NCM118A-MEDSURG3-PRELIM PDF

ST. DOMINIC COLLEGE OF ASIA INTRODUCTION TO School of Nursing and TOPIC...

ST. DOMINIC COLLEGE OF ASIA INTRODUCTION TO School of Nursing and TOPIC CRITICAL CARE AND Allied Health Studies NCM 118A EMERGENCY SITUATIONS FIRST SEMESTER 1 I. DEFINITION OF CRITICAL CARE NURSING nursing organizations. This mechanism will still have to be approved before it can be made a Critical care nursing is concerned with human requirement for critical care practice. responses to life-threatening problems, such as trauma, major surgery, or (major) complications of CCNAPI – Critical Care Nurses Association of the illness. Philippines, Inc. The human response can be a physiological or psychological phenomenon. The focus of the critical care nurse includes both III. EDUCATION OF CRITICAL CARE NURSING the patient's and family's responses to illness and PRACTICE involves prevention as well as cure. Because patients' medical needs have become Critical Care Nurses are registered nurses, who increasingly complex, critical care nursing are trained and qualified to practice critical care encompasses care of both acutely and critically ill nursing. patients. They possess the standard critical care nursing competencies in assuming specialized and II. DEVELOPMENT OF CRITICAL CARE expanded roles in caring for the critically ill patients NURSING PRACTICE and their family. Likewise, each critical care nurse is personally Since In 1970, the health care system in the responsible and committed to continuous learning Philippines was greatly affected by advancements and updating of his/her knowledge and skills. in care and technology and the changing nature of The critical care nurses carry out interventions and care. These factors influenced the development of collaborates patient care activities to address life- specialty practice, particularly in critical care. threatening situations that will meet patient's Critical care practice is a collaborative process, biological, psychological, cultural, and spiritual and nurses play a vital part in it. Critical care nurse needs. assume the role of direct caregivers to the patient. They are expected to possess the competency Graduate with a bachelor's degree in Nursing necessary to work in complex critical care areas or Program the intensive care unit (ICU) environment. To be Passes the national licensure examination able to meet the demands of this type of care, administered by the Professional Regulatory Board recruitment of nurses must be based on skill of Nursing (PRC-BON). levels. The patient to nurse ratio in the ICU of mot The Philippine Nursing Act of 2002 (RA 9173) Metro Manila tertiary hospitals is usually 1:2. provides guidance to enable the nurse to practice However, this is not a consistent picture in other and mandates the PRC-BON-recognized specialty government or private hospitals throughout the organizations and the Department of Health (DOH) country. to develop comprehensive nursing specialty Most critical care nurses in the Philippines have programs such as CCN (Article VII, Section 31). not been educationally prepared for critical care To fulfill this mandate, the specialty organization, practice. They have developed knowledge and CCNAPI, provides training to critical care nurses. skills 'on the job' through mentoring or precepting On the other hand, the DOH provides the Nurse by senior nurses. There is no difference in salary Certification Program where nurses are given between critical care nurse and 'ordinary' ward certification on thirteen specialties (cardiovascular nurses, and newly hired nurses can be deployed nursing, renal nursing, emergency and trauma immediately in any ICU setting to augment staffing. nursing, orthopedic and rehabilitation nursing, However, with the specialization program as mental health nursing, infectious disease nursing, required by the Nursing Act 2002, most hospitals pulmonary nursing, maternal and child nursing, are trying to comply with the guidelines for hospital pediatric nursing, operating room nursing, accreditation to have nurses trained and educated anesthesia care nursing, geriatric and gerontology in critical care nursing practice. nursing, public health nursing). Critical care program are provided by only a few tertiary hospitals in Metro Manila. These program IV. TRAINING OF NURSES FOR CRITICAL are not currently reviewed or accredited by the CARE SERVICES national Critical Care Nurse Association of the Philippines. However, development of a The institution / hospital should provide training mechanism for accreditation of specialty programs opportunities to ensure staff competencies. is being discussed by the Professional Regulation This will enable the nurse working in the critical Commission Board of Nursing and specialty care units to cope with the complexities and TRANSCRIBED BY: RLB  demands of the changing needs of the critically ill ▪ Indirect Patient Care – Care of the Family patients. - Understands family needs and provide o Orientation Program – New recruits to the information to allay fears and anxieties and critical care units shall attend an orientation - Assists family to cope with the life- program and be given opportunities to work threatening situation and/or patient's under senior staff supervision. Experienced impending death. staff in the unit should be readily available for consultation. 2) Extended roles as critical care nurses o In-Service Training Program (Staff Critical care nurses have roles beyond their Development Program) – Critical Care professional boundary. With proper training and in Nurses Association of the Philippines, Inc. accordance with established guidelines, recommends that all practicing CCN shall algorithms, and protocols that are continuously continuously update their knowledge, skills, reviewed and updated, critical care nurses also and behavior through active participation in perform procedures and therapies that are Critical Care Nursing Education or its related otherwise done by doctors. Such procedures and field. therapies are: o Post-graduate Courses – Post graduate - Sampling and analyzing arterial blood gases; courses are part of higher education taken - Weaning patients off ventilators; after a Bachelor's Degree that are accredited - Adjusting intravenous analgesia / sedations; from the Commission of Higher Education - Performing and interpreting ECGs; (CHED) or the Professional Regulation - Titrating intravenous and central line Commission-Board of Nursing (PRC-BON). medicated infusion and nutrition support; o Continuing Professional Education – - Initiating defibrillation to patient with ventricular Continuing Professional Education Programs is fibrillation or lethal ventricular tachycardia; a type of education that consist of updated - Removal of pacer wire, femoral sheaths and knowledge and other pertinent information that chest tubes, and will help the Critical Care Nurse to attain - Other procedures deemed necessary in their broader understanding of critical care practice respective institutions under a clinical protocol. and its related field. The goal includes Critical Care Nurses development of skill, behavior 3) Educator that will help them view the critically ill person As an educator, the critical care nurse must be in a holistic dimension. able to: - Provides health education to patient and family V. PROFESSIONAL ACTIVITIES OF CRITICAL to promote understanding and acceptance of CARE NURSING the disease process this facilitate recovery and In response to the changes and expansions within - Participates in the training and coaching of and outside the healthcare environment, critical novice healthcare team members to achieve care nurses have broadened their roles in the cohesiveness in the delivery of patient care. practice levels. Competencies of critical care nurses are honed and developed to achieved their 4) Patient Advocate roles in practice, management / leadership and The critical care nurses' role includes being an research. advocate – someone who acts or intercedes on o Professional Role behalf or another. Typically, the critical care nurse o Management and Leadership Role may be in the best position to act as the liaison o Researcher between patient and family and other team members and department because they are the Professional Role healthcare professionals with the most o The critical care nurse executes their practice roles interpersonal contact with the patients. To perform 24-hours a day to provide high quality care to the this function adequately, the nurse must be critically ill patient. knowledgeable about the involved in all aspects of 1) Care Provider the patient's care and have a positive working ▪ Direct Patient Care relationship with other team members. The critical - Detects and interprets indicators that care nurses are expected to: signify the varying conditions of the - Acts in the best interests of the patient and critically ill with the assistance of advanced - Monitors and safeguards the quality of care technology and knowledge; which the patient receives. - Plans and initiates nursing process to its full capacity in a need driven and proactive Management and Leadership Role manner; o The critical care nurse in management and - Acts promptly and judiciously to prevent or leadership role will be able to assume the following halt deterioration of patients' condition responsibilities: when conditions warrant, and - Performance of management and leadership - Co-ordinates with other healthcare skills in providing safe and quality care; providers in the provision of optimal care to - Accountability for safe critical care nursing achieve best possible outcomes. practice; TRANSCRIBED BY: RLB  - Delivery of effective health programs and The qualification of Acute Care Nurse Practitioner services to critically ill patients in the acute (ACNP) include: setting; o should have the recommended number of post - Management of the critical care nursing unit or registration (licensed experience) nursing acute care setting; experience which are spent in the critical field, - Taking the lead and supervision of nursing exhibiting in-depth professional knowledge and support staff, and skills. - Utilization of appropriate mechanism for An Acute Care Nurse Practitioner (ACNP) is a collaboration, networking, linkage-building and holder of: referrals. o Clinical master's degree in a clinical nursing specialty (Medical-Surgical) such as Critical Role in Research Care Nursing or; o The critical care nurse's role in research will entail o Master’s degree in nursing or related discipline the following responsibilities: such as management together with recognized - Engage self in nursing or other health-related critical care training qualifications. research with or under the supervision of an The Acute Care Nurse Practitioner execute the experienced researcher; nursing team leader's responsibilities as - Utilization of guidelines in the evaluation of designated in the position of Advanced Nurse research study or report Practitioner. - Application of the research process in improving patient care infusing concepts of OUTCOME SPECIALIST quality improvement in partnership with other Outcome management has been introduced into team-players. the healthcare system to ensure achievement of quality and cost-effectiveness in the delivery of VI. ADVANCED PRACTICE LEVEL patient care. Some critical care units have adopted clinical The development of the Advanced Practice pathways (e.g., Critical Pathways, Protocols, Nursing is the future direction in the Philippines Algorithms and Orders) in the management of and to be bench marked with other countries. For specific diseases such as Acute Myocardial now, a thorough study of Advanced Practice in Infarction and Cardiothoracic Surgeries. critical care is being undertaken to align with the Qualified nurse experts are involved in the PRC-BON initiative on specialization framework. development and implementation of patient The current global healthcare environment outcomes management. demands critical care nurses to have advanced knowledge and skills to provide the highest VIII. CRITICAL CARE possible level of care to the critically ill patients. CCNAPI supports the following descriptions of It is the direct delivery of medical care for a advanced practice roles. critically ill or injured patient (Department of Health and Human Services, 2008). VII. EXPANDED ROLE o To be considered critical, an illness or injury must acutely impair one or more vital organ NURSE SPECIALIST systems to such a degree that there is a high Graduate of Bachelor of Science in Nursing probability of life-threatening deterioration. Registered Nurse Critical care involves highly complex decision- A registered nurse who have more than 3 years of making and is usually, but not always, provided in uninterrupted practice experience in the critical a critical care area such as coronary care unit, an care field. Act as a critical care nurse specialist intensive care unit, or an emergency department. when has attained advanced education and expertise in caring patients with critical problems. CRITICAL CARE NURSING He/she is also eligible to be certified by the PRC- It is concerned with human responses to life- Board of Nursing as a Clinical Nurse Specialist. threatening problems, such as trauma, major CCNAPI recommends that a graduate study or surgery, or complications of illness. The human master's degree program should support the response can be a physiological or psychological development of critical care nursing specialization phenomenon. The focus of the critical care nurse goes beyond the basic baccalaureate nursing includes both the patient's and family's responses degree. to illness and involves prevention as well as cure. The critical care nurse specialist is responsible for Because patients' medical needs have become building up nursing competencies in the ICU entity. increasingly complex, critical care nursing encompasses care of both acutely and critically ill ACUTE CARE NURSE PRACTITIONER patients. Acute Care Nurse Practitioner (ACNP) in the critical care unit takes lead in developing evidence- based practices to meet changing clinical needs and facilitates patient care processes across professional and organizational boundaries. TRANSCRIBED BY: RLB  CRITICAL NURSE CHARACTERISTICS - Her previous experience coupled with the Systematically evaluates the quality and ability to see the “big picture” often allows her effectiveness of nursing practice to anticipate possible untoward events and Evaluates own practice in relation to professional develop interventions to prevent them. practice standards, guidelines, statues, rules, and regulations Caring Practices Acquires and maintains current knowledge and o “Nursing activities that create a compassionate, competency in patient care supportive, and therapeutic environment for Contributes to the professional development of patients and staff, with the aim of promoting peers and other healthcare providers comfort and preventing unnecessary suffering.” Acts ethically in all areas of practice o A caring critical care nurse can make an enormous Uses skilled communication to collaborate with the difference in the critical care experience for a healthcare team to provide care in a safe, healing, frightened patient and family. humane, and caring environment o Able to anticipate patient/family changes and Uses clinical inquiry and integrates research needs, varying caring approach to meet their findings into practice needs. Considers factors related to safety, effectiveness, cost, and impact in planning and delivering care Advocacy and Moral Agency Provides leadership in the practice setting for the o “The nurse promotes, advocates for, and protects profession the rights, health, and safety of the patient.” o AACN states that "Foremost, the critical care nurse IX. CRITICAL CARE COMPETENCIES is a patient advocate and defines advocacy as (AACN's Synergy Model for Patient Care) 'respecting and supporting the basic rights and Clinical Inquiry beliefs of the critically ill patient.’ Clinical Judgment o A nurse might want to consider the following: Caring Practices ▪ What type of issues (including end-of-life Advocacy and Moral Agency issues) might arise in the clinical setting for Systems Thinking which the patient may need an advocate? Facilitator of Learning ▪ What is owed to the patient, and what are the duties of the nurse in those circumstances? Response to Diversity ▪ If she encountered one of those situations, Collaboration how would the nurse be able to determine what the patient or family desires or what Clinical Inquiry would be in the patient's best interests? o Critical care nurse should be engaged in the ▪ Would the nurse be able to differentiate her “ongoing process of questioning and evaluating needs and desires from those of the patient? practice and providing informed practice.” ▪ How certain could she be? o Provide care based on the best available evidence ▪ How would the nurse act for her patient or rather than on tradition. empower her patient and his family to o An expert critical care nurse might be able to communicate their needs and desires to the evaluate research and develop evidence-based rest of the healthcare team? agency policies and protocols. ▪ How would the nurse respond if she thought o Critical care nurses (both novice and expert) can that the quality of patient's care was being develop the mindset that questioning practice is an jeopardized? issue of safety. ▪ How would the nurse ensure that the o A safe practitioner is one who wonders, “Why do discussion was a mutual exploration of we do things this way?” or “Why am I being asked concerns and not a confrontation? to provide this specific type of care to this patient at this moment?” Systems Thinking o “Managing the existing environmental and system Clinical Judgment resources for the benefit of patients and their o “Clinical reasoning which includes clinical decision- families.” making, critical thinking, and global grasp of the o For a vulnerable patient and family, being in an situation, coupled with nursing skills acquired unfamiliar and overwhelming healthcare system through a process of integrating formal and can be intimidating, even frightening. Having a experiential knowledge.” nurse who knows how the system works and o Able to collect and interpret basic data and then explains it to the patient and family, or who helps follow pathways and algorithms when providing the patient and family obtain what they need, can care. make the difference between an experience that is o When unsure about how to respond, often defers overpowering for the family and one that the to the expertise of other nurses. patient and family believe they can endure. o An expert nurse is able to use past experience, o An expert nurse knows how to negotiate and recognize patterns of patient problems, and "see navigate for the patient throughout the healthcare the big picture." system to obtain the necessary or desired care. TRANSCRIBED BY: RLB  Facilitator of Learning o Nurses should be able to facilitate both informal and formal learning for patients, families, and members of the healthcare team. o An expert nurse would be able to “creatively modify or develop patient/ family educational programs and integrate family/patient education throughout the delivery care.” Response to Diversity o Defines response to diversity as “sensitivity to recognize, appreciate, and incorporate diversity into the provision of care.” o An expert nurse would anticipate the needs of the patient and family based on their cultural, spiritual, or personal values, and would tailor the delivery of care to incorporate these values. Collaboration o Defines collaboration in its Synergy Model as “working with others in a way that promotes each person's contributions toward achieving optimal and realistic patient/family goals.” o An expert nurse might facilitate the active involvement and contributions of others in meetings and role model leadership and accountability during the meetings. TRANSCRIBED BY: RLB ST. DOMINIC COLLEGE OF ASIA School of Nursing and BASICS OF MECHANICAL TOPIC VENTILATION Allied Health Studies NCM 118A FIRST SEMESTER 2 I. DEFINITION OF MECHANICAL VENTILATION Neuromuscular Diseases: Myasthenia Gravis, Guillain-Barre Syndrome, and Poliomyelitis (failure Mechanical ventilation is the use of a ventilator to of the normal respiratory neuromuscular system) move room air or oxygen enriched air into and out Musculoskeletal Abnormalities: Such as chest of the lungs mechanically to maintain proper levels wall trauma. of oxygen and carbon dioxide in the blood. Infectious Diseases of the lung such as pneumonia, tuberculosis. II. GOALS OF MECHANICAL VENTILATION Obstructive Lung Disease in the form of asthma, Mechanical ventilation alone does not treat or chronic bronchitis or emphysema. reverse the underlying pathology leading to the Conditions such as pulmonary edema, need for ventilator support. Rather, it is applied as atelectasis, pulmonary fibrosis. one of the support systems until the reversal of the Patients who have received general anesthesia pathological condition, so that the patient may then as well as post cardiac arrest patients require become weaned from mechanical ventilation. ventilatory support until they have recovered from the effects of the anesthesia or out from a Danger. GOAL Improve gas exchange PARAMETERS VENTIALTION NORMAL Relive respiratory distress INDICATED RANGE Improve pulmonary mechanics A) Pulmonary Permit lung and airway healing Function Studies: Avoid complication Respiratory Rate >35 15-20 (breaths/min) Tidal Volume TARGET 100 bpm originating in the SA node symptoms of HF Cause: o Medication regimen o Fever, apprehension, physical activity anemia, o Prescribed dietary plan hyperthyroidism o Need to avoid fatigue and plan for rest period o Drugs (epinephrine, theophylline) o Myocardial Ischemia, caffeine TX: correction of underlying cause, elimination of VII. CARDIAC DYSRHYTHMIAS stimulant, sedatives, propranolol Disturbance in electrical rhythms Abnormal conduction of electrical impulses that result in malfunction of heart muscle SINUS BRADYCARDIA When the sinus node creates an impulse at a slower-than-normal rate. Causes include lower metabolic needs (e.g., sleep, athletic training, hypothermia, hypothyroidism), vagal stimulation (e.g., from vomiting, suctioning, severe pain, extreme emotions), medications (e.g., CONDUCTING SYSTEM OF THE HEART calcium channel blockers, amiodarone, beta- 1. SA Node – the pacemaker blockers), increased intracranial pressure, and 2. AV Node – slowest conduction myocardial infarction (MI), especially of the inferior 3. Bundle of His – branches into the right and the wall. left bundle branch All characteristics of sinus bradycardia are the 4. Purkinje Fibers – fastest conduction same as those of normal sinus rhythm, except for the rate. The patient is assessed to determine the THE HEART: PHYSIOLOGY hemodynamic effect and the possible cause of the The intrinsic conduction system causes the heart dysrhythmia. If the decrease in heart rate results muscle to depolarize in one direction from stimulation of the vagus nerve, such as with The rate of depolarization is around 75 beats per bearing down during defecation or vomiting, minute attempts are made to prevent further vagal The SA node sets the pace of the conduction This electrical activity is recorded by the If the bradycardia is from a medication such as a Electrocardiogram (ECG) beta-blocker, the medication may be withheld. If the slow heart rate causes significant hemodynamic changes, resulting 1. Shortness of breath 2. Decreased level of consciousness 3. Angina, hypotension 4. ST-segment changes 5. Premature ventricular complexes Treatment is directed toward increasing the heart rate. o Atropine, 0.5 to 1.0 mg given rapidly as an intravenous (IV) bolus TRANSCRIBED BY: RLB  ATRIAL DYSRHYTHMIAS Atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration ATRIAL FLUTTER usually is normal and constant. In NSR, a P wave Atrial rate 250-400 bpm, ventricular rate 75-150 precedes each QRS complex, the rhythm is bpm essentially regular, the PR interval is 0.12 to 0.20 Saw-toothed pattern/shape (F waves) second in duration, and the QRS interval is 0.06 to Usually indicates the presence of organic heart 0.10 second in duration. Bradycardia is a slowed disease heart rate, and tachycardia is a fast heart rate. Cause: o Valvular disease, hypertension, SYNCHRONIZED CARDIOVERSION cardiomyopathy, hyperthyroidism, moderate to Synchronized countershock heavy alcohol consumption to convert an undesirable o Among the elderly, common causes are CAD rhythm to a stable rhythm and COPD TX: correction of underlying problem, Consider sedation betablockers, calcium channel blocker, Turn on defibrillator amniodarone, digitalis Attached monitor leads to the patient – Engage the synchronization mode by pressing the “sync” control button Look for marker on R waves indicating sync mode Select appropriate energy level Position conductor pads / paddle Announce to team member: o “Charging cardioverter – STAND CLEAR.” o Press charge button on apex paddle (right hand) “I am going to shock on three. One, I’m clear, two, you are clear, three everybody’s clear.” (check ATRIAL FIBRILLATION yourself one more time before pressing the Rapid disorganized and uncoordinated twitching of SHOCK BUTTONS) atrial musculature HR: 350-600 bpm Atria quiver → lead to formation of thrombi No definitive P wave can be observed VENTRICULAR DYSRHYTHMIAS Different rates radial & apical Rhythm: atrial & ventricular – regular to irregular PREMATURE VENTRICULAR COMPLEX (PVC) Cause: Firing of an irritable pacemaker in the ventricles o Rheumatic – mitral stenosis before the next normal sinus impulse reaches the o Thyrotoxicosis, cardiomyopathy AV node. o Hypertensive heart disease, CHD PVCs occurs in repetitive patterns Intervention: o Bigeminy – every other heartbeat o Administer oxygen o Trigeminy – every third heartbeat o Administer anticoagulants as prescribed o Quadrigeminy – every fourth heartbeat because of risk of thrombi o Couplet – 2 sequential PVCs o Administer cardiac medications as prescribed Cause: to control the ventricular rhythm and assist in o Hypoxemia the maintenance of cardiac output o Hypokalemia ▪ TX: digitalis, propranolol o Prepare client for cardioversion as prescribed PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence The P waves may be absent. There is no PR of P waves, presence of wide and bizarre QRS interval complexes, and a compensatory pause that follows the ectopy. PVCs are considered dangerous when they are frequent (more than 6/min), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client’s cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly arrhythmias. TRANSCRIBED BY: RLB  Intervention: ▪ STABLE o Administer O2 as prescribed o Administer antidysrhythmic drugs - Amniodarone - Lidocaine - Procainamide ▪ UNSTABLE o Administer O2 as prescribed o Administer antidysrhythmic drugs as prescribed o Prepare synchronized cardioversion if unstable o Attempt COUGH CPR – ask client to cough hard every 1-3 seconds ▪ PULSELESS CLIENT with V-tach → DEFIBRILLATION and CPR With ventricular tachycardia in a stable client, the nurse assesses airway, breathing, and circulation; administers oxygen; confirms the rhythm via a 12- lead ECG. With pulseless ventricular tachycardia, the physician or a specially trained nurse must immediately defibrillate the client or initiate CPR followed by defibrillation as soon as possible. Ventricular Dysrhythmias – INTERVENTION: VENTRICULAR FIBRILLATION o Notify physician if PVCs occur Life threatening condition o Treatment of underlying cause Disorganize ventricular rhythm o Evaluate O2 saturation- to assess hypoxemia Ventricle quiver and there is no cardiac output o Administer O2 as prescribed Client lack of BP, RR and HR o Evaluate electrolytes: K+ FATAL if not successfully terminated within 3-5 o Lidocaine may be prescribed minutes o Notify the physician if the client complains of Cause: chest pain o Idiopathic sudden death, electrical shock VENTRICULAR TACHYCARDIA (V-Tach) VT, it usually is not possible to determine the atrial Occurs due to repetitive firing of an irritable rhythm. The ventricular rhythm usually is regular or ventricular ectopic focus. nearly regular. The P waves usually are not visible Atrial: 60-100bpm / Ventricular: 110-250 bpm and are obscured in the QRS complexes. VT Can lead to CARDIAC ARREST occurs with repetitive firing of an irritable Cause: ventricular ectopic focus, usually at a rate of 140 to o Acute MI, CAD, digitalis intoxication, 180 beats/min or more. hypokalemia Types: o Stable client with sustained VT – with pulse (-) s/sx decrease cardiac output o Unstable client – with pulse (+) s/sx of decrease cardiac output Intervention: o DEFIBRILLATE the client immediately – 3x at 200, 300, 360 Joules o Initiate CPR o Administer O2 as prescribed TRANSCRIBED BY: RLB  o Administer epinephrine or vasopressin and antidysrhythmic therapy with amiodarone or lidocaine. MANAGEMENT FOR DYSRHYTHMIAS Vagal maneuver Carotid sinus massage Valsalva’s maneuver Cardioversion Defibrillation SYNCHRONIZED CARDIOVERSION Ventricular tachycardia Paroxysmal supraventricular tachycardia Atrial fibrillation Atrial flutter TRANSCRIBED BY: RLB