UNIT 1-ECG AND CODE MANAGEMENT

Question 1

Identify this rhythm

Answer 1

Artifact

1. You will see artifact on the monitor when leads and electrodes are not sexure, or if there is muscle activity (shievering) or electrical interferce
2. Artifact is a distortion of the baseline and waveforms seen on the ECG

Question 2

What are your nursing interventions when you have Artifact on your ECG?

Answer 2

Because accurate interpretation of cardiac rhythm is difficult when artifiact is present. If artifact occurs, check the connections in the equipment. You may need to replace the electrodes if the conductive gel has dried out.

Question 3

What are the four properties of cardiac cells that enable the conduction system to start an electrical impulse, send it through the cardiac tissue, and stimulate muscle contraction?

Answer 3

1. Automaticity
2. Excitability
3. Conductivity
4. Contractility

Question 4

What is automaticity?

Answer 4

The ability to initate an impulse spontaneously and continuously

Question 5

What is excitability?

Answer 5

Is the ability to be electrically stimulated

Question 6

What is conductivity?

Answer 6

The aility to transmit an impusle along a membrane in an orderly manner

Question 7

What is contractility?

Answer 7

The ability to respond mechanically to an impulse

Question 8

Describe the function of the conduction system?

Answer 8

1. Normal cardiac impulse begins in the sinoatrial (SA) node in the upper right atrium.
2. It spreads over the atrial myocardium via interatrial pathways and internodal pathways, causing atrial contraction.
3. The impulse then travels to the atrioventricular (AV) node, through the bundle branches. It ends in the purkinje fibers, which transmits the impulse to the ventricles.

Question 9

Dysrhythias result from disorders of….

Answer 9

impusle formation, conduction of impulses or both

Question 10

The SA node is the normally the ___1___ of the heart? firing at how many times per min?

Answer 10

1. Pacemaker
2. 60-100

Question 11

What should we know about secondary pacemakers from another site?

NOT CLEAR ON THIS

Answer 11

Can fire in two ways
1. If the SA node fires more slowly than a secondary pacemaker, the electrical signals from the secondary pacemaker may “escape” The secondary pacemaker will then fire automatically at its intrinisc rate.
2. Another way that secondary pacemakers can start is when they fire more rapidly than the normal pacemaker of the SA node. “triggered beats” (early or late) may come from an ectopic focus or accessory pathway which is outside the normal conduction pathway in the atria, AV node or ventricles. The results in a dysrthmia, which replaces the normal sinus rhythm.

Question 12

What is the intrinsic rate of the AV node or the His- Purkinje system?

Answer 12

AV node fires at a rate of 40 to 60 times per minute or the His-purkinje system at a rate of 20-40 times per min

Question 13

The autonomic nervious system play an important role in the rate of….. in the cardiac system.

Answer 13

1. Impulse formation
2. Speed of conduction
3. Strength of cardiac contraction

Question 14

What are the components of the autonomic nervous system that affect the heart?

Answer 14

1. Vagus nerve fibers of the parasympathetic nervous system and nerve fibers of the sympathetic nervous system

Question 15

How does stimulation of the vagus nerve which a part of the parasympathetic nervous system affect the heart?

Answer 15

1. Decreases rate of firing of the SA node
2. Slowed impusle conduction of the AV node

Question 16

How does stimulation of sympathetic nerves in the sympathetic nervous system affect the heart?

Answer 16

1. Increases rate of SA node
2. Increases impulse conduction of AV node
3. Increase cardiac contractility

Question 17

What are some sympathetic nervous system responses?

Answer 17

Stressed state
1. Pupils expand
2. Fast & shallow breathing
3. Heart pumps faster
4. Gut INACTIVE

Question 18

What are some parasympathetic nervous system symptoms?

Answer 18

Calm
1. Pupils shrink
2. Slow deep breaths
3. Heart slows
4. Gut ACTIVE

Question 19

What is Telemetry monitoring?

Answer 19

It is the observation of the patients HR and rhythm at a site distant from the patient

Question 20

What are the 2 types of systems used for telemetry monitoring?

Answer 20

1. Centralized monitoring
2. Bedside advanced alarm systems

Question 21

Centeralized monitoring system- ECG requires….

Answer 21

The nurse or a telemetry tech to contionusly observe a group of patients ECGs at a central location

Question 22

Advanced alarm system bedside monitoring does not require….

Answer 22

Constant survallience. These systems have the cability of detecting and storing data. Advanced alarm systems provide different levels of detection of dysrhythimas, ischemia or infarction.

Question 23

What do we need to remember about computerized monitoring systems?

Answer 23

They are not fail proof. We should frequently assess all monitored patients for any signs of hemodynamin instability

Question 24

What should we know about the P wave?

Answer 24

1. It is the 1st waveform that is normally seen.
2. This wave should be upright (postive deflection) with a rounded top in lead

Question 25

The P wave represents what part of the cardiac conduction system?

Answer 25

The P wave represents the SA node sending out an electrical impulse and represents atrial depolarization (contraction)

Question 26

What should we know about the QRS wave (or complex)

Answer 26

1. Normally follows the P wave. 2. Can take on many different forms 3. Normal QRS complexes are usually pointy and skinny in width.

Question 27

The QRS complex represents what in the cardiac conduction system?

Answer 27

This complex represents ventricular depolarization (contraction) The ventricles depolarize from the endocardial layer (inside of the heart) to the epicardial layer (outermost layer of the heart)

Question 28

How do we calculate the HR on an ECG

Answer 28

1. Count the number of QRS complexes in 1 min 2. QRS complexes in 6 seconds and multiply by 10

Question 29

How does regularity determined when looking at the ECG?

Answer 29

Regularity can be determined by counting the boxes between the waveforms being measured, such as p wave to pwave or qrs to qrs complex (r to r). A regular rhythm will have the same number of boxes or equal space between waveforms or complexes

Question 30

What are important concepts and questions to consider with our assessment of cardiac rhythm?

Answer 30

1. Interpret the rhythm AND evaluate the clinical status of the patient 2. Is the patient hemodynamically stable? 3. Determine cause of dysrthymia - This is a priority. For example, tachycardias may be the result of a fever and may cause a decrease in cardiac output and hypotension. Electrolyte distubances can cause dysrthmias and if not treated can be life-threatening 4. Treat the patient, not the monitor

Question 31

How should we assess the cardiac rhythm?

Answer 31

When assessing a cardiac rhythm, use a consistent and systematic approach. 1. Pwave - look for its presence, is it upright or more inverted? Is there one for every QRS complex or more than one? Are there atrial fibrillatory or flutter waves? 2. P-R interval - Is it normal duration or prolonged 3. Ventricular rate and rhythm? - Is it regular or irregular 4. QRS complex - Measure the duration of the QRS complex. Is it normal or prolonged 5. ST segment - Is it isometric (flat), elevated, or depressed 6. Q-T interval - Measure the duration of the Q-T interval is it normal or prolonged 7. T wave - Is it upright or inverted

Question 32

Identify this rhythm

Answer 32

Normal Sinus Rhythm which refers to a rhythm that starts in the SA node at a rate of 60-100 times per min and follows the normal conduction path way

Question 33

Identify this dysrhythmias

Answer 33

Sinus Bradycardia

Question 34

What do we need to know about sinus bradycardia

Answer 34

1. Sinus bradycardia may be a normal sinus rhythm in aerobically trained athletes and in some people during sleep 2. May be associated with some disease states

Question 35

What is sinus bradycardia?

Answer 35

It occurs in response to a parasympathetic nerve stimulation and certain drugs, carotid sinus massage, valsalva maneuver, hypothermia, increased introcular pressure, vagal stimulation and administration of certain drugs like adrenergic blockers, calcium channel blockers

Question 36

What are some common disease states associated with sinus bradycardia?

Answer 36

1. Hypothyroidism 2. Increased ICP 3. Hypoglycemia 4. Inferior myocardinal infarction (MI)

Question 37

What are the manifestations of sinus bradycardia

Answer 37

1. Hypotension 2. Pale, cool skin 3. Weakness 4. Angina 5. Dizziness or syncope 6. Confusion or disorienatation 7. SOB Clinical significance of sinus bradycardia depends on how the patient tolerates it.

Question 38

Symptomatic bradycardia refers to a HR that is....

Answer 38

Less than 60beats/min and is inadequate for the patients condition, causing the patient to experience symptoms

Question 39

Treatment of sinus bradycardia includes?

Answer 39

1. Atropine (anticholinergic drug) usually given to symptomatic patients 2. Pacemaker 3. Stop offending drugs

Question 40

Identify this rhythm?

Answer 40

Sinus Tachycardia

Question 41

Identify this rythem

Answer 41

Sinus Tachycardia

Question 42

What do we need to know about sinus tachycardia

Answer 42

1. The conduction pathway is the same in sinus tachycardia as that in normal sinus rhythm. 2. The p wave is normal, procedes each QRS complex and has a normal shape and duration 3. The P-R interval is normal and the QRS complex has a normal shape and duration

Question 43

What is the rate of sinus tachycardia?

Answer 43

101-180beats/min

Question 44

What causes sinus tachycardia?

Answer 44

1. The discharge rate from the sinus node increases because of vagal inhibition or sympathetic stimulation 2. Sinus tachycardia is associated with physiologic and psycholotic stressors such as exercise, fever, pain, hypovolemia, anemia, hypoxia, hypoglycemia, MI, heart failure, hyperthyridism, axiety and fear 3. It can also be an effect of drugs such as epi, norepinephrine, atropine, caffeine, theophylline, or hydralazine, sudafed

Question 45

What are manifestations of sinus tachycardia?

Answer 45

1. Dizziness 2. Dyspnea 3. Hypotension 4. Angina in patients with CAD Clinical significance of sinus tachycardia depends on the patients tolerance of increased HR.

Question 46

What is the treatment of sinus tachycardia

Answer 46

1. Guided by cause for example for the patient who is experiencing tachycardia from pain... effective pain managment will treat tachycardia 2. Vagal maneuver 3. B-adrenergic blockers - Metoprolol can be given to reduce HR and decrease myocardial oxygen consumption

Question 47

Identify this rythem

Answer 47

PSVT- Paroxysmal Suptraventricular tachycardia

Question 48

What is PSVT?

Answer 48

Is a dysrhythmia startin gin an etopic focus anywhere above the bifurcation of the bundle of HIS. Identification of the ectopic focus is often difficult even with a 12 lead.

Question 49

What is the HR of someone experiencing PSVT

Answer 49

151-220 beats/min and the rhythm is regular or slightly irregular

Question 50

What does the rhythm present with PSVT?

Answer 50

The P wave is often hidden in the preceding T wave. If seen, it may have an abnormal shape. The P-R interval may be shortned or normal, and the QRS complex is usually normal.

Question 51

Identify this rhythm?

Answer 51

PSVT

Question 52

Why do PSVT occur?

Answer 52

1. Because of a reentrant phenomenon (reexcitation of the atria when there is a one-way block) 2. Usually a PAC triggers a run of repeated premature beats

Question 53

What is a PSVT?

Answer 53

Paraoxysmal refers to an abrupt onset and ending. Termination is sometimes folled by a brief period of asystole

Question 54

In a normal heart PSVT is associated with...

Answer 54

1. Overexertion 2. EMotional stress 3. deep inspiration 4. Stimulants such as caffeine and tobacco PSVT is also associate dwith rheumatic heart disease, dig tox, CAD, or cor pulmonale

Question 55

What are the manifestations of PSVT?

Answer 55

1. HR is 150-220 beats/min (add for clarification) 2. HR >180 leads to decreased cardiac output and stroke volume 3. Hypotension 4. Dyspnea 5. Angina Clinical significance of PSVT dpends on the associated symptoms

Question 56

What is the treatment of PSVT?

Answer 56

1. Vagal stimulation 2. IV Adenosine #1 Drug 3. IV b-adrenergic blockers (Sotalol) 4. Calcium channel blockers (Diltizem) 5. Amiodarone 6. DC cardioversion (direct current) - used if vagal stimulation and drug therapy are ineffective and the patient becomes hemodynamically unstable.

Question 57

Identify this rhythm

Answer 57

Effect of Adenosine 1. Explain that the patient may feel chest pressure afte med is given 2. Injection site should be as close to heart as possible 3. Monitor patients ECG continously brief periods of asystole is common 4. Assess for flushing,dizziness, chest pain or palpitation

Question 58

Identify this rhythm

Answer 58

Atrial flutter which is a atrial tachydysrthythmia identifed by recurring, regular sawtooth-shaped flutter waves that originate from a signle extopic focus in the right atrum or less commonly, the left atrium

Question 59

What is the atrial rate of atrial flutter

Answer 59

200-350 beats per min

Question 60

What is the ventricular rate of atrial flutter?

Answer 60

150 beats/min

Question 61

How is atrial flutter discribed?

Answer 61

1. Atrial rhythm is regular and ventricular rhythm is usually regular 2. The P-R interval is variable and not measureable 3. The ORS complex is usually normal. Becuase the AV node can delay signal from the atria, there is usually some AV block in a fixed ratio of flutter waves to QRS complexes

Question 62

How is adenosine given?

Answer 62

IV closest to the patient givin in 1-3 seconds followed by a rapid flush of 20ml of saline. 1st dose 6mg, 2nd dose 12 mg,

Question 63

Atrial flutter is typically associated with?

Answer 63

1. Chronic lung disease 2. Cardiomyopathy 3. Hyperthyroidism 4. Hypertention 5. PE 6. drugs - digoxin, quindine, and epi Can occur in a healthy heart but its rare.

Question 64

What is the treatment of atrial flutter

Answer 64

1. Pharmacologic agent - Calcium channel blocker and b adrenergic blockers, antidysrthymic 2. Electrical cardioverson may be performed to convert the atrial flutter to sinus rhythm in an emergency ( The patient is hemodynamically unstable) and electively. 3. Radiofrequency catheter ablation is a treatment of choice for atrial flutter. Usuing a low-voltage, high-frequency form of electrical engery. The tissue is ablated (or destroyed) the dysrhythmia is ended and normal sinus rhythm is restored.

Question 65

Patients with atrial flutter at at an increased risk of?

Answer 65

Stroke because of the risk of thrombus formation in the atria from the stasis of blood. Warfarin is given to prevent stroke in patients with atrial flutter

Question 66

What is the primary treatment goal of atrial flutter?

Answer 66

1. Slow ventricular response by increase AV block.

Question 67

Identify this ryrthm

Answer 67

Atrial Fibrillation 1. Most common clnically significant dysrhymia w/ respect to morbidity and mortality rates and economic impact 2. The dysrhythmia may be paroxymal and end spontanously or be persistent lasting longer than 7days

Question 68

What causes Afib and what can it cause if left untreated?

Answer 68

1. As with atrial flutter-- causes a decrease in CO and increased risk of stroke 2. Often develops acutely with thyrotoxicosis, alcohol intoxication, caffeine, electrolyte disturbances, stress, cardiac surgery 2. A fib results in a decrease in CO because of ineffective atrial contractions (loss of atrial kick) and/or a rapid ventricular response. Thrombi (clots) form in the atria because of blood stasis. An embolized clot may develop and pass to the brain, causing a stroke.

Question 69

Afib is usually occurs in the patient with....

Answer 69

1. Heart disease 2. CAD 3. Rheumatic heart disease 4. Cardiomyopathy 5. HTN heart disease 6. HF 7. Pericadiitis

Question 70

How is afib characterized?

Answer 70

1.By a total disorganization of atrial electrical activity due to multiple ectopic foci resulting in loss of effective atrial contraction 2.During atrial fibrillation, the atrial rate may be as high as 350 to 600 beats/min 3.P waves are replaced by chaotic, fibrillatory waves. 4.Ventricular rate varies and the rhythm is ususally IRREGULAR

Question 71

When the ventricular rate is between 60-100 beats/min in a fib this is considered....

Answer 71

Atrial fibrillation with controlled ventricular response example b

Question 72

Atrial fibrillation with a ventricular rate greater than 100 beats/min is atrial fibrillation with a ...... response

Answer 72

rapid or uncontrolled ventricular response aka AFIB with RVR example c

Question 73

What is the treatment of Atrial Fibrillation?

Answer 73

1. Slow the ventrial response by increasing the AV block 2. Drugs to control ventricular rate and/or convert to sinus rhythm (amiodarone and ibutilide most common) 3. Electrical cardioversion 4. Anticoagulation 5. Radiofrequency ablation 6. Maze procedure with cryoblation

Question 74

What is the goal of treatment for afib?

Answer 74

Goal of treatment includes a decrease in a ventricular response (to less than a 100 beats/mins) prevention of stroke and conversion to sinus rhythm, if possible.

Question 75

If a patient is in atrial fibrillation for longer than 48 hours what must we initate before the cardioversion?

Answer 75

anticoagulation therapy with warfarin for 3 to 4 weeks before

Question 76

What might be ordered in order to rule out the presence of clots in the atria before a cardioversion?

Answer 76

A transesophageal echocardiogram if there are no clots present we can proceed

Question 77

What happens if drugs or cardioversion cannot convert afib to a normal sinus rhythm?

Answer 77

Long-term anticoagulation therapy is required and warfarin is drug of choice

Question 78

Identify this rhythm?

Answer 78

PVC: Premature ventricular contraction which is a contraction coming from an ectopic focus in the ventricles. It is the premature (earlY)occurence of a QRS complex A PVC is wide and distorted in shape compared to a qrs complex coming down the normal conduction pathway

Question 79

What are PVCs that arise from different foci and appear in a different shape from each other called?

Answer 79

Mulifocal PVC

Question 80

PVCs that have the same shape are called?

Answer 80

Unifocal PVCs

Question 81

When every other beat is a PVC, the rhythm is called...

Answer 81

Ventricular bigeminy

Question 82

When every third beat is a PVCs it is called...

Answer 82

Ventricular trigeminy

Question 83

What occurs when there are three or more consecutive PVCs?

Answer 83

Ventricular tachycardia

Question 84

PVCs are associated with....

Answer 84

1. Stimulants such as caffeine, alcohol, nicotine, aminophylline, epi, isoproterenolm and digoxin, electrolye imbalances, hypoxia, heart disease, emtional stress, fever, exercise 2. Disease states like MI, mitral valve prolapse, HF and CAD

Question 85

Treatment for PVCs include?

Answer 85

1. Correct cause 2. Antidysrthmics Usually not harmful in the patient with a normal heart

Question 86

Identify this rhythm?

Answer 86

Ventricular Tachycardia

Question 87

Ventricular rate in vtach is how many beats/min

Answer 87

150 to 250 beats/min Rhythm may be regular or irregular

Question 88

What causes torsades de pointe

Answer 88

Mg deficiency. Can only give mg if you know what the mag level is

Question 89

Ventricular tachycardia is associated with....

Answer 89

1. Heart disease 2. Electrolyte imbalances 3. Drugs 4. CNS disorders

Question 90

Patients in Vtach can be considered __1__ or __2__

Answer 90

1. Stable (has a pulse) 2. Unstable (no pulse)

Question 91

Identify this rhythm

Answer 91

Ventricular fibrillation Vfib which is a severe derangment of the heart rhythm characterized on ECG by irregular waveforms of varying shapes and amplitude. This represents the firing of multiple ectopic foci in the ventricle. Mechanically the ventricle is simply quievering with no effective contraction, and consequently no CO occurs. Lethal dysrhythmia- HR not measurable. Irreglar and chaotic.

Question 92

VFIB is associated with

Answer 92

1. MI 2. Ischemia 3. Disease states 4. Procedures

Question 93

How does a patient present in vfib?

Answer 93

Unresponsive, pulseless and apneic If not treated rapidly, dealth will result

Question 94

How do you treat VFIB?

Answer 94

1. Treat with immediate CPR and ACLS 2. Defibrillation 3. Drug therapy (epinephrine, vasopression)

Question 95

Identify this rhythm

Answer 95

Asystole- represent the total absence of ventricular electrical activity Occasionally P waves are seen No ventricular contraction occurs because depolarization does not occur

Question 96

How do patients with asystole present?

Answer 96

Unresponsive, pulseless, and apneic Lethal and requires immediate tx You should always assess rhythm in more than one lead..

Question 97

What is the prognosis of a patient in asystole?

Answer 97

Poor

Question 98

Asystole is usually the result of...

Answer 98

Advanced cardiac disease, severe conduction disturbance, or end stage HF

Question 99

How is asystole treated?

Answer 99

Treat with immediate CPR and ACLS measures Epinepherine and or vasopressin Intubation

Question 100

Identify this rhythm HINT NO PULSE

Answer 100

Pulseless electrical activity- Is a situation in which organized, electrical activity is seen on the ECG, but there is no mechanical activity of the ventricles and the patient has NO PULSE Prognosis is POOR unless the underlying cause is quickly identified and treated

Question 101

What are your Hs and Ts? | MUST KNOW 6H 5p

Answer 101

H's 1. Hypovolemia 2. Hypoxia 3. Hydrogen ION (acidosis) 4. Hyper-/hypokalemia 5. Hypoglycemia 6. Hypothermia T's 1. Toxins(drug overdose) 2. Tamponade (cardiac) 3. Thrombosis (MI and pulmonary) 4. Tension Pneumothorax 5. Trauma

Question 102

What is the treatment of PEA?

Answer 102

1. CPR followed by intubaiton and IV epinephrine 2. Treatment is directed toward correction of the underylying cause

Question 103

Identify this rhythm

Answer 103

3rd degree AV heart block (complete heart block)- Constitutes one form of AV dissociation in which no impulses from the atria are conducted to the ventricles. THe atria are stimulated and contract independently of the ventricles. the ventricular rhythm is an escape rhythm, and the ectopic pacemaker may be above or below the vifurcation of the bundle of his Atrial rate is usually a sinus rate of 60-100 Ventricle rate depends on the site on the site of the block. if its the AV node the rate is 40-60 beats/min and if its in the his-purkinje system it is 20-40 beats/min

Question 104

Describe the characteristic of thrid degree AV heart block on the ECG

Answer 104

1. Atrial and ventricular rhythms are regular but unreleated to each other 2. The P wave has a normal shape 3. The P-R interval is variable and there is no relationship between the Pwave and the QRS complex. 4. THe QRS complex is normal if an escape rhythm is initated at the bundle of his or above it is widened if an escape rhythm is initatied below the bundle of his.

Question 105

3rd degree AV heart block (complete heart block) is associated with.... and results in... which can lead to what....

Answer 105

1. Associated with severe heart disease (CAD, MI), some systemic disease (amylodosis), certain drugs (digoxin, b-adrenergic drugs, calcium channel blockers) 2. Usually results in decreased cardiac output with subsequent ischemia, HF, and shock 3. Can Lead to syncope, HR and shock

Question 106

How is 3rd degree AV heart block treated?

Answer 106

1. Pacemaker 2. Drugs to increase heart rate if needed while awaiting pacing. (atropine, dopamine,epi) usually temporary to increase HR and support BP until temporary pacing is started. Will need a permenant pacemaker asap.

Question 107

What is a pacemakers purpose?

Answer 107

1. Control heart rate when conduction is compromised 2. Single chamber pacemaker- paces either the atria or ventricle 3. Dual chamber pacemaker- paces both atrum and ventricle

Question 109

What are CPR ratio for an adult?

Answer 109

30:2

Question 110

What is our CPR rate for an adult?

Answer 110

100-120 compressions per min

Question 111

How many breaths per 6 seconds

Answer 111

2

Question 112

How many J do we charge our biphasic defibrillator to?

Answer 112

120-200J

Question 113

How many J do we charge our monophasic defibrillator to?

Answer 113

360