Download Cardiovascular Pharmacology

Cardiovascular--EKG’s / Cardiac Monitoring
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Static Presentation
Lead II
Jerry Carley RN, MSN, MA, CNE
Digitalis pupurea (Foxglove)
University of Southern Nevada
Summer2010
Part II
At the conclusion of this class (and after some practice)
the nurse will be able to:
1. State the four characteristics of cardiac muscle, and relate these
characteristics to cardiac output.
2. Trace the flow of blood through the heart & lungs, naming all associated
structures
3. Trace electrical conduction through the cardiac conduction system and
correlate to the EKG Tracing.
4. State the intrinsic rates of SA node, atria, AV node, and Ventricles
5. Identify waveforms, landmarks on the EKG tracing: P, QRS, T, U, baseline
6. Identify and measure P-R Interval (PRI), QRS duration, ST Segment
7. Using an EKG tracing, Calculate heart rate and rhythm
8. Using data from EKG analysis, determine name of cardiac rhythm
9. Based upon identified cardiac rhythm, correlate & determine rhythm’s
effect on cardiac output.
10. Identify NSR, SB, ST, SVT, A-fib, A-flut, 1st-2nd-3rd degree AV Blocks,
PVC’s, PAC’s, V-Tach, V-Fib, Toursades, Asystole, PEA
11. Identify nursing actions related to cardiac monitor readings and care of
the cardiac patient.
12. Be familiar with the following medications and their effect on the cardiac
output: Alpha Blockers, Beta Blockers, Ca Channel Blockers, Atropine,
Lidocaine, amiodarone, epinephrine, digoxin
13. Nursing care of the cardiac patient, including considerations
related to all aspects of physical assessment, including cardiac
monitoring, activities of daily living, diet, and medications.
Concept Map: Selected Topics in Cardiovascular Nursing
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
Cardiac Monitoring
Lab Monitoring
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, more…
PATHOPHYSIOLOGY
Myocardial Infarction
Acute Coronary Syndrome
Valvular Heart Disease
Pacemakers
CABG
Abdominal Aortic Aneurysm
Pericarditis
Peripheral Vasc Disease (PVD)
Fem-Pop Bypass Graft
Shock / Fluid Deficit
Raynaud’s Phenomenon
Arrhythmias / Dysrhythmias
PHARMACOLOGY
Cardiac Glycosides
ACE Inhibitors
Alpha Blockers
Beta Blockers
Antiarrhythmics
Catecholamines
Anticoagulants
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary
REMEMBER:
At the ‘end of the day,’
IT’S ALL ABOUT
C.O. =
HR&R x SV
B.P. = C.O. X P V R
SVR
*
*
Tissue perfusion of vital organs…and everything else….
An Affirmation
“It’s all about cardiac output.
Boy, don’t I know it now.”
s All About…
What Factors
Affect
Cardiac Output ?
Medications
Baroreceptors
Sympathetic
Nervous
System
Medications
Blood
Volume
Chemoreceptors
Preload,
Afterload
C.O.
= Heart
Rate
x = Stroke
Volume
Cardiac
Output
HR X
SV
And,
Many more factors !
Blood
Volume
Parasympathetic
Nervous
System
Condition of
Cardiac
Conduction
System*
Condition
Of
Myocardium
Condition of
It’sHeart
All
About
Valves
Cardiac Output !
Viscosity
Of
Blood
Example of Multiple Factors in Cardiac
Output
Chemoreceptors
Baroreceptors
The SinoAtrial Node:
60-100 impulses / minute
Sympathetic Effects:
Parasympathetic Effects:
Recall / Quiz :
 1. Distinguishing Characteristics of Cardiac Muscle:








C________,
C________, A__________, R___________.
2. Intrinsic ‘Rates’ if Cardiac Tissue:
SA Node =____; (Atrial Muscle=_____) AV Node=_____;
Ventricular Muscle =_____.
3. Conduction Pathways in the Heart:
____>_____+_____>_____>_____>______>_________
4. “Interval Times,” i.e., how long it takes these impulses to reach
certain points within the conduction pathway:
P-R Interval=_____ QRS=_____
5. FORMULA FOR CARDIAC OUTPUT:____________
6. FORMULA FOR BP:_________________
7. “IT’S ALL ABOUT:_________ ________”
R&L
Common
Carotid
Arteries
Superior
Vena
Cava
Left
Subclavian
Artery
Lungs
Lungs
LUNGS
Cardiac Conduction Pathways
 SA Node >>
 Inter nodal & Intra atrial pathways (Bachmann’s Bundle)>>
 AV Node >>
 Bundle of His >>
 Right & Left Bundle Branches >>
 Purkinje Fibers
Intrinsic Rates…
“automaticity”
Sino Atrial Node
(SA Node)
60-100 ipm
Atrial Muscle
~ 60 ipm
Atrio-Venticular Node
(AV Node)
40 – 60 ipm
Ventricular
Muscle
20-40 ipm
“Rate & Rhythm”
“Automaticity”
 Intrinsic rates
 SA Node =







60 – 100 i.p.m.
Atrial Muscle =
60 i.p.m.
AV Node =
40 – 60 i.p.m.
Ventricular Muscle =
20 -40 i.p.m.
Conduction Pathways
and rough correlation to the ECG Waveform
SA Node
Internodal & Intra-atrial
Pathways
AV Node
Bundle of His
(R) & (L)
Bundle Branches
Purkinje
Fibers
QRS : < 0.12 seconds
T Wave
Baseline
PRI: 0.12-0.20 seconds
Causes Of Dysrhythmias / Arrhythmias
 1. Drugs (Medications & Others)




Digoxin, quinidine, caffeine, nicotine, alcohol,
cocaine..others….
2. Acid-Base & Electrolyte Imbalances:
K+,
Ca++,
Mg+
3. Marked Thermal Changes
4. Disease & Trauma (Including Surgery)
5. Stress
Rhythm Identification
Each Has Specific Criteria…





Normal Sinus Rhythm (NSR)
Sinus Rhythm
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
Atrial Flutter
 Atrial Fibrillation
 Junctional Rhythms
 Supraventricular Tachycardia (SVT
& PAT)

 Ventricular Tachycardia
 Toursades de Pointes
 Ventricular Fibrillation
 Asystole
 Pulseless Electrical Activity (PEA)
 “Paced Rhythms”
 Individual Ectopics:


 Heart Blocks: 1st, 2nd, 3rd
POTENTIALLY
LETHAL


Premature Atrial Contractions
Premature Junctional Contractions
Premature Ventricular Contractions
Artifact
Terminology:
Bradyarrhythmias versus tachyarrhythmias
Wide-complex tachycardia versus narrow-complex
tachycardia
REMEMBER:
At the ‘end of the day,’
IT’S ALL ABOUT
C.O. =
HR&R x SV
B.P. = C.O. X P V R
SVR
*
*
Tissue perfusion of vital organs…and everything else….
An Important Caveat / Caution….
 Cardiac Monitoring is a powerful diagnostic and
patient care tool (only)
 Correlate the monitor reading to the patient’s
condition !
 Check / Assess your patient for cardiac output!
 The terms “EKG” and “ECG”
ARE INTERCHANGEABLE
The “Stepwise” Method
EKG PAPER
EKG
PAPER
“Amplitude”
Or Strength of
Electrical
Impulse
Small Block = 0.04 sec
5 Small Blocks = 1 Large Block = 0.20 sec
5 Large Blocks = 1 second
TIME
Note: Standard EKG Machines “run” at 25 mm/sec
“Standard” Limb Leads
Lead II
“universal”-Most useful
“ Chest Leads
(for 12-Lead ECG)
“
The ECG Complex, Wave forms,
Intervals, Segments
P Waves











Signal from the Sino Atrial Node (SA Node)
“Normal Pacemaker of the heart”
Should be upright ( Lead II )
Should all look ~ alike
Should have 1:1 ratio with QRS Complexes
Rhythms generated by this called “Sinus”, e.g.,
Sinus Rhythm,
Normal Sinus Rhythm,
Sinus Bradycardia,
Sinus Tachycardia,
Sinus Arrhythmia
P-R Interval
(PRI)
 Measure from beginning of P Wave to first deflection (up or down)
from baseline to start QRS Complex
 Time it takes for impulse to go from SA Node to ventricles
 Normal time = 0.12 to 0.2 seconds ( 3-5 little blocks…)
 (3 x 0.04= 0.12… 5 x 0.04= 0.20)
 Less than 0.12 sec PRI may indicate AV Node--“junctional” problem
 Greater than 0.20 sec indicates AV Block
(1st – 2nd- 3rd
degree)

PRI’s should all be ~ equal
QRS
Complex
General Overview: Are they narrow or wide?
Electrical conduction through the ventricles
Ventricular Function ~ = Cardiac Output
Appearance is generally consistent with ventricular function
Normal = < 0.12 seconds
“3 little boxes” (3 x 0.04 = 0.12 sec)
QRS should all be ~ same form / shape
If greater than 0.12 seconds, indicates “trouble,”
i.e., a conduction delay in the ventricles
S T Segment
?
 Time from ventricular depolarization to ventricular
repolarization
 Frequently “speaks” of trouble within the ventricles
 Elevated or depressed ST segment may indicate previous or
ongoing ischemia or damage to ventricular myocardium
 General rule of thumb:


ST Depression ↓ = Ischemia
ST Elevation ↑ = Infarction
T Waves
 Represent repolarization of Ventricles, i.e., “preparing




to beat again”
Should be upright (lead II)
Should appear ~ same
“Flipped or inverted T waves” may be sign of prior or
ongoing ventricular damage
Prolonged QT Interval may represent problems with
ventricular repolarization— due to damage or
medication effect
“U” WAVES
 Potassium Effect
 HYPOKALEMIA
 Fairly Rare….
P
QRS
T
U
P
QRS
T
U
P
QRS
T
U
P
TALL “TENT-LIKE” T Waves
Caused by: K+ Hyperkalemia
Either One, if not corrected,
Means that ventricular tachycardia,
And / or ventricular fibrillation
IS on the way!
QRS
Overview— Develop Your Method
Practice IT & Follow IT !
Repetition—Repetition--Repetition
 1. General Overview of strip
 2. Rate
 3. Rhythm
 4. P Waves
 5. P-R Interval (PRI)
 6. QRS Interval
 7. Q-T Interval
Apply findings
and
observations
to CRITERIA
REMEMBER:
At the ‘end of the day,’
IT’S ALL ABOUT
C.O. =
HR&R x SV
B.P. = C.O. X P V R
SVR
*
*
Tissue perfusion of vital organs…and everything else….
Measuring Time and Events…
P
P
Baseline or
Isoelectric line
Three Methods for rate determination…
120
Easy Way:
start
12 x 10 (almost 11)= 120’s
Accurate if the rhythm is REGULAR
150
100
60
75
Memorize…. OR divide 300
By # of Big Boxes Between
QRS complexes…or divide 60 by # seconds
between qrs’s
Discussion …
Measuring PRI & QRS
Rates…Intervals…
Remember the “normals”:
 PRI= 0.12 – 0.20 seconds
 (SA Node to Ventricles)
 QRS = < 0.12 seconds
 Time Through the Ventricles
End of Cardiovascular Disease AH II
Part 2
We Will Continue in a moment
 But first……..
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