1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 8 Advanced Cardiovascular Monitoring Skills

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Automatic Blood Pressure Monitoring

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Arterial Pressure Monitoring

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Observations to Report to the Nurse Immediately The sterile dressing covering the insertion site is loose, wet, or soiled There is redness, swelling, drainage, or bleeding at the insertion site There is blood in the tubing The tubing is disconnected There has been a change in the position of the patient or the bed (in other words, the transducer needs to be leveled and zeroed) There is a change in the waveform or pressure reading on the monitor The patient complains of pain, numbness, or tingling in the hand The patient’s hand is pale, blue, or cold

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Telemetry

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Myocardial Cell

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What is a dysrhythmia? A.Irregular rate only B.Irregular rhythm only C.Irregular rate and rhythm D.Can be either or both irregular rate or rhythm

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Can be either or both irregular rate or rhythm A dysrhythmia is an irregular heart rate, rhythm, or both. Remember that for the heart to be an effective pump, it must contract in two coordinated phases (atrial systole/ventricular diastole, followed by ventricular systole/atrial diastole). Rhythms that are irregular or rates that are too fast can affect the ventricles’ ability to fill with an adequate amount of blood or pump strongly enough to send the blood out of the heart.

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Sinoatrial Node (Sinus) Dysrhythmias Sinus bradycardia: in sinus bradycardia, the SA node fires electrical impulses at a rate that is slower than normal (that is, less than 60 impulses per minute in an adult) Sinus tachycardia: in sinus tachycardia, the SA node fires electrical impulses at a rate that is faster than normal (that is, greater than 100 impulses per minute in an adult)

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Atrial Dysrhythmias Atrial flutter: in atrial flutter, atrial contraction (represented by the P waves on the ECG) is regular but faster than normal (250 to 400 times per minute) Atrial fibrillation: is caused by rapid, uncoordinated twitching of the myocardium of the atria; in atrial fibrillation, the P waves are irregular and small, and they occur at a rapid rate all along the ECG

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question: The person with atrial fibrillation may feel which of the following? A.Light-headed with palpitations B.Unconscious C.Nothing because there are no symptoms D.Muscle movements may be uncoordinated

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A. Light-headed with palpitations The ventricular rhythm is usually very irregular, and the rate of ventricular contraction is high (usually between 120 and 200 times per minute). When the ventricular rate is so rapid, the ventricles are not able to fill adequately with blood between beats. As a result, the maximum amount of blood is not sent out to the body with each beat. The person may feel light-headed and complain of chest palpitations (awareness that the heart is beating).

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Atrioventricular Junction Dysrhythmias Junctional rhythm: occurs if the SA node fails to fire and send an electrical impulse through to the AV node or if the SA node fires the impulse too slowly Atrioventricular nodal re-entry tachycardia: impulses that are conducted to the AV node get “rerouted” along another conduction pathway back to the AV node over and over again at a rapid rate

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Ventricular Dysrhythmias Premature ventricular contraction Ventricular tachycardia Ventricular fibrillation

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Atrioventricular Blocks First-degree atrioventricular block Second-degree atrioventricular block * Type I - Wenckebach rhythm * Type II - Mobitz type I rhythm Third-degree atrioventricular block (Mobitz type II rhythm)

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Observations to Report to the Nurse Immediately The PR interval is longer than it was earlier The ST interval changes The QRS complex has changed in shape or widened The tracing does not return to the baseline in between the QRS complex and the T wave The T wave has increased in size or changed the direction of deflection The ECG shows a new dysrhythmia that was not there before The person complains of chest pain or discomfort The person complains of shortness of breath The person complains of dizziness The person is unconscious

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Artifacts Can Be Caused by: Electrical interference from other electrical equipment (such as an electric razor) or monitoring devices in the area Loose electrodes, especially if the person is diaphoretic (sweating) or has recently been repositioned Electrodes that have dried out Electrodes that have been placed over an excessively hairy area Defective monitor or lead wires Patient movement (for example, from shivering or brushing the teeth)

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question What are abnormal ECG tracings that do not represent the heart’s electrical activity? A.AV block B.Dysrhythmia C.Artifact D.Bundle of His

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Artifact Artifact can be caused by electrical interference from other electrical equipment (such as an electric razor) or loose electrodes, especially if the person is diaphoretic (sweating) or has recently been repositioned.

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question: In a 12-lead ECG, how many electrodes are placed on the chest? A.12 B.4 C.10 D.3

21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. 10 A 12-lead ECG is used to diagnose a heart condition. A 12- lead ECG uses 10 electrodes.