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CHAPTER 12
CARDIOPULMONARY PROCEDURES
PRETEST
True or False
1.
Blood enters the right atrium from the superior and
inferior vena cava.
2.
The cardiac cycle represents one complete
heartbeat.
3.
A standard electrocardiogram consists of 10 leads.
4.
An electrolyte facilitates the transmission of
electrical impulses.
5.
Leads V1 through V6 are known as the augmented
leads.
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PRETEST, CONT.
True or False
6.
Electrodes that are too loose can cause an
alternating current artifact.
7.
When running an ECG, the medical assistant should
work on the left side of the patient.
8.
An ECG that it within normal limits is said to have a
normal sinus rhythm.
9.
The most serious cardiac dysrhythmia is atrial
fibrillation.
10. The purpose of a pulmonary function test is to
assess cardiac functioning.
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Content Outline
Introduction to Electrocardiography
1. Electrocardiograph:
instrument used to record the
electrical activity of the heart
2. Electrocardiogram (ECG):
graphic representation of the
electrical activity of the heart
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Introduction to
Electrocardiography, cont.
3. Purpose
a. Detect an abnormal cardiac rhythm
(dysrhythmia)
b. Help diagnose damage to heart caused by
myocardial infarction
c. Assess the effect on the heart of digitalis or
other cardiac drugs
d. Determine the presence of electrolyte
disturbances
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Introduction to
Electrocardiography, cont.
e. Assess progress of rheumatic fever
f. Determine presence of hypertrophy of the
heart chambers
g. Use before surgery to assess cardiac risk
during surgery
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Introduction to
Electrocardiography, cont.
4. ECG cannot detect all cardiovascular
disorders
a. Cannot always detect impending heart
disease
5. Used to assess cardiac functioning
a. Along with other diagnostic/laboratory tests
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Introduction to
Electrocardiography, cont.
6. MA responsible for running ECG, which
includes:
a. Preparation of patient
b. Operation of electrocardiograph
c. Identification and elimination of artifacts
d. Labeling the completed ECG
e. Care and maintenance of
electrocardiograph
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Introduction to
Electrocardiography, cont.
7. ECG machine formats:
a. Single-channel format: one lead recorded
at a time
b. Three-channel format: three leads
recorded at one time
•
Most offices use
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Three-Channel Electrocardiograph
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Structure of the Heart
1. Heart consists of four chambers
a. Upper chambers
•
Right atrium
•
Left atrium
b. Lower chambers
•
Right ventricle
•
Left ventricle
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Structure of the Heart
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Structure of the Heart, cont.
2. Pathway of blood through the heart
a. Blood enters right atrium: from superior
and inferior vena cava
•
Brought back to heart after circulating in body
•
Deoxygenated: contains very little oxygen and
high in carbon dioxide (CO2)
b. Enters right ventricle
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Structure of the Heart, cont.
c. Pumped to the lungs
•
By way of pulmonary artery
– In lungs:
1) Picks up oxygen
2) Gives off CO2
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Structure of the Heart, cont.
d. Returns to the left atrium of heart
•
By way of pulmonary veins
e. Enters left ventricle
•
Most powerful chamber of the heart
– Pumps blood to entire body
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Structure of the Heart, cont.
f. Pumped into the aorta to be distributed to
the body
•
Nourishes tissues with oxygen and nutrients
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Conduction System of the Heart
1. Sinoatrial node (SA node)
a. Located in upper portion of right atrium
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
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Conduction System of the Heart
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Conduction System of the Heart,
cont.
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
•
Blood forced through cuspid valves and into
ventricles
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Conduction System of the Heart,
cont.
c. Impulse picked up by atrioventricular (AV)
node
•
Knot of modified myocardium
– Located at base of right atrium
d. AV node delays impulse momentarily
•
Gives ventricles a chance to fill with blood
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Conduction System of the Heart,
cont.
e. Impulse transmitted to bundle of His
•
Bundle of His is divided into right and left bundle
branches
f. Bundle branches: relays impulse to the
Purkinje fibers
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Conduction System of the Heart,
cont.
g. Purkinje fibers: distributes impulse evenly
to right and left ventricles
•
Causes ventricles to contract
– Forces blood out of ventricles: into
pulmonary artery and aorta
h. Entire heart relaxes momentarily
i. New impulse initiated by SA node
j. Cycle repeats
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Conduction System of the Heart
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Cardiac Cycle
1. Represents one complete heartbeat
2. Consists of:
a. Contraction of atria
b. Contraction of ventricles
c. Relaxation of entire heart
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Cardiac Cycle
3. ECG: records electrical activity that causes
cardiac cycle to occur
4. ECG cycle: graphic representation of cardiac
cycle
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ECG Cycle
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Waves
1. P wave
a. Represents electrical activity associated
with contraction of atria
b. Known as: atrial depolarization
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2. QRS complex (consists of Q, R, S waves)
a. Represents electrical activity associated
with contraction of ventricles
b. Known as: ventricular depolarization
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Waves, cont.
3. T wave
a. Represents electrical
recovery of the
ventricles
•
Muscle cells are
recovering in
preparation for
another impulse
b. Ventricular
repolarization
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Waves, cont.
4. U wave
a. Occasionally follows
T wave
b. Small wave
c. May be associated
with repolarization
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Baseline, Segments, and Intervals
1. Baseline
a. Flat, horizontal line that separates various
waves
b. Waves deflect either upward or downward
from baseline:
•
Positive deflection: wave deflects upward
•
Negative deflection: wave deflects downward
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Baseline, Segments, and Intervals,
cont.
2. ECG: divided into segments and
intervals
a. Purpose: Interpretation and analysis of ECG
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Baseline, Segments, and Intervals,
cont.
3. Segment: portion of the ECG between
two waves
a. P-R segment:
•
From the end of atrial depolarization to the
beginning of ventricular depolarization
– Represents time needed for impulse to be
delayed at AV node
b. S-T segment:
•
From the end of ventricular depolarization to the
beginning of repolarization of ventricles
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Segments
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Baseline, Segments, and Intervals,
cont.
4. Interval: length of a wave or length of
wave with a segment
a. P-R interval:
•
From the beginning of atrial depolarization to
the beginning of ventricular depolarization
b. Q-T interval:
•
From the beginning of ventricular depolarization
to the end of repolarization of the ventricles
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Baseline, Segments, and Intervals,
cont.
5. Baseline (after T wave or U wave):
a. Period when entire heart returns to resting
or polarized state
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Intervals
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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 made up of 25 small squares
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Electrocardiograph Paper
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Electrocardiograph Paper, cont.
2. Physician uses graph to measures
waves, intervals, and segments
a. Determines if ECG is within normal limits
3. Paper consists of:
a. Black or blue base with white plastic
coating
b. Black or red graph printed on top of coating
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Electrocardiograph Paper, cont.
4. Heated stylus moves over heat-sensitive
paper
a. Melts away plastic coating
b. Results in recording of the ECG cycles
5. Paper is also pressure-sensitive
a. Handle carefully to avoid making
impressions
•
May interferes with proper reading of ECG
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Standardization of the
Electrocardiograph
1. Electrocardiograph must be
standardized for every recording
a. Quality control measure
•
Ensures an accurate and reliable recording
•
Means ECG run on one electrocardiograph:
compares in accuracy with a recording run on
another machine
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Standardization of the
Electrocardiograph, cont.
2. Normal standardization
mark:
a. Height: 10 mm (10 small
squares)
b. Width: approximately 2
mm wide (2 small
squares)
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Standardization of the
Electrocardiograph, cont.
3. Three-channel machine: automatically
records standardization marks on
recording
4. If standardization mark is more or less
than 10 mm high:
a. Machine must be adjusted
b. Consult operating manual for adjustment
info
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Electrocardiograph Leads
1. Consists of 12 leads
2. Each lead
a. Provides an electrical "photograph" of
heart's activity from a different angle
b. Results in 12 "photographs" of the heart
•
Facilitates thorough interpretation of heart's
activity
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Electrocardiograph Leads, cont.
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 machine by lead wires
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Electrode
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Electrocardiograph Leads, cont.
4. Amplifier: device located in machine that
amplifies the electrical impulses
a. Electrical impulses given off by the heart:
very small
•
Must be made larger (amplified)
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Electrocardiograph Leads, cont.
5. Galvanometer: changes amplified
voltages into mechanical motion
6. Stylus (heated):
a. Records heart tracing on ECG paper
•
By melting plastic coating on ECG paper
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Electrocardiograph Components
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Electrocardiograph Leads, cont.
7. Limb electrodes
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)
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Electrocardiograph Leads, cont.
8. Chest electrodes
a. Abbreviated V or C
b. Uses six chest electrodes
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Electrocardiograph Leads, cont.
9. Electrode used with three-channel
recording
a. Disposable
b. Consists of self-adhesive tab
•
Contains an electrolyte
– Electrolyte: facilitates transmission of an
electrical impulse
c. Electrode applied to skin using adhesive
backing
•
Thrown away after use
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Bipolar Leads
1. Leads I, II, III
2. Each bipolar lead: uses
two limb electrodes to
record electrical activity
of heart
a. Lead I: records heart's
voltage between right arm
and left arm
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Bipolar Leads, cont.
b. Lead II: records heart's
voltage between right arm
and left leg
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Bipolar Leads, cont.
c. Lead III: records heart's
voltage between left arm
and left leg
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Bipolar Leads, cont.
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
physician
Courtesy the Burdick Corporation, Milton, Wisc.
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Augmented Leads
1. aVR (augmented
voltage—right arm)
a. Records heart's voltage
between:
•
Right arm electrode and
a central point between
left arm and left leg
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Augmented Leads, cont.
2. aVL (augmented
voltage—left arm)
a. Records heart's
voltage between:
•
Left arm electrode and
a central point between
right arm and left leg
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Augmented Leads, cont.
3. aVF (augmented
voltage: left leg or
foot)
a. Records heart's
voltage between:
•
Left leg electrode and
a central point
between right arm and
left arm
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Augmented Leads, cont.
4. Leads I, II, III, aVR, aVL, and aVF
a. Records voltage from side to side and from
top to bottom of heart
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Chest Leads
1. V1, V2, V3, V4, V5, and V6
a. Record heart's voltage from front to back of
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: to
ensure an accurate and reliable
recording
3. Normally ECG is recorded with paper
moving at speed of 25 mm/second
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Chest Leads
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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Maintenance of the
Electrocardiograph
1. Casing
a. Clean frequently
•
Use a mild detergent and soft cloth to remove
dust and dirt
•
Do not use solvents or abrasives
– Can damage finish of casing
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Maintenance of the
Electrocardiograph, cont.
2. Patient cable, lead wires, power cord
a. Clean with a cloth saturated with a
disinfectant
b. Never immerse these items in cleaning
solution
•
Can damage them
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Electrocardiograph Capabilities
Three-Channel Recording Capability
1. Records electrical activity of three leads
simultaneously
a. (Single-channel: records only one lead at a
time)
2. Advantage
a. ECG can be run in less time
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Three-Channel Recording
Capability, cont.
3. Leads recorded simultaneously
a. I, II, III
b. aVR, aVL, aVF
c. V1, V2, V3
d. V4, V5, V6
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Three-Channel ECG
Courtesy the Burdick Corporation, Milton, Wisc.
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Three-Channel Recording
Capability, cont.
4. Requires three-channel recording paper
(8½ by 11 inches)
a. Printout: fits easily into patient's chart
5. Most have copy capability
a. Quickly produces recording of last ECG
recorded
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Teletransmission
1. Transmits recording over phone line to
ECG data interpretation site
2. Recording interpreted by cardiologist
a. Computer analysis may also be performed
3. Interpretation and ECG recording:
electronically transmitted to sending
office same day
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Interpretive Electrocardiograph
1. Built-in computer program
a. Analyzes recording as it is being run
2. Provides immediate information on
heart's activity
a. Leads to earlier diagnosis and treatment
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Interpretive Electrocardiograph,
cont.
3. Patient data: must be entered into
electrocardiograph before running
a. Patient age
b. Sex
c. Height
d. Weight
e. Medications
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Interpretive Electrocardiograph,
cont.
4. Analysis printed at top of recording
a. Along with reason for interpretation
5. Results reviewed and further interpreted
by physician
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Interpretive ECG
Courtesy the Burdick Corporation, Milton, Wisc.
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Artifacts
1. Important to produce a clear and
concise ECG
a. Can be easily read and interpreted by
physician
2. Occasionally artifacts appear in
recording
a. Artifact: additional electrical activity picked
up by electrocardiograph
•
Interferes with normal appearance of ECG
cycles
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Artifacts, cont.
3. Artifacts must be identified and
corrected by the MA
4. Most common artifacts:
a. Muscle
b. Wandering baseline
c. Alternating current (AC)
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Artifacts, cont.
5. If unable to correct artifacts: machine
may be broken
a. Contact service technician with following
info:
•
What has already been done to locate and
correct problem
•
Leads in which artifact occurs
•
Sample of the artifact
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Muscle Artifact
1. Characterized by: fuzzy, irregular
baseline
Courtesy the Burdick Corporation, Milton, Wisc.
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Muscle Artifact, cont.
2. Due to:
a. Involuntary muscle movement (somatic
tremor)
b. Voluntary muscle movement
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Muscle Artifact, cont.
3. Caused by:
a. Apprehensive patient
•
To correct:
– Reduce apprehension: relaxes muscles
1) Explain the procedure
2) Reassure patient that ECG is painless
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Muscle Artifact, cont.
b. Patient discomfort
•
To correct: make patient more comfortable
– Make sure table is wide enough to support
patient's arms and legs
– Place pillow under patient's head
– Make sure room temperature is comfortable
for patient:
1) Patient has removed clothing: may be
cold
a) Can cause shivering
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Muscle Artifact, cont.
c. Patient movement
•
To correct:
– Instruct patient to lie still and not to talk
d. Physical condition (e.g., Parkinson's
disease)
•
To correct:
– Try to record when tremor is at a minimum
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Wandering Baseline Artifact
Courtesy the Burdick Corporation, Milton, Wisc.
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Wandering Baseline Artifact, cont.
1. Caused by:
a. Loose electrodes
•
To correct:
– Make sure electrodes are attached firmly to
patient's skin
– If electrode pulls loose:
1) Reattach with tape
2) Replace with a new electrode
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Wandering Baseline Artifact, cont.
– Make sure clips are firmly attached to
electrodes
– Make sure patient cable is well-supported
on patient's abdomen or table
1) Do not allow cable to dangle
b. Body creams, oils, or lotions on skin at
electrode application site
•
To correct:
– Remove by rubbing with alcohol using
friction
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Alternating Current Artifact
1. Due to electrical interference
2. Can leak out: from power used by
electrical appliances in room
a. May be picked up by patient
•
Are carried into machine:
– Results in AC artifact
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Alternating Current Artifact, cont.
3. Appearance of AC artifact:
a. Small straight spiked lines that are
consistent
Courtesy the Burdick Corporation, Milton, Wisc.
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Alternating Current Artifact, cont.
4. Caused by:
a. Lead wires not following body contour
•
Dangling lead wires pick up AC
•
To correct:
– Arrange lead wires to follow body contour
and to lie flat
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Alternating Current Artifact, cont.
b. Other electrical equipment in room: may
leak AC
•
To correct:
– Unplug nearby electrical equipment (lamps,
autoclave, electrically powered examining
table)
c. Wiring in walls, ceiling, floors
•
To correct:
– Move patient table away from walls
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Alternating Current Artifact, cont.
d. Improper grounding of the
electrocardiograph
•
Machine is automatically grounded when
plugged in (by three-prong plug)
•
Make sure plug is securely in wall outlet
•
RL electrode picks up AC from patient and
carries it into machine
– AC is then carried away by grounding
system of machine
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Interrupted Baseline Artifact
Courtesy the Burdick Corporation, Milton, Wisc.
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Interrupted Baseline Artifact, cont.
1. Caused by:
a. Metal tip of lead wire becoming detached
from alligator clip
•
To correct:
– Reattach lead to alligator clip
b. Broken patient cable
•
To correct
– Replace patient cable
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Holter Monitor Electrocardiography
1. Portable ambulatory monitoring system
2. Records cardiac activity of patient for 24
hours
3. Patient maintains daily activities while
being monitored
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Holter Monitor Electrocardiography,
cont.
4. Noninvasive procedure used to
diagnose:
a. Cardiac rhythm abnormalities
b. Conduction abnormalities
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Holter Monitor Electrocardiography,
cont.
5. Specific uses:
a. Evaluate unexplained syncope
b. Discover intermittent cardiac dysrhythmias not
picked up on ECG
c. Assess effectiveness of antidysrhythmic
medications
•
Examples:
– Digitalis
– Antianginal medications
d. Assess effectiveness of artificial pacemaker
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Holter Monitor Electrocardiography,
cont.
6. Holter monitor consists
of:
a. Electrodes placed on
patient's chest
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Holter Monitor Electrocardiography,
cont.
b. Portable recorder: continually monitors
heart's activity
•
Types:
– Magnetic tape recorder: uses a magnetic
tape to record heart's activity
– Computerized
digital recorder:
uses a compact
flash memory
card to record to
heart's activity
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Holter Monitor Setup
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Holter Monitor Electrocardiography,
cont.
7. Recorder held in a case
worn on:
a. Belt, around patient's
waist
b. Hung over patient's
shoulder by strap
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Holter Monitor Electrocardiography,
cont.
8. MA responsible for:
a. Preparing patient
b. Applying and removing monitor
c. Instructing patient for procedure
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Holter Monitor Patient Guidelines
9. Holter Monitor Patient Guidelines
a. Keep electrodes and monitor dry
•
Do not shower, bathe, or swim while wearing
monitor
– Ensures accurate recording
– Prevents damage to recorder
b. Do not touch or move the electrodes
•
Prevents occurrence of artifacts on recording
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Holter Monitor Patient Guidelines,
cont.
c. Do not handle monitor or take out of case
d. Depress event marker only momentarily
when symptom occurs
•
Overuse of marker: causes masking of ECG
signals
e. Do not use an electric blanket while
wearing monitor
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Electrode Placement
1. Electrode consists of:
a. Plastic electrode plate with adhesive
backing
b. Central sponge pad
•
Contains an electrolyte gel
c. Electrode is disposable: discard after use
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Holter Monitor Electrode
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Electrode Placement, cont.
2. Electrodes must be properly placed on
patient's chest
a. Ensures accurate recording
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Electrode Placement, cont.
3. Check monitor after hooking up patient:
a. Purpose: To make sure a clear signal is
being relayed from electrodes to recorder
b. Procedure for checking monitor:
•
Attach one end of a test cable to recorder
•
Attach other end to ECG machine
•
Record a baseline strip
•
Observe for correct waveforms and absence of
artifacts
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Electrode Placement, cont.
4. If problem occurs:
a. Patient may not be hooked up properly
b. Malfunction of cable or lead may be present
c. Reconnect leads and reposition electrodes
and check again
•
If problem still exists: monitor may need to be
repaired
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Activity Diary
1. Patient uses to record all
activities/emotional states during
monitoring period
a. Examples of activities to record:
•
Physical exercise
•
Walking up/down stairs
•
Smoking
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Activity Diary
•
Bowel movements
•
Meals (including alcohol and caffeinated
beverages)
•
Sexual intercourse
•
Medications consumed
•
Sleep periods
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Activity Diary, cont.
b. Examples of emotional states to record
•
Stress
•
Anger
•
Excitement
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Activity Diary, cont.
2. Also record physical symptoms:
a. Dizziness
b. Fainting
c. Palpitations
d. Chest pain
e. Dyspnea
f. Nausea
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Activity Diary, cont.
3. Include in recording:
a. Time of occurrence
4. Purpose of diary:
a. Dysrhythmia on tape compared with
patient's diary
•
To correlate symptoms with cardiac activity
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Activity Diary
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Event Marker
1. Most monitors have an event marker
a. Used with diary for patient evaluation
2. Patient depresses marker (momentarily)
when experiencing a symptom
a. Electronic signal placed on magnetic tape
or flash memory card
3. Alerts technician to significant event on
recording
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Evaluating Results
1. Holter monitor removed at end of 24hour period
2. Recording is evaluated by:
a. Viewing and analyzing recording on a
Holter scanning screen
b. Computer analysis
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Evaluating Results
3. Printouts of the recording: can be
obtained for further study
4. Physician provided with written report
a. Along with selected printouts of abnormal
cardiac activity (e.g., dysrhythmias)
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Cardiac Dysrhythmias
1. Normal ECG: consists of P wave, QRS
complex, and T wave
a. Repeats in a regular pattern (see Figure 12-4)
2. Normal sinus rhythm: ECG that is within
normal limits
a. Waves, intervals, segments, cardiac rate: fall
within normal range
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Cardiac Dysrhythmias, cont.
3. Normal heart rate range: 60 to 100 beats
per minute (bpm)
4. Sinus bradycardia: Below 60 bpm
5. Sinus tachycardia: Above 100 bpm
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Cardiac Dysrhythmias, cont.
6. Cardiac abnormalities include:
a. Extra beats
b. Abnormal rhythm (dysrhythmia)
c. Abnormal heart rate
7. MA should be able to identify
dysrhythmias on ECG
a. Alert physician
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Atrial Premature Contraction (APC)
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
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Atrial Premature Contraction (APC)
From Huang S, et al: Coronary care nursing, Philadelphia, 1989, Saunders.
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Atrial Premature Contraction (APC),
cont.
2. Clinical Aspects
a. Common in healthy individuals
b. Often caused by intake of stimulants
(caffeine, tobacco)
c. Can also be associated with:
•
Serious atrial dysrhythmias
•
Structural heart disease
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Paroxysmal Atrial Tachycardia
(PAT)
1. Description
a. Abrupt episode of tachycardia
b. Heart rate: 150 to 250 bpm
c. Sudden onset and termination
d. Only last few seconds; then heart rate
returns to normal
e. ECG cycles are very close together: due to
increased heart rate
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Paroxysmal Atrial Tachycardia
(PAT)
From Huang S, et al: Coronary care nursing, Philadelphia, 1989, Saunders.
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Paroxysmal Atrial Tachycardia
(PAT), cont.
f. Patient experiences
•
Sudden pounding or fluttering of chest
•
Weakness and breathlessness
•
Acute apprehension
•
Occasionally syncope
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Paroxysmal Atrial Tachycardia
(PAT), cont.
2. Clinical Aspects
a. One of most common rhythm disorders
b. Often occurs in healthy patients
•
Especially young adults with normal hearts
c. Can also occur in patients with organic
heart disease
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Atrial Flutter
1. Description
a. Rapid regular fluttering of atrium
b. Heart rate: 250 to 350 bpm
c. More than one P wave precedes QRS
complex
•
Can range from 1 to 8
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Atrial Flutter, cont.
d. P wave appears as saw-toothed spikes
between QRS complexes
e. QRS complexes are normal
f. T wave usually lost in P waves
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Atrial Flutter, cont.
2. Clinical Aspects
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
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Atrial Flutter, cont.
•
Acute myocardial infarction
•
Chronic lung disease
•
Hypertensive heart disease
•
Pulmonary emboli
•
Patients who have undergone cardiac surgery
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Atrial Fibrillation (AF)
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 to180 bpm)
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Atrial Fibrillation (AF)
From Huang S, et al: Coronary care nursing, Philadelphia, 1989, Saunders.
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Atrial Fibrillation (AF), cont.
2. Clinical Aspects
a. Occurs in healthy individuals
•
Caused by stress, excessive alcohol
consumption, vomiting
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Atrial Fibrillation (AF), cont.
b. Can occur in patients with heart disease
•
Individuals under 50: may be caused by
– Congenital heart disease
– Rheumatic heart disease with mitral valve
involvement
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Atrial Fibrillation (AF), cont.
•
Individuals over 50: may be caused by
– Coronary artery disease
– Mitral valve disease
1) Hypertension heart disease
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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
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Premature Ventricular Contraction
(PVC), cont.
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
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Premature Ventricular Contraction
(PVC)
From Huang S, et al: Coronary care nursing, Philadelphia, 1989, Saunders.
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Premature Ventricular Contraction
(PVC), cont.
2. Clinical Aspects
a. Seen in normal individuals in all age groups
b. Caused by:
• Anxiety
• Alcohol
• Smoking
• Certain medications (e.g.,
epinephrine)
• Caffeine
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Premature Ventricular Contraction
(PVC), cont.
c. Can also 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
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Ventricular Tachycardia (VT)
1. Description
a. Series of three or more consecutive PVCs
•
Occur at a rate of 150 to 250 bpm
b. May occur suddenly and last for short time
•
Or may last for a long time
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Ventricular Tachycardia (VT), cont.
c. QRS complexes are bizarre and widened
d. No P waves present
From Huang S, et al: Coronary care nursing, Philadelphia, 1989, Saunders.
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Ventricular Tachycardia (VT), cont.
e. Sustained VT: life-threatening
•
Prevents adequate filling time for heart
•
May degenerate into ventricular fibrillation and
cardiac arrest
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Ventricular Tachycardia (VT), cont.
2. Clinical Aspects
a. Usually see in patients with acute or
chronic heart disease
b. Indicative of coronary artery disease
c. Also occurs as a complication of
myocardial infarction
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Ventricular Fibrillation (VF)
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 on ECG
e. No recognizable P waves, QRS complexes,
or T waves
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Ventricular Fibrillation (VF)
From Huang S, et al: Coronary care nursing, Philadelphia, 1989, Saunders.
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Ventricular Fibrillation (VF), cont.
f. No effective ventricular pumping action
g. Must be treated immediately
h. Can lead to sudden death
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Ventricular Fibrillation (VF), cont.
2. Clinical Aspects
a. Most common cause: acute myocardial
infarction
b. Can also occur in patients with:
•
Organic heart disease
•
Cardiac dysrhythmias
c. May be preceded by PVCs or ventricular
tachycardia or may occur spontaneously
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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Pulmonary Function Tests
1. Purpose of PFT: To assess lung
functioning
2. Assists in detection of pulmonary
disease
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Pulmonary Function Tests, cont.
3. PFT tests include:
a. Spirometry
b. Lung volumes
c. Diffusion capacity
d. Arterial blood gas studies
e. Pulse oximetry
f. Cardiopulmonary exercise tests
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Spirometry
1. Noninvasive screening test often
performed in 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/or graph
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Spirometry, cont.
3. Considered a screening test
a. Abnormal results: require additional PFT
tests
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Spirometry, cont.
4. Indications for performing spirometry
a. Patients who exhibit symptoms of lung
dysfunction (e.g., dyspnea)
b. Patients at high risk for lung disease
•
Smoking
•
Exposure to environmental pollutants
– Coal dust
– Asbestos
– Exhaust fumes
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Spirometry, cont.
c. Patients with lung disease
•
Asthma
•
Chronic bronchitis
•
Emphysema
d. Patients who will undergo surgery:
•
To assess probable lung performance during an
operation
e. Evaluation of lung disability/impairment for
a compensation program (e.g., coal miner)
•
Provide a number of measurements to assess
lung function
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Spirometry Test Results
1. Spirometry: provides numerous measurements
to assess lung function
2. Forced Vital Capacity (FVC): Maximum
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
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Spirometry
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Spirometry Test Results, cont.
•
To be considered an adequate test:
– Patient must forcibly blow out all air and
continue smooth, continuous exhaling for 6
seconds
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Spirometry Test Results, cont.
•
Minimum of three acceptable efforts must be
obtained
– Some patients have trouble performing
breathing maneuver due to:
1) Physical impairment
2) Poor motivation
3) Do not understand instructions
a) Be patient and work with patient to
help perform maneuver
b) If unable to perform maneuver after
eight attempts: discontinue testing
o
Fatigue may affect accuracy of
results
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Spirometry Test Results, cont.
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
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Spirometry Test Results, cont.
4. FEV1/FVC Ratio: Comparison of FEV1
with FVC
a. Patient with healthy lungs: 70% to 75% of
air exhaled (FVC) is exhaled in the first
second (FEV1) of breathing maneuver
•
Expressed as a percentage
•
Example: patient with healthy lungs may have
ratio of 85%
– Means that 85% of exhaled air was exhaled
during first second of breathing maneuver
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Spirometry Test Results, cont.
b. Patients with chronic obstructive
pulmonary disease (COPD): ratio falls below
70% to 75%
•
Patient unable to move exhaled air out of lungs
because of an obstruction to the airflow
– 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%
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Spirometry Parameters
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Spirometry Test Results, cont.
5. Evaluating the Results
a. Demographic factors used to evaluate
results entered into the machine:
•
Age
•
Sex
•
Weight
•
Height
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Spirometry Test Results, cont.
b. Based on demographic factors: computer
calculates predicted values.
•
Predicted value: What the results should be for
a patient with healthy lungs
c. Once test run: physician compares
measured values with predicted values
•
Values are printed out on the spirometry report
•
Assists physician in detecting pulmonary
disease
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Predicted and Measured Values
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Patient Preparation
6. Patient Preparation
a. Do not eat 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
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Patient Preparation, cont.
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
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Calibration
7. Calibration of the spirometer
a. Perform each day 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)
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Post-Bronchodilator 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
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Post-Bronchodilator Spirometry,
cont.
3. Purpose: informs physician how
treatment will 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
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What Would You Do?
What Would You Not Do?
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What Would You Do?
What Would You Not Do?
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POSTTEST
True or False
1.
An electrocardiogram is a recording of the electrical
activity of the heart.
2.
The AV node sets the pace of the heart.
3.
The P wave represents the contraction of the
ventricles.
4.
If the electrocardiograph is standardized, the
standardization mark will be 20 mm high.
5.
Electrocardiograms are normally recorded with the
paper moving at a speed of 25 mm/sec.
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POSTTEST, CONT.
True or False
6.
A muscle artifact can be identified by its fuzzy,
irregular baseline.
7.
The patient is permitted to shower while wearing a
Holter monitor.
8.
A patient with a PAT dysrhythmia often experiences
weakness and acute apprehension.
9.
A spirometer measures how much air is exhaled by
the lungs and how fast it is exhaled.
10. Spirometry can be used to assess a patient with
emphysema.
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