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159 Cards in this Set
- Front
- Back
Tachycardia s/s
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chest discomfort, paleness, anxiety, cool skin, syncope from hypotension.
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What is the danger of tachycardia?
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May lead to HF
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What happens to CO during tachycardia?
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Initial increase in CO and BP followed by a drop in both CO and BP due to decreased ventricular filling time.
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What physically happens to heart muscle with tachycardia?
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works harder to keep up with demand, resulting in thickening of ventricles
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What happens to BP with tachycardia?
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BP Decreases
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How does blood flow, starting from the vena cavae?
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Blood flows from Vena Cavae to Right Atrium-> through Tricuspid valve-> Right ventricle -> then through the pulmonic valve -> pulmonary arteries to lungs where it is oxygenated -> returns through the pulmonary veins -> into the left atrium -> then through the mitral valve -> to the left ventricle -> then through the aortic valve -> into systemic circulation-> returns to the heart via the vena cavae.
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Blood supply to the heart is delivered via the coronary ____ during _______.
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arteries
diastole |
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2 types of MIs
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Anterior MI and inferior MI
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Blockage of the ___ (____ ________ ________ _______) interrupts blood flow to anterior left ventricle, some right ventricle, cordae tendinae, papillary muscles. HIGH MORTALITY RATE!!!
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LAD (Left anterior descending artery)
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Blockage of LAD is anterior or inferior MI?
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Anterior
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Blockage of the ___ ________ _______ interrupts blood flow to the lateral and posterior wall of the lft ventricle, left atrium, and the SA node 50%, and AV node 10%
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left circumflex artery
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Blockage of the left circumflex artery is anterior or inferior MI?
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Anterior MI
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Blockage of the ___ (_____ ________ ______) interrupts blood flow to the right ventricle, right atrium, inferior and posterior left ventricle, and SA node 50%, AV node 90% of population
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RCA (Right coronary artery)
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Blockage of the RCA (Right coronary artery) is anterior or inferior MI?
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Inferior MI
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Normal conduction pathway of the heart?
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SA node located in the upper right atrium->
AV node at the bottom of the right atrium down the Bundle of His to Right and Left bundle branches to the Purkinje fibers in the ventricles. |
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The ___ ______ initiates atrial contraction at a rate of 60-100 BPM
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SA Node
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The ___ ________ delays conduction to give the ventricles time to fill
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AV Node
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The ___ ____ ____ and ____ ______ transmit the signal to the ventricles, initiating ventricular contraction from the bottom up.
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Bundle of His and Bundle Branches
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The ______ ________ stimulate contractile muscles to contract, pushing blood out of the ventricles.
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Purkinje fibers
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Easy way to remember blood flow pathway
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Body
Right Lungs Left Body |
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What causes the heart to pump?
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Ca
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Automaticity
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Ability of cardiac cell to initiate an impulse on its own
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Excitability
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Ability of cardiac cell to respond to electrical stimulus
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Conductivity
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Ability of one cardiac cell to transmit an electrical impulse to another
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Contractility
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Ability of cardiac cell to contract after receiving an impulse (after depolarization)
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Action potential
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The depolarization and repolarization events of the cell membrane
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Depolarization= muscle ________
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contraction
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Repolarization= muscle ________
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relaxation
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What is every cardiac cell capable of?
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Generating it's own impulse
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The fastest speed will...
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rule the heat no matter where it comes fom
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What is normally the pacemaker of the heart?
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SA node
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What node serves as a backup pacemaker for the heart?
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Av node
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SA node rate?
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Rate of 60 to 100 beats/min
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AV Node rate?
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Rate of 40- 60 beats/min
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Bundle of His: has ability to _____-_______ electrical activity
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self-initiate
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Bundle of His Rate?
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Rate of 40-60
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Purkinje fibers Rate?
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Rate of 20- 40 beats/min
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Are muscle fibers stimulated one at a time?
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No, because of the lattice like network, many fibers are stimulated at a time
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At the resting state, is the inside of the cell more + or more - ?
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Inside is more +
outside is more - |
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What happens during depolarization of the cardiac cell?
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Ca and Na begin to enter the cell while K exits, this changes the polarity of the cell, and contraction begins
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When is depolarization complete?
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When inside of cell is more + because of the marge amount of Na now inside
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When does repolarization begin?
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When K starts going in and Na starts exiting the cell.
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Does Na enter the cell ANY other time than during depolarization?
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Yes, Na is constantly leaking inside the cell, but the depolarization only occurs when a certain level is reached
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What basic vital sign will and EKG tell you?
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HR
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Will EKG show you cardiac output?
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No
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Will EKG show you action potential?
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No
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Will EKG show you ejection fraction?
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No
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Will EKG show you systolic function?
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No
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What does an EKG tell you?
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An EKG translates the heart's electrical activity into line tracings on paper.
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When an impulse comes toward the + electrode, what is shown on the EKG?
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a + deflection (upwave)
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When an impulse goes away from the + electrode, what is shown on the EKG?
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A - deflection (downward spike)
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The direction of flow of an impulse is called the...
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cardiac axis
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Which lead is ground?
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Green
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Which lead is positive?
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white
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Which lead is negative?
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black
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What is the name of the line that the EKG follows?
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isoelectric line (with positive and negative deflections)
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P wave =
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The positive deflection indicating atrial depolarization, usually rounded at top. Usually precedes the QRS complex, unless there is a conduction deficit, at which point the p-wave may be before the QRS, “intertwined” with the QRS, show up after the QRS, or be inverted.
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PR-Interval
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The time it takes for an impulse to conduct through the atria and AV node up to the instant of ventricular depolarization.
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QRS complex=
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Deflection indicating ventricular depolarization
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ST-Segment
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represents early repolarization of ventricles and ends with onset of T-wave.
(elevated in STEMIs) |
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T-Wave
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Deflection indicating ventricular repolarization
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QT-interval
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period from beginning of ventricular depolarization to end of T-wave
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What segment is sometimes elevated in MI?
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ST segment
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When do we see a wide QRS complex?
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During bundle block
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Why is there a wide QRS complex during a bundle block?
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Conduction slows so it takes longer for the ventricles to contract
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If EKG has ST elevated,it is indicative of...
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MI
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On EKG paper, 6 seconds contains how many big boxes?
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30
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P-Wave
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Represents ATRIAL depolarization
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P-R Interval
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Duration of time from the beginning of P-wave to the beginning of QRS complex. PR Interval (PRI) represents the time required for an impulse to travel from the SA node to the AV Junction
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QRS Complex
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Represents Ventricular Depolarization
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T-Wave
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Represents Ventricular repolarization
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Regularity
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The consistency of the distance between two measured objects
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Consistent
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Does the event occur each expected time, or are there instances where the expected event does not occur (inconsistent)?
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7 Steps toAnalyzing a rhythm strip
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Reg or Irregular
Rate P waves present? P wave for every QRS? Measure P-R interval (Nl= 0.12- 0.2 sec) Measure QRS (nl= 0.04- 0.12 sec) Interpret rhythm |
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nl PR interval
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0.12 to 0.20 sec
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nl QRS interval
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0.04 to 0.12 sec
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What does a prolonged PR-Interval > 0.20 seconds indicate?
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indicates a delay in conduction through AV node or Bundle of His
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What does a PR-Interval <0.12 second indicate?
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second indicates that the impulse progressed rapidly through the atria to ventricles via pathway other than AV node and Bundle of His, or that the originating signal was from cells close to AV node or Bundle of His.
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Bradycardia
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rate of <60 bpm
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Normal rate
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60-100 bpm
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Tachycardia
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rate of >100
100-160 |
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Normal Sinus Rhythm Criteria
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Reg rhythm
Sinus rate 60-100 bpm 1 p before every QRS PR nl QRS nl |
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Sinus Bradycardia Criteria
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Same as NSR but Rate <60
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Causes of Sinus Bradycardia
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Excessive vagal stimulation, hypoxia, vomiting, suctioning, Valsalva Maneuver, Beta Blockers, Calcium channel blockers, Digitalis
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Treatments for Sinus Bradycardia
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Only treat if symptomatic!
Atropine, O2 therapy, external pacemaker, initiate fluid volume replacement Avoid parasymp stimulation (ex. Prolonged suctioning-stimulation of gag reflex, straining) |
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Sinus Tachycardia Criteria
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Same as NSR except for rate is >100
(100-150) |
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Sinus Tachy causes?
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SNS stimulation, Vagal inhibition, anxiety, pain, stress, PE, hyperthyroidism, drugs, alcohol, Hypovolemic shock, MI, infection, HF
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Sinus Tachy treatments?
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Calm the patient, Rest, O2 therapy, admin Nitro or Morphine as prescribed, diuretics, Beta Blockers
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What causes atrial rhythms?
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SA node fails to generate an impulse, the atrial tissue may initiate an impulse anywhere in the atrium.
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3 types of atrial rhythms?
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Premature Atrial Contraction
Atrial Flutter Atrial Fibrillation |
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Premature Atrial Complexes
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Ectopic focus of atrial tissue fires an impulse before the next sinus impulse is due.
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Premature Atrial Complexes Criteria
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Rhythm: IRREGULAR W/ PAC
Rate: nl 60-100 P WAVES: premature, abnl shape, size, direction (pointed) PR: NORMAL OR PROLONGED QRS: nl |
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Causes of PACs?
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Low K
Stimulants: Caffeine, alcohol, nicotine, Anxiety |
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When interpreting PAC, how do we write it out?
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Always write underlying rhythm first:
IE: Sinus Rhythm/Sinus Brady/Sinus Tachy with 1 (2,3,etc) PAC |
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What does P wave look like with PACs?
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present, pointed, irregular
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Treatments for PAC?
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None
Tell them to stop smoking and drinking. Keep stress low. |
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What is Atrial flutter?
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Originates in an atrium, a single irritable focus takes over. Rapid succession of f waves “flutter waves”
Since AV node has long refractory period not all waves conduct to the ventricles. Maybe 2:1 to 4:1 |
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During Atrial flutter, what are the P waves?
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The flutter waves
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Are we looking at R wave to R wave measurements during Atrial flutter?
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No, because we are looking at atrial rate
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Atrial flutter rate?
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Rate: 250 to 350 times per minute
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Atrial flutter distinguishing appearance?
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p wave sawtooth appearance
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Causes of Atrial flutter?
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Caffeine, alcohol, nicotine, anxiety, low potassium
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Symptoms of atrial flutter?
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decreased cardiac output- pale, dizzy, confusion, hypotension, fatigue
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Major treatments for A flutter?
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Adenosine
Cardioversion Maze procedure For maintenance: beta blockers and cardizem |
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What is cardioversion?
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Paddles that shock person. Synchrnized shock to reboot the heart
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What is Adenosine?
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A medication that is slammed IV, restarts the heart
6 mg rapid IV, followed by a 20 ml saline flush and elevate the arm. May be repeated X 1 |
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What is atrial Fibrillation?
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Multiple, rapid impulses from many atrial foci. Top of heart quivering, blood can pool and stagnate in atrium
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What does Atrial Fibrillation result it?
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Loss of atrial kick results in <C.O. and increased risk of atrial thrombus... RISK OF CLOTS
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Atrial fibrillation pt looks like...
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dizzy
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What does the R-R rhythm look like in A fib?
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Irregularly irregular. All over the place ventricles contracting irregularly
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A fib criteria?
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Irregularly Irregular rhythm (R-R is irregular), atrial rate 350-600 – Ventricular rate varies, No P waves, irregular deflections called f-waves, PR not measurable, QRS = (0.4-0.12)
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A fib cause?
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Multiple waves of electrical activity flow across the atria.
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Major treatments of A fib?
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Digoxin to slow HR,
Coumadin to prevent clot formation, Cardioversion, Maze Procedure, Radio Frequency Ablation |
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Coumadin teaching
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Limit VITAMIN K intake
(foods to limit- prunes, cabbage, asparagus, brussel sprouts, green leafy veggies, broccoli) Avoid cranberry juice Use electric shaver, be carefu not to cut self, look for s/s bleeding inside and out (dark tarry stools) No alcohol or NSAIDs |
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Digoxin teaching
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If HR <60 hold med
Look for s/s toxicity (blurry viz, color halos, GI distress) Avoid antacids w in 2 hrs of Dig Get Dig and K levels checked Notify HCP if signs of toxicity |
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How do you know a patient is reprofusing after an MI?
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The EKG rate will change- crazy rhythms- ventricular rhythms
(due to the shock to heart from flood of electrolytes and O2 when heart all of a sudden opens up) |
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4 Ventricular Rhythms?
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Premature Ventricular Complexes
Ventricular Tachycardia Ventricular Fibrillation Asystole |
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What is the key to identifying Premature Ventricular Complexes (PVCs)?
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atrial rate is that of underlying rhythm (usually sinus) interrupted by early wide bizarre QRS complex. Usually seen as inverted.
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What is happening curing PVCs?
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Irritable ventricular cells are firing on their own and are seen as early ventricular rhythms followed by a pause.
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Most common cause of Premature Ventricular Complexes (PVCs)?
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Hypoxia
can occur in healthy people, d/t caffeine, nicotine, alcohol, ischemia, fever, heart failure, dig toxicity, electrolyte imbalances |
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If you see that PVCa are starting to occur on the T WAVE it means...
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it is a precurser to V-Tach
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In the first hours after an MI, many times EKG shows..
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Sinus Tach with PVCs
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Do we treat PCVs?
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no, not unless pt is symptomatic
Symptomatic: correct underlying problem/cause: anxiety, stress,caffeine or nicotine use, COPD/ asthma, hyperthyroidism |
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Ventricular Tachycardia Criteria
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REGULAR Rhythm, No atrial rate, ventricular rate 140-180, No visible P-waves, PR not measurable, Wide QRS (> than .12)
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What’s Happening during V tach?
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Repetitive firing of a ventricular ectopic focus.
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V tach can be cause by?
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MI, hypokalemia, hypomagnesemia, HF, drug toxicity, hypotension
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What is the first thing you do if you see V Tach on the monitor?
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Check the patient.
Check leads, S/S/Vitals |
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If V tach patient has no pulse, what do you do?
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Start CPR!
Because V tach can turn into V fib |
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Treatments for V Tach?
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1st check the patient for SOB, LOC, hypotension. Check Leads, vitals, get crash cart. Give O2, Call physician, Admin CPR, cardioversion, Lidocaine, Amiodarone
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Amiodarone use?
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Life threatening arrhythmias ONLY- recurrent ventricular tachycardia
Used as last resort treatment d/t severe and potentially lethal adverse effects |
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Amiodarone action
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Produces prolonged phase of repolarization- slows conduction of the SA node and increases refractory period of the AV node
slows heart rate by blocking the Ca channel |
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Lidocaine use?
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Treatment of arrhythmias r/t cardiac surgery and acute MI, and treatment of ventricular tachycardia
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Lidocaine action?
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Weakens phase 4 diastolic depolarization, decreases automaticity, and decreases or causes no change in the excitability and membrane responsiveness
Decreases action potential of Purkinje fibers and ventricular muscles- raising the ventricular tachycardia threshold |
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What is V-Fib?
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Life threatening! Electrical chaos in the ventricles. No perfusion at all! Fatal in 3-5 minutes!
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V-fib is caused by?
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Hypokalemia, Hypomagnesemia, hemorrhage, anti-dysrhythmic therapy, shock, trauma
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V-Fib major treatment?
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Priority is to Fibrillate the patient, then provide CPR for 5 cycles, then another shock. Give O2 therapy, Amiodarone, Lidocaine, vasopressin, epinephrine, magnesium sulfate
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How much perfusion is going on with V-fib?
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None, zip, zero, zilch!
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What to do if you see V-fib on monitor?
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Check pt!
Check leads! CPR!!!!!! |
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What is ventricular Asystole?
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Also called ventricular standstill: complete absence of any ventricular rhythm-“ Flat-lined”
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What to do if you see Asystole on monitor?
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Check pt!
Check leads! CPR!!!!!! |
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What does pacer rhythm look like?
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There will be a vertical spike prior to Q-wave
Spike from pacemaker and wide QRS complexes look like PVC but has a spike |
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AKG- Artifact
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Happens with poor conduction
Some causes include: poorly contacting electrodes patient movement/ sneezing Faulty equipment (ex. nicked electrode wires) |
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How to resolve artifact?
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To resolve problem: apply new leads, assure that they are flat against the skin, uncross cables, make sure patient is not grabbing cables, etc…
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Adenosine
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slammed into IV- stops heart for a few seconds to “reboot” it at a regular rhythm- given with MD present, and with crash cart ready
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Cardioversion
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low voltage procedure done with patient awake.
synchronized electrical impulses that reset heart rhythm (low voltage shocking) Make sure pt withheld Digoxin 48 hrs prior Must be on anticoagulants for 4-6 weeks before procedure (elective) BE SURE O2 IS OFF AND AWAY FROM PT! |
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Defibrillation
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This is an asynchronous counter shock to the heart, allowing the sinus node to regain control of the heart. It is critical in resolving VT or VF. It should NOT be delayed for ANY REASON. The earlier it is done, the greater the chance for survival.
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What should continue until a defibrillator is available?
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CPR
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What to announce before shock is delivered?
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Before delivering the shock, loudly command all personnel to clear contact with the patient and the bed. Check to make sure all have complied.
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When is Defib recommended/needed?
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All V-Fib and pulsemess V-Tach only
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How many times to shock with Defib?
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twice with 5 minutes of CPR in between
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AICD (or ICD) Automatic Implantable Cardioverter Defibrillators
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Implanted device that monitors HR, maintains/controls HR (pacemaker), and shocks heart if needed
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AICD (or ICD) Use?
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For pts with 1+ episodes of VTach or Vfib not caused by MI.
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AICD (or ICD) Patient teaching
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Psych eval/teaching needed. Anxiety/distress often comes with procedure and device, follow medications as prescribed, necessary med education, report s/s of dizziness, nausea, vomiting, and chest pain to health care provider, (HCP)
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Pacemaker post op insertion priorities
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Report and redness, swelling, or drainage at the pacemaker insertion site. If site near shoulder, teach ROM exercises to perform to prevent shoulder stiffness, do not wear tight clothing that can cause irritation, avoid rough activities
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Pacemaker post op Discharge teaching
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Teach how to take a pulse and to report a pulse over 100 bpm or anything lower than that set of their device to a HCP, Keep cellphones 6in away from the generator, Stay away from strong magnets (MRIs, car motors, etc), Do not go through metal detectors, only allow the use of a wand, Avoid places with high voltage (ex. Powerlines), always carry card identifying presence of the device or a medical alert bracelet, provie more medication teaching, if they experience a defib shock they must sit or lie down immediately and contact their Dr., anyone touching the pt during shock may be shocked as well,
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Major treatments for PAC
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None, just tell them to stop smoking and drinking. Keep stress low.
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Major treatments for ST
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Calm the patient,
Rest, O2 therapy, admin Nitro or Morphine as prescribed, diuretics, Beta Blockers |
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Major treatments for VT
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1st check the patient for SOB, LOC, hypotension.
Check Leads, vitals Get crash cart. Give O2, Call physician, Admin CPR, cardioversion, Lidocaine, Amiodarone |
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Major treatments for SB
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Atropine,
O2 therapy, external pacemaker, initiate fluid volume replacement |