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BASIC ECG WORKSHOP FOR NURSES AND MEDICAL ASSISTANT.pptx
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- 2. MODULE 1 :THE HEART AND BASIC ECG
- 3. Objectives ▪ Describe thenormal cardiac anatomy and physiology and normal electrical conduction through the heart. ▪ Identify and relate waveforms to the cardiac cycle.
- 4. Cardiac Anatomy ▪ 2upper chambers ▪ Right and left atria ▪ 2 lower chambers ▪ Right and left ventricle ▪ 2 Atrioventricular valves (Mitral & Tricuspid) ▪ Open with ventricular diastole ▪ Close with ventricular systole ▪ 2 Semilunar Valves (Aortic & Pulmonic) ▪ Open with ventricular systole ▪ Open with ventricular diastole
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- 6. The Cardiovascular System ▪Pulmonary Circulation ▪ Unoxygenated – right side of the heart ▪ Systemic Circulation ▪ Oxygenated – left side of the heart
- 7. Anatomy Coronary Arteries ▪2 major vessels of the coronary circulation ▪ Left main coronary artery ▪ Left anterior descending and circumflex branches ▪ Right main coronary artery ▪ The left and right coronary arteries originate at the base of the aorta from openings called the coronary ostia behind the aortic valve leaflets.
- 8. Physiology Blood Flow Unoxygenatedblood flows from inferior and superior vena cava Right Atrium Tricuspid Valve Right Ventricle Pulmonic Valve Lungs
- 9. Physiology Blood Flow Oxygenatedblood flows from the pulmonary veins Left Atrium Mitral Valve Left Ventricle Aortic Valve Systemic Circulation
- 10. Physiology ▪ Cardiac cycle ▪Represents the actual time sequence between ventricular contraction and ventricular relaxation ▪ Systole ▪ Simultaneous contraction of the ventricles ▪ Diastole ▪ Synonymous with ventricular relaxation ▪ When ventricles fill passively from the atria to 70% of blood capacity
- 11. Physiology ▪ Heart rate(HR) ▪ Number of contractions (beats per minute) ▪ Normal heart rate is 60 – 100 beats per minute (bpm) ▪ Stroke volume (SV) ▪ Volume of blood being pumped out of ventricles in a single beat or contraction ▪ Normal stroke volume is 60 – 130 mL
- 12. Physiology ▪ Cardiac output(CO) ▪ Amount of blood pumped by the left ventricle in one minute ▪ Normal cardiac output is 4 – 8 L/min Cardiac Output = Stroke Volume x Heart Rate !
- 13. Normal Electrical ConductionSystem SA node AV node Bundle of his Left & Right bundle branches Purkinje fibers
- 14. Electrical Conduction SystemECG Waveforms One complete cardiac cycle = P, Q, R, S, (QRS complex), and T wave
- 15. Electrical Conduction SystemECG Waveforms ▪ P wave ▪ Atrial depolarization (contraction) ▪ QRS Complex ▪ Ventricular depolarization, atrial repolarization ▪ T wave ▪ Ventricular repolarization (resting phase)
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- 17. Methods / Placementof ECG 3 Leads 5 Leads 12 Leads
- 18. MODULE 2 :INTERPRETING A RHYTHM STRIP (BREAKDOWN THE ECG PAPER)
- 19. Objectives ▪ Utilize asystematic process when approaching the interpretation of the ECG. ▪ Identify normal and abnormal components on the ECG.
- 20. Reading ECG GraphPaper Graph paper allows a visual measurement of: ▪ Time (rate) ▪ Measured on the horizontal line ▪ Amplitude (voltage) ▪ Measured on the vertical line
- 21. P – atrialdepolarization (0.12s) PR – onset of ventricular depolarization (0.12-0.2s) QRS – depolarization of ventricles (0.04 – 0.12s) T – ventricle repolarization Con’t
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- 23. MODULE 2 :INTERPRETING A RHYTHM STRIP (ANYLYSING A RHYTHM STRIP USING 5 STEPS APPROACH)
- 24. Step 1: Determineregularity. Step 2: Assess the P waves. Step 3: Determine PR interval. Step 4: Determine QRS duration Step 5: Calculate the rate. How to analyze the rhythm?
- 25. Step 1: Determineregularity Look at the R-R distances (using a caliper or markings on a pen or paper). Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular? Irregularly irregular?
- 26. Step 2: Assessthe P waves Are there P waves? Do the P waves all look alike? Do the P waves occur at a regular rate? Is there one P wave before each QRS? Interpretation? Normal P waves with 1 P wave for every QRS
- 27. Step 3: DeterminePR interval Normal: 0.12 - 0.20 seconds. (3 - 5 boxes) Interpretation?
- 28. Step 4: QRSduration Normal: 0.04 - 0.12 seconds. (1 - 3 boxes) Interpretation? 0.08 seconds
- 29. Step 5: CalculateRate: The ten times method (6 second strip) –For Regular or Irregular HR Several methods can be used. o Method 1 - 6 Second Interval x 10 o Method 2 - Rule of 300 o Method 3 - Rule of 1500
- 30. METHOD 1 6-Second intervalx 10 Count the number of QRS complexes or P wave over a 6 second interval. Multiply by 10 to determine heart rate. This method works well for both regular and irregular rhythms.
- 31. EXAMPLE METHOD 1 6-Secondinterval x 10 Count the number of R in 6 second strip and multiply that number by 10 e.g.: 7 × 10 = 70 beats per minute
- 32. For thistracing, determine the heart rate using the 6-second interval x 10 method Answer: 14 x 10 = 140 beats per minute. Practice Makes Perfect
- 33. METHOD 2 :Rule 300 Number of big box between R divided into 300 Fast but only for regular rhythms
- 34. EXAMPLE METHOD 2 300divided by number of large squares in one R-R interval 300 x 4 = 75 beats per minute.
- 35. Practice Makes Perfect Forthis tracing, determine the heart rate using the rule of 300 Number of big box between R divide into 300. e.g.: 300 ÷ 6 = 50 beats per minute
- 36. METHOD 3 :Rule 1500 • Only for regular rhythms. • Most accurate method. • Count the number of small square for a typical R-R interval. • Divide this number into 1500 to determine heart rate.
- 37. EXAMPLE METHOD 3 1500divided by 38 = 40 beats per minutes
- 38. Practice Makes Perfect •For this tracing, determine the heart rate using the 1500 method
- 39. REVISION RULES OF 300 ONLY FOR REGULAR RHYTHMS FAST CALCULATION RULES OF 1500 ONLY FOR REGULAR RHYTHMS MOST ACCURATE 6 SECONDS INTERVAL FOR BOTH REGULAR & IRREGULAR RHYTHMS” NUMBER OF P WAVE IN 6 SECONDS (30 LARGE SQUARE) X 10 Not very accurate & Used only for very quick estimate
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- 41. MODULE 3 :IDENTIFICATION OF RHYTHM AND TREATMENT (SINUS RHYTHM,SINUS DYSRHYTHMIAS AND NURSING MANAGEMENT)
- 42. Objectives ▪ Recognize sinusdysrhythmias on ECG and relate cause, significance, symptoms, and treatment.
- 43. Sinus Rhythms ♥ Rhythmsthat originate in the sinoatrial node (SA node) ♥ 5 Common Variations of a sinus rhythm: • Normal sinus rhythm (60 – 100 bpm) • Sinus bradycardia (< 60 bpm) • Sinus tachycardia ( >100 bpm) • Sinus arrhythmia (60 – 100 bpm)
- 44. Normal Sinus Rhythm Sinusrhythm is the normal regular rhythm of the heart set by the natural pacemaker of the heart called the sinoatrial node. It is located in the wall of the right atrium. Normal cardiac impulses start there and are transmitted to the atria and down to the ventricles.
- 45. 5 Steps toIdentify Normal Sinus Rhythm 1. What is the rate? 60-100 beats per minute 2. What is the rhythm? Atrial rhythm regular Ventricular rhythm regular 3. Is there a P wave before each QRS? Are P waves upright and uniform? Yes Yes 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes 0.06-0.12 seconds (1 ½ to 3 small squares)
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- 47. Normal Sinus RhythmNursing Interventions ▪ No interventions required!!Monitor patient if ordered by physician.
- 48. Sinus Bradycardia Sinus bradycardia isa regular but unusually slow heart beat (less than 60 bpm). Sinus bradycardia is often seen as a normal variation in athletes, during sleep, or in response to a vagal maneuver. Sinus Bradycardia
- 49. 5 Steps toIdentify Sinus Bradycardia Rhythm 1. What is the rate? Less than 60 beats per minute 2. What is the rhythm? Atrial rhythm regular Ventricular rhythm regular 3. Is there a P wave before each QRS? Are P waves upright and uniform? Yes Yes 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes 0.06-0.12 seconds (1 ½ to 3 small squares)
- 50. • Rhythm -Regular • Rate – Slow (<60 bpm) • QRS Duration - Normal • P Wave - Present • P-R Interval - Normal SINUS BRADYCARDIA
- 51. Causes and S/Sof Sinus Bradycardia Causes ▪ Hypoglycemia ▪ Hypothermia ▪ Hypothyroidism ▪ Previous cardiac history ▪ Medications ▪ Toxic exposure ▪ MI – Inferior wall involving right coronary artery Signs and Symptoms ▪ Syncope ▪ Dizziness ▪ Chest Pain ▪ Shortness of Breath ▪ Exercise Intolerance ▪ Cool, clammy skin
- 52. Risk and MedicalTx of Sinus Bradycardia Risk ▪ Reduced Cardiac Output Medical Treatment ▪ Atropine ▪ Pacing if the patient is hemodynamically compromised ▪ Treatment will be based on whether patient is symptomatic
- 53. Sinus Bradycardia Nursing Interventions Assesspatient – Are they symptomatic? Give oxygen and monitor oxygen saturation Monitor blood pressure and heart rate Notify consultant
- 54. Sinus Tachycardia Sinus Tachycardia isa fast heartbeat related to a rapid firing of the sinoatrial (SA) node. The clinical dysrhythmia depends on the underlying cause. It may be normal depending on the patient.
- 55. 5 Steps toIdentify Sinus Tachycardia Rhythm 1. What is the rate? 101-160 beats per minute 2. What is the rhythm? Atrial rhythm regular Ventricular rhythm regular 3. Is there a P wave before each QRS? Are P waves upright and uniform? Yes Yes 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes 0.06-0.12 seconds (1 ½ to 3 small squares)
- 56. Sinus Tachycardia • Rhythm- Regular • Rate - Fast (> 100 bpm) • QRS Duration - Normal • P Wave - Present • P-R Interval - Normal
- 57. Causes and S/Sof Sinus Tachycardia Causes ▪ Damage to heart tissues from heart disease ▪ Hypertension ▪ Fever ▪ Stress ▪ Excess alcohol, caffeine, nicotine, or recreational drugs such as cocaine ▪ A side effect of medications ▪ Response to pain ▪ Imbalance of electrolytes Signs and Symptoms ▪ Dizziness ▪ Shortness of breath ▪ Lightheadedness ▪ Rapid pulse rate ▪ Heart palpitations ▪ Chest pain ▪ Syncope
- 58. Risk and MedicalTx of Sinus Tachycardia Risk ▪ Cardiac output may fall due to inadequate ventricular filling time • Myocardial oxygen demand increases • Can precipitate myocardial ischemia or infarct Medical Treatment • Aimed at finding and treating cause
- 59. Sinus Tachycardia Nursing Interventions Assesspatient – Are they symptomatic? Are they stable? Give oxygen and monitor oxygen saturation Monitor blood pressure and heart rate Notify dr ACLS Protocol Look for the cause of the tachycardia and treat it Fever – give acetaminophe n or ibuprofen Stimulants – stop use (caffeine, OTC
- 60. Sinus Arrhythmia ▪ Sinusarrhythmia is a normal variation in the beating of your heart. A sinus arrhythmia refers to an irregular or disorganized heart rhythm. ▪ This rate usually increases with inspiration and decreases with expiration.
- 61. 5 Steps toIdentify Sinus Arrhythmias 1. What is the rate? 60-100 beats per minute 2. What is the rhythm? Irregular (varies more than 0.08 sec) 3. Is there a P wave before each QRS? Are P waves upright and uniform? Yes Yes 4. What is the length of the PR interval? 0.12-0.20 seconds (3-5 small squares) 5. Do all QRS complexes look alike? What is the length of the QRS complexes? Yes 0.06-0.12 seconds (1 ½ to 3 small squares)
- 62. Causes and S/Sof Sinus Arrhythmia Cause ▪ Heart disease ▪ Moderate to extreme stress ▪ Excessive consumption of stimulants like caffeine, nicotine, and alcohol ▪ Intake of medications like diet pills as well as cough and cold medicines Signs and Symptoms ▪ Usually asymptomatic
- 63. Risk and MedicalTx of Sinus Arrhythmia Risk ▪ Reduced cardiac output Medical Treatment ▪ Treatment is usually not required unless patient is symptomatic. If patient is symptomatic, find and treat the cause.
- 64. ANY QUESTIONS? ? ANYQUESTIONS ?
- 65. Module 3 :IDENTIFICATION OF RHYTHM & TREATMENT ATRIAL DYSRHTMIAS AND NURSING MANGEMENT
- 66. Learning outcome : 1.Identify specific cardiac dysrhythmias 2. Describe the appropriate nursing interventions for specific dysrhythmias
- 67. 1. When thesinoatrial (SA) node fails to generate an impulse; atrial tissues or internodal pathways may initiate an impulse 2. The 4 most common atrial arrhythmias include: • Atrial Flutter (rate varies; usually regular; saw-toothed) • Atrial Fibrillation (rate varies, always irregular) • Supraventricular Tachycardia (>150 bpm) • Premature Atrial Complexes (PAC’s) Atrial Rhythms
- 68. 1. Atrial flutteris a coordinated rapid beating of the atria. Atrial flutter is the second most common tachyarrhymia. Atrial Flutter
- 70. Causes and Signand symptom of Atrial Flutter Causes ▪ > 60 years old ▪ Valve disorder (mitral) ▪ Thickening of the heart muscle ▪ Ischemia ▪ Cardiomyopathy ▪ COPD ▪ Emphysema Signs and Symptoms • Palpitations • SOB • Anxiety • Weakness • Angina • Syncope
- 71. Risk and MedicalTx for Atrial Flutter Risk ▪ Clot formation in atria (atria not completely emptying) ▪ Stroke ▪ Pulmonary Embolism ▪ Dramatic drop in cardiac output Medical Treatment ▪ Synchronised Cardioversion – treatment of choice ▪ Antiarrhymics such as amiodarone to convert the flutter ▪ Slow the ventricular rate by using diltiazem, verapamil, digitalis, or beta blocker ▪ Heparin to reduce incidence of thrombus formation
- 72. Atrial Flutter NursingInterventions ▪ Assess Patient ▪ O2 if not already given ▪ Start IV if not already established and hang NS ▪ Notify doctor ▪ Prepare for synchronized cardioversion or drug therapy
- 73. Atrial Fibrillation • Theelectrical signal that circles uncoordinated through the muscles of the atria causing them to quiver (sometimes more than 400 times per minute) without contracting. The ventricles do not receive regular impulses and contract out of rhythm, and the heartbeat becomes uncontrolled and irregular. It is the most common arrhythmia, and 85 percent of people who experience it are older than 65 years.
- 75. Causes and signand symptom of Atrial Fibrillation Causes ▪ Hypoxia ▪ Hypertension ▪ Congestive heart failure ▪ Coronary artery disease ▪ Dysfunction of the sinus node ▪ Mitral valve disorders ▪ Rheumatic heart disease ▪ Pericarditis ▪ Hyperthyroidism ▪ Excessive alcohol or caffeine consumption Signs and Symptoms ▪ Heart palpitations ▪ Irregular pulse which feels too rapid or too slow, racing, pounding or fluttering ▪ Dizziness or light-headedness ▪ Fainting ▪ Confusion ▪ Fatigue ▪ Trouble breathing ▪ Difficulty breathing when lying down ▪ Sensation of tightness in the chest
- 76. Risk and MedicalTx of Atrial Fibrillation Risk ▪ Clot formation in atria (atria not completely emptying) ▪ Stroke ▪ Pulmonary Embolism ▪ Dramatic drop in cardiac output Medical Treatment ▪ Rate control (slow ventricular rate to 80- 100 beats/minute) ▪ Digoxin ▪ Beta-adrenergic blockers ▪ Calcium channel blockers ▪ Example - Verapamil (give IV if needed for quick rate control) ▪ Antiarrhymics such as amiodarone to convert the fibrillation ▪Synchronized cardioversion
- 77. ▪ Assess Patient ▪O2 if not already given ▪ Start IV if not already established and hang NS ▪ Notify doctor ▪ Prepare for synchronized cardioversion or drug therapy Atrial Flibrillation Nursing Interventions
- 78. Supraventricular Tachycardia (SVT) Encompassesall fast (tachy) dysrhythmias in which heart rate is greater than 150 beats per minute (bpm)
- 80. Causes and Signand symptom of SVT Causes ▪ Find underlying cause • Stimulants • Hypoxia • Stress or over-exertion • Hypokalemia • Atherosclerotic heart disease Signs and Symptoms ▪ Palpitations ▪ Chest discomfort (pressure, tightness, pain) ▪ Lightheadedness or dizziness ▪ Syncope ▪ Shortness of breath ▪ A pounding pulse. ▪ Sweating ▪ Tightness or fullness in the throat ▪ Tiredness (fatigue) ▪ Excessive urine production
- 81. Risk and MedicalTx of SVT Risk ▪ Heart failure with prolonged SVT Medical Treatment ▪ Stable patient’s (asymptomatic) ▪ Vagal maneuvers ▪ Drug management ▪ Adenosine 6+12+12 ▪ Synchronized Cardioversion if unstable
- 82. SVT Nursing Interventions ▪Assess Patient ▪ O2 if not already given ▪ Start IV if not already established and hang NS ▪ Notify doctor ▪ Prepare for synchronized cardioversion or drug therapy
- 83. Premature Atrial Contractions (PAC’s) ▪A PAC is not a rhythm, it is an ectopic beat that originates from the atria. ▪ Normal beat, but just occurs early!
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- 87. Cause and signand symptom PAC’s Cause ▪ Occurs in healthy patients without heart disease ▪ Stress ▪ Stimulants ▪ Hypertension ▪ Valvular condition ▪ Infectious diseases ▪ Hypoxia Signs and Symptoms ▪ Palpitations ▪ Skipped beat
- 88. Risk and MedicalTx PAC’s Risk ▪ Most benign – no risk ▪ May be a sign of underlying heart condition Medical Treatment ▪ No treatment necessary if asymptomatic ▪ Treat the cause • Drug therapy • Beta Blockers Calcium Channel Blockers
- 89. PAC Nursing Interventions ▪Assess patient ▪ Monitor patient
- 90. MODULE 3 :IDENTIFICATION OF RHYTHM & TREATMENT JUNCTIONAL DYSRHYTMIAS AND NURSING MANAGEMENT
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- 100. MODULE 3 :IDENTIFICATION OF RHYTHM AND MANAGEMENT VENTRICULAR DYSRHYTMIAS AND MANAGEMENT
- 101. • Introduction • PrematureVentricular Contractions ( PVC ) • Ventricular Tachycardiac ( VT ) • Ventricular Fibrillation ( VF ) • Ventricular Asystole ( Cardiac Standstill )
- 102. Introduction • Is adisturbance in the normal rhythm of the electrical activity of the heart that arises in the ventricles • In US, approximately 300,000 cases of sudden cardiac death occurs each year • up to one-third are attributable to ventricular fibrillation (VF) • People who have survived a major cardiac event • such as myocardial infarction or cardiac arrest • are at increased risk for VF up to 2 years after the event
- 103. • Types ofventricular dysrhythmias include :- • Premature Ventricular Contractions ( PVCs ) • which can have one focus or can arise from multiple foci • Ventricular Tachycardia ( VT ) • which can lead to VF or sudden cardiac death • Ventricular Fibrillation ( VF ) • which results in death if not treated immediately • Ventricular asystole (cardiac standstill) • which no cardiac output occurs and full cardiopulmonary arrest results
- 105. Premature Ventricular Contractions •Early ectopic beats that arise from the ventricles • Atrial rate: Regular • Ventricular rate: Irregular • QRS complex: Wide and distorted, usually longer than 0.14 sec • Occurrence: Single, in pairs, or alternating with regular sinus beats
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- 108. Sinus Rhythm withBigeminy Unifocal PVCs
- 109. Sinus Rhythm withTrigeminy Unifocal PVCs
- 110. Sinus Rhythm withQuadgeminy Unifocal PVCs
- 111. Sinus Rhythm withMultifocal Couplet PVCs
- 112. Sinus Rhythm withRun of Ventricular Tachycardia (triplet PVCs)
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- 115. Ventricular Tachycardiac • Threeor more premature ventricular contractions in a row dissociated from the atrial contraction • P waves: In sustained VT, none are identifiable; usually buried within aberrant, bizarre ventricular contractions • Ventricular rate: Usually 100–220 beats per min • Ventricular rhythm: May start and stop suddenly
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- 121. • Pulse ? •Stable or Unstable ?
- 122. Signs and Symptoms •Hypotension • Acute altered mental status • Signs of shocks • Chest discomfort • Acute heart failure
- 126. Ventricular Fibrillation •Disorganized, ineffectivecontraction of the ventricle •P waves: None •QRS complex: None •Ventricular rhythm: Chaotic rhythm with a wavy baseline
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- 133. SHOCK ENERGY • Biphasic: 120 – 200 J • Monophasic : 360 J • Important : Safety – announce firmly, clearly, facing patient
- 134. REVERSIBLE CAUSES Hypovolemia TensionPneumothorax Hypoxia Tamponade ( Cardiac ) Hydrogen Ion ( Acidosis ) Toxins Hypo / Hyperkalemia Thrombosis, Pulmonary Hypothermia Thrombosis, Coronary
- 135. Ventricular Asystole • Atrialrhythm: None • P, QRS, T waves: None • Ventricular rhythm: None
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- 139. MODULE 3 :IDENTIFICATION OF RHYTHM AND MANAGEMENT AV BLOCK AND NURSING MANAGEMENT
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- 148. 148 MOBITZ TYPE 1/ WENKEBACH
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