118-Week 4-Responses to Altered Tissue Perfusion.pdf

NCM 118: Emergency Nursing Composed of the pathway of the Week 4: Responses to Altered Tissue Perfusion sinoatrial node, the atrioventricular Lecturer: Mrs. Ma. Lovel...

NCM 118: Emergency Nursing Composed of the pathway of the Week 4: Responses to Altered Tissue Perfusion sinoatrial node, the atrioventricular Lecturer: Mrs. Ma. Lovella Aquino, RN node, the bundle of His, bundle branches (right & left), and the purkinje PART 1: RESPONSES TO ALTERED TISSUE ELECTRICAL fibers. PERFUSION CONDUCTION Sinoatrial (SA) Node: natural pacemaker ANATOMY AND PHYSIOLOGY SYSTEM Pathway: starts at the SA node → will HEART pass to the AV node through the Function: serves as a muscular pump propelling blood internal pathway → to the Bundle of into and through vessels to and from all parts of the body. His → Right bundle branch → left Pumps blood throughout the body for organs to operate bundle branch → Purkinje fibers which is why it is a major organ. CARDIAC EFFECTS CARDIAC EFFECTS Review! Of your Sympathetic Nervous System Of your Parasympathetic Nervous System Our blood vessels comprise the: veins and arteries Cardiac activity: Cardiac effects: Veins - carry deoxygenated blood towards the heart; it ○ Heart rate increases, ○ Will slow the SA nodes' contains valves which guide the blood flow and avoid backflow ○ Enhances the AV charge because the pressure inside is weak. node function ○ Slow AV node conduction 2 main veins: Inferior vena cava and superior vena cava ○ Shortens the bundle of ○ Increased refractoriness ○ Inferior vena cava: Responsible for draining blood from His and purkinje fibers Manifestations: the trunk and the visceral organs in the lower body. ○ Shortens the ○ bradycardia ○ Superior vena cava: Responsible for draining the blood ventricular muscle ○ sometimes transient from the head and upper body. refractoriness heart block Arteries - carry oxygenated blood; the blood inside this will be ○ Increased ventricular pushed through the other parts of the body; Pressure inside the contraction arteries is strong which is why it doesn't have valves. ○ Increased peripheral ○ Away from the heart. vascular resistance ○ Aorta - major artery; carries oxygenated blood to the Manifestations: entire body. ○ Tachycardia, ○ Hypertension REMEMBER! ○ Increased cardiac All systemic arteries spring from the aorta and it branches into 3: output Ascending aorta SYMPATHETIC NERVOUS SYSTEM RECEPTORS Aortic arch Alpha is located in the vascular smooth muscles Descending aorta Beta 1 located in myocardium Beta 2 located in lungs also peripheral vasculature Dopaminergic located in renal, mesenteric, cerebral, and HEART coronary arteries Right Atrium (Top) Once stimulated, these will be clinical responses: 4 CHAMBERS Left Atrium (Top) ○ Alpha stimulation: peripheral vasoconstriction → OF THE HEART Left Ventricle (Bottom) hypertension Right Ventricle (Bottom) ○ Beta 1: increase heart rate and contractility ○ Beta 2: peripheral vasodilation and bronchodilation It is important that we memorize this ○ Dopaminergic: vasodilation since it will come up in our other topics, PATHWAY OF BLOOD FLOW especially in the ECG Blood comes from the right atrium from the body and it moves Atrioventricular valves (AV valves): into the right ventricle and is pushed into the pulmonary VALVES OF THE consists of the tricuspid and mitral arteries in the lungs HEART valves After picking up oxygen, the blood travels back to the heart Semilunar valves: contains the through the pulmonary veins into the left atrium to the left pulmonic valve and aortic valve ventricle then to the body’s tissues through the aorta. Epicardium: a.k.a. The visceral ASSESSMENT OF THE HEART pericardium; the outer layer where the SUBJECTIVE DATA OBJECTIVE DATA coronary arteries lie. Nursing history Physical assessment: Myocardium: thick-muscular layer of ○ Previous medical to confirm and to 3 LAYERS OF the heart, and contracts to facilitate condition formulate nursing dx and THE HEART blood flow into and out of the ventricles ○ Px’s feelings implement interventions Endocardium: innermost part of the ○ Cannot be More on the things we atria and ventricles; made up of measured, but only can measure smooth tissue and it functions as the said (ex. Nag sakit Diagnostic procedures surface for the heart valves. akong chest) 3 techniques This is a fibrous sac that surrounds the ○ Symptoms and ○ Inspection heart complaints of px ○ Palpation It holds the heart and has fluid inside to ○ Auscultation PERICARDIUM lubricate the heart to prevent friction INSPECTION from occuring during the contractions. Base of heart (or precordium: chest wall), left sternal Pericarditis - infection of the border, and apex of the heart pericardium. Note for visible pulsations: HEAVES One unique characteristic of the heart ○ Forceful apical impulse may be visible secondary to because it has the ability to initiate underlying ventricular hypertrophy electrical activity. Heaves are best felt with the heel of the hand at the AUTOMATICITY We study the ECG so that we can sternal border further understand the ability of the Normal finding: the precordium is symmetrical; no heart to initiate electrical activity. heaves noted (document) PALPATION Apical impulse: Note for location and amplitude Notes by: ur usual sharing notes group! ;) 1  Normal finding: Apical impulse recognizable at the 5th HEART SOUNDS intercostal space at the left midclavicular line Note for presence of THRILL ○ Palpable vibration caused by a turbulent blood flow through a heart valve; a palpable murmur or other unusualities Document if there is thrill: noted thrill at the 5th intercostal space ○ IF NONE: no thrill noted upon palpation Apical pulse is also known as point of maximum impulse ○ At the apex, 5th intercostal space at the left midclavicular line SYSTOLE (Pumping) ○ Period of ventricular contraction resulting in ejection of blood from the ventricles into the pulmonary artery and aorta Diastole (Filling) ○ Period of ventricular relaxation resulting in ventricular filling Normal Findings: In one heartbeat, there is only one S1 and S2 Caused by the closure of the MITRAL and TRICUSPID valves (“LUB”) Atrioventricular valve (Mitral and AUSCULTATION S1 Sound Tricuspid valves) Note the rate and rhythm of the apical pulse Closure of AV valves ○ Number of beats per minute, then check rhythm if Heard best at apex it’s regular or irregular Caused by the closure of the AORTIC and PULMONIC valves (“DUB”) S2 Sound Closure of semilunar valves Heard best at the base, aortic and pulmonic area TAKE NOTE! The period between S1 and S2 corresponds with ventricular systole ○ So sa S1 diba ni close man si AV valve, after ana niya, pump na dayon, mo contract, so open usa si semilunar kay para mo contract si ventricles. SO CARDIAC LANDMARKS mao na sha ang Ventricular Contraction. After Where we will put our stethoscope that, sud napod si S2, mo close napod si pulmonic Use diaphragm valves. Mnemonic: APEToMan The period between S2 and S1 corresponds with ventricular diastole APEToMan EXTRA/ABNORMAL HEART SOUNDS R side of the sternum in the 2nd Aortic Point Also called “ventricular gallop” intercostal space Has a low-pitched sound L side of the sternum in the 2nd (LUB-DUB-DUB) Pulmonic Point intercostal space ○ Low-pitched sounds are heard L side of the sternum in the 3rd best with the bell of your Erb’s Point stethoscope intercostal space The second DUB, is an abnormal early L side of the sternum in the 4th S3 Sound Tricuspid valve diastolic sound during period of rapid intercostal space ventricular filling L side of the sternum in the 5th An abnormal early diastolic sound Mitral valve intercostal space during period of rapid ventricular filling Can be a sign of systolic congestive heart failure A typical finding in children and athletes Also called “atrial gallop” Has a low-pitched sound (LUB-LUB-DUB) S4 Sound An abnormal late diastolic sound during atrial systole Can be a sign of systolic congestive heart failure A blowing or whooshing sound heard during a heartbeat Murmurs Can be heard with a stethoscope upon auscultation Notes by: ur usual sharing notes group! ;) 2  Caused by heart valve diseases; Could be: heart failure, chronic kidney disease without turbulent blood flow through the heart hemodialysis treatment, peripheral vascular diseases valves (ex. Valve stenosis) (such as DVT) ○ Pitting edema: when pressure is applied to the swollen area, a pit or indentation will remain ○ Non-pitting edema: typically associated with conditions affecting the thyroid and lymphatic system, and the resulting fluid build-up can be composed of a variety of substances, including proteins, salts, and water. During assessment, when no murmurs can be heard, you can document it as “No murmurs noted” Murmurs can also be graded and is graded according to description NAIL BEDS / CAPILLARY REFILL TIME Test to indicate the adequacy of arterial perfusion to the extremities. Compress the nail bed and release pressure Normal CRT: reperfusion within 2 seconds. Figure. Levine Scale of Grading Heart Murmur ○ If more than that, it would be a possibility of cardiovascular disease. ASSESSMENT OF OTHER SYSTEMS ALLEN TEST INSPECTION Assess collateral blood flow to the hands, generally in JUGULAR VEIN DISTENTION (JVD) preparation for a procedure that has the potential to Bulging of the external disrupt blood flow in either the radial or ulnar artery (e.g., jugular vein arterial puncture) JVD is a sign of increased How to do it? Central Venous Pressure ○ Patient elevates the hand, then repeatedly makes a (CVP) fist (open and close) Bulging occurs due to fluid ○ The examiner places a digital occlusive pressure overload over the radial and ulnar artery. Upon assessment you will ○ Then releases the artery first document: “Jugular vein Positive Allen Test: the patient may have an adequate distention noted when a dual blood supply to the hand (normal filling time) patient is sitting in an Negative Allen Test: may not have adequate dual blood upright position” supply (prolonged filling time) CENTRAL VENOUS PRESSURE VARICOSITIES Indicates how much blood is flowing back into your heart Veins become enlarged, dilated, and overfilled with and how well your heart can move that blood into your blood; valves in the vein are not functioning properly lungs and the rest of your body causing pooling of blood and later on becomes an The presence of fluid overload will limit the flow of fluid enlarged vein. to your heart and other parts of the body A common condition caused by weak or damaged vein walls and valves. PALPATION ○ Veins have one way valves inside then that open HEPATOJUGULAR REFLUX and close to keep blood flowing toward the heart. Also known as “abdominojugular test” Weak or damaged valves or walls in the veins can Performed when right ventricular or biventricular heart cause blood to pool and even flow backwards. failure is suspected Firm pressure is applied over the RUQ for 30-60 HOMAN’S SIGN seconds while observing jugular venous pulse Used to detect DEEP VEIN THROMBOSIS (DVT) Positive HJR sign - defined by an increase in the jugular ○ Positive Homan’s Sign: calf pain at the dorsiflexion venous pressure (JVP) > 3cm, sustained for more than of foot seconds, and signifies that the right ventricle cannot PALPATION accommodate the augmented venous return Peripheral pulses AUSCULTATION ○ Brachial BRUITS ○ Radial A sound heard over an artery reflecting turbulence of ○ Femoral flow ○ Popliteal Caused by narrowing of an artery (stenosis) ○ Dorsalis pedis ○ Posterior tibial INSPECTION Pulse Amplitude Scale ARM / LEG EDEMA ○ 0: Absent (non-palpable) Abnormal accumulation of fluid in dependent areas of ○ +1: Weak (diminished and thready, difficult to the body, caused by fluid volume excess, brought about palpate) by different factors ○ +2: Normal Notes by: ur usual sharing notes group! ;) 3  ○ +3: Increased (easy to palpate and pulse is full) ○ +4: Bounding (strong; abnormal) DIAGNOSTIC ASSESSMENT (NON-INVASIVE) LABORATORY TESTS: BLOOD CHEMISTRY LIPID PANEL / LIPID PROFILE A panel of blood tests used to find abnormalities in lipids, such as cholesterol, triglycerides, and lipoproteins. Normal values: ○ Cholesterol: less than 200 mg/dL ○ Triglycerides: 100-200 mg/dL ○ HDL (Good Cholesterol): 35-70 mg/dL in Males; 35-85 mg/dL in Females ○ LDL (Bad Cholesterol): less than 160 mg/dL Done after fasting for 10 - 12 hours SERUM POTASSIUM Has a major role in cardiac function; it helps nerves and muscles communicate NV: 3.5-5.0 mEq/L Hyperkalemia: heart block, asystole, ventricular dysrhythmias Hypokalemia: ventricular tachycardia, ventricular fibrillation, torsades de pointes SERUM CALCIUM CORRECT LEAD PLACEMENTS FOR THE 12-LEAD ECG Necessary for blood coagulability and automaticity of (CHEST) the sinus and AV nodes ○ Normal values: 8.6-10.2 mg/dL Hypercalcemia: increased myocardial activity, ventricular fibrillation Hypocalcemia: slow and impaired myocardial contractility C-REACTIVE PROTEIN Protein produced by the liver in response to systemic inflammation An acute marker of inflammation Plays a role in the development of atherosclerosis CORRECT LEAD PLACEMENTS FOR THE 12-LEAD ECG ○ Normal values: 0.3 to 1.0 mg/dL (LIMBS) CHEST X-RAY Used to determine size, contour, and position of the heart RA: anywhere between the right Also used for confirming placement of pacemakers shoulder and right elbow and cardiac catheters LA: anywhere between the left shoulder and left elbow ELECTROCARDIOGRAM (ECG) RL: anywhere below the right The measurement of electrical activity in the heart torso and above the right ankle and the recording of such activity as a visual trace (on LL: anywhere below the left torso paper or on an oscilloscope screen), using electrodes and above the left ankle placed in a standard position on the skin of the limbs and chest. Leads: a specific view of the electrical activity of the heart. 12-lead ECG is used to diagnose dysrhythmias, ECHOCARDIOGRAM conduction abnormalities, myocardial ischemia, injury, or Echocardiography; also known as cardiac ultrasound infarction. The test will usually be carried out at a hospital or clinic Automaticity is one characteristic of your heart. It will be by a cardiologist, cardiac physiologist, or a trained measured or seen through the ECG. technician called a sonographer. Uses sound waves to show how blood flows through the 2 COLOR CODING STANDARDS FOR 12 LEAD ECG heart and heart valves. PLACEMENT GUIDE Sensors are attached to the chest and sometimes the legs to check the heart rhythm during the test. American Heart Association (AHA) International Electrotechnical Commission (IEC) Notes by: ur usual sharing notes group! ;) 4  DIAGNOSTIC ASSESSMENT (INVASIVE) ANGIOGRAPHY - an imaging technique CARDIAC CATHETERIZATION that involves the injection of a radiopaque An invasive procedure in which contrast agent into the arterial catheter. radiopaque arterial and venous catheter The contrast agent is filmed as it passes are advanced into the right and left through the chambers of the heart, aortic heart. arch, and the major arteries. Site of catheter insertion: femoral, radial, Coronary Angiography brachial arteries Performed to observe the coronary artery DEFINITION Commonly performed on an outpatient anatomy and evaluate the degree of basis and requires 2-6 hours of bedrest atherosclerosis. post-op A catheter is positioned into the right and Radiopaque contrast agents are used to left coronary arteries so that the visualize the coronary arteries radiopaque contrast can be injected directly The gold standard diagnostic test for into each artery. coronary artery disease (CAD) Diagnose CAD/Pulmonary artery hypertension/Valvular heart disease Assess coronary artery patency Determine extent of atherosclerosis Measure the hemodynamics of the right INDICATION and left side of the heart S Evaluation and treatment of cardiac arrhythmias Assessment of pericardial and myocardial Ventriculography diseases Another angiographic technique performed Evaluation of heart failure to evaluate the size and function of the left ventricle. A type of angiography in which x-rays are taken as a radiopaque contrast agent is injected into the left or right ventricle of the heart through a catheter. Dysrhythmias Venous spasm Infection of the insertion site (common complication) COMPLICAT ○ not practicing proper hygiene and IONS proper cleaning of site; not observing PROCEDUR Catheter is inserted through a peripheral aseptic technique E/PURPOSE blood vessel into the heart, to visualize the Cardiac perforation structures inside & function Cardiac arrest Other purpose PRE-OPERATIVE MANAGEMENT ○ To obtain cardiac tissue samples for Instruct pts to fast for 8-12 hours before biopsy. procedure. ○ Close small holes inside the heart Inform about the expected duration of the ○ Place wire devices, called stents, in procedure narrowed arteries to keep them ○ Usually less than 2 hours; done to open avoid anxiousness ○ Heart X-ray film Availability of IV access Could be inserted at the femoral artery, Inform the pt. that occasional pounding brachial, or radial artery sensation/palpitation is felt because of Right Heart Catheterization extra heartbeats especially when the An invasive hemodynamic procedure that catheter tip touches the endocardium allows direct measurement of right-sided (innermost). cardiac pressures and calculation of Teach deep breathing exercises cardiac output ○ To eliminate/lessens the risk of Passage of the catheter from an having dysrhythmias antecubital or femoral vein into the right NSG MGMT POST-OPERATIVE MANAGEMENT atrium, right ventricle, pulmonary artery, Monitor for signs of bleeding or and pulmonary arterioles. hematoma on the catheter access site. RIGHT HEART; catheter starts at the vein Assess peripheral pulses in the affected TYPES (antecubital or femoral) extremity q15 mins for 1 hour, q30 mins Left Heart Catheterization for 1 hour, and qHourly for 4 hours or Performed to evaluate the aortic arch and until discharged (Lower extremity pulses: its major branches, patency of the coronary dorsalis pedis/posterior tibial pulses, Upper arteries, and the function of the left extremity: radial pulse) ventricle and mitral and aortic valves Evaluation of vital signs, CRT of affected Performed by retrograde catheterization of extremity and unaffected extremity for the left ventricle. comparison LEFT HEART; catheter starts at the right ○ Normal CRT: Reperfusion within 2 brachial or femoral artery then advances seconds to the aorta then left ventricle. Attach cardiac monitor to check for signs of dysrhythmias Notes by: ur usual sharing notes group! ;) 5  Bed rest for 2-6 hours; semi fowler’s PULMONARY ARTERY PRESSURE (PAP) position Monitor for vasovagal responses: Used for assessing left ventricular bradycardia, hypotension, nausea function, diagnosing the etiology of If vasovagal reaction is noted: shock, and evaluation of response to ○ Elevate lower extremities above vasoactive medications. the level of the heart for blood flow Pulmonary catheter and pressure to return to the heart monitoring is used. ○ Administer IV fluid bolus - Balloon-tipped, flow directed ○ Administer atropine IVTT (treats catheter with distal and bradycardia) proximal lumen Pain management is done by administering analgesic meds per doctor’s order For instances of contrast agent-induced nephropathy: Give oral and IV hydration, monitor serum creatinine levels ○ To check on kidney function HEMODYNAMIC MONITORING The use of direct pressure monitoring systems for critically ill patients that require continuous assessment of the cardiovascular system to diagnose and manage their complex medical condition DEFINITION INTRA-ARTERIAL BP MONITORING Used to obtain continuous and direct BP measurements, the site is also used Disposable Flush System - composed of for collecting arterial blood gas (ABG) IV NSS, tubing, stopcocks, flush device measurement. Pressure Bag - prevents clotting by Preferred site: Radial Artery delivering 3-5 ml solution from the flushing The technique involves the insertion of a system catheter into a suitable artery and then Transducer - converts pressure to displaying the measured pressure wave electrical signal on a monitor. Amplifier / Monitor Pneumothorax COMPLICAT Infection IONS Air embolism CENTRAL VENOUS PRESSURE (CVP) Measurement of the blood pressure of the vena cava or the right atrium. ○ Distend or bulging of the external jugular vein. Reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back to the arterial system. Preferred site: Subclavian vein Hand Hygiene FORMS OF Normal CVP: 2-6 mmhg Dressing HEMODYNA ○ If greater than 6 mmhg - - Wear sterile gloves when changing MIC Hypervolemia or Right-Sided HF dressing MONITORIN (heart failure) - Use >0.5 Chlorhexidine preparation G ○ If less than 2 mmhg- Hypovolemia with alcohol Local anesthetic agent is used before - Gauze dressing: change every 2 days insertion NSG MGMT - Transparent dressing: change every 7 ○ Using a sterile technique, the days physician threads a single lumen or Catheter site care multi lumen catheter through the - Assess site regularly; signs of vein into the vena cava just above or inflammation, hematoma or bleeding within the right atrium. - Remove dressing for thorough ○ Once inserted, a dry, sterile dressing assessment: is applied. ❖ Tenderness to the site Notes by: ur usual sharing notes group! ;) 6  ❖ Check temp: if there are any The horizontal direction fever without known source represents passage of time ❖ Any signs of infection; redness The entire box, or 1 second = around the site, inflammation, 25 mm/sec pus, etc 5 mm or 5 boxes = 0.2 sec or Pressure monitor system care 200 msec ○ Keep all components sterile. 1mm or 1 small box = 0.04 sec ○ Replace transducer and tubing or 40 msec flush device at 96 hrs interval. ○ IV dilution: change every 24 hours ○ Important: DO NOT infuse dextrose-containing solution (since it’s glucose and it can serve as a medium of growth for bacteria); Rather, use plain NSS Bathing ○ Do not submerge the catheter in water. Patient education ○ Instruct the patient to report One small box is equal to 0.04 sec, then 1 mm, then 0.1mV any discomforts/unusualities INTERPRETING THE ELECTROCARDIOGRAM from the catheter site ECG is composed of: immediately. Wave forms Activity intolerance related to insufficient ○ P wave oxygen for activities of daily living ○ QRS complex Anxiety related to breathlessness ○ T wave Imbalanced nutrition: less than body ○ (U wave) - not requirements related to nausea; anorexia normally seen secondary to venous congestion Intervals Impaired peripheral tissue perfusion ○ PR NSG related to venous congestion ○ QT DIAGNOSIS Disturbed sleep pattern secondary to ○ TP nocturnal dyspnea ○ PP Powerlessness related to progressive ○ RR nature of condition Segments High risk for ineffective therapeutic ○ PR regimen management related to lack of ○ ST knowledge Pain related to impaired circulation P WAVE PART 2: RESPONSES TO ALTERED TISSUE Represents an electrical impulse starting PERFUSION at the SA node with a duration of 0.11 or less seconds. ECG OR ELECTROCARDIOGRAM Is the 1st positive deflection on the ECG THE ECG GRID and indicates atrial depolarization (contraction) QRS COMPLEX Represents the contraction of the ventricles with a duration of less than 0.12 seconds Indicates ventricular depolarization (contraction) and atrial repolarization (relaxation). Photo: the ECG Grid T WAVE It reflects the ventricular repolarization The ECG waves are recorded on special graph paper (relaxation) process when cardiac muscle that is divided into 1mm2 grid-like boxes. The ECG cells reset their electrical charge after paper speed is ordinarily 25 mm/sec contraction. Each 1mm (small) horizontal box corresponding to 0.04 Also called the resting state sec, with heavier lines forming larger boxes that include 5 Ventricles relax in this waveform small boxes and represent 0.2 sec intervals. The vertical direction U WAVE represents the strength of Thought to represent the late repolarization of the electrical voltage. Positive purkinje fibers in the ventricles and is more often not voltage moves the stylus up, shown on a rhythm strip Negative voltage moves it Mostly seen in patients with hypokalemia downward. Each millimeter vertically represents 0.1 millivolt. 10 vertical boxes is one millivolt. Notes by: ur usual sharing notes group! ;) 7  Is analyzed whether it is above or below the isoelectric line to determine signs of pericarditis or atrial ischemia PR SEGMENT DEPRESSION: Pericarditis PR SEGMENT DEPRESSION/ ELEVATION: Atrial Ischemia ST SEGMENT Represents early ventricular repolarization ○ Otherwise known as the early relaxation of your ventricles Measured from the end of the QRS complex to the beginning of the T wave PR INTERVAL Is analyzed whether it is above or below the isoelectric line to determine signs of Measured from the beginning of the P cardiac ischemia wave to the beginning of the QRS Plays an important role in identifying complex. patients with Ischemia or Myocardial infarction Represents the time needed for the SA node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization SUMMARY Duration: 0.12 - 0.20 seconds ECG is composed of your wave forms, intervals, and segments QT INTERVAL Wave Forms - P wave, QRS complex, and T wave Measured from the beginning of ○ Hypokalemia - Presence of U waves which is not the QRS Complex to the end of seen in a usual rhythm strip the T Wave Intervals - PR interval, QT interval, TP interval, PP Represents the total time for interval, RR interval ventricular depolarization and Segments - PR segment, ST segment repolarization Duration: 0.32 - 0.40 seconds ALTERATIONS IN PERFUSION TP INTERVAL 1. Arrhythmia This is an isoelectric period where 2. Dysrhythmia there is no electrical activity ARRHYTHMIA/ DYSRHYTHMIA happening. Abnormal rhythm of your heartbeat Measured from the end of the T Wave Arrhythmia to the beginning of the next p wave ○ rhythm of your heart beat is too fast or Blanko wa ni siya,wala rani siyay ganap too slow dire normally CHARACTE Dysrhythmia RISTICS ○ the rate of your heartbeat is irregular but is within the normal range PP INTERVAL ○ Classified by the site of origin - SA Measured from the beginning of one P wave to the node, atrial and AV node, ventricular beginning of the next one node Used to determine atrial rate and rhythm NORMAL SINUS RHYTHM RR INTERVAL RATE: 60-100 bpm Measured from one R in the QRS Complex to the next R RHYTHM: REGULAR in the next QRS Complex Sinus rhythm is the name given to the normal rhythm of Used to determine ventricular rate and rhythm the heart where the electric stimuli are initiated. The SA Previously si PP Interval is used to determine your atrial nodes are then conducted then the AV node, the bundle rate and rhythm, while your RR is used to determine your of HIS, the bundle branches which is your right and left ventricular rate and rhythm bundle, your purkinje fibers. Depolarization or your contraction and repolarization or PR SEGMENT your relaxation of the atria and the ventricles show up as Is the flat line between the end of the P 3 distinct waves on your ECG. It shows equal intervals wave and the start of the QRS complex from one another. Reflects the time delay between atrial If the beat is okay and normal per heartbeat, then it will and ventricular activation just reflect a normal sinus rhythm. Notes by: ur usual sharing notes group! ;) 8 DIFFERENT WAVEFORMS Palpitations P Wave: normal and consistent MANIFESTA Hypotension shape before the QRS complex TIONS Angina with CVD QRS complex: normal and Myocardial infarction consistent shape and duration MGMT Beta-blockers (e.g. Metoprolol, Atenolol) T wave: normal and consistent shape ATRIAL DYSRHYTHMIAS PR interval: consistent interval Atrial Flutter between 0.12 - 0.20 secs Atrial fibrillation ATRIAL FLUTTER DIFFERENT DYSRHYTHMIAS (Accdg. to its site of origin) 1. Sinus node dysrhythmias 2. Atrial dysrhythmias 3. Ventricular dysrhythmias 4. Conduction abnormalities SINUS NODE DYSRHYTHMIAS Sinus Bradycardia DEFINITION Sinus Tachycardia SINUS BRADYCARDIA Rate: >150 bpm (200-300 bpm IN SOME CASES) Rhythm: Irregular Causes: COPD, pulmonary hypertension, valvular diseases P Wave: Sawtooth shaped, F wave QRS Complex: Shape and duration normal, but sometimes may be absent T wave: Not seen DEFINITION Rate: 0.12 seconds POLYMORPHIC VTACH T WAVE: can be seen PR INTERVAL: If P wave is in front of QRS, PR is < 0.12 seconds TYPES P:QRS RATIO: 1:1, 0:1 CHARACTE RISTICS Subform: Torsades de pointes Common in patients who have hypomagnesemia. If the patient is low in magnesium, give magnesium sulfate. So definitely you will see a polymorphic vtach in the ECG of patients with hypomagnesemia. Inconsistent height and size of duration of the QRS complex Difference of the two is the size of the CLINICAL Palpitations QRS complex. MANIFESTA Chest pain Assess First! TIONS ○ Check Pulse first. (Check atria Assess PVCs if more than 6 per minute function) Assess ECG if more than 6 pm, this could ○ If with Pulse: Vtach with pulse MEDICAL lead to ventricular tachycardia ASSMNT ○ If without Pulse: Pulseless Vtach MGMT LIDOCAINE IV AND DX Manifestations: TAKE NOTE: Lidocaine is not just an FINDINGS ○ Palpitations anesthetic, it’s also an antiarrhythmic drug ○ Weakness VENTRICULAR TACHYCARDIA ○ Dyspnea ○ Unconsciousness (Pulseless Vtach) If pulseless Vtach: Defibrillate ○ Defibrillation: the asynchronous delivery of energy such as shock is DEFINITION delivered randomly during the Rate: cardiac cycle Ventricular Rate: 100 - 200 bpm MGMT If Vtach with Pulse: O2 Therapy, Rhythm: Irregular Cardioversion, Antiarrhythmic drugs Causes: MI, CAD ○ Cardioversion: the delivery of energy that is synchronized to the QRS complex Vtach is an Emergency Case = Check pulse FIRST so we know our management Notes by: ur usual sharing notes group! ;) 10  VENTRICULAR DYSRHYTHMIAS 2ND DEGREE AV BLOCK MOBITZ TYPE I VENTRICULAR FIBRILLATION (WENCKEBACH) DESCRIPTI ON DESCRIPTI ON RATE: Indefinite Rate: Depends on the underlying rhythm RHYTHM: Irregular Rhythm: Irregular CAUSES: Cardiomyopathy (Weakened heart muscle), previous heart attack, congenital heart defects, electrolyte abnormalities CHARACTE RISTICS CHARACTE PR interval: Becomes longer with each RISTICS succeeding ECG complex followed by a skipped beat. P Wave: Cannot be seen QRS Complex: Chaotic, Unrecognizable 2ND DEGREE AV BLOCK TYPE II T Wave: Cannot be seen PR Interval: Cannot be determined CLINICAL Palpitations MANIFESTA Pulseness TIONS Unconscious DESCRIPTI Defibrillate ON MGMT Anti-arrhythmias VENTRICULAR ASYSTOLE Rate: Depends on the underlying rhythm Rhythm: Irregular CHARACTE DESCRIPTION RISTICS PR interval: is constant with each Flat line succeeding ECG complex followed by a Rate: None skipped beat. Rhythm: None MANIFESTATION Unconscious 3RD DEGREE AV BLOCK Check connection (COMPLETE HEART BLOCK) ○ Don’t call for a code right away! Maybe the connection is loose. MGMT Check V/S, LOC Initiate CPR ○ Verify first before initiating DESCRIPTI CPR. Then, call for code. ON Rate: Depends on the underlying rhythm CONDUCTION ABNORMALITIES Two impulses stimulate the heart. 1ST DEGREE ATRIOVENTRICULAR BLOCK ○ It doesn’t follow the correct pathway of the electrical conduction P Wave: Normal but not related to QRS PR interval: Varies because there is no P and QRS relationship. PP & RR interval: Regular (in sinus DESCRIPTI rhythm, the PP and RR intervals are ON CHARACTE regular but the P wave has no relationship Rate: Depends on the underlying rhythm RISTICS with the R wave) Rhythm: Irregular Ventricular Rate: usually 40-60 bpm and ○ Clue: For conduction abnormalities, narrow when it is driven by a junctional always check for PR intervals. Same pacemaker (AV node). ra ang PR interval QRS: Wide and QRS) inside heart vessels ○ The Atria and ventricles are working on their own. Nicotine use They are not complementing each other anymore, Diabetes mellitus (DM) so that's why the PQRS are having no relations. Hypertension Fixed interval, then drop beat. Hyperlipidemia RISK Diet FACTORS Stress Sedentary lifestyle Elevated c-reactive protein Take Note: Increasing age ○ Rate of conduction of abnormalities (AV Blocks) is Familial predisposition Bradycardic (