Management of Patients Module 1

ANATOMY, PHYSIOLOGY, &

With Dysrhythmias and
ELECTRICAL CONDUCTION
Conduction Problems

Ric-An Artemio S. Gadin, MAN, RN, FRIN

Cardiac Anatomy Cardiac Anatomy

2 upper chambers 2 major vessels of the coronary
 Right and left atria 2 lower circulation
chambers  Left main coronary artery

 Right and left ventricle  Left anterior descending

2 Atrioventricular valves and circumflex branches

(Mitral & Tricuspid)  Right main coronary artery

 Open with ventricular  The left and right coronary

diastole arteries originate at the base

 Close with ventricular systole
of the aorta from openings
called the coronary ostia
2 Semilunar Valves behind the aortic valve
(Aortic & Pulmonic) leaflets.
 Open with ventricular systole

 Open with ventricular

diastole

Physiology: Blood Flow Physiology

Cardiac cycle
 Represents the actual time sequence between ventricular
contraction and ventricular relaxation
Systole
 Simultaneous contraction of the ventricles

Diastole
 Synonymous with ventricular relaxation

 When ventricles fill passively from the atria to 70% of blood

capacity

1
Physiology Physiology
Heart rate (HR) Pre-load
 Number of contractions (beats per minute)  Volume and stretch of the ventricular myocardium at the end

 Normal heart rate is 60 – 100 beats per minute (bpm) of diastole

Stroke volume (SV) After-load
 Volume of blood being pumped out of ventricles in a single  Amount of pressure against which the left ventricle must work

beat or contraction during systole to open the aortic valve

 Normal stroke volume is 60 – 130 ml  Clinically measure by systolic blood pressure

Cardiac output (CO)

 Amount of blood pumped by the left ventricle in one minute

 Normal cardiac output is 4 – 8 L/min

Cardiac Output = Stroke Volume x Heart Rate Pre-load

Normal Electrical Conduction System

Module 2
 SA node
INTERPRETING EKG  Inter-nodal pathways
RHYTHM STRIPS  AV node
 Bundle of his
 Left & Right bundle
branches
 Purkinje fibers

Normal Electrical Conduction System Normal Electrical Conduction System

Structure Function and Location Structure Function and Location

Sinoatrial (SA) Dominant pacemaker of the heart, located Bundle of His Transmits impulses to bundle branches.
node in upper portion of right atrium. Intrinsic Located below AV node.
rate 60–100 bpm. Left bundle Conducts impulses that lead to left
Internodal Direct electrical impulses between SA and branch ventricle.
pathways AV nodes. Right bundle Conducts impulses that lead to right
Atrioventricular Part of AV junctional tissue. Slows branch ventricle.
(AV) node conduction, creating a slight delay before Purkinje system Network of fibers that spreads impulses
impulses reach ventricles. Intrinsic rate rapidly throughout ventricular walls.
40–60 bpm. Located at terminals of bundle branches.
Intrinsic rate 20–40 bpm.

2
Electrical Conduction System
EKG Waveforms
One complete cardiac P wave
 Atrial depolarization
cycle = (contraction)
 P, Q, R, S, (QRS QRS Complex
complex), and T  Ventricular depolarization,
wave atrial repolarization
T wave
 ▪ Ventricular repolarization
(resting phase)

The Electrocardiogram (ECG)

 ECG/EKG-a graphic representation of cardiac activity

 An ECG is a series of waves and deflections recording the
heart’s electrical activity from a certain “view.”
 Many views, each called a lead, monitor voltage changes
between electrodes placed in different positions on the body.
 Leads-wires generally color coded. For the EKG to receive a
clear picture of electrical impulses, there must be a positive, a
negative and a ground. The exact portion of the heart being
visualized depends on lead placement

EKG Leads EKG Leads

 Baseline-isoelectric line-no current flow in the heart;  Limb leads

consists of positive, negative deflections or biphasic
complex  Bipolar leads-measures activity between 2
 3 or 5 lead- used for monitoring the current cardiac points (I, II, III)
activity of patients at risk for cardiac abnormalities
 Lead ll or MCL1-modified chest leads mostly used  Unipolar leads-positive electrodes only-
because of ability to visualize P waves. MCL provides a aVR, aVL, aVF
R sided view of the heart. MCL6-L sided view of the
heart  Chest leads-6 precordial leads

3
Standard Limb Lead Electrode
Placement

Standard Chest Lead Electrode Reading EKG Graph Paper

Placement
Graph paper allows a visual
measurement of:
 Time (rate)

 Measured on the

horizontal line
 Amplitude (voltage)

 Measured on the vertical

line

Paper divided into small Darker lines divide paper into

squares: every 5th square vertically and
 Width = 1 millimeter (mm) horizontally:
 Time interval = 0.04  Large squares measure 5

seconds mm in height and width

 Represents time interval

 1 small square = 0.04 of 0.20 seconds

seconds  25 small squares in each

large square

 1 large square = 0.20

seconds

4
Interpreting EKG Rhythm Strips

 First and most important The five-step approach, in order of application,

 ASSESS YOUR PATIENT!!
includes analysis ofthe following:
 Read every strip from left to right, starting at the beginning of
the strip 1. Heart rate
 Apply the five-step systematic approach that you will learn for 2. Heart rhythm
consistency with each strip that you interpret
3. P wave

4. PR interval

5. QRS complex

Step 1 – Heart Rate

 Count the number of electrical impulses as represented by Methods to determine heart rate
PQRST complexes conducted through the myocardium in 60  The 6 second method
seconds (1 minute)  Denotes a 6 second interval on EKG strip

 Strip is marked by 3 or 6 second tick marks on the top or

 Atrial rate: Count the number of P waves bottom of the graph paper
 Ventricular rate: Count the number of QRS complexes  Count the number of QRS complexes occurring within the 6

second interval, and then multiply that number by 10

 Using rate determination chart

 More accurate calculation of HR

 ▪ Preferred method

 ▪ Must use this method for the test!!

 6 second method  Using rate determination

chart
 Count spaces

between R to R
 Find number of

spaces on the chart

to determine the rate

5
 Step 2 – Rhythm

 Example Rhythm
 A sequential beating of the heart as a result of the generation
of electrical impulses
 Classified as:

 Regular pattern: Interval between the R waves is regular

 Irregular pattern: Interval between the R waves is not

regular

Step 3 – P Wave
 P wave is produced when the left and right atria depolarize
Measuring a Rhythm
 First deviation from the isoelectric line
 Measure the intervals between R waves (measure from R to
 Should be rounded and upright
R)
 P wave is the SA node pacing or firing at regular intervals
 If the intervals vary by less than 0.06 seconds or 1.5
 This pattern is referred to as a sinus rhythm ▪
small boxes, the rhythm is considered to be regular
 If the intervals between the R waves (from R to R) are
 P wave: 5 questions to ask
variable by greater than 0.06 seconds or 1.5 small 1. Are P waves present?
boxes, the rhythm is considered to be irregular 2. Are P waves occurring regularly?
3. Is there one P wave present for every QRS complex present?
4. Are the P waves smooth, rounded, and upright in appearance,
or are they inverted?
5. Do all P waves look similar?

Step 4 – PR Interval

 Measures the time interval

from the onset of atrial
contraction to onset of
ventricular contraction
 Measured from onset of P
wave to the onset of the
QRS complex

 Normal interval is 0.12–

0.20 seconds (3-5 small
squares)

6
 Step 5 – QRS Complex

PR interval: 3 questions to ask  The QRS complex presents depolarization or contraction of

1. Are the PR intervals greater than 0.20 seconds? the ventricles
2. Are the PR intervals less than 0.12 seconds?  ▪ Q wave

3. Are the PR intervals consistent across the EKG strip?  First negative or downward deflection of this large
complex
 R wave

 First upward or positive deflection following the

 P wave (tallest waveform)

 S wave

 The sharp, negative or downward deflection that follows

the R wave
 Normal interval is 0.06-0.12 seconds (1 ½ to 3 small boxes)

 QRS complex: 3 questions to ask

1. Are the QRS complexes greater than 0.12 seconds (in
width)?
2. Are the QRS complexes less than 0.06 seconds (in
width)?
3. Are the QRS complexes similar in appearance across the
1. HR = # of boxes between R’s = 19 spaces = 79bpm
EKG strip?
2. Rhythm = regular or irregular = irregular (R-R’s are equal)
3. P waves = P wave for every QRS? = yes
4. PR interval = measure from beginning of P to beginning of
QRS = 0.12
5. QRS = measure from start of Q to end of S = 0.08

T Wave U Wave

 Produced by ventricular  Usually not visible on EKG

repolarization or relaxation strips
 Commonly seen as the  If visible, typically follows
first upward or positive the T wave
deflection following the  Appears much smaller than
QRS complex T wave, rounded, upright,
or positive deflection if they
are present
 Cause or origin not
completely understood
 May indicate hypokalemia

7
Artifact

 EKG waveforms from sources outside the heart

Module 3
 Interference is seen on the monitor or EKG strip SINUS RHYTHMS
 4 causes
 Patient movement (most common)

 Loose or defective electrodes (fuzzy baseline)

 Improper grounding (60 cycle interference)

 Faulty EKG apparatus

Normal Sinus Rhythm

 Rhythms that originate in the sinoatrial node (SA node)  Sinus rhythm is the normal regular rhythm of the heart set by
 5 Common Variations of a sinus rhythm: the natural pacemaker of the heart called the sinoatrial node.
 Normal sinus rhythm (60 – 100 bpm)
It is located in the wall of the right atrium. Normal cardiac
impulses start there and are transmitted to the atria and down
 Sinus bradycardia (< 60 bpm)
to the ventricles.
 Sinus tachycardia ( >100 bpm)

 Sinus arrhythmia (60 – 100 bpm)

 Sinus pause/arrest

5 Steps to Identify Normal Sinus Normal Sinus Rhythm Nursing

Rhythm Interventions
1. What is the rate? 60-100 beats per minute  No interventions required!! Monitor patient if
2. What is the rhythm? Atrial rhythm regular ordered by physician.
Ventricular rhythm regular
3. Is there a P wave Yes
before each QRS?
Are P waves upright Yes
and uniform?
4. What is the length of 0.12-0.20 seconds (3-5 small
the PR interval? squares)
5. Do all QRS Yes
complexes look alike?
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

8
Sinus Bradycardia 5 Steps to Identify Sinus Bradycardia
Rhythm
 Sinus bradycardia is a regular but unusually slow heart beat 1. What is the rate? Less than 60 beats per minute
(less than 60 bpm). Sinus bradycardia is often seen as a 2. What is the rhythm? Atrial rhythm regular
normal variation in athletes, during sleep, or in response to a Ventricular rhythm regular
vagal maneuver.
3. Is there a P wave Yes
before each QRS?
Are P waves upright Yes
and uniform?
4. What is the length of 0.12-0.20 seconds (3-5 small
the PR interval? squares)
5. Do all QRS Yes
complexes look alike?
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

Causes and S/S of Sinus Bradycardia Risk and Medical Tx of Sinus

Bradycardia
 Causes  Signs and Symptoms  Risk  Medical Treatment
 Hypoglycemia  Syncope  Reduced Cardiac  Atropine

 Hypothermia  Dizziness Output  Pacing if the patient is

 Hypothyroidism  Chest Pain hemodynamically

 Previous cardiac history  Shortness of Breath
compromised
 Treatment will be based
 Medications  Exercise Intolerance
on whether patient is
 Toxic exposure  Cool, clammy skin
symptomatic
 MI – Inferior wall

involving right coronary

artery

Sinus Bradycardia Nursing Sinus Tachycardia

Interventions
 Assess patient – Are they symptomatic?  Sinus Tachycardia is a fast heartbeat related to a rapid firing
 Give oxygen and monitor oxygen saturation of the sinoatrial (SA) node. The clinical dysrhythmia depends
 Monitor blood pressure and heart rate on the underlying cause. It may be normal depending on the
patient.
 Start IV if not already established
 Notify MD

9
5 Steps to Identify Sinus Tachycardia Causes and S/S of Sinus Tachycardia
Rhythm
1. What is the rate? 101-160 beats per minute  Causes  Signs and Symptoms
 Damage to heart tissues  Dizziness
2. What is the rhythm? Atrial rhythm regular
Ventricular rhythm regular from heart disease
 Shortness of breath
 Hypertension
3. Is there a P wave Yes  Lightheadedness
 Fever
before each QRS?  Rapid pulse rate
 Stress
Are P waves upright Yes
 Excess alcohol, caffeine,
 Heart palpitations
and uniform?
nicotine, or recreational  Chest pain
4. What is the length of 0.12-0.20 seconds (3-5 small drugs such as cocaine
the PR interval? squares)  Syncope
 A side effect of medications
5. Do all QRS Yes  Response to pain
complexes look alike?  Imbalance of electrolytes
What is the length of 0.06-0.12 seconds (1 ½ to 3 small  Hyperthyroidism
the QRS complexes? squares)

Risk and Medical Tx of Sinus Sinus Tachycardia Nursing

Tachycardia Interventions
 Risk  Medical Treatment  Assess patient – Are they symptomatic? Are they stable?
 Cardiac output may fall  Aimed at finding and  Give oxygen and monitor oxygen saturation
due to inadequate treating cause  Monitor blood pressure and heart rate
ventricular filling time  Start IV if not already established
 Myocardial oxygen
 Notify MD
demand increases
 Can precipitate

myocardial ischemia or
infarct

Sinus Tachycardia Nursing Sinus Arrhythmia

Interventions
 ACLS Protocol  A sinus arrhythmia refers to an irregular or
 Look for the cause of the tachycardia and treat it
disorganized heart rhythm.
 Fever – give acetaminophen or ibuprofen

 Stimulants – stop use (caffeine, OTC meds, herbs,

 This rate usually increases with inspiration
illicit drugs) and decreases with expiration.
 Anxiety – give reassurance or ant-anxiety medication

 Sepsis, Anemia, Hypotension, MI, Heart Failure,

Hypoxia
 Narrow QRS Complexes – consider vagal maneuvers,

adenosine, beta blocker, calcium channel blocker, or

synchronized cardioversion
 Wide QRS Complexes – consider anti-arrhythmic such as

procainamide, amiodarone, or sotalol

10
5 Steps to Identify Sinus Bradycardia Causes and S/S of Sinus Arrhythmia
Rhythm
1. What is the rate? 60-100 beats per minute  Cause  Signs and Symptoms
2. What is the rhythm? Irregular (varies more than 0.08 sec)  Heart disease  Usually asymptomatic

3. Is there a P wave Yes  Moderate to extreme

before each QRS? stress

Are P waves upright Yes  Excessive consumption
and uniform? of stimulants like
4. What is the length of 0.12-0.20 seconds (3-5 small caffeine, nicotine, and
the PR interval? squares) alcohol
 Intake of medications
5. Do all QRS Yes
complexes look alike? like diet pills as well as
What is the length of 0.06-0.12 seconds (1 ½ to 3 small cough and cold
the QRS complexes? squares) medicines

Risk and Medical Tx of Sinus Sinus Arrest or Pause

Arrhythmia
 Risk  Medical Treatment  A sinus pause or arrest is defined as the
 Reduced cardiac output  Treatment is usually not

required unless patient

transient absence of sinus P waves that last
is symptomatic. If from 2 seconds to several minutes.
patient is symptomatic,
find and treat the cause.

5 Steps to Identify Sinus Arrest Causes and S/S of Sinus Pause/Arrest

Rhythm
1. What is the rate? Variable, depending on frequency  Causes  Signs and Symptoms
2. What is the rhythm? Irregular, when sinus arrest is present  This may occur in  Sometimes

3. Is there a P wave Yes, if QRS is present individuals with healthy asymptomatic

before each QRS? hearts during sleep  Syncope

Are P waves upright Yes, if QRS is present  Myocarditis  Dizziness

and uniform?  Cardiomyopathy  LOC

4. What is the length of 0.12-0.20 seconds (3-5 small  MI  Bradycardia

the PR interval? squares)  Digitalis toxicity

5. Do all QRS Yes, when present  Age- elderly

complexes look alike?  Vagal stimulation
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

11
Risk and Medical Tx of Sinus Sinus Pause/Arrest Nursing
Pause/Arrest Interventions
 Risk  Medical Treatment  Assess Patient
 Sudden cardiac death  Only treated if patient  Give oxygen and monitor oxygen saturation
(rare) symptomatic  Monitor blood pressure and heart rate
 Syncope  Atropine  Start IV if not already established
 Fall  Pacemaker  Notify MD
 Thromboembolic events  ACLS Protocol
including stroke  Look for the cause of the sinus arrest and treat it
 CHF
 Medication
 Atrial tachyarrhythmias -
 Electrolyte imbalance
such as atrial flutter or
 Natural deterioration of the cardiac system
fibrillation
 May require artificial pacemaker for treatment if symptomatic

Atrial Rhythms
Module 4  When the sinoatrial (SA) node fails to generate an impulse;
ATRIAL RHYTHMS atrial tissues or internodal pathways may initiate an impulse

 The 4 most common atrial arrhythmias include:

 Atrial Flutter (rate varies; usually regular; saw-toothed)

 Atrial Fibrillation (rate varies, always irregular)

 Supraventricular Tachycardia (>150 bpm)

 Premature Atrial Complexes (PAC’s)

Atrial Flutter 5 Steps to Identify Atrial Flutter

Rhythm
 Atrial flutter is a coordinated rapid beating of 1. What is the rate? Atrial: 250-400 bpm
Ventricular: variable
the atria. Atrial flutter is the second most
2. What is the rhythm? Atrial: regular
common tachyarrhymia. Ventricular: may be irregular
3. Is there a P wave Normal P waves are absent;
before each QRS?
Are P waves upright flutter waves (f waves)
and uniform? (sawtooth pattern)
4. What is the length of Not measurable
the PR interval?
5. Do all QRS Yes
complexes look alike?
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

12
Risk and Medical Tx for Atrial Flutter Atrial Flutter Nursing Interventions
 Risk  Medical Treatment  Assess Patient
 Clot formation in atria  Cardioversion –  O2 if not already given
(atria not completely treatment of choice  Start IV if not already established and hang NS
emptying)  Antiarrhymics such as
 Notify MD
 Stroke procainamide to convert
 Prepare for cardioversion
 Pulmonary Embolism the flutter
 Dramatic drop in cardiac  Slow the ventricular rate

output by using diltiazem,

verapamil, digitalis, or
beta blocker
 Heparin to reduce
incidence of thrombus
formation

Atrial Fibrillation 5 Steps to Identify Atrial Fibrillation

Rhythm
 The electrical signal that circles uncoordinated through the 1. What is the rate? Atrial: 350-400 bpm
muscles of the atria causing them to quiver (sometimes more Ventricular: variable
than 400 times per minute) without contracting. The 2. What is the rhythm? Irregularly irregular
ventricles do not receive regular impulses and contract out of
3. Is there a P wave Normal P waves are absent; replaced
rhythm, and the heartbeat becomes uncontrolled and
before each QRS? by f
irregular. It is the most common arrhythmia, and 85 percent
Are P waves upright waves
of people who experience it are older than 65 years.
and uniform?
4. What is the length of Not discernable
the PR interval?
5. Do all QRS Yes
complexes look alike?
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

Causes and S/S of Atrial Fibrillation Risk and Medical Tx of Atrial

Fibrillation
 Medical Treatment
 Causes  Signs and Symptoms  Risk
 Rate control (slow ventricular
 Hypoxia  Heart palpitations  Clot formation in atria rate to 80-100 beats/minute)
 Hypertension  Irregular pulse which feels (atria not completely
 Digoxin
too rapid or too slow, racing, emptying)
 Congestive heart failure
pounding or fluttering  Beta-adrenergic blockers
 Coronary artery disease  Stroke
 Dizziness or light-  Calcium channel blockers
 Dysfunction of the sinus headedness  Pulmonary Embolism
 Example - Verapamil (give IV
node  Fainting
 Dramatic drop in cardiac
if needed for quick rate
 Mitral valve disorders output
 Confusion control)
 Rheumatic heart disease
 Fatigue  Antithrombotic therapy
 Pericarditis  Trouble breathing  Correction of rhythm
 Hyperthyroidism  Difficulty breathing when  Chemical or electrical
 Excessive alcohol or lying down cardioversion
caffeine consumption  Sensation of tightness in the

chest

13
Atrial Fibrillation Nursing Supraventricular Tachycardia (SVT)
Interventions
 Assess Patient  Encompasses all fast (tachy) dysrhythmias in
 O2 if not already given
which heart rate is greater than 150 beats per
 Start IV if not already established and hang NS
minute (bpm)
 Notify MD
 Prepare for cardioversion

5 Steps to Identify Supraventricular Causes and S/S of SVT

Tachycardia Rhythm
1. What is the rate? Atrial: 150-250 bpm  Causes  Signs and Symptoms
Ventricular: 150-250 bpm  Find underlying cause  Palpitations

2. What is the rhythm? Regular  Chest discomfort

 Stimulants
(pressure, tightness, pain)
3. Is there a P wave Usually not discernable, especially at  Hypoxia
 Lightheadedness or
before each QRS? the  Stress or over-exertion dizziness
Are P waves upright high rate range
 Hypokalemia  Syncope
and uniform? (becomes hidden in the QRS)
 Atherosclerotic heart  Shortness of breath
4. What is the length of Usually not discernable disease  A pounding pulse.
the PR interval?
 Sweating
5. Do all QRS Yes  Tightness or fullness in the
complexes look alike? throat
What is the length of 0.06-0.12 seconds (1 ½ to 3 small  Tiredness (fatigue)
the QRS complexes? squares)
 Excessive urine

production

Risk and Medical Tx of SVT SVT Nursing Interventions

 Risk  Medical Treatment  Assess Patient

 Heart failure with  Stable patient’s  O2 if not already given
prolonged SVT (asymptomatic)  Vagal maneuvers (cough and valsalva)
 Vagal maneuvers  Start IV if not already established and hang NS
 Drug management  Notify MD
 Adenosine  Prepare for cardioversion
 Cardioversion if

unstable

14
Premature Atrial Contractions (PAC’s) 5 Steps to Identify Premature Atrial
Contraction (PAC)
 A PAC is not a rhythm, it is an ectopic beat that originates 1. What is the rate? Usually regular but depends on the
from the atria. underlying
 Normal beat, but just occurs early! rhythm
2. What is the rhythm? Irregular as a result of the PAC
3. Is there a P wave Usually upright but premature and
before each QRS? abnormal
Are P waves upright shape
and uniform?
4. What is the length of 0.12-0.20 seconds (3-5 small boxes)
the PR interval?
5. Do all QRS Yes
complexes look alike?
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

Cause and S/S PAC’s Risk and Medical Tx PAC’s

 Cause  Signs and Symptoms  Risk  Medical Treatment

 Occurs in healthy  Palpitations  Most benign – no risk  No treatment necessary

patients without heart  Skipped beat  May be a sign of if asymptomatic

disease underlying heart  Treat the cause

 Stress condition  Drug therapy

 Stimulants  Beta Blockers

 Hypertension  Calcium Channel

 Valvular condition Blockers

 Infectious diseases

 Hypoxia

PAC Nursing Interventions

 Assess patient
Module 5
 Monitor patient JUNCTIONAL RHYTHMS

 Junctional Rhythm
 Premature Junctional Complex
 Nonparoxysmal Junctional Tachycardia.
 Atrioventricular nodal reentry tachycardia (AVNRT)

15
Junctional rhythmias or Idionodal 5 Steps to Identify Junctional
rhythm Arrhythmia
 Occurs when the AV node, instead of the sinus node, 1. What is the rate? 40–60 bpm
becomes the pacemaker of the heart.
 When the sinus node slows (eg, from increased vagal tone) or 2. What is the rhythm? Regular
when the impulse cannot be conducted through the AV node
(eg, because of complete heart block), the AV node 3. Is there a P wave Absent, inverted, buried, or retrograde
automatically discharges an impulse. before each QRS?
Are P waves upright
and uniform?
4. What is the length of None, short, or retrograde
the PR interval?
5. Do all QRS Yes
complexes look alike?
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

Risk and Medical Tx of Junctional Premature Junctional Contraction

Arrhythmia (PJC)
 Risk  Medical Treatment  A premature junctional
 Reduced Cardiac  Atropine  complex is an impulse that starts in the AV nodal area before
Output  Pacing if the patient is  the next normal sinus impulse reaches the AV
hemodynamically  node
compromised
 Treatment will be based

on whether patient is
symptomatic

5 Steps to Identify Premature Causes and S/S of Premature

Junctional Contraction (PJC) Junctional Contraction (PJC)
1. What is the rate? Depends on rate of underlying rhythm  Causes  Signs and Symptoms
 toxic levels of digoxin  rarely produces

2. What is the rhythm? Irregular whenever a PJC occurs (level greater than 2.5 significant symptoms
ng/ml)
 signs of intrinsic
 excessive caffeine intake
3. Is there a P wave Absent, inverted, buried, or retrograde pacemaker failure.
 inferior wall myocardial
before each QRS? in the PJC infarction (MI)
Are P waves upright
 rheumatic heart disease
and uniform?
 valvular disease
4. What is the length of None, short, or retrograde  hypoxia,
the PR interval?
 Heart failure,
5. Do all QRS Yes  swelling of the AV junction
complexes look alike? after heart surgery.
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

16
 Risk and Medical Tx Premature Premature Junctional Contraction
Junctional Contraction (PJC) (PJC) Nursing Interventions
 Risk  Medical Treatment  Assess patient
 no risk  No treatment necessary  Monitor patient
 May be a sign of if asymptomatic
underlying heart  Treat the cause

condition

Nonparoxysmal Junctional Tachycardia 5 Steps to Identify Nonparoxysmal

Junctional Tachycardia
 Caused by enhanced automaticity in the junctional area, 1. What is the rate? 70–120 bpm
resulting in a rhythm similar to junctional rhythm, except at a
rate of 70 to 120.
2. What is the rhythm? Regular

3. Is there a P wave Absent, inverted, buried, or retrograde

before each QRS?
Are P waves upright
and uniform?
4. What is the length of None, short, or retrograde
the PR interval?
5. Do all QRS Yes
complexes look alike?
What is the length of 0.06-0.12 seconds (1 ½ to 3 small
the QRS complexes? squares)

Causes and S/S of Nonparoxysmal Risk and Medical Tx of

Junctional Tachycardia Nonparoxysmal Junctional Tachycardia
 Causes  Signs and Symptoms  Risk  Medical Treatment
 digitalis toxicity,  rarely produces  May compromise  No treatment necessary
 myocardial ischemia, significant symptoms cardiac output if asymptomatic
 hypokalemia,  signs of intrinsic  May be a sign of  Treat the cause
 or chronic obstructive pacemaker failure. underlying heart
pulmonary disease. condition

17
Atrioventricular Nodal Reentry Tachycardia 5 Steps to Identify Atrioventricular
Nodal Reentry Tachycardia
 a common dysrhythmia that occurs when an impulse is 1. What is the rate? Atrial rate usually 150 to 250;
conducted to an area in the AV node that causes the impulse ventricular rate usually 120 to 200
to be rerouted back into the same area over and over again at 2. What is the rhythm? Regular; sudden onset and
a very fast rate. termination of the tachycardia
3. Is there a P wave before Usually very difficult to discern
each QRS? Are P waves
upright and uniform?

4. What is the length of the If the P wave is in front of the QRS,

PR interval? the PR interval is less than 0.12
seconds
5. Do all QRS complexes Usually normal, but may be
look alike? What is the abnormal
length of the QRS
complexes?

Causes and S/S of Atrioventricular Risk and Medical Tx of AV Nodal

Nodal Reentry Tachycardia Reentry Tachycardia
 Causes  Signs and Symptoms  Risk  Medical Treatment
 Caffeine  vary with the rate and  May compromise
 Alleviate
 Nicotine duration of the cardiac output
tachycardia
symptoms that
 hypoxemia  May be a sign of

 palpitations. underlying heart affect quality of

 Stress

 Coronary artery disease

 restlessness, condition life.
 chest pain,
 Cardiomyopathy
 shortness of breath,

 Pallor

 hypotension,

 loss of
consciousness.

Nursing Interventions for AV Nodal

Reentry Tachycardia Module 6
 Vagal maneuvers, such as carotid
 sinus massage (Fig. 27-14), gagging, breath
VENTRICULAR RHYTHMS
holding, and immersing
 the face in ice water

18
 Ventricular Rhythms Premature Ventricular Contractions
 The most common variations:
 A PVC is not a rhythm, but an ectopic beat that arises from an
 Premature ventricular contractions (PVC’s)
irritable site in the ventricles.
 These 8 rhythms are the lethal ones: KNOW THESE  PVCs appear in many different patterns and shapes, but are
 Idioventricular rhythm (ventricular escape rhythm; rate always wide and bizarre compared to a “normal” beat
usually >20 – <40 bpm)
 Ventricular tachycardia (>150 bpm)

 Ventricular fibrillation

 Torsades de Pointes

 Asystole - Cardiac Standstill

 Accelerated Idioventricular rhythm (>40 bpm)

 Agonal rhythm (20 or less bpm)

 Pulseless Electrical Activity (PEA)

5 Steps to Identify Premature PVC Patterns

Ventricular Contractions (PVC’s)
1. What is the rate? Atrial: usually normal
Ventricular: usually normal
Depends on underlying rhythm
2. What is the rhythm? Depends on underlying rhythm;
Irregular during PVC’s
3. Is there a P wave before Absent with PVC’s
each QRS? Are P waves
upright and uniform?
4. What is the length of the Not measureable during PVC’s
PR interval?
5. Do all QRS complexes Varies
look alike? What is the Wide and bizarre (>0.12 sec), occurs
length of the QRS earlier than expected
complexes?

Causes and S/S of PVC’s Nursing Interventions for PVC’s

 Causes  Signs and Symptoms  Assess patient

 Exercise  Palpitations  O2 at 2 liters; Oxygen may abate the PVC’s
 Stress  Weakness  Start IV if not already established and hang NS
 Caffeine  Dizziness  Monitor for frequent PVC’s and deterioration to more serious
 Heart disease: MI, CHF,  Hypotension rhythms
 Cardiomyopathy, Mitral

valve prolapse
 Electrolyte imbalances

 Hypoxia

 Tricyclic
antidepressants
 Digitalis toxicity

19
 Risk and Medical Tx of PVC’s Idioventricular Rhythm

 Risk  Treatment  Idioventricular arrhythmia is also termed ventricular escape

 Reduced cardiac output  Oxygen rhythm. It is considered a last-ditch effort of the ventricles to
 Heart failure  Treat the cause
try to prevent cardiac standstill.
 The SA node and AV node have failed
 May convert to V-Tach  Lidocaine is the drug of

or V-Fib choice, although  Rate usually between 20 to 40 beats per minute (bpm)

procainamide is  Cardiac output is compromised!!

sometimes used

Keys to identifying: rhythm is SLOW, no P wave, wide & bizarre QRS!

5 Steps to Identify Idioventricular Causes and S/S of Idioventricular

Rhythm Rhythm
1. What is the rate? Ventricular: 20-40 bpm  Causes  Signs and Symptoms
2. What is the rhythm? Usually regular  Drugs- Digitalis  Pale

3. Is there a P wave Absent  MI  Cool with mottled skin

before each QRS?  Metabolic imbalances  Weakness

Are P waves upright  Hyperkalemia  Dizziness
and uniform?
 Cardiomyopathy  Hypotension
4. What is the length of Not measureable  Alteration in mental
the PR interval? status
5. Do all QRS Wide and bizarre (>0.12 sec), with T
complexes look alike? wave deflection
What is the length of
the QRS complexes?

Risk and Medical Tx of Nursing Interventions Idioventricular

Idioventricular Rhythm Rhythm
 Risk  Medical Treatment  Assess your patient: patient will most likely
 Usually a terminal event  Atropine

occurring before
be symptomatic with a weak, thready pulse
 Pacing
ventricular standstill  Dopamine when
 Run continuous monitor strips/record
 Death- cardiac arrest hypotensive  Begin CPR
 CPR
 Call Code Blue / “E” Cart
 Notify MD
 Start IV if not already established and hang
NS


20
Ventricular Tachycardia 5 Steps to Identify Ventricular
Tachycardia (V-Tach)
 Ventricular tachycardia almost always occurs in diseased 1. What is the rate? 101-250 bpm
hearts. 2. What is the rhythm? Atrial rhythm not distinguishable
 Rhythm in which three or more PVCs arise in sequence at a Ventricular rhythm usually regular
rate greater than 100 beats per minute. 3. Is there a P wave No

 V-tach can occur in short bursts lasting less than 30 seconds, before each QRS?
causing few or no symptoms. Are P waves upright
and uniform?
 Sustained v-tach lasts for more than 30 seconds and requires
immediate treatment to prevent death. 4. What is the length of Not measurable
 V-tach can quickly deteriorate into ventricular fibrillation. the PR interval?
5. Do all QRS Wide and bizarre (>0.12 sec)
complexes look alike?
What is the length of
the QRS complexes?

Causes and S/S of V-Tach Risk and Medical Tx of V-Tach

 Causes  Signs and Symptoms  Risk  Medical Treatment

 Usually occurs with  Chest discomfort  Major cause of sudden  If there is no pulse, begin
underlying heart disease (angina) cardiac death CPR and follow ACLS
 Commonly occurs with  Syncope
protocol
myocardial ischemia or  If there is a pulse and the
 Light-headedness or
infarction patient is unstable -
dizziness
 Certain medications may cardiovert and begin drug
 Palpitations therapy
prolong the QT interval
predisposing the patient  Shortness of breath  Amiodarone
to ventricular tachycardia  Absent or rapid pulse  Lidocaine
 Electrolyte imbalance  Loss of consciousness  With chronic or recurrent
 Digitalis toxicity  Hypotension VT
 Congestive heart failure  Give antiarrhythmics

Nursing Interventions for V-Tach Ventricular Fibrillation

 Assess your patient  V-Fib (coarse and fine)

 If symptomatic, treatment must be aggressive and immediate  Occurs as a result of multiple weak ectopic foci in the
 Pulse present ventricles
 Oxygen  No coordinated atrial or ventricular contraction
 Patent IV (preferably x2)  Electrical impulses initiated by multiple ventricular sites;
 Monitor patient very closely
impulses are not transmitted through normal conduction
pathway
 Pulseless
 Call Code Blue

 Begin CPR

 Defibrillate ASAP

 Start IV if not already established and hang NS

 • Notify MD

21
5 Steps to Identify Ventricular Causes and S/S of V-Fib
Fibrillation
1. What is the rate? Not discernible  Causes  Signs and Symptoms
 AMI  Loss of consciousness

2. What is the rhythm? Rapid, unorganized, not discernable  Untreated VT  Absent pulse

 Electrolyte imbalance
3. Is there a P wave No  Hypothermia
before each QRS?
 Myocardial ischemia
Are P waves upright
 Drug toxicity or
and uniform?
overdose
4. What is the length of None
 Trauma
the PR interval?
5. Do all QRS None
complexes look alike?
What is the length of
the QRS complexes?

Causes and S/S of V-Fib Risk and Medical Tx of V-Fib

 Causes  Signs and Symptoms  Risk  Medical treatment

 AMI  Loss of consciousness  Death  CPR with immediate

 Untreated VT  Absent pulse defibrillation

 Electrolyte imbalance  Initiate ACLS algorithm

 Hypothermia

 Myocardial ischemia

 Drug toxicity or

overdose
 Trauma

Nursing Interventions V-Fib Torsades de Pointes Rhythm

 Assess your patient  Torsades de pointes is associated with a prolonged QT

 Many things can mimic v-fib on a monitor strip such as interval. Torsades usually terminates spontaneously but
electric razor or shivering frequently recurs and may degenerate into ventricular
 You must check your patient!
fibrillation.
 Treatment must be aggressive and immediate  The hallmark of this rhythm is the upward and downward
deflection of the QRS complexes around the baseline. The
 Start CPR/ACLS
term Torsades de Pointes means “twisting about the points.”
 Call a Code Blue

 Defibrillate ASAP

 Start IV if not already established and hang NS

 Notify MD

22
5 Steps to Identify Torsades de Causes and S/S of Torsades de
Pointes Pointes
1. What is the rate? Ventricular: 150-250 bpm  Causes  Signs and Symptoms
 Is associated with  Chest pain

2. What is the rhythm? Regular or irregular prolonged QT interval  Loss of consciousness

 Is often caused by drugs
 Dizziness
3. Is there a P wave No conventionally
 Nausea
recommended in treating
before each QRS?
VT  Shortness of breath
Are P waves upright
 Phenothiazine or tricyclic
and uniform?
antidepressant overdose
4. What is the length of Not measurable
 Electrolyte disturbances,
the PR interval?
especially hypokalemia
5. Do all QRS Wide and bizarre, some deflecting and hypomagnesemia
complexes look alike? downward and
What is the length of some deflecting upward
the QRS complexes?

Risk and Medical Tx of Torsades de Nursing Interventions for Torsades de

Pointes Pointes
 Risk  Medical Treatment  Assess your patient
 Death  Begin CPR and other code  Make sure their aren’t any loose leads or leads that have
measures come off the patient
 Eliminate predisposing
 Start CPR
factors - rhythm has tendency
to recur unless precipitating  Call a Code Blue
factors are eliminated  Start IV if not already established and hang NS

 Administrate magnesium  Notify MD

sulfate bolus
 Must treat the cause – usually giving Magnesium
 Synchronized

cardioversion is indicated
when the patient in
unstable if possible or
defibrillate

Asystole 5 Steps to Identify Asystole

 Ventricular standstill 1. What is the rate? none

2. What is the rhythm? none

3. Is there a P wave none

before each QRS?
Are P waves upright
and uniform?
4. What is the length of none
the PR interval?
5. Do all QRS none
complexes look alike?
What is the length of
the QRS complexes?

23
Causes and S/S of Asystole Risk and Medical Tx of Asystole

 Causes  Signs and Symptoms  Risk  Medical Treatment

 Extensive myocardial  No palpable pulse  Death – if not yet dead  CPR

damage, secondary to  No measurable BP  ACLS protocol

acute myocardial  Loss of consciousness
infarction
 Failure of higher

pacemakers
 Cardiac tamponade

 Prolonged v-fib

 Pulmonary embolism

Nursing Interventions for Asystole

 Assess your patient

Module 7
 Make sure their aren’t any loose leads or leads that have CONDUCTION
come off the patient
 Treatment must be aggressive and immediate ABNORMALITIES
 Call a Code Blue

 Start CPR/ACLS

Atrioventricular Blocks First degree AV block

 Impulses in the SA node are blocked or delayed - heart blocks  Prolonged PR interval that results from a delay in the AV
 Underlying rhythm is sinus node’s conduction of sinus impulse to ventricles
 Rate normal or slow-symptomatic or asymptomatic  All parameters are normal except for prolonged PR interval
 Site of block is either AV node or bundle branches (hallmark of 1st degree)
 First dgree  Usually asymptomatic
 Second degree  Causes-AV node ischemia, digitalis toxicity, use of
 Type l-Mobitz l betablockers or calcium blockers
 Type ll- Mobitz 2  Treatment- treat cause
 Third degree

24
5 Steps to Identify First degree AV Second Degree Block Type I (Mobitz I
block or Wenckebach)
1. What is the rate? Depends on rate of underlying rhythm  Progressive prolongation of the impulse
 Cyclic pattern is produced: PR interval continues to increase
2. What is the rhythm? Regular in length until an impulse is not conducted (QRS dropped)
 Atrial rhythm is regular but ventricles ar irregular
 Cause - MI, digitalis toxicity, medication effects
3. Is there a P wave Normal (upright and uniform)
before each QRS?  Treatment - atropine if heart rate is slow & asymptomatic,
pacemaker.
Are P waves upright
and uniform?
4. What is the length of Prolonged (0.20 sec)
the PR interval?
5. Do all QRS Normal (0.06–0.10 sec)
complexes look alike?
What is the length of
the QRS complexes?

5 Steps to Identify Second Degree Block Second Degree Block-Mobitz ll

Type I (Mobitz I or Wenckebach)
1. What is the rate? Depends on rate of underlying rhythm  Increased risk of progression to 3rd degree
 Ratio of P waves to QRS complexes (2:1 block, 3:1 block or
4:1 block)
2. What is the rhythm? Irregular  PR interval is constant or regular for every conducted beat
 Intermittent absence of QRS
3. Is there a P wave Normal (upright and uniform)  Causes-same as type l
before each QRS?  Treatment-02, atropine if patient is symptomatic, epinephrine,
Are P waves upright dopamine, pacemaker if block continues and symptoms are
and uniform? present
4. What is the length of Progressively longer until one P wave
the PR interval? is blocked and a QRS is dropped
5. Do all QRS < 0.12 if at AV node
complexes look alike?
What is the length of > if block is at bundle branch
the QRS complexes?

5 Steps to Identify Second Degree Block Third Degree or Complete Heart

Type II (Mobitz II) Block (CHB)
1. What is the rate? Atrial rate (usually 60–100 bpm);  SA node sends out impulses as usual but not one is
faster than ventricular rate conducted to the ventricles
2. What is the rhythm? Atrial regular and ventricular irregular  Atria & ventricles beat independently of each other-AV
dissociation
 Cause-MI, lesion on conduction system, hypoxia, medication
3. Is there a P wave Normal (upright and uniform); more P side effects
before each QRS? waves than QRS complexes  Treatment-pacemaker insertion
Are P waves upright
and uniform?
4. What is the length of Normal or prolonged but constant
the PR interval?
5. Do all QRS Usually wide (0.10 sec)
complexes look alike?
What is the length of
the QRS complexes?

25
5 Steps to Identify Third Degree or
Complete Heart Block (CHB)
1. What is the rate? Atrial: 60–100 bpm; ventricular: 40–60

Thank
bpm if escape focus is junctional, 40 bpm
if escape focus is ventricular
2. What is the rhythm? Usually regular, but atria and ventricles act
independently
3. Is there a P wave Normal (upright and uniform); may be

You
before each QRS? Are superimposed on QRS complexes or T
P waves upright and waves
uniform?
4. What is the length of the Varies greatly
PR interval?
5. Do all QRS complexes Normal if ventricles are activated by
look alike? What is the junctional escape focus; wide if escape
length of the QRS focus is
complexes? ventricular

ACTIVITY Sample Strip

STRIP RACE
 MECHANICS:
 Rhythms strips will be flashed for a maximum of 1 minute

 A GROUP SHOULD RACE TO:

 Identify / recognize tracings using the 5 steps (1 POINT

EACH)
 Interpret the ECG tracing (5 POINTS)

 Points will be QUIZE Scores (Maximum of 20 Points) 1. Rate:  210 - 214 bpm
 A GROUP SHOULD RACE TO: 2. Rhythm  Regular
 STEAL 3. P Waves  None
 Opponent Groups can CHALLENGE answers 4. PR Interval  None
 If challenger is correct, challenger will earn points. 5. QRS  Wide (0.12 sec), bizarre
6. Interpretation  VT—monomorphic

Strip 1 Strip 2

1. Rate: 1. Rate:
 115 / 120 bpm  None
2. Rhythm 2. Rhythm
 Regular  None
3. P Waves 3. P Waves
 Normal  None
4. PR Interval 4. PR Interval
 0.12 sec  None
5. QRS 5. QRS
 QRS: 0.10 sec  None
6. Interpretation 6. Interpretation
 Sinus tachycardia  Asystole

26
Strip 3 Strip 4

1. Rate: 1. Rate:
 41 / 40 bpm  58 / 60 bpm
2. Rhythm 2. Rhythm
 Regular  Regular
3. P Waves 3. P Waves
 Normal  Normal
4. PR Interval 4. PR Interval
 0.20 sec  0.32 sec
5. QRS 5. QRS
 0.24 sec  0.08 sec
6. Interpretation 6. Interpretation
 Sinus bradycardia with a bundle branch  Sinus bradycardia with 1st-degree AV block
block

Strip 5 Strip 6

1. Rate: 1. Rate:  150 bpm

 Atrial 350 bpm, ventricular 88–115 bpm
2. Rhythm 2. Rhythm  regular
 Irregular
3. P Waves 3. P Waves  none
 None
4. PR Interval 4. PR Interval  none
 None
5. QRS 5. QRS  Wide and bizarre (>0.12 sec)
 0.12 sec
6. Interpretation 6. Interpretation  VT—monomorphic
 Atrial fibrillation

Strip 7 Strip 8

1. Rate: 1. Rate:  200–250 bpm

 Atrial 125 bpm,ventricular 44 bpm
2. Rhythm 2. Rhythm  Irregular
 Regular
3. P Waves 3. P Waves
 Normal  None
4. PR Interval 4. PR Interval
 0.16 sec  None
5. QRS 5. QRS  Wide (0.12 sec), bizarre
 0.10 sec
6. Interpretation 6. Interpretation
 2nd-degree AV block Type II with 3:1  VT—torsade de pointes
conduction

27
Strip 9 Strip 10

1. Rate: 1. Rate:
 50–75 bpm  Basic rate 68 bpm
2. Rhythm 2. Rhythm
 Irregular  Irregular
3. P Waves 3. P Waves
 Normal  Normal
4. PR Interval 4. PR Interval
 0.12–0.28 sec  0.16 sec
5. QRS 5. QRS
 0.08 sec  0.10 sec
6. Interpretation 6. Interpretation
 2nd-degree AV block Type I  Sinus rhythm with multiform PVCs— couplets

Strip 11 Strip 12

1. Rate: 1. Rate:
 Atrial 60 - 75 bpm, ventricular 48-50 bpm  Indeterminate
2. Rhythm 2. Rhythm
 Regular  Irregular
3. P Waves 3. P Waves
 Normal, superimposed on QRS and T waves  None
4. PR Interval 4. PR Interval
 Varies  None
5. QRS 5. QRS
 0.16 sec  None
6. Interpretation 6. Interpretation
 3rd-degree AV block  VF

Strip 13 Strip 14

1. Rate: 1. Rate:
 Atrial =350 bpm, ventricular 94–167 bpm  75 bpm
2. Rhythm 2. Rhythm
 Irregular  Regular
3. P Waves 3. P Waves
 None  Normal
4. PR Interval 4. PR Interval
 None  0.16 sec
5. QRS 5. QRS
 0.10 sec  0.08 sec
6. Interpretation 6. Interpretation
 A-fib  Normal sinus rhythm

28
Strip 15

Thank
1.

2.

3.

4.
Rate:
Rhythm
P Waves



250 bpm
Regular
None, Buried in T waves
You
PR Interval  Not measurable
5. QRS  0.08 sec
6. Interpretation  SVT

29