Cardiac Rhythms
Name each wave seen in an EKG complex and indicate what is happening in the heart with each wave.
P wave- atrial depolarize/ contract (0.06-0.12sec).
PR interval- conduction from atria to ventricles (<0.20sec).
QRS complex- ventricles depolarize/ contract (<0.12sec).
ST segment- begins ventricular repolarization/ get ready for next beat (on isoelectric line).
T wave- ventricle repolarize-0.16sec
List treatments/ interventions for each of the following rhythms: AFib, AFib with RVR, AFlutter, junctional rhythm, accelerated junctional, VTach, VFib, PEA, asystole
Atrial Fibrillation (AFib)
Anticoagulation to prevent stroke (e.g., warfarin, DOACs)
Rate control with beta blockers or calcium channel blockers
Rhythm control with amiodarone or cardioversion if unstable
AFib with Rapid Ventricular Response (RVR)
Immediate rate control with diltiazem or metoprolol
Synchronized cardioversion if unstable
Anticoagulation as indicated
Atrial Flutter
Rate control similar to AFib
Anticoagulation
Synchronized cardioversion often effective
Junctional Rhythm
Treat underlying cause (e.g., hypoxia, digoxin toxicity)
Atropine if symptomatic
Consider pacing if unstable
Accelerated Junctional Rhythm
Usually no treatment if asymptomatic
Hold causative medications (e.g., digoxin)
Monitor closely
Ventricular Tachycardia (VTach)
With pulse (stable): IV antiarrhythmics (e.g., amiodarone, lidocaine)
With pulse (unstable): synchronized cardioversion
Pulseless VTach: immediate defibrillation and CPR
Ventricular Fibrillation (VFib)
Immediate defibrillation
Begin CPR
Administer epinephrine
Consider amiodarone after defibrillation
Pulseless Electrical Activity (PEA)
Begin high-quality CPR immediately
Administer epinephrine
Identify and treat reversible causes (e.g., H's and T's)
Asystole
Begin CPR immediately
Administer epinephrine
Do not defibrillate
Address possible reversible causes
Explain the difference between a NSTEMI and a STEMI. What will be noted on the EKG for both conditions? How does treatment differ?
NSTEMI= non ST elevation MI= partial blockage of bloodflow through coronary arteries. Will see ST depression & possible T wave inversion. Tx: heparin infusion until cath procedure in 12-72 hours. STEMI= complete blockage of bloodflow. Will see ST elevation in 2 contiguous leads. Tx: Urgent cath lab!
Describe the effect on the client's system that each of the following drug classifications will have. Think of times each will be used for shock!
Positive inotropes- improves contractility of heart. Vasopressors- strengthens contraction/ increases CO/ vasoconstricts. Vasopressin- causes fluid reabsorption to improve preload. Sympathomimetics- mimics SNS- increases HR and CO. Sodium Nitroprusside (Nipride)- vasodilates to decrease SVR (afterload).
Define a flail chest. List clinical manifestations. Discuss treatment.
Defined: fracture of 3 or more consecutive ribs in 2 or more places. Forms "flail segment" that moves opposite of normal respirations (paradoxical breathing), shallow rapid breathing, tachycardia, crepitus. Tx: support ventilation with supplemental O2 or ventilator, pain control.
Explain how to determine whether a client in a dysrhythmia is stable or unstable. This will affect urgency of treatment!
Stable- no clinical manifestations noted with dysrhythmia. Client's cardiac output is enough to sustain normal body functions.
Unstable- clinical manifestations seen. Note decreased cardiac output symptoms- dizzy, lightheaded, hypotension, etc. ACT QUICK!!!!
Name the 2 main drugs that are utilized to restore blood flow to the coronary arteries in the event of an MI. Then, list safety precautions needed for administration and follow-up care.
Nitroglycerin-decrease preload/afterload-decrease workload of heart/ decrease O2 demand. Dilates coronary arteries to increase blood flow to heart muscle. Causes low BP- if SBP 100 or below, NO NITRO! Use IV pump!
Tissue plasminogen activator (tPA)- thrombolytic to dissolve clot. Monitor for bleeding
List the clinical manifestations of cardiac tamponade. What is the treatment?
Anxiety/restlessness, sharp chest pain worse w/ deep breath, dyspnea, JVD, pulsus paradoxus (BP changes w/ respiratory cycle), muffled heart tones, pain often relieved w/ sitting up, lightheadedness. Treated by needle aspiration from pericardial sac- called pericardiocentesis or pericardial window.
List the treatments for each type of shock over and above the general treatments of patent airway, maximize O2 delivery, maintain O2 at >90% or PaO2>60mmHg, optimize MAP. Remember Pa02 < 60 mmgHg is fatal.
•Cardiogenic- support pump (IABP). Fluids/ vasopressors to maintain CO. Find & fix underlying heart problem.
•Obstructive- remove obstructions.
•Distributive- see slides on neurogenic, septic, anaphylactic
•Hypovolemic- stop fluid loss & replace lost fluids. Monitor effectiveness of fluid replacement.
Differentiate between a pneumothorax, tension pneumothorax, and hemothorax. Describe the difference between open and closed pneumothoraxes. Think of what you will hear with percussion- tympany versus dullness!
Pneumothorax- air in pleural space but is not pressing on heart or opposite lung. Tension pneumothorax- air getting into pleural space & cannot exit so it accumulates & presses on structures in mediastinum (heart & other lung). Hemothorax- blood in pleural space. Open- open to environment.
Describe how to identify each of the following rhythms. NSR, sinus tachy, SVT, sinus brady, 1st degree AV block, 2nd degree AV block type 1, 2nd degree AV block type 2, 3rd degree AV block
Normal Sinus Rhythm (NSR)
Regular rhythm
P wave before every QRS
Consistent PR interval
Narrow QRS
2. Sinus Tachycardia
Regular rhythm
P wave before each QRS
Fast rate
Narrow QRS
3. Supraventricular Tachycardia (SVT)
Very fast, regular rhythm
P waves often hidden
Narrow QRS
Sudden onset/offset
4. Sinus Bradycardia
Regular rhythm
P wave before each QRS
Slow rate
Narrow QRS
5. 1st Degree AV Block
Regular rhythm
P wave before every QRS
Prolonged PR interval (but constant)
Narrow QRS
6. 2nd Degree AV Block Type I (Wenckebach)
Irregular rhythm
PR interval progressively lengthens, then drops a QRS
More P waves than QRS
7. 2nd Degree AV Block Type II (Mobitz II)
Regular or irregular rhythm
PR interval constant
Randomly dropped QRS
More P waves than QRS
8. 3rd Degree AV Block
Atria and ventricles beat independently
No consistent PR interval
More P waves than QRS
Wide or narrow QRS
A client is to have a procedure for the placement of a mechanical heart valve. List the advantages and disadvantages of mechanical vs biologic valves. List some preoperative education to give the client regarding home care following mechanical valve replacement surgery.
Mechanical valves are longer lasting & more durable. However they have higher risk for VTEs, so educate they will require lifelong anticoagulation. Biologic valves are less durable & tend to cause earlier complications. These do not require risky anticoagulant drug therapy.
List, in order, the chambers and valves that blood flows through as it enters and leaves the heart.
Enters into right atrium, passes tricuspid valve to right ventricle, through pulmonic valve to pulmonary arteries to lungs where blood is oxygenated. Comes out of lungs through pulmonary veins back to left atrium, through mitral valve to left ventricle. Goes past aortic valve to aorta and to body.
Signs and symptoms of neurogenic shock. Then, what is the treatment once identified?
Bradycardia, poor thermoregulation, resp failure/ arrest if injury above C3, bladder & bowel dysfunction, skin cool or warm & dry, flaccid paralysis below level of injury. Tx: maintain ABCs, supplemental O2, fluid to fill tank, possible atropine or vasopressors, stabilize spinal cord, keep warm.
List emergency equipment to keep at the bedside for a client with a chest tube. 1- What would you do in the event of dislodgement of chest tube from patient? 2- What would do if the drainage system disconnects from the chest tube?
Emergency equipment: 2 clamps. Vaseline gauze/occlusive dressing. Bottle of sterile water.
1- cover with vaseline gauze and call for help
2- place end of chest tube in bottle of sterile water and call for help
Describe how to identify each of the following rhythms. AFib, AFib with RVR, AFlutter, junctional rhythm, accelerated junctional, VTach, VFib, PEA, asystole.
9. Atrial Fibrillation (AFib)
Irregularly irregular rhythm
No P waves
Fibrillatory baseline
Variable rate
10. AFib with RVR
Same as AFib
Rapid ventricular rate
11. Atrial Flutter
Sawtooth flutter waves
Regular or irregular
No true P waves
Atrial rate faster than ventricular rate
12. Junctional Rhythm
Regular rhythm
P waves absent, inverted, or after QRS
Slow rate
Narrow QRS
13. Accelerated Junctional Rhythm
Same as junctional
Faster rate
14. Ventricular Tachycardia (VTach)
Regular rhythm
Wide, bizarre QRS
No P waves
Can have a pulse or be pulseless
15. Ventricular Fibrillation (VFib)
Chaotic, irregular rhythm
No identifiable waves
No pulse
16. Pulseless Electrical Activity (PEA)
Any organized rhythm
No pulse
17. Asystole
Flatline or nearly flat
No electrical activity
No pulse
Describe the procedure and indication for cardiac catheterization and percutaneous coronary intervention (PCI) which includes angioplasty and stenting. Then, do the same for a coronary artery bypass graft (CABG).
Cardiac catheterization: cath threaded through blood vessels to heart. Contrast dye injected to determine bloodflow to determine if blockage present + severity of block. PCI: fixes blockage with angioplasty (balloon) or stents. If not helping angina- open chest & bypass obstructed vessel with CABG.
A client is to have an atrial and ventricular pacemaker inserted into the heart. Describe where, on the EKG, you will see the pacemaker spike to indicate is has discharged the atrial impulse and the ventricular impulse.
Atrial- right before the P wave. Ventricular- right before the QRS complex.
List the indications for an intraaortic balloon pump. Then, list the complications with clinical manifestations for each.
Increase coronary perfusion in MI, facilitate left ventricular ejection in heart failure or cardiogenic shock.
Balloon leak- poor peripheral pulses. Displacement of balloon- absent peripheral pulses, severe drop in urinary output. Clots along balloon- may travel. Hemorrhage- bleeding. Infection- S/S.
HOB will likely be less than 30 degrees to prevent occlusion of the femoral catheter.
Name the chambers present on a dry suction drainage system for a chest tube. Indicate what is NORMAL in each chamber. Then, state what abnormal findings may mean for your client's condition.
Collection chamber- receives air/fluid from chest tube. Should have <100mL/hr of drainage.
Water seal chamber- gets air out of chest but not back in. Tidaling NORMAL. None= kink/occlusion/displacement OR lung reexpanded. Bubbling normal with insertion but not after. Bubbling= disconnect or air leak.
List treatments/ interventions for each of the following rhythms: NSR, sinus tachy, SVT,sinus brady, 1st degree AV block, 2nd degree AV block type 1, 2nd degree AV block type 2, 3rd degree AV block
1. Normal Sinus Rhythm (NSR)
No treatment needed
Continue monitoring
Maintain baseline vitals and oxygenation
2. Sinus Tachycardia
Treat the underlying cause (e.g., fever, dehydration, anxiety, pain)
Beta blockers or calcium channel blockers if symptomatic
Monitor hemodynamics
3. Supraventricular Tachycardia (SVT)
Vagal maneuvers (e.g., bear down, cough)
Adenosine IV push (if stable)
Synchronized cardioversion (if unstable)
Long-term: consider ablation or medications
4. Sinus Bradycardia
Treat only if symptomatic (e.g., dizziness, hypotension)
Atropine first-line
Transcutaneous pacing, dopamine or epinephrine drip if unresponsive
Monitor for worsening block
5. 1st Degree AV Block
Usually benign, no treatment needed
Monitor for progression
Adjust medications that slow conduction (e.g., beta blockers, digoxin)
6. 2nd Degree AV Block Type I (Wenckebach)
Often asymptomatic, observe
If symptomatic: atropine, monitor
Transcutaneous pacing if deteriorating
7. 2nd Degree AV Block Type II (Mobitz II)
High risk of progressing to 3rd degree block
Pacemaker required
Temporary pacing if symptomatic
Hold AV-nodal blockers
8. 3rd Degree AV Block (Complete Heart Block)
Medical emergency
Immediate transcutaneous pacing
Prepare for permanent pacemaker
Stop AV-nodal blocking agents
List the interventions to be given to a client having an acute ST elevation myocardial infarction.
Allow to assume position of comfort. Keep calm (decreases O2 demand). VS. Give O2. 12 lead EKG. Draw cardiac enzymes (troponin I). Aspirin chewed- 324 mg. IV access. Nitroglycerin as bolus doses- may then start as drip. Morphine for uncontrolled pain with nitroglycerin.
What are the risks of Percutaneous Coronary Intervention and Coronary Artery Bypass Graft surgery?
Percutaneous Coronary Intervention (PCI) Risks:
Bleeding at catheter insertion site
Hematoma
Contrast-induced nephropathy (kidney injury) -increased with oral Metformin-hold metformin and flush with IV fluids
Arrhythmias
Myocardial infarction during the procedure
Allergic reaction to contrast dye
Coronary Artery Bypass Graft (CABG) Risks:
Surgical site infection
Sternal wound complications (especially in diabetics)
Stroke (higher risk than PCI)
Bleeding requiring transfusion or reoperation
Arrhythmias (especially atrial fibrillation post-op)
Respiratory complications (e.g., pneumonia
Name all of the measurements which can be taken from the pulmonary artery catheter. Where is the measurement taken? Then, list what each measurement will tell you in relation to the workload of the heart.
RAP/ CVP- taken in R atrium to tell preload or backflow of blood from R ventricle. ScvO2- taken in R atrium. Oxygenation status of blood right before entering lungs. PAP- taken inside lung capillaries (balloon deflated)- tells PVR & R ventricle afterload. PAWP- taken at distal tip- L heart function.
List the items which are necessary for preop teaching in a client having a chest surgery. List postop priorities of care for a client after chest surgery.
Preop ed: use of O2, chance of intubation, chance for blood products needed, purpose & logistics of chest tubes, plan for pain control, importance of TCDB exercises & incentive spirometry, how to splint incision.
Postop priorities: pain control, monitor for infx, chest tube care, maintain resp funtion