Cardiac Arrhythmias (2).pdf for nursing student

arythmia

1. Under supervision of
Assist Prof Dr / Shreen abdalmonaem
Prepared By
Ahmed Gamal Fahmy
Wifaq Ali

2. Regionsof
theHeart
Sinus
Atrial
Junctional
Ventricular
▪CardiacRhythm&Dysrhythmias
▪AnatomyandPhysiologyoftheHeart
▪WhatisanEKG?
▪StagesoftheHeartBeat &Howwemeasurethem
▪StepstoInterpretRhythms
▪Sinus
▪Atrial
▪Junctional
▪Ventricular
▪HeartBlocks
▪Pacemakers
▪12L-ECG

3. ▪CardiacRhythm&Dysrhythmias
Objectives:
•CorrelatethecomponentsofthenormalECGwithphysiologicevents
oftheheart.
•DefinetheECGasa waveformthatrepresentsthecardiacelectrical
eventinrelationtothe leaddepicted(placementof electrodes).
•AnalyzeelementsofanECGrhythmstrip:ventricularandatrial rate,
ventricularandatrialrhythm,QRScomplexandshape,QRSduration,P
waveandshape,PRinterval,andPQRSratio.
•IdentifytheECGcriteria,causes,andmanagementofseveral
dysrhythmias,includingconductiondisturbances.
•Usethenursingprocessasaframeworkforcareofpatientswith
dysrhythmias.

4. FourChamberoftheHeartand
the Heartbeat
The Left side
Sendsoxygen
Richblood
through the
Aortato
Thebody
Thecombinationof the1
st
and2
nd
part
of the heartbeat Creates the Lub-Dub,
the first and second sounds of the
heartbeat
Oxygen-rich blood
fromlungsfills
leftatrium
The Right
Ventricle
Sendsblood
through the
Pulmonary
Artery
TotheLungsto
pickupOxygen
RightAtrium
Oxygen-poor
bloodfromthe
body fills right
atrium
RightVentricle
LeftAtrium
LeftVentricle

5. Whatmakestheheartpump?
NaturalElectricImpulses
Whichstimulateheartmuscletocontract
•Theheartismadeprimarilyofmuscle
•Whenthemusclecontracts,itsqueezesthebloodthroughtheheart
andouttothelungsortothebody
•Pacemakers:Thehearthasnaturalpower
generatorsthattellthehearttopump.
Theprimary pacemakeristheSANode
Located inthetop oftheRightAtrium
The AV node is located in the junction
OfbothAtriaandboth Ventricles

6. Thisishowthenormalpathwayforelectricitytotravelthroughtheheart
SAnode
AVnode
BundleofHis
•Leftbundlebranch
•Rightbundlebranch
=
Myocardiumcontracts
Whenwelose power!
SANode(inherentrateof60–100)
Atrial foci(inherentrateof60–80)
Junctionalfoci(inherentrateof40–60)
Ventricularfoci(inherentrateof20–40)
•Myocardium-oneofthreelayersoftheheart.Musclecellswhich makeup
thebulkoftheheart.Theyareabletogenerateor passonelectricity.
•Electricitythatoriginatedatthepacemakercells,nowwavesacrossthe
musclecells,causingthemtocontractwhichpumpsthebloodthroughthe
heart.

7. WhatIsAnEKG/ECG?
•Thiscommonnoninvasivediagnostic
testrecordstheelectricalactivityof
theheartandisusefulfordetecting
cardiacdysrhythmias,locationand
extentofMI,andcardiac
hypertrophyandforevaluationof
theeffectivenessofcardiac
medications.
•AnECGmachinerecordsthese
electricalsignalsacrossmultiple
heartbeatsandproducesanECG
stripthatisinterpretedbya
healthcareprofessional.

8. TheElectricalBasisoftheEKG/ECG
•Electricalimpulsesarepresentontheskinsurfaceatavery
lowvoltage;TheEKGmachinepicksuptheseimpulsesand
amplifiesthem.
•ElectricalactivityissensedbyElectrodesareplacedonthe
skinsurfacetopickuptheseimpulsesandgiveusa pictureof
howtheyaretravelingintheformofanElectrocardiogram.
ThisisprintedonEKGpaperandiscalleda Rhythmstripor an
EKGstrip
Interventions:
•Determinetheclient’sabilitytoliestill;advisetheclienttoliestill,
breathenormally,andrefrainfromtalkingduringthetest.
•Reassuretheclientthat anelectrical shockwillnotoccur.
•Documentanycardiacmedicationstheclientistaking.

9. ElectrocardiogramLeads
•Electrode
•Anadhesivepadthatcontains
conductivegeland attachestopatient’s
skin
•Leads
•The leadwiresconnecttheelectrodesto
thecardiacmonitor
QRS
StagesoftheHeartbeat:
P
wave
T
wave
Atria
contract
Ventricles
relax
Ventricles
contract
PWave,QRS&TWavemake uponecompleteCARDIAC CYCLE

10. Duration(Time)
MeasuredinSeconds
As the paper prints out……
wearemeasuringtime…….

11. •EKGpaperisdividedintosmall
squares andlargersquares
•Large squares are defined by a
darkline.They are 5 squares
high and 5 squares long (0.20
seconds)
•Small squares may be lines or
maybedotswithinthedarklines.
Theyare0.04seconds

12. LookformarksbelowEKGgrid
Everymarkis3seconds
(2marks=6seconds)
Countthe#ofbeatsby10’s(10-20-30-40…)
Ona6secondstrip
HRforexampleabove=80bpm

13. SinusRhythmandAtrialRhythm
PR=.12-.20
JunctionalRhythm
PR<.12
VentricularRhythm
WideQRS

14. P
Q
R
S
T
PRInterval
QRSInterval
QTinterval
May be done In ICU’s and if
patient is on certain
medications(i.e.Tikosyn)
•Heartrate
•PRinterval
•QRSinterval
•QTInterval
Aneasy methodto measurethe different waveformsis a ruler (If you do not have one,seeyour
clinicaleducator).Othermethodsincludeusingcalipers,memorizing charts,usingtablesor
evenascrappieceofpaper.

15. Article
•EKGwaveformsfromsourcesoutsidetheheart
•Interferenceseenona monitoror EKGstrip
•4causes
•Patientmovement(i.e.pt.withtremors)
•Loose ordefectiveelectrodes(fuzzybaseline)
•Impropergrounding(60cycleinterference)
•FaultyEKGapparatus
When two cars are traveling a distance at the same miles per hour, the one with the
shorterdistancewillarriveattheirdestinationfirst.Likewise,ittakesacertainamount
of time forelectricitytotraveltoadestinationintheheart.By measuring these
distances and how long it takes to travel, we get a picture of what is going on in the
heart.

16. 1.Arethebeatsatregularorirregularintervalsapart?
2.Doyousee P,QRS,Tpattern?
3.WhatistheHEARTRATE?
4.Whatis thePRINTERVAL?
5.Whatis theQRSINTERVAL?
NormalValues
Heart Rate:
PRInterval:
60-100beatsperminute
.12-.20seconds
QRSInterval:<.11seconds

17. DeterminationofHeartRateUsing6-SecondStripMethod
•Themethodcanbe usedtodetermineheartrateforregularand
irregularrhythms.
•Todetermineatrialrate,countthenumberof Pwavesin6seconds
andmultiplyby10toobtaina fullminuterate.
•Todetermineventricularrate,countthenumberof Rwavesor QRS
complexesin6secondsandmultiplyby10toobtainafullminute
rate.
•Foraccuracy,timingshouldbeginonthePwaveortheQRScomplex
andendexactlyat 30largeblockslater.

18. Theyarenamedforthestructureoftheheartwherethefoci (acell
sendingoffanelectricalimpulse)islocatedthatisproducingthe
abnormalrhythm
❑Sinus(Sinusnode)
❑Atrial(anycellintheatria)
❑Junctional(Areabetweentheatria&
ventricles)
❑Ventricular(anycellintheventricles)
❑AVBlocks(AVnodeblockingsomeor
allofthepassageofelectricitythrough
it)
RegionsoftheHeart

19. •Ratenormal60-100
•PRnormal.12-.20
•QRSnormal<.11
•Rhythmoriginatesfromthe sinoatrialnode.
•Atrialandventricularrhythmsareregular.
•TheSAnodehasgeneratedanimpulsethatfollowedthenormalpathway
oftheelectricalconductionsystem
•Segments(theflatpartsoftheisoelectricline)areelectricallyquiet
•PRintervalandQRSwidtharewithinnormallimits.

20. Interventions:
1.Thetreatmentisdirectedtowardeliminationofthecause,ratherthanthe
dysrhythmia.
2.Urgencyisdependentontheeffectofrapidheartrateoncoronaryartery
fillingtimetopreventcardiacischemia.
•Atrialandventricularratesare100to180beats/minute.
•Atrialandventricularrhythmsareregular.
•PRintervalandQRSwidtharewithinnormallimits.

21. SinusBradycardia(SB)
Intervention:
1.Theurgencyoftreatmentdependsontheeffectoftheslowrateon
maintenanceof CardiacOutput(CO)
2.Atropine0.5to1.0mg IVpushblocksvagalstimulationtotheSANodeand
thereforeacceleratesheartrate.
3.Ifthebradycardiapersists,apacemakermayberequired.
•Atrialandventricularrhythmsareregular.
•Atrialandventricularratesarelessthan60beats/minute.
•PRintervalandQRSwidtharewithinnormallimits.
•Treatmentmaybenecessaryifthe clientissymptomatic(signsof
decreasedcardiacoutput).
•Notethatalowheartratemaybenormalforsomeindividuals.

22. •Normal exceptirregular
•Thedifferencebetweenthefastesttwoheartbeats(from1QRStothe
nextQRS)andtheslowesttwoheartbeatsisgreaterthan.12sec
Intervention:
1.Documentdysrhythmia
2.Evaluateneurologicalstatus
3.Treatmentisnotusuallyrequiredunlesssymptomaticbradycardiais
present

23. •Periodofnoelectricalactivity,thenelectricalactivityresumes
•Thismayoccurinindividualswithhealthyhearts.Itmayalsooccur
withincreasedvagaltone,myocarditis,MI,anddigitalistoxicity.
•Ifthepauseis prolonged
Intervention:
•Thetreatmentof thisdysrhythmiadependsontheunderlying
cause.
➢If thecauseisduetoincreasedvagaltoneandthepatientis
symptomatic,atropinemaybegiven.

24. Normalrhythm,but…NoPulse*
Electricalactivityispresentbutthereisnopulse,sotheheartisnot
beating!Somethinghashappenedtopreventthe musculartissuefrom
respondingtothe electrical activity
(i.e.↓↑K+,hypothermia,Pneumothorax,cardiactamponade,hypovolemia,
drugoverdose,pulmonaryor coronarythrombosis)
CodeBLUE!
Intervention:
•CardiacResuscitation(ACLS/BLS)tomaintaincardiacoutput.
•DrugTherapy–Epinephrine1mgevery3-5minutes
•SodiumBicarbonate1mEqper kilogram

25. •Noelectricalactivity
•Asystoleoccursmostcommonlyfollowingtheterminationofatrial,AV
junctionalorventriculartachycardia.Thispauseisusuallyinsignificant.
•Asystole of longer duration in the presence of acute Myocardial
Infarction (MI)andCoronaryArteryDisease(CAD)isfrequentlyfatal.
CodeBlue
Intervention:
•CardioPulmonaryResuscitation
•Artificialpacing
•Atropine

26. AtrialRhythmsReview
•AtrialFlutter
•AtrialFibrillation
•ParoxysmalAtrialTachycardia

27. AtrialFlutter
Cancountthe#of flutterwaves(Pwaves)
•Atrialectopicpacerfiresat arateof200-400beatperminute
•Occurs in a variety of heart diseases-rheumatic, coronary,
hypertensive,alsocardiomyopathy,hypoxia,heart failure,
•May beasymptomaticorhavepalpitations
Intervention:
•DigoxinandQuinidinepreparationsmaybeused.
•Beta-adrenergicblockers(Esmolol)mayalsobeused.
•Calciumchannelblockers,(Diltiazem)maybeusedtoslowAVnodal
conduction
•Mayusecardioversion.(Smalldosesofelectricalcurrentareusually
successful

28. AtrialFibrillation(A-fib)
•Multiplerapidimpulsesfrommanyfocidepolarizeintheatriainatotally
disorganizedmanneratarateof 350to600times/minute.
•Theatriaquiver,whichcanleadtotheformationof thrombi.
•UsuallynodefinitivePwavecanbeobserved,onlyfibrillatorywavesbefore
each QRS.
Interventions:
•Administeroxygen.
•Administeranticoagulantsas prescribedbecauseof theriskof emboli.
•Administercardiacmedicationsasprescribedtocontroltheventricular
rhythmandassistinthe maintenanceof cardiacoutput.
•Preparethe clientforcardioversionas prescribed.
•Instructtheclientintheuseofmedicationsasprescribedtocontrolthe
dysrhythmia.

29. •Suddenratechange>150bpm
•TherateisoftensorapidthatP-wavearenotobviousbutmaybe
“buried”intheprecedingT-wave.
•PATmayoccurinthenormalas wellas diseasedheart.
➢It isacommoncomplicationofWolfe-Parkinson-Whitesyndrome.
Interventions:
•Treatmentisdirectedfirsttoslowingtherateandsecondtorevertingthe
dysrhythmiatoanormalsinusrhythm.
•Reducingtheratemaybeaccomplishedbyhavingthepatientperforma
ValsalvaManeuver.
•AdenosineisachoiceforPATassociatedwithhypotension
•Beta-adrenergicblockersandCalciumchannelblockers
•Cardioversioncanbeusedifdrugtherapyisineffective.

30. •Suddenratechange>150 bpm
•It can also occur with a condition known as Wolf-Parkinson-White
syndrome,whichmost oftenseeninyoungpeopleand infants
•Asensationof feeling theheartbeatoftenwithanirregularorfast
rate.
CannotdistinguishaPwaveaftertheHRgetsfast
Interventions:
•Controllingtherateandpreventinghemodynamiccollapse
•VagalManeuvers
•Cardioversionifpatientisunstableorhypotensive.
•Adenosine,CalciumChannelBlockerorBeta-blockers

31. 3Beats=
1VentricularBeat=PrematureVentricularContraction(PVC)
2Beats=Couplet
Triplet
Everysecondbeatisventricular=
Bigeminy Every
thirdbeat= Trigeminy
Morethan3beatsatfastrate=VentricularTachycardia(V-Tach)
Ventricularbeatsatslowrate=Idioventricular
Ventricularbeatstwistingtall-short-tall=Torsades
NoQRS,justshaking=VFib

32. –If it arises from the Ventricular area, it will be a QRS which is wide and
bizarreshaped.
–Increasefromthepatient’snormal amount
–MultiplePVCsinarow
–PVCfallsontheTwaveofpreviousbeat
–Multifocal(theyarise fromdifferentcells,thereforetheyaredifferent
shapes)
–6or > /min, couplets, R onT,or Multifocalare no longerconsideredtobe
a warningorprecursortothedevelopmentofventriculartachycardia
MultifocalPVCs
Awide bizarreQRS

33. InterventionofPVCs
•PVCsisprecursorsofmoreseriousventriculardysrhythmias.
•Administeroxygenasprescribed.
•ThestandardtreatmentofPVCsiswithlidocainebyI.V.Push
•Be alert tothedevelopmentof confusion,slurringof speechand
diminishedmentation,becauselidocainetoxicityaffectsthecentral
nervoussystem.
•Lidocainemustbeusedwithextremecautioninpatientswithliver
diseaseandinelderlypatients.
•AtropineshouldbeusedwithcautionintheAcuteM.I.
•Anti-arrhythmicmedications–Beta-blockers,calciumchannel
blockers
•ElectrolytesReplacement–MagnesiumsupplementsandPotassium
Supplements
•Radiofrequencycatheterablationtreatment
•Lifestylemodification

34. •4ormoreventricularbeatsin a row
•Rateof140to250beats/minuteormore
•CodeBLUE!
•Ventriculartachycardiaalmostalwaysoccursindiseased
hearts.
•Patientsareoftensymptomaticwiththisdysrhythmia.
Ifyoustepon
A Tack, you will
Getoff ofitfast!
6beatsofV-Tach
Interventions:
•CardiopulmonaryResuscitation(CPR)
•DefibrillateorCardioversionifPatientstaysinV-Tach&needsourhelpto
switch.
•Somepharmacologicalinterventionsincludelidocaine,pronestyl,and
bretylium.

35. •Squigglyline
•Code BLUE!
•Thisdysrhythmiaresultsintheabsenceofcardiacoutput.
•Almostalwaysoccurswithseriousheartdisease,especiallyacuteMI.
Intervention:
•CardiopulmonaryResuscitation(CPR)andACLSProtocol.
•Administeroxygenasprescribed.
•DefibrillateorCardioversionifPatientstaysinV-Tach&needsourhelpto
switch120to200joules(biphasic)or 360joulesmonophasic)
•VasoactiveandAnti-arrhythmicMedications

36. HeartBlocks

37. What’stheDifferenceBetweenHeart
& Block?
Electricityblockedfromtraveling
normally=dysrhythmia
Blockage
Cloggedbloodvessels=decreasein
oxygentotheheart=heartattack
Plumbing!
Electricity!

38. BundleBranchBlocks(BBB)
It takeslongerforelectricitytotravelaroundthe
blockadetocontracttheventricles.
Thisshowsasa wideQRS≥.12
•Leftbundlebranchblockismore
ominousthanright bundlebranchblock
becauseitusuallyispresentindiseased
hearts.
•Bothmaybecausedbyhypertension,
MI,or cardiomyopathy.
•Abifasicularblockmayprogresstothird
degree heartblock.
Intervention:
•Cardioresynchronization
•ArtificialpacingforabifasicularblockthatisassociatedwithanacuteMI.

39. AtrialVentricularHeartBlocks
TheAVNodeacts asthegatekeeperforthe ventricles,holdingtheelectrical
impulseabriefintervaltomakesuretheAtriahavefinishedcontracting
thusexpellingallthebloodintotheventriclesbeforeallowingthe
ventriclestocontract.
•Electricity contracts atria first,
thentravelsdowntocontract
theventricles.
•If the electricity is blocked
betweentheatria&ventricles,
thetraveltime(PR)is
abnormal.
•Hence,AVblockshavean
abnormal PRinterval.

40. •PRinterval>.20
•Thisisthemostcommonconductiondisturbance.
•Itoccursinbothhealthyanddiseasedhearts.
A V//
ExamplePRintervals:.28-.28-.28-.28-.28-.28
Interventions:
•Treatingtheunderlyingcausebymedicationthatcanmodifiedor
withheld.(Beta-Blockers,CalciumChannelBlockers, Digitalis
Toxicity.)
•Observingforprogressiontoa moreadvancedAVblock.

41. normal
longer longer droppedQRS
ExamplePRintervals:.14-.20-.32–B-.14-.20–32-B
Interventions:
▪Treatmentisusuallynot indicatedasthisrhythmusually
produces nosymptoms.
▪External pacingandatropineforacute,symptomaticepisodes
•SeconddegreeAVblocktypeI occurs
in theAVnodeabovetheBundleof
His.
•PRintervalgraduallylongeruntilaQRS
isdropped“B”indicatesaBlockedBeat
•Thepatternisrepeated
•ItisoftentransientandmaybeduetoacuteinferiorMIordigitalistoxicity.

42. •Itcanoccur afteran acuteanterior
MIduetodamageinthe bifurcation
orthebundlebranches.
•Itismoreseriousthanthe typeI
block.
•Harmful--mayindicateseriousheart
diseaseorprogressto3rddegree
block
BlockedQRS
ExamplePRintervals:.16–B-.16–B-.16-.16-B
Interventions:
▪Externalpacingandatropineforacute, symptomaticepisodes
▪Permanentpacingforchroniccompleteheartblock.
▪Dopamineforseverehypotension

43. •Completeblockoftheatrial impulses
occursattheA-Vjunction,common
bundleorbilateralbundlebranches.
•Anotherpacemakerdistaltotheblock
takesoverinordertoactivatethe
ventriclesor ventricularstandstillwill
occur.
normal
blocked blockedblocked
short
blocked
normal
blocked
ExamplePRintervals:.14–B-.20–B–B-.12–B-.44-.32-B
Interventions:
▪Externalpacingandatropineforacute,symptomaticepisodes
▪Othermedications:ISOPROTERENOL,DOPAMINE,
▪Permanentpacingforchroniccompleteheartblock.

44. ▪V-Tach
▪V-Fib
▪Asystole
▪Torsades
▪PEA
WhichrhythmsareaCODEBlue?

45. NursingAssessment:
•Palpitations,IrregularHeart Rate
•BodyWeakness,Fatigue,Dizziness
•NauseaandVomiting
•Pallor
•Decreasedlevelofconsciousness
•Diaphoresis,Coldandclammyskin
•Painat: Chest,Back,NeckJawandArm
NursingDiagnosis:
•RiskforDecreasedCardiacOutput
•ActivityIntolerance
•IneffectiveTissuePerfusion
•DeficientKnowledge
•Anxiety
•TherapeuticRegimen:IneffectiveManagement
CardiacDysrhythmias:Nursing Process

46. NursingPlanningand Goals:
•Prevent/treatlife-threateningdysrhythmias.
•Supportpatient/SOindealingwithanxiety/fearof potentiallylife-
threateningsituation.
•Assistinidentificationofcause/precipitatingfactors.
•Reviewinformationregardingcondition/prognosis/treatmentregimen.
•Maintain/achieveadequatecardiacoutputas evidencedbyBP/pulse
withinnormalrange,adequateurinaryoutput,palpablepulsesofequal
quality,usuallevelof mentation.
•Displayreducedfrequency/absenceof dysrhythmia(s).
•Participateinactivities thatreducemyocardialworkload.
•Be freeofsignsof toxicity;displayserumdruglevelwithinindividually
acceptable range.
•Verbalizeunderstandingofcondition,prognosis,andfunctionof
pacemaker(if used).
•Verbalizeunderstandingoftherapeuticregimen.
•Correctlyperformnecessaryproceduresandexplainreasonsforactions.

47. NursingInterventions:
▪Documentanyarrhythmiasinamonitoredpatient.
▪Notifythedoctorifa changeinpulsepatternorrateoccursinan
unmonitoredpatient.
▪Asordered,obtainanECGtracinginanunmonitoredpatienttoconfirm
andidentifythetypeof arrhythmiapresent.
▪Bepreparedtoinitiatecardiopulmonaryresuscitation,ifindicated,when
a lifethreateningarrhythmiaoccurs.
▪Administermedicationasordered,monitorforadverseeffect,and
performnursinginterventionsrelatedtomonitoringvitalsigns,
hemodynamicmonitoring,andappropriatelaboratorywork.
▪Provideadequateoxygenandreduceheartworkload whilecarefully
maintainingmetabolic,neurologic,respiratory,andhemodynamic
status.
▪Evaluatethemonitoredpatient’sECGregularlyforarrhythmia.

48. NursingInterventions:
▪Monitorforpredisposingfactors,suchasfluidandelectrolyteimbalance,
andsignsof drugtoxicity,especiallywithdigoxin.
▪Teachthepatienthowtotakehispulseandrecognizean irregularrhythm
andinstructhimtoreportalterationsfromhisbaselinetothedoctor.
▪Emphasizetheimportanceof keepinglaboratoryandphysician’s
appointments.
NursingProcess:Evaluation
•Freeoflife-threateningdysrhythmiasandcomplicationsof impaired
cardiacoutput/tissueperfusion.
•Anxietyreduced/managed.
•Diseaseprocess,therapyneeds,andpreventionof complications
understood.
•Planinplacetomeetneedsafterdischarge.

49. References:
•LippincottManualofNursingPractice.LippincottWilliams andWilkins
•SaundersComprehensiveNursingReview
•HandbookforBrunnerandSuddarth: Medical-SurgicalNursing12th
edition.LWW
•Morton and Fontaine, “Critical Care Nursing: a Holistic Approach.” 9th edition,
2009.LWW
•Forimagestakenfromhttps://www.google.com.sa