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158 Cards in this Set
- Front
- Back
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how many leads are on the chest for a 12-lead ekg?
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6 or so
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what is an ekg actually telling you?
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it tells what the electrical activity is like at that moment in time
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why is it called a 12-lead ekg?
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it is showing 12 different viewpoints of the heart (typically the left ventricle)
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if a pt is suspected to having a right ventricle MI, what do we do with the leads to see the right side of the heart?
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move the leads to the right side of the chest to show the electrical activity from that side
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which lead is the most commonly monitored lead?
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lead 2
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what is another term for the baseline on an ekg? what does above the line mean? below the line?
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isoelectric; above the line is positive; below the line is negative
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When looking at the leads, what is RA? LA? LL?
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RA- negative (right upper chest)
LA- ground (left upper chest) LL- positive (left lower abdomen) |
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what direction is the lead looking during electrical activity?
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the normal way that the heart depolarizes
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when looking at lead 2 on the ekg strip, what is the positioning of the leads on the pt's chest?
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negative is RA, ground is LA, positive is LL (most common)
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when looking at lead 1 on the ekg strip, what is the positioning of the leads on the pt's chest?
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the negative is RA and positive is LA-will have smaller complexes than lead 2
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when looking at lead 3 on the ekg strip, what is the positioning of the leads on the patient's chest?
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ground is RA, negative is LA, and positive is LL
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what does the QRS complex represent?
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ventricular depolarization; this is when movement of electrolytes (Na, K, Ca) occurs
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what is the absolute refractory period?
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when the cells can't respond to any electrical impulses, no matter how strong
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what is the relative refractory period?
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the period after the absolute refractory period where the cell can begin to respond to electrical impulses (must be strong impulses)
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if you see a peak above the baseline on the ekg strip, what direction does this show the conduction going? what about a peak below the baseline?
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towards the positive electrode; towards the negative electrode (away from the positive)
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what is the primary pacemaker and where is it located?
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sinus node and it is located in the right atrium
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how many times a minute does the sinus node normally fire?
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60-100 times a minute
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what is the first bump called on the ekg strip?
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the P wave. also, known as atrial depolarization, positive reflection
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what happens after the atria depolarize (after the P wave)?
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the atria contract while the tricuspid and mitral valves are open
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where are impulses held while the atria contract?
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in the AV node
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after the atria contract, what happens to the tricuspid and mitral valves? what also occurs next?
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the valves close and the ventricles are able to contract
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what is the pathway for the electrical impulses after the AV node and where do they go?
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the next pathway is through the bundle of HIS. which then breaks into two branches, a left and a right bundle. the left goes to the left ventricle and the right goes to the right ventricle
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what is the last place for electrical conduction to occur within the heart?
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the Perkinje Fibers
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if the ventricular rate is less than 40 and the Sinus node and AV node fail, what can be used?
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the Perkinje Fibers can be used as an escape mechanism
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atrial contraction can also be called:
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atrial kick or atrial systole
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what is the normal PR interval (in time)?
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0.12-0.20 seconds
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what is happening when the QRS complex is going on?
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ventricular depolarization
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from what point to what point is the QRS complex measured? what is the typical length of time for this?
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from the beginning of the QRS to the end of the QRS. should be < 0.12 seconds
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when does ventricular contraction occur?
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during the ST segment
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at what point does ventricular repolarization occur?
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during the QT interval (somewhere between the beginning of QRS and end of T)
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what is the length of time for the QT interval?
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less than 0.40 seconds
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there should be a ________ before every QRS complex?
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P wave
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There should be a _________ after every P wave?
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QRS complex
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if the HR is fast, is the QT interval long or short?
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short
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if the HR is slow, is the QT interval long or short?
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long
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a pt is more likely to get a dysrhythmia when?
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the longer the QT interval, the more chance of a pt acquiring a dysrhythmia
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when looking at an EKG strip, a big box, big line to big line, represents:
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5 little boxes, 0.20 seconds total
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when looking at an EKG strip, each little box is how much time?
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0.04 seconds
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the large has marks at the top of the strip represent:
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3 seconds
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in order to determine a HR by looking at the EKG strip, you need to:
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count the number of R spikes in a 6 second time frame, then multiply by 10.
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what is the difference between sinus rhythm, tachycardia, and bradycardia?
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HR
normal: 60-100 tachy: greater than 100 brady: less than 60 |
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what is symptomatic bradycardia?
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when a pt is having bradycardia and the body is not tolerating it well. the pt will begin to develop symptoms related to the bradycardia
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what is the drug of choicec to fix bradycardia? how about the treatment of choice?
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atropine 0.5-1.0mg (doesn't always work)
pacemaker |
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what is another drug of choice that can be used with bradycardia?
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dopamine, especially in adults. also helps raise the blood pressure
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if a pt is given a caclium channel blocker and begins experiencing problems related to the Ca channel blocker, what intervention may be done to help?
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give the patient calcium
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if a pt has a U wave, where does that show on the strip? what is most likely cause for this?
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U waves will show up right after the T wave. a lot of times the reason for a U wave being present is because of the potassium.
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if your temperature is increased by 1 degree C, how much does the metabolic rate increase? how much does the HR increase?
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metabolic rate will increase 10% and the HR will increase 10bpm
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what is a premature ventricular contraction (PVC)?
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a ventricular contraction that comes a little premature. there is usually no P wave and the QRS is typically greater than 0.12 seconds (most of the time >0.14 seconds)
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why is it significant for the heart to beat a little prematurely?
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the ventricles don't have adequate time to fill
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when looking at a strip for PVC's, what do the waves and complexes do?
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QRS complex will be the opposite of P wave and T wave.
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what is torsades de pointes? how is it treated?
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ventricular tachycardia with a HR > 300bpm. med of choice is isopril, this will speed up the HR. treatment of choice is transvenous pacemaker. has to be transvenous so that the pacemaker can be at a HR greater than the pt's HR.
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what is the mechanism behind speeding up the HR torsades de pointes even though the pt's HR is already >300 bpm?
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the idea is to speed it up to the point that it kicks it back down to normal. it's almost as though it tuckers out from going so fast, then resets itself
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what are ectopic beats?
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beats that occur outside of the SA node
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if a pt has more than one PVC that look the same, they are called:
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unifocal
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if a pt has more than one PVC that doesn't look the same, it is called:
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multifocal
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what are two PVCs in a row called?
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back to back
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what is a PVC, normal beat, PVC, normal beat called?
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bigeminy
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what is a PVC, 2 normal beats, PVC. 2 normal beats called?
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trigeminy
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if a QRS complex of a PVC falls on relative refractory period, what can this cause? when should this be treated and with what medications?
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V-tach or v-fib; only treat on pts that are having PVCs with chest pain; typical drugs are Mg and amiodarone
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what is the mechanism of action when using Mg or amiodarone for PVCs with chest pain?
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these drugs will help suppress the SA node function.
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if a pt has PVCs, is this of concern?
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only if the pt is experiencing chest pain or has had previous heart problems
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if a pt is having rhythms on the monitor but doesn't have a pulse, what should you do?
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first, check your pt. if they are ok, most likely a monitor issue. if the pt is not ok, prepare to shock
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when shocking a pt, when looking at the strip, where do you want to shock them? when do you not want to shock them? what is this also called?
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on the R wave; on the relative refractory period; synchronized cardioversion
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what are the two drugs of choice for ventricular dysrhythmias?
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magnesium and amiodarone
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if a pt is showing a rhythm on their strip that is a bunch of squiggly lines, but without any P waves, QRS complexes, or T waves, what could this indicate?
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first check your pt...if they have a pulse then this probably doesn't mean anything. the sticky pads are most likely bad and need to be replaced.
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what do you need to do to a pt before shocking them if they are cold?
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warm them up first
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what percentage of CO is from the atrial kick?
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20-30%
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during atrial fibrillation, what is happening?
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the atria is receiving lots of impulses that aren't directed to the AV node, causing impulses to spread erratically through the atrium, causing it to "quiver". because of this, the ventricles can't fill completely, thus ↓CO
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what is hemodynamic monitoring?
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anything that is done to a pt that will alter the preload, afterload, contractility, and heart rate
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where can central venous pressure (CVP) be obtained from?
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the right atrium, aka right atrial pressure
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what is a SWAN?
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thermodilution pulmonary artery catheter
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what is an arterial line (A-line)?
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a line that is put into an artery, typically the radial artery. it can measure pressures continuously and is a great site for blood draws at any time.
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what does the transducer of an a-line do?
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converts electrical signals and pressures to signals that can be displayed on the monitor
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what is important to know about the transducer?
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the transducer needs to be at the level of the right atrium also known as the phlebostatic axis
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does a pt have to be lying flat or at an angle to be able to use the transducer?
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either one is fine, as long as the transducer moves with the pt (is at the same phlebostatic axis)
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what does it mean to zero the transducer?
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this is when the transducer stopcock is opened to air, telling the transducer to ignore atmospheric pressures
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what does leveling the transducer mean?
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putting the transducer at the level of the right atrium (phlebostatic axis)
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why is it important to not put a pt on their side when they have an a-line?
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the readings won't be as accurate
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if a pt has an a-line and a BP >160 or has been on large amounts of heparin, what is important to know?
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don't remove the a-line until other issues have been resolved. there is an ↑ risk of bleeding
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what is the most common site used for an a-line?
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the radial artery
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what is the allen's test?
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when you occlude both radial and ulnar artery until circulation stops to the hand. Then release the ulnar artery, keeping the radial artery occluded. Watch to see how long it takes for hand to become pink again. Document results.
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when looking at an EKG strip, what is the dicrotic notch?
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when the pulmonic valve is closing
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if you have a small catheter in a large artery, what is a potential complication?
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catheter whip may occur causing some arterial wall damage
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after an a-line has been placed, what is another thing that you want to look for?
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distal flow. check to make sure cap refill is good, there's no numbness or tingling, and the hands aren't cold. if any of these symptoms occur, take the a-line out
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what is the pulse pressure?
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the difference between the systolic and diastolic
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what is the pulse deficit?
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the difference of pulse between the apical and peripheral pulses
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what does widened and narrowed mean in reference to pulse pressures?
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widened means ↑ pulse pressure
narrowed means ↓ pulse pressure |
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what is pulsus paradoxus?
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when there is a drop in systolic pressure by10-20 mmHg on inspiration. can also increase HR 10-20 bpm
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what are some reasons for a dampened waveform to occur with arterial lines?
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catheter whip (underdampened)
air bubbles, clots, or kinks (overdampened) |
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if there is a suspected clot at the end of the a-line, what should never be done?
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fast flushing the line. this could knock loose the clots and cause further complications
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what is the most common reason for a pt getting an air embolis?
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changing the line of an arterial line
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aside from right atrial pressure, what else would it be called for the CVP to measure?
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right ventricular preload
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what is the normal CVP (according to debbie)?
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2-6
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what is preload?
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the pressure in the ventricles at the end of diastole. it is created by the volume in the ventricles. the more volume in the ventricles, the more stretch of the muscles (to a point), the harder the contraction
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what does a high CVP mean?
what does a low CVP mean? |
too much volume
too little volume |
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what is another indication of an elevated CVP?
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JVD
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if a patient has a central venous pressure monitoring system going, what is important for them to NOT do while the line is open to air?
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it is important that they don't inhale. this will most likely cause an air embolism
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what does it mean if the pulmonary artery pressure ↑?
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pulmonary vessels are constricted and the right ventricle is having to pump harder to get the blood through
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what pressure does the "wedge" measure?
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left ventricle pressure
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what are some indications for pulmonary artery pressure monitoring?
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Hypovolemic shock
Early septic shock Advanced septic shock or multisystem failure Cardiogenic shock Acute respiratory distress syndrome (non-cardiogenic shock) |
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what happens to the HR when a pt is under stress?
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it will change, most likely increasing
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what is the stroke volume?
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the amount of blood ejected with each contraction. normal is 60-80cc's
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what is the ejection fraction?
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the percentage of blood ejected from the heart. normal is 60-75%
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what does a low SvO2 mean?
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the tissues are hypoxic
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how can you decrease prelod in heart failure pts?
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decreasing venous return to the heart. this is typically done with nitroglycerin. it's considered a venous dilator at 200mcg/min or less
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what is systemic vascular resistance?
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this tells us how vasoconstricted the arteriole system is. it's also known as Left ventricular afterload. a high number means that there is vasoconstriction and the heart is working harder. low number means vasodilated.
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what happens to the SVR when a pt is hypovolemic?
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the vessels begin to vasoconstrict, causing a high SVR.
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what is the best drug to take care of an increased systemic vascular resistance?
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nitropresside (Nipride). needs to be protected from light, otherwise it will breakdown and be uneffective.
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what does the nitropresside break down to once in the body?
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thiocyanate (aka cyanide)
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how can you tell the difference between heart failure and dryness?
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auscultate breath sounds. most likely would here crackles. assess for JVD and pitting edema in the extremities
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how would a pt present if they had a high SVR?
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cold and sweaty (vasoconstricted)
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how would a pt present if they had a low SVR?
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pink and warm (vasodilated)
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what is the normal CO in a person?
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4-8L/min; it's the amount of blood that goes out of a pt in one minute
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what is the thermodilution method of figuring CO?
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push saline as fast as possible into the right atrium. then measure the amount of time it takes for the temp change to occur at the tip of the catheter. Must know the temp of saline beforehand
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what is pulmonary vascular resistance?
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right ventricular afterload
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what kind of drugs are used for decreasing pulmonary vascular resistance and what are they doing?
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ACE inhibitors, calcium channel blockers: they decrease the vascular afterload, aka unloading
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how does an intraaortic balloon pump affecte the afterload?
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it decreases it.
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what is the afterload?
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the pressure the ventricle most generate to overcome the resistance to ejection created in the arteries and arterioles
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during diastole, what is happening with the coronary arteries?
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there is a slight amount of backflow and they have increased perfusion
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what are some ways to fix pulmonary HTN (PVR)?
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drugs, balloon pump, or fix the problem. fixing the problem is the best alternative.
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what is the best way to fix pulmonary HTN?
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fixing the hypoxia
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at a high dose, what is dopamine considered?
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vasopressor (vasoconstrictor). will increase blood pressure
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what agent can be used as an afterload agent?
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nitroglycerin of doses over 200mcg/min
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what are some drugs that can be used to ↑ SVR and constrict the vessels?
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dopamine
norepinephrine (levafed) epi vasopressins |
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what happens to muscles as they become hypoxic?
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they lose contractility
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what is calciums involvement with the heart?
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helps with the contracting of the heart
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as the heart contracts harder, what will it need more of?
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oxygen
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what does a positive inotrope do?
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increases the contraction
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what does a negative inotrope do?
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decreases the contraction
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what is a common inotrope?
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digoxin
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what are some titratable drugs that can be used to lower or raise BP? what do these drugs need in order to work?
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dobutamine (Dobutrex) and dopamine. the sympathetic nervous system has to be working for these drugs to work properly
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what are a couple of examples of negative inotropes?
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beta blockers and calcium channel blockers
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what do you chromotropes do?
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affect the HR.
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what does the nurse need to do before removing a wedge?
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have a cxr taken of the pt and look for loops or knots
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what is the normal wedge pressure?
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8-12
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how much of the cardiac cycle is done during systole?
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1/3
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how much of the cardiac cycle is done during diastole?
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2/3
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when putting in a pulmonary artery occlusion pressure, how much air can be injected into the balloon?
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1.5 cc's
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what is the normal systolic and diastolic pressures of the right ventricle?
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15-25mmHg
2-8mmHg |
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what is the normal pulmonary artery systolic (PAS)?
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15-25mmHg
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when can right ventricle pressures be seen?
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only on insertion and removal. if you see it othewise, it means the catheter is in the right ventricle and can cause damage.
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what does the pulmonary pressure tell us?
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how hard the right ventricle is contracting
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should the pressure in the pulmonary vessels ever be zero?
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no, if it is, the pt is most likely dead
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what is the pulmonary artery diastolic (PAD)?
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8-15mmHg
also has a dicrotic notch (closure of the pulmonic valve) |
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what is a possible complication of having a PAOC in place?
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may cause regurge from the ventricle to the atria. the valve isn't able to close completely because of the catheter getting in the way.
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what does the wedge represent?
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left ventricular preload
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what is going on with the ventricles during diastole?
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AV valves are open and the ventricles are resting
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theoretically, what is happening with the wedge in the pulmonary vessels?
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the tip of the catheter is looking into the left atrium and into the left ventricle. the tip of the catheter lies just in front of the balloon and is hooked up to the transducer.
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what is the pulmonary artery pressure(PAP)?
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the mean pressure
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as the doctor inserts the wedge into place, once he/she is happy with placement, what is done?
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the balloon is deflated and catheter is sutured into place
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for pts that have a sick heart, what is a typical wedge pressure for them?
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14-16mmHg
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what is a better indication of cardiac output?
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cardiac index
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how is mean arterial pressure (MAP) measured?
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SBP+(2 X DBP)/3
normal: 70-100mmHg |
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how is cardiac index (CI) measured?
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CO/BSA
normal: 2.5-4.5L/min/m2 |
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how is stroke volume (SV) measured?
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CO X 1000/HR
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why is cardiac index more accurate than cardiac output?
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it takes into account for body surface area, which individualizes to each pt.
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if you have high doses of dopamine (>20mcg), what other drug is this considered? This drug is also the synthetic form of what?
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levafed; norepinephrine
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what is important to know about insulin with critically ill patients?
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Insilun – tight glycemic control 80 – 110, glucose is irritating and causes a release of inflammatory agents, causing inflammation, and something about how when the body is under stress it releases insulin but cant break it down so increases stress response
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