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Adult Health Nursing II Block 7.0

Adult Health Nursing II Block 7.0. Topic: Cardiovascular Nursing & EKG Monitoring , part 2 Module: 2.3. Cardiovascular--- EKG’s / Cardiac Monitoring. Dynamic Presentation . Static Presentation. Lead II. Part II. Digitalis pupurea (Foxglove).

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Adult Health Nursing II Block 7.0

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  1. Adult Health Nursing II Block 7.0 Topic: Cardiovascular Nursing & EKG Monitoring , part 2 Module: 2.3

  2. Cardiovascular--- EKG’s / Cardiac Monitoring Dynamic Presentation Static Presentation Lead II Part II Block 7.0 Module 2.3 Digitalis pupurea (Foxglove)

  3. At the conclusion of this class (and after some practice) the nurse will be able to: State the four characteristics of cardiac muscle, and relate these characteristics to cardiac output. 2. Trace the flow of blood through the heart & lungs, naming all associated structures Trace electrical conduction through the cardiac conduction system and correlate to the EKG Tracing. State the intrinsic rates of SA node, atria, AV node, and Ventricles 5. Identify waveforms, landmarks on the EKG tracing: P, QRS, T, U, baseline 6. Identify and measure P-R Interval (PRI), QRS duration, ST Segment 7. Using an EKG tracing, Calculate heart rate and rhythm 8. Using data from EKG analysis, determine name of cardiac rhythm 9. Based upon identified cardiac rhythm, correlate & determine rhythm’s effect on cardiac output. 10. Identify NSR, SB, ST, SVT, A-fib, A-flut, 1st-2nd-3rd degree AV Blocks, PVC’s, PAC’s, V-Tach, V-Fib, Toursades, Asystole, PEA 11. Identify nursing actions related to cardiac monitor readings and care of the cardiac patient. 12. Be familiar with the following medications and their effect on the cardiac output: Alpha Blockers, Beta Blockers, Ca Channel Blockers, Atropine, Lidocaine, amiodarone, epinephrine, digoxin Block 7.0 Module 2.3

  4. 13. Nursing care of the cardiac patient, including considerations related to all aspects of physical assessment, including cardiac monitoring, activities of daily living, diet, and medications. Block 7.0 Module 2.3

  5. Concept Map: Selected Topics in Cardiovascular Nursing ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation Cardiac Monitoring Lab Monitoring PHARMACOLOGY Cardiac Glycosides ACE Inhibitors Alpha Blockers Beta Blockers Antiarrhythmics Catecholamines Anticoagulants PATHOPHYSIOLOGY Myocardial Infarction Acute Coronary Syndrome Valvular Heart Disease Pacemakers CABG Abdominal Aortic Aneurysm Pericarditis Peripheral Vasc Disease (PVD) Fem-Pop Bypass Graft Shock / Fluid Deficit Raynaud’s Phenomenon Arrhythmias / Dysrhythmias Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more… Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary Block 7.0 Module 2.3

  6. REMEMBER: At the ‘end of the day,’ IT’S ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R Cardiac Output! * * Tissue perfusion of vital organs…and everything else…. Block 7.0 Module 2.3

  7. An Affirmation “It’s all about cardiac output. Boy, don’t I know it now.” Block 7.0 Module 2.3

  8. What Factors Affect Cardiac Output ? It’s All About… Cardiac Output Medications Sympathetic Nervous System Medications Baroreceptors Cardiac Output = HR X SV Blood Volume Chemoreceptors Preload, Afterload C.O. = Heart Rate x Stroke Volume Condition Of Myocardium And, Many more factors ! It’s All About CardiacOutput ! Condition of Cardiac Conduction System* Viscosity Of Blood Condition of Heart Valves Parasympathetic Nervous System Blood Volume Block 7.0 Module 2.3

  9. Example of Multiple Factors in Cardiac Output Chemoreceptors Baroreceptors The SinoAtrial Node: 60-100 impulses / minute Sympathetic Effects: Parasympathetic Effects: Block 7.0 Module 2.3

  10. Recall / Quiz : • 1. Distinguishing Characteristics of Cardiac Muscle: C________, C________, A__________, R___________. • 2. Intrinsic ‘Rates’ if Cardiac Tissue: • SA Node =____; (Atrial Muscle=_____) AV Node=_____; Ventricular Muscle =_____. • 3. Conduction Pathways in the Heart: ____>_____+_____>_____>_____>______>_________ • 4. “Interval Times,” i.e., how long it takes these impulses to reach certain points within the conduction pathway: • P-R Interval=_____ QRS=_____ • 5. FORMULA FOR CARDIAC OUTPUT:____________ • 6. FORMULA FOR BP:_________________ • 7. “IT’S ALL ABOUT:_________ ________” Block 7.0 Module 2.3

  11. R & L Common Carotid Arteries Left Subclavian Artery Superior Vena Cava Lungs Lungs LUNGS Block 7.0 Module 2.3

  12. Cardiac Conduction Pathways • SA Node >> • Inter nodal & Intra atrial pathways (Bachmann’s Bundle)>> • AV Node >> • Bundle of His >> • Right & Left Bundle Branches >> • Purkinje Fibers Block 7.0 Module 2.3

  13. Intrinsic Rates… “automaticity” Sino Atrial Node (SA Node) 60-100 ipm Atrial Muscle ~ 60 ipm Atrio-Venticular Node (AV Node) 40 – 60 ipm “Rate & Rhythm” Ventricular Muscle 20-40 ipm Block 7.0 Module 2.3

  14. “Automaticity” • Intrinsic rates • SA Node = • 60 – 100 i.p.m. • Atrial Muscle = • 60 i.p.m. • AV Node = • 40 – 60 i.p.m. • Ventricular Muscle = • 20 -40 i.p.m. Block 7.0 Module 2.3

  15. Conduction Pathways and rough correlation to the ECG Waveform SA Node Internodal & Intra-atrial Pathways AV Node Bundle ofHis (R) & (L) BundleBranches Purkinje Fibers QRS : < 0.12 seconds T Wave Baseline Block 7.0 Module 2.3 PRI: 0.12-0.20 seconds

  16. Block 7.0 Module 2.3

  17. Causes Of Dysrhythmias / Arrhythmias • 1. Drugs (Medications & Others) Digoxin, quinidine, caffeine, nicotine, alcohol, cocaine..others…. • 2. Acid-Base & Electrolyte Imbalances: K+, Ca++, Mg+ • 3. Marked Thermal Changes • 4. Disease & Trauma (Including Surgery) • 5. Stress Block 7.0 Module 2.3

  18. Block 7.0 Module 2.3

  19. POTENTIALLY LETHAL Rhythm IdentificationEach Has Specific Criteria… • Normal Sinus Rhythm (NSR) • Sinus Rhythm • Sinus Bradycardia • Sinus Tachycardia • Sinus Arrhythmia • Atrial Flutter • Atrial Fibrillation • Junctional Rhythms • Supraventricular Tachycardia (SVT & PAT) • Heart Blocks: 1st, 2nd, 3rd • Ventricular Tachycardia • Toursades de Pointes • Ventricular Fibrillation • Asystole • Pulseless Electrical Activity (PEA) • “Paced Rhythms” • Individual Ectopics: • Premature Atrial Contractions • Premature Junctional Contractions • Premature Ventricular Contractions • Artifact Terminology:Bradyarrhythmias versus tachyarrhythmias Wide-complex tachycardia versus narrow-complex tachycardia Block 7.0 Module 2.3

  20. REMEMBER: At the ‘end of the day,’ IT’S ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R Cardiac Output! * * Tissue perfusion of vital organs…and everything else…. Block 7.0 Module 2.3

  21. An Important Caveat / Caution…. • Cardiac Monitoring is a powerful diagnostic and patient care tool (only) • Correlate the monitor reading to the patient’s condition ! • Check / Assess your patient for cardiac output! • The terms “EKG” and “ECG” ARE INTERCHANGEABLE Block 7.0 Module 2.3

  22. The “Stepwise” Method Block 7.0 Module 2.3

  23. EKG PAPER Block 7.0 Module 2.3

  24. EKG PAPER Small Block = 0.04 sec 5 Small Blocks = 1 Large Block = 0.20 sec 5 Large Blocks = 1 second TIME Note:Standard EKG Machines “run” at 25 mm/sec “Amplitude” Or Strength of Electrical Impulse Block 7.0 Module 2.3

  25. “Standard” Limb Leads Lead II “universal”-- Most useful Block 7.0 Module 2.3

  26. “ Chest Leads “ (for 12-Lead ECG) Block 7.0 Module 2.3

  27. The ECG Complex, Wave forms, Intervals, Segments Block 7.0 Module 2.3

  28. P Waves • Signal from the Sino Atrial Node (SA Node) • “Normal Pacemaker of the heart” • Should be upright ( Lead II ) • Should all look ~ alike • Should have 1:1 ratio with QRS Complexes • Rhythms generated by this called “Sinus”, e.g., • Sinus Rhythm, • Normal Sinus Rhythm, • Sinus Bradycardia, • Sinus Tachycardia, • Sinus Arrhythmia Block 7.0 Module 2.3

  29. P-R Interval (PRI) • Measure from beginning of P Wave to first deflection (up or down) from baseline to start QRS Complex • Time it takes for impulse to go from SA Node to ventricles • Normal time = 0.12 to 0.2 seconds ( 3-5 little blocks…) • (3 x 0.04= 0.12… 5 x 0.04= 0.20) • Less than 0.12 sec PRI may indicate AV Node--“junctional” problem • Greater than 0.20 sec indicates AV Block (1st – 2nd- 3rd degree) • PRI’s should all be ~ equal Block 7.0 Module 2.3

  30. QRS Complex General Overview: Are they narrow or wide? Electrical conduction through the ventricles Ventricular Function ~ = Cardiac Output Appearance is generally consistent with ventricular function Normal = < 0.12 seconds “3 little boxes” (3 x 0.04 = 0.12 sec) QRS should all be ~ same form / shape If greater than 0.12 seconds, indicates “trouble,” i.e., a conduction delay in the ventricles Block 7.0 Module 2.3

  31. S T Segment ? • Time from ventricular depolarization to ventricular repolarization • Frequently “speaks” of trouble within the ventricles • Elevated or depressed ST segment may indicate previous or ongoing ischemia or damage to ventricular myocardium • General rule of thumb: • ST Depression ↓ = Ischemia • ST Elevation ↑ = Infarction Block 7.0 Module 2.3

  32. Block 7.0 Module 2.3

  33. T Waves • Represent repolarization of Ventricles, i.e., “preparing to beat again” • Should be upright (lead II) • Should appear ~ same • “Flipped or inverted T waves” may be sign of prior or ongoing ventricular damage • Prolonged QT Interval may represent problems with ventricular repolarization— due to damage or medication effect Block 7.0 Module 2.3

  34. “U” WAVES • Potassium Effect • HYPOKALEMIA • Fairly Rare…. P QRS T U P QRS T U P QRS T U P QRS T U TALL “TENT-LIKE” T Waves Caused by: K+ Hyperkalemia Either One, if not corrected, Means that ventricular tachycardia, And / or ventricular fibrillation IS on the way! Block 7.0 Module 2.3

  35. Block 7.0 Module 2.3

  36. Overview— Develop Your Method Practice IT & Follow IT ! Repetition—Repetition--Repetition • 1. General Overview of strip • 2. Rate • 3. Rhythm • 4. P Waves • 5. P-R Interval (PRI) • 6. QRS Interval • 7. Q-T Interval Apply findings and observations to CRITERIA Block 7.0 Module 2.3

  37. REMEMBER: At the ‘end of the day,’ IT’S ALL ABOUT C.O. = H R & R x S V B.P. = C.O. X P V R S V R Cardiac Output! * * Tissue perfusion of vital organs…and everything else…. Block 7.0 Module 2.3

  38. Measuring Time and Events… P P Baseline or Isoelectric line Block 7.0 Module 2.3

  39. Three Methods for rate determination… 120 start 300 150 100 60 Easy Way: 12 x 10 (almost 11)= 120’s Accurate if the rhythm is REGULAR 75 Memorize…. OR divide 300 By # of Big Boxes Between QRS complexes…or divide 60 by # seconds between qrs’s Block 7.0 Module 2.3

  40. Discussion …Measuring PRI & QRS Block 7.0 Module 2.3

  41. Rates…Intervals…Remember the “normals”: • PRI= 0.12 – 0.20 seconds • (SA Node to Ventricles) • QRS = < 0.12 seconds • Time Through the Ventricles Block 7.0 Module 2.3

  42. End of Cardiovascular Disease AH II Part 2We Will Continue in a moment • But first…….. • …..a word from our sponsors……. Block 7.0 Module 2.3

  43. Power Point XL®(slidepidemHCl)Doses of 50, 100, or 150 slides • Indications: Powerful relief from NSRI* • (Nursing School Related Insomnia) • Power Point XL® is indicated for the treatment of chronic insomnia related to nursing school stress. • With a starting dose of 50 slides per hour, P-P XL® is proven effective at hastening the onset of sleep in over 85% of nursing students. • When combined with extremely boring material, the effect is even more pronounced* Warning: use cautiously with students with preexisting sleep apnea. • “P-P XL® helped me get my get my recommended 8 hours of sleep every day! Four hours at home, 1 hour in Pharmacology, two hours in Pedi, and 2 hours in Adult Health I ! I’ve never felt so refreshed! Wait—that adds up to eight, doesn’t it?” • --Samantha Jones, Fictitious Nursing Student ~END OF PRESENTATION~ GO TO THE NEXT PRESENTATION, Module 2.4 Block 7.0 Module 2.3

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