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BASIC ECG

BASIC ECG . N240 – Advanced Med-Surg K. Brooks, RN, MSN. Starting with the Basics …. What are the functions of the heart? Electrical: “impulse” Mechanical: “pump” “contraction” What is the normal blood flow through the heart?

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BASIC ECG

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  1. BASIC ECG N240 – Advanced Med-Surg K. Brooks, RN, MSN

  2. Starting with the Basics … • What are the functions of the heart? • Electrical: “impulse” • Mechanical: “pump” “contraction” • What is the normal blood flow through the heart? • What is the normal electrical pathway conduction? • Nodes (SA, AV, Bundle) • Inherent Rates

  3. Electrical Conduction Pathway SA Node – “pacemaker” of the heart (60-100bpm) AV Node – junction of the atria and ventricles (40-60bpm) Bundles – Bundle of His connects the AV node to the bundle branches (20-40bpm)

  4. Normal Cardiac Cycle

  5. “EKG” - Electrocardiogram An EKG is a useful tool for diagnosing a variety of cardiac abnormalities. It displays the activity of the heart’s electrical impulse flow through the conduction system. What does it tell us? • the electrical conduction through the heart • areas of ischemia or myocardial damage • LV Hypertrophy • electrolyte disturbances / drug toxicity

  6. ECG PAPER • EACH E.C.G PAPER DIVIDED TO SMALL SQ WITH LENGTH 1mm BOTH VERITICALLY AND HORIZONTALLY ,,,,,,,,,,,EVERY 5 SMALL SQ FORM ONE LARGE SQ ALSO HORIZONATLY AND VERTICALLY

  7. VERTICAL MEASURMANT VOLTAGE SMALL SQ=0.1MV ,,,,,,,,,,,LARGE SQ =0.5mv ANY ECG MACHINE STANDARDIZED IN SUCH MANNER THAT IMPUSLE OF MILLIVOLT WILL CAUSE A DEFLECTION OF 10 SMALL SQUARE OR 2 LARGE SQ . Or 1 mvolt THIS NORMAL VOLTAGE FOR ALL EVERY ECG WHAT CLINICAL APPLICATION FOR THAT

  8. HORIZONTAL MEASURMENT • 1mm = SMALL SQ = 0.04 SECOND AND 5mm= ONE LARGE SQ = O.20 SECOND THEN 1 SECOND = 5 LARGE SQ OR 25mm and 1 minute = 300 large square • What is benefit for that ???

  9. EKG Tracing ………. • Grid Paper • Each small box = 0.04 seconds • Each large box = 0.20 seconds (5 small boxes across) • One second is 5 large boxes • Three seconds is 15 large boxes • Six seconds is 30 large boxes • Each minute has 300 large boxes

  10. 300\R-R the heart regular • If the heart rate iirugular • Count R falling in 30 L sq XXX 10 • Or count R in 15 LS XXXX20

  11. Anther method • Every 5mm (L S )= 0.20 sec >>>>>>> 1 second = 25mm=2.5cm every 3second = 7.5cm every 6 second 15cm • By ruller count R in 15 cm XXXXby 10

  12. The Concept of a “Lead” By combining certain limb leads into a central terminal, which serves as the negative electrode, other leads could be formed to "fill in the gaps" in terms of the angles of directional recording. These leads required augmentation of voltage to be read and are thus labeled.

  13. What Is In Each Beat? (the cardiac cycle in waves, complexes, and intervals) • P Wave – atrial contraction or depolarization, (usually upright) • QRS Complex – time for ventricular contraction or depolarization (usually upright) (0.04 - 0.12sec) (delays in the bundle branches will widen the QRS) • T Wave – ventricular repolarization “recharging” (usually upright) • PR Interval – time between atrial depolarization to ventricular depolarization (beginning of P wave to beginning of QRS)(0.12 - 0.20sec) (prolonged PR = delays in the AV node conduction) • QT Interval – represents one complete ventricular depolarization and repolarization (beginning of QRS to the end of the T wave) (0.32 – 0.44sec) (disturbances are usually due to electrolyte disturbances or drug effects)

  14. Reading a Rhythm StripWhat Do I Look For? • Regularity - What is the R – R Interval? • Rate - Is the rate normal (60-100), slow, or fast? ***Six-second strip method - (30 big boxes) & multiply times ten • P Wave – Is there a P wave before every QRS? Is it upright? • QRS Complex – Is there a normal QRS complex following each P wave? Wide or normal? • T wave – How does your T wave look? Upright? • Measure your intervals – PR Interval, QRS, QT

  15. “Practice Strip”

  16. “Check Your Pulse”

  17. Match the Rhythm with the Pt • After assessing the EKG strip in a systematic method, gather the information about your pt’s assessment: med hx, s/sx, labs. • Does the rhythm make sense for the pt? • What is going on with the pt? 2nd level assessment

  18. The following should be considered when interpreting ECG • NEVER GIVE IMPRESSION ON SINGLE ECG PARTICULARLY IF THE RESULT NOT FIT WITH CLINICAL DATA

  19. What is Normal? “Normal” Sinus Rhythm The electrical impulse originates in the SA Node • Rhythm ► Regular (R to R Interval) • Rate ► Regular (60 – 100 beats/minute) • P wave ► before every QRS complex 4) QRS complex ► narrow, not wide (0.04-0.10sec)

  20. A Slight Deviation from “Normal”“too slow and too fast” Sinus Bradycardia 1st Level Assessment • Rate? (less than 60bpm) • Symptoms? (subjective and objective) 2nd Level Assessment • Reasons? Etiology? Nursing Interventions Pharmacology

  21. Sinus Tachycardia 1st Level Assessment • Rate? (> than 100) • Symptoms? (subjective and objective) 2nd Level Assessment • Reasons? Etiology? Nursing Interventions

  22. ECG ABNORMALITIES MAY BE SEEN IN NORMAL HEALTHY PERSON IN ABSENCE OF ORGANIC HEART DISEASE 1 – EARLY REPOLARIZATION 2- HIGH LV VOLTAGE 3-JUVENILE T WAVE 4-ATHLETIC T WAVE 5-INSIGNIFICANT Q WAVES IN AVL , 1 V5 AND V6 6-RIGHT AXIS DEVIATION 7-SHORT PR INTERVAL 8-FIRST DEGREE HEART BLOCK 9-RBBB

  23. ECG MAY NORMAL OR UNINTERPRETED IN PRESENCE OF ORGANIC HEART DISEASE IN FOLLOWING SITUATION 1-ACUTE MI ESPECIALLY EARLY PRESENTATION OR MASKED BY WPW ,LBBB AND PACE MAKER 2-PATIENT WITH SEVER CORONARY ARTERY DISEASE 3-WITH ACUTE PULMONARY EMBOLISM NORMAL ECG OR NON SPECIFIC 4- IN SOME CASE OF LV OR RV HYPERTROPHY 5-ECG MAY NORMAL IN BETWEEN ATTACK OF a-PAROXYSMAL AF b-PAROXYSMAL SVT

  24. SOME MEDICAL DISEASE MAY BE MANIFEST WITH ECG 1-CVA ( INTRACERBRAL Hage ) 2-DRUGS TOXISITY 3-ELECTROLYTE DISORDER 4-ENDOCRINE DISEASE

  25. TIFECT & ECG 1-LIMB REVERSAL 2-VOLTAGE CALIBRATION 3-INCORRECT PAPER SPEAD 4-EXTERNAL ELECTRICAL INTERFERENCE 5-PATIENT MOVEMENT ( VULONATARY OR BY DIEASE e.g. PARKINSONS

  26. P –WAVE • ABSENT( AF, SINUS NODE ARREST , HYPERK+) • INVERTED( LEAD MALPLACEMT,DEXTROCARDIA) • TO TALL (…..P PULMONALE ….) • TOO WIDE (…..P MITRALE….)

  27. PR INTERVAL SHORT 1-NORMAL VARIENT 2-L.G.L SY NDROME 3-WPW SYNDROME 4-AV- JUNCTION RHTYUM LONG 1- HEART BLOCK 2-DRUGS -VARY 1- SECOND DEGREE HB 4-DEPRESSED PERICARIDITIS ELEVATED ATRIAL INFARCTION

  28. QRS 1-ABNORMAL SHAPE BBB & FASCICLUR BLOCK 2-ABNORMAL DURATION AND SHAPE WPW , HYEPK+ ,VENTRICULAR RHYTHUM , PACE MAKE

  29. AMPILTUDE LOW IN HYPOTHRYRDISM , CALBIRATION PERICARIDAIL EFFUSION HIGH AMLITUDE CALBIRATION L.V.H AND RVH POST. MI

  30. Q- WAVES PHYSIOLOGICAL SMALL IN AVL , I, V5 AND V6 PATHOLOGICAL 25% OF R HIGHT

  31. ST DEPRESSION 1- ISHEMIA 2-POST MI 3-DRUGS 4-STRIAN PATTERN 5-RESIPROCAL CHANGES

  32. ST- ELEVATION 1-MI 2-PERICARIDITIS 3-ANUERYISM 4-EARLY REP 5-PRINZMATEAL ANGINA 6-METASTASIS MYCARDIUM

  33. T WAVES TO TALL HYPERKALMEAI MI TOOSMALL INVERTED …DISTURBANCE REPOLARIZTION ( ISHEMIA , INFLAMATION ,DRUGS ,HYPOXIA TOXINS))

  34. QT INTERVAL LONG 1-DRUGS 2-ISHEMIA 3- MI 4-HCMP 5-HYPOTHERMAI 6-CVA

  35. U- WAVES ?????? S S

  36. What is an Arrythmia anyways? • Definition: a disorder of impulse formation. An abnormal electrical conduction that changes the heart rate and rhythm. A disturbance in the heart’s rhythm. • Why? Causes? • Classified according to their origin • Some are mild, asymptomatic – require no treatment • Some are catastrophic – require immediate emergency response • They can influence cardiac output and blood pressure

  37. “Clinical Significance” • Thousands of people suffer with arrythmias • Dysrhythmias are responsible for over 44,000 deaths each year. • There site of origin can often lead us to the problem area • About 15% of strokes occur in patients with atrial arrythmias • A large majority of sudden cardiac deaths are thought to be caused by ventricular dysrhythmias.

  38. What is The Big Deal? Why are we so concerned with Arrythmias? SV x HR = CO • SV dependent on filling time, adequate volume, and myocardial muscle function • HR dependent on electrical stimulus, Autonomic NS, Parasympathetic NS • Too Fast • Too Slow NOT GOOD!!! • Too Irregular

  39. Some of you might be feeling a bit overwhelmed at this time ….

  40. Atrial Arrythmias • Atrial arrythmias occur because there are other pacemakers in the atria competing to be the “commander” • SA Node is not healthy and unable to lead

  41. Atrial Fibrillation Results from disorganization of atrial electrical activity without effective atrial contraction. Repetitive, irregular, uncontrolled depolarization. Atrial rate ~ 350-600 bpm, Ventricle - varies • No P Wave! Very “jiggly” baseline wave • No PR Interval • Irregular with a wavy baseline • Rate - Controlled vs. Uncontrolled • Loss of “Atrial Kick” • Emboli Potential

  42. Atrial Fibrillation • 1st Level Assessment • 2nd Level Assessment • Nursing Consideration • Pharmacologic Consideration • Digoxin • Ca+ Channel Blockers • Beta Blockers • Coumadin

  43. On Your Own …. You are responsible for reviewing pharmacology re: arrhythmias: • Please know the actions, doses, side effects, nursing considerations, monitoring, precautions, therapeutic drug levels, s/sx toxicity for the following drugs: • Digoxin • Ca+ Channel Blockers (verapamil, diltiazem) • Beta Blockers (atenolol, metoprolol) • Anticoagulants (warfarin)

  44. Atrial Flutter Results from the atria stimulated to contract 250-350 bpm in a circuit fashion around the atrium • No true P waves – F waves larger than P waves (flutter waves) • Sawtooth-shaped waves • Usually a regular rhythm D/T AV Node filter • Ventricular Rate – atria to ventricle ratio (2:1 or 4:1) Assessment and treatment the same as Atrial Fib

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