal sinus rhythm sinus bradycardia sinus tachycardia atrial fibrillation atrial flutter premature ventricular contractions (PVCs) ventricular tachycardia ventricular fibrillation asystole pulseless electrical activity (PEA) supraventricular tachycardia Demonstrate defibrillator safety to include clearing area, charging, discharging, and how to use various defibrillator pads Differentiate between defibrillation and synchronized cardioversion. Effectively manage a cardiac arrest scenario utilizing Sim-Man. Readings: Lynn, P. (2015). Taylor’s clinical nursing skills: A nursing process approach. (4th ed.) Philadelphia: Lippincott Williams & Wilkins. 2 Key Terms Box 16-1 Skill 16-5 Skill 16-7 I. ECG Complex Applying a Cardiac Monitor p. 915-916 p. 938 p.943-948 Performing Emergency Manual External Defibrillation (Asynchronous) p. 932-936 The EKG The electrocardiogram (EKG) is a graphic recording of the electrical potentials produced in association with the heartbeat. Impulse formation and conduction produce weak electrical currents that spread throughout the entire body. By applying electrodes to various positions on the body and connecting these electrodes to an electrocardiographic apparatus, the EKG is recorded. Examples of the electrocardiograph include the standard EKG machine, bedside monitors, or telemetry monitors. The placement of electrodes record waveforms, which look different in different positions. The most common lead placement for continuous monitoring is Lead II. Lead placement should be coordinated with the monitoring operating system according to manufacturer directions. The EKG is recorded on ruled paper, which measured horizontally, represents time, and vertically, distance. The time measurements are important in dysrhythmia recognition. The EKG is usually recorded at the standard paper speed of 25 mm/second or 1 inch/second thus, the time value of each small square is 0.04 seconds and the value of each large square (5 small squares) is 0.2 seconds, which represents distance in mm. Vertically, the value of each small square is 1 millivolt in amplitude 3 II. Cardiac Conduction System SA node (sinoatrial) is located in the upper right atrium near the junction of the superior vena cava and the right atrium. o SA node cells have highest automaticity and fastest rate of impulse formation at 60 –100/ minute o Considered the pacemaker of the heart AV node (atrioventricular) is located in the posterior floor of the right atrium at the upper portion of the intraventricular septum. o Conduction slows down here to allow adequate time for the atria to fully contract completely filling the ventricular chambers o Automatic rate of impulse formation is 40-60/minute Bundle of His (common bundle) had direct continuity with the lower portion of the AV node in the intraventricular septum Right and left bundle branches continue from the Bundle of His and transmit impulse through the intraventricular septum Purkinje fibers connect the bundle branches directly to myocardial cells through the intricate network 4 P wave- Deflection produced by atrial depolarization P-R interval – Occurs from the beginning of the P wave (atrial depolarization) to the beginning of the QRS complex (ventricular depolarization) o Measures total atrial conduction time o Normal P-R interval is 0.12 – 0.20 seconds (varying depending on heart rate o A longer interval indicates first degree heart block QRS complex – Deflection or series of deflections produced by ventricular depolarization o Normal QRS interval is 0.06 – 0.11 seconds o If it is 0.12 seconds or above, there is definite delay in conduction through the ventricle ST segment – From the end of the QRS complex (ventricular depolarization) to the beginning of the T wave (ventricular repolarization) o Segment is usually isoelectric or flat o Elevation or depression may represent injury or disease of ventricular muscle o If not smooth, look for a P wave in it T wave – Deflection produced by ventricular repolarization o Peak of the T is the most vulnerable (relative refractory period) 5 III. 5 – Step Plan to Analysis of EKG Rhythm Strip 1.) Analyze the rate – Measure both the atrial rate and ventricular rate Rates below 60 are bradycardias Rates above 100 are tachycardias 2.) Analyze the rhythm Use paper or calipers Measure the regularity of the rhythm Look for consistency in P-P intervals (atrial rhythm) and R-R intervals (ventricular rhythm) 3.) Analyze the P wave and P-QRS relationship Should be upright and smooth in Lead II In a normal sinus rhythm every P wave is followed be a QRS complex. 4.) Analyze the P-R intervals All P-R intervals should be the same P-R interval should be within .12 -.20 seconds Shorter or longer P-Rs usually are caused by a conduction defect 5.) Analyze the QRS intervals Each QRS should be similar in appearance QRS should be no greater than 0.11 seconds QRS 0.12 or longer denotes a delay in ventricular conduction, usually a bundle branch block 6 7