Telemetry Interpretation

Telemetry Interpretation

1Anatomy and Physiology ReviewHeartAtriaVentriclesValvesCardiac Cycle

http://www.bostonscientific.com/lifebeat-online/heart-smart/how-your-heart-works.html?2Electrophysiology ElectricalAutomaticityAbility to initiate an electrical impulse spontaneously and repetitively (pacemaker)ExcitabilityAbility of non-pacing cells to respond to electrical impulse and to depolarize ConductivityAbility to transmit an electrical stimulus from cell to cell leading to rapid succession of depolarization (contraction)MechanicalContractilityAbility of atria and ventricles to contract (shorten muscle fiber length in response to electrical stimulation, generate pressure to propel blood forward)

3Electrical ConductionElectrical ConductionSA NodeInternodal PathwaysIntra-atrial Pathways (Bachmanns Bundle)AV NodeBundle of HisBundle BranchesLeft and RightPurkinje Fibers

http://www.bostonscientific.com/lifebeat-online/heart-smart/electrical-system.html?4MonitoringTypesContinuousIntermittentLeadsI, II, III, avF, avr, avl, mcl12 leads (V1, V2, V3, V4, V5, V6)

5Standard Limb Leads

Lead Placement

12-Lead

5-Lead

MonitoringElectrodesApplied to non-bony surfacesAvoid hairy areasGelBatteriesArtifact

EKG Paper LayoutHash mark to hash mark equals 3 seconds (depending on telemetry paper used)Thick line to thick line equals 0.20 secSmall box to small box equals 0.04 sec

Rhythm Strip ComponentsP waveP-R IntervalQRS ComplexST SegmentT WaveU Wave

P-waveP-wave represents atrial depolarization (contraction)Smooth and roundUpright Precedes each QRS complexPresent or absentDoes every p-wave have a QRS complex following it?

PR IntervalMeasured from the beginning of the P wave to the beginning of the QRS complex (AV conduction)Interval 0.12 0.20 secondsIntervals greater than 0.20 seconds is indicative of a heart block

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QRS ComplexQRS complex represents ventricular depolarization (contraction)Measured from Q-wave to S-wave at the baselineNormal time interval 0.04-0.12 secLonger interval could be result of medication or cardiac disease (MI)Is there a QRS complex after EVERY P-wave?

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ST SegmentST segment represents the end of ventricular depolarization and the beginning of repolarizationMeasured from the end of the S-wave to the beginning of the T-waveNormal time interval 0.08-0.12 secSlight upward shape (slope)However, time is not as significant as the shape and direction Elevation or depression could be the result of infarction, ischemia or electrolyte imbalances

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T waveT wave represents ventricular repolarization (recovery/relaxation)Measured from the beginning of the T-wave to the return of the T-wave to the baselineRound, smooth, slightly asymmetrical and uprightLarger than a P waveAbnormalitiesInversionTall and peakedFlat

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Other Wave Forms QT IntervalTotal time required for ventricular depolarization and repolarizationMeasure from beginning of QRS to the end of the T waveNormal time interval < 0.44 secondsU-waveWhen present follows the T waveSeen more often in Lead 3Suggest electrolyte imbalance (K)

21EKG Strip Interpretation Things to consider:RhythmRegular or irregularRateP-wave Present for every QRS complexShapePR IntervalQRS length**Others if needed QT interval or U waveInterpretation

Determining RhythmExamine the distance between wave forms and then determine if regularly spacedAtrial RhythmMeasure the P-P intervalVentricular Rhythm **Measure the R-R intervalAny variation the rhythm is irregular

**Most commonly used

23RateSA nodePacemaker of the heartRate 60-100Sympathetic and ParasympatheticAV nodeBack up pacemakerRate 40-60Sympathetic and ParasympatheticBundle of His and Purkinje fibersRate 20-40Sympathetic only

Determining Heart Rate (Method 1)If the rhythm is regularCount the number of QRS complexes in a 6 second strip, multiply by 10

3 hash marks (6 second strip)

Six second count25Determining Heart Rate (Method 2)If the rhythm is irregularCount the number of small boxes between QRS complexes and divide into 1500Must use the longest and shortest complexes to determine heart rate range 1500 # small boxes from 1 QRS complex to the next complex

Little Block method26Determining Heart Rate (Method 3)One large box, the heart rate is 300 BPM (300/1) Two large boxes, the heart rate is 150 BPM (300/2) Three large boxes, the heart rate is 100 BPM (300/3) Four large boxes, the heart rate is 75 BPM (300/4)

27Big block method/Memory MethodRhythm PatternsSinus RhythmsRhythm regular (R-R and P-P)Rate 60 - 100P WaveRound, smooth, upright, precedes each QRS complexPR Interval0.12 0.20 secondsQRS Complex0.04 -0.12 secondsTreatmentNone, unless symptomatic

Normal Sinus RhythmRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

30RhythmRegularRate100P waverounded, upright and precedes each QRS complexPR Interval0.16 secondsQRS complex0.08 secondsInterpretation Normal sinus rhythmTreatmentNoneSinus TachycardiaRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

31RhythmRegularRate120 (12x10)P wavesrounded, upright, precedes each QRS complexPR Interval0.16 secondsQRS Complex0.08 secondsInterpretationSinus TachycardiaTreatmentTreat the cause

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 Hyperthyroidism

Signs and Symptoms Dizziness Shortness of breath Lightheadedness Rapid pulse rate Heart palpitations Chest pain Syncope

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

Nursing InterventionsAssess patient Are they symptomatic? Are they stable? Give oxygen and monitor oxygen saturation Monitor blood pressure and heart rate Start IV if not already established Notify MD

Sinus BradycardiaRhythmRateP WavePR IntervalQRS ComplexInterpretations

32RhythmRegularRateappx. 45 (the last QRS complex is not complete)P wavesmall, rounded, upright precedes each QRS complexPR Interval0.20 secondsQRS complex0.12 secondsInterpretationSinus BradycardiaTreatmentIf symptomatic, see below

Causes Hypoglycemia Hypothermia Hypothyroidism Previous cardiac history Medications Toxic exposure MI Inferior wall involving right coronary artery

Signs and Symptoms Syncope (Blackouts fainting)Dizziness Chest Pain Shortness of Breath Exercise Intolerance Cool, clammy skin

Risk Reduced Cardiac Output

Medical Treatment Atropine Pacing if the patient is hemodynamically compromised Treatment will be based on whether patient is symptomatic

Nursing InterventionsAssess patient Are they symptomatic? Give oxygen and monitor oxygen saturation Monitor blood pressure and heart rate Start IV if not already established Notify MD

Sinus Rhythms

Sinus arrhythmia 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.

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

Risk Reduced cardiac output

Medical Treatment Treatment is usually not required unless patient is symptomatic. If patient is symptomatic, find and treat the cause.

A sinus pause or arrest is defined as the transient absence of sinus P waves that last from 2 seconds to several minutes.

Causes This may occur in individuals with healthy hearts during sleep Myocarditis Cardiomyopathy MI Digitalis toxicity Age- elderly Vagal stimulation

Signs and Symptoms Sometimes asymptomatic Syncope Dizziness LOC Bradycardia

Risk Sudden cardiac death (rare) Syncope Fall Thromboembolic events including stroke CHF Atrial tachyarrhythmias - such as atrial flutter or fibrillation

Medical Treatment Only treated if patient symptomatic Atropine Pacemaker

Nursing Interventions Assess Patient Give oxygen and monitor oxygen saturation Monitor blood pressure and heart rate Start IV if not already established Notify MD

33An older client has been taking metoprolol (Toprol) for hypertension for the past 3 days. Her daughter states that she has become confused, dizzy, and weak since starting the drug. How will the telephone triage nurse respond to the daughters concerns?

Shes getting older, so confusion is common with aging.Did your mother pass out at any time in the past few days?Tell your mother to stop taking the metoprolol for a week.Tell your mother to only take half of the drug today.Rationale: The nurse should assess for syncopal episodes related to bradycardia. Metoprolol (Toprol) is a beta-blocker and can lead to a decreased heart rate. Symptoms related to bradycardia may also include dizziness and weakness, confusion, hypotension, diaphoresis, shortness of breath, and chest pain. Confusion should not be dismissed as simply age-related. The client should not abruptly stop taking metoprolol because it may cause serious side effects such as chest pain or a myocardial infarction. The drug should be gradually decreased if it is to be discontinued. The nurse will need to confer with the provider regarding a change in the dose. Before contacting the provider, the nurse should first assess for other symptoms that may be related to bradycardia.

34Atrial RhythmsRhythmRegular, irregular or irregularly irregularRate40-60 beats/minute (can be as high as 250-300 beats/minute)P WaveSaw tooth (F) or irregularly shaped (f)PR Interval Not measurableQRS Complex0.04 0.12 seconds

35Atrial FlutterRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmRegularRate100/70P Wave None (F waves)PR IntervalNot measurable (F waves)QRS Complex0.04 secondsInterpretationAtrial flutter with 2:1/3:1 ratio

Atrial FlutterAtrial flutter is a coordinated rapid beating of the atria. Atrial flutter is the second most common tachyarrhymia.

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

Risk Clot formation in atria (atria not completely emptying) Stroke Pulmonary Embolism Dramatic drop in cardiac output

Medical Treatment Cardioversion treatment of choice Antiarrhymics such as procainamide to convert the flutter Slow the ventricular rate by using diltiazem, verapamil, digitalis, or beta blocker Heparin to reduce incidence of thrombus formation

Nursing InterventionsAssess Patient O2 if not already given Start IV if not already established and hang NS Notify MD Prepare for cardioversion

36Atrial FibrillationRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

37http://www.youtube.com/watch?v=TnCHQiMGwhw

RhythmIrregularly irregularRate68-125 beats/minP Waveunmeasurable (f waves)PR Interval unmeasurable (f waves)QRS Complex0.04 secondsInterpretationAtrial fibrillation

The electrical signal that circles uncoordinated through the muscles of the atria causing them to quiver (sometimes more than 300-600 times per minute) without contracting. The ventricles do not receive regular impulses and contract out of rhythm, and the heartbeat becomes uncontrolled and irregular. Ventricular response (rapid if > 100 beats per minute)

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

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) Antithrombotic therapy Correction of rhythm Chemical or electrical cardioversion

Amiodarone hydrochloride (Cordarone)Used for AF, PAF, PSVT, life-threatening ventricular dysrhythmias300 mg IV push for cardiac arrest in VF/pulseless VT150 mg IVP over 10 min (15 mg/min), followed by 360 mg IV over next 6 hr (1 mg/min), followed by 540 mg IV over next 18 hr (0.5 mg/min)After first 24 hr, continue maintenance infusion of 720 mg/24 hr (0.5 mg/min)Monitor for return of rhythm and pulse when used for recurrent unstable VT or VF.Return of rhythm and pulse is the expected response.Use with extreme caution in patients receiving other antidysrhythmics.Amiodarone reduces the hepatic and renal clearance of certain antidysrhythmics, specifically procainamide, quinidine, and flecainide.Use caution in patients with pulmonary, hepatic, or thyroid disease.Amiodarone can cause fatal toxicity, especially in patients receiving more than 600 mg daily.Perform continuous cardiac monitoring while the patient is receiving the loading dose.There is a slow onset of antidysrhythmic effect and a high risk for life-threatening dysrhythmias.

Nursing InterventionsAssess Patient O2 if not already given Start IV if not already established and hang NSMonitor coagulation levels (PT, PTT)Observe for bleedingNotify MD Prepare for cardioversion

Other Atrial Rhythms

http://www.youtube.com/watch?v=04mpSKZGkG0

Adenosine38Other Common DysrhythmiasPremature Atrial contractions (PACs)

A PAC is not a rhythm, it is an ectopic beat that originates from the atria. Normal beat, but just occurs early!

Cause Occurs in healthy patients without heart disease Stress Stimulants Hypertension Valvular condition Infectious diseases Hypoxia

Signs and Symptoms Palpitations Skipped beat

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

Nursing InterventionsAssess patient Monitor patient

39Ventricular RhythmsRhythmRegular or irregularRateGreater than 150 beats/minutes, may not be measurableP WaveAbsentPR IntervalAbsentQRS ComplexWide, bizarre

Ventricular TachycardiaRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmRegularRate>130P WaveNonPR IntervalNoneQRS ComplexWide and bizarreInterpretationVentricular Tachycardia

Ventricular tachycardia almost always occurs in diseased hearts. Rhythm in which three or more PVCs arise in sequence at a rate greater than 100 beats per minute. V-tach can occur in short bursts lasting less than 30 seconds, causing few or no symptoms. Sustained v-tach lasts for more than 30 seconds and requires immediate treatment to prevent death. V-tach can quickly deteriorate into ventricular fibrillation.

Causes Usually occurs with underlying heart disease Commonly occurs with myocardial ischemia or infarction Certain medications may prolong the QT interval predisposing the patient to ventricular tachycardia Electrolyte imbalance Digitalis toxicity Congestive heart failure

Signs and Symptoms Chest discomfort (angina) Syncope Light-headedness or dizziness Palpitations Shortness of breath Absent or rapid pulse Loss of consciousness Hypotension

Risk Major cause of sudden cardiac death

Medical Treatment If there is no pulse, begin CPR and follow ACLS protocol If there is a pulse and the patient is unstable - cardiovert and begin drug therapy Amiodarone Lidocaine With chronic or recurrent VT Give antiarrhythmics Long term may need ICD placed Ablation may be used for reentry

Nursing InterventionsAssess your patient If symptomatic, treatment must be aggressive and immediate Pulse present Oxygen Patent IV (preferably x2) Monitor patient very closely Pulseless Call Code Blue Begin CPR Defibrillate ASAP Start IV if not already established and hang NS Notify MD

41Ventricular FibrillationRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmIrregularRateUnmeasurableP WaveUnmeasurablePR IntervalUnmeasurableQRS ComplexUnmeasurableInterpretationVentricular Fibrillation

V-Fib (coarse and fine) Occurs as a result of multiple weak ectopic foci in the ventricles No coordinated atrial or ventricular contraction Electrical impulses initiated by multiple ventricular sites; impulses are not transmitted through normal conduction pathway

Causes AMI Untreated VT Electrolyte imbalance Hypothermia Myocardial ischemia Drug toxicity or overdose Trauma

Signs and Symptoms Loss of consciousness Absent pulse

Risk Death

Medical treatment CPR with immediate defibrillation Initiate ACLS algorithm

Nursing Interventions

Assess your patient Many things can mimic v-fib on a monitor strip such as electric razor or shivering You must check your patient! Treatment must be aggressive and immediate Start CPR/ACLS Call a Code Blue Defibrillate ASAP Start IV if not already established and hang NS Notify MD

42Ventricular AsystoleRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

Asystole or Agonal rhythm is when the rhythm is 20 beats or less per minute. Frequently is seen as the last-ordered semblance of a heart rhythm when resuscitation efforts are unsuccessful

Causes Trauma Acute MI Natural progression to death

Signs and Symptoms Loss of consciousness No palpable pulse or measurable BP

Risk Death

Medical Treatment CPR/ACLS Protocol If life saving efforts have already been attempted no further treatment

Nursing InterventionsMake sure their arent any loose leads or leads that have come off the patient Call a Code Blue Start CPR Notify MD If death is the expected outcome: Monitor vital signs Record rhythm progression Support family and friends

Epinephrine (Adrenalin)Used for asystole, VF, VT, PEA, hypotension, anaphylaxis1-mg IV bolus followed by 20-mL saline flush every 3-5 minMonitor for return of rhythm and pulse when used for asystole or VF.Return of rhythm and pulse is the expected response.Assess for tachycardia, dysrhythmias, or hypertension.Adverse reactions can occur with a dramatic response.43Other Common DysrhythmiasPremature Ventricular contractions (PVCs)

Bigeminy

Couplets

A PVC is not a rhythm, but an ectopic beat that arises from an irritable site in the ventricles. PVCs appear in many different patterns and shapes, but are always wide and bizarre compared to a normal beat

Causes Exercise Stress Caffeine Heart disease: MI, CHF, Cardiomyopathy, Mitral valve prolapse Electrolyte imbalances Hypoxia Tricyclic antidepressants Digitalis toxicity

Signs and Symptoms Palpitations Weakness Dizziness Hypotension

Risk Reduced cardiac output Heart failure May convert to V-Tach or V-Fib

Treatment Oxygen Treat the cause Lidocaine is the drug of choice, although procainamide is sometimes used

Nursing InterventionAssess patient O2 at 2 liters; Oxygen may abate the PVCs Start IV if not already established and hang NS Monitor for frequent PVCs and deterioration to more serious rhythms (e.g. Ventricular tachycardia)

44A client is on a cardiac monitor. The nurse suddenly notices there are no ECG complexes and the alarm sounds. What is the priority action of the nurse?

Call a code blue and shout for help.Begin chest compressions and ventilations.Assess the client and check lead placement.Press the record button to get an ECG strip.Rationale: The first action to take when the monitor does not display a complex and the alarm sounds is check for the placement of leads. A lead that has come off the clients chest wall will cause the monitor to alarm. It is not unusual for a lead to be displaced due to diaphoresis, movement, or poor attachment. Checking the placement of leads should be done before beginning CPR, calling for help, instituting a code blue, or using the ECG machine for assessment.

45Heart block and Pacers

Pacemaker spike

46PacemakersUsesType TemporaryPermanent MaintenanceNursing Responsibility

http://www.youtube.com/watch?v=3il0ii7Svwk

Temporary pacing is a nonsurgical intervention that provides a timed electrical stimulus to the heart when either the impulse initiation or the conduction system of the heart is defective. The electrical stimulus then spreads throughout the heart to depolarize the cells, which should be followed by contraction and cardiac output. Electrical stimuli may be delivered to the right atrium or right ventricle (single-chamber pacemakers) or to both (dual-chamber pacemakers).

When a pacing stimulus is delivered to the heart, a spike (or pacemaker artifact) is seen on the monitor or ECG strip. The spike should be followed by evidence of depolarization (i.e., a P wave, indicating atrial depolarization, or a QRS complex, indicating ventricular depolarization). This pattern is referred to as capture, indicating that the pacemaker has successfully depolarized, or captured, the chamber.

Permanent pacemakerSee handout in blackboard on nursing care of client post pacemaker47A client reports not feeling well for the past week after taking digoxin (Lanoxin), which was prescribed a month ago. Which statement by the client indicates possible digoxin toxicity?

I am short of breath and my hands are swollen.I have chest pain and tingling in my fingers.I am constipated and have trouble sleeping.I have double vision and feel sick to my stomach.48LETs PRACTICELets PracticeRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmRegularRate115 bpm/regular P wavesround, upright and precede each QRS complexPR interval 0.18 sec QRS duration 0.06 sec Identification Sinus tachycardia TreatmentNone, treat the cause50Lets PracticeRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmRegularRate 214 bpm P wavesUnable to determine PR interval Unable to determine QRS duration 0.14 sec Identification Monomorphic ventricular tachycardia

51Lets PracticeRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmIrregularRate55 to 94 bpm P wavesunable to determinePR interval Unable to determine QRS duration 0.10 sec Identification Atrial fibrillation (controlled)

52Lets PracticeRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmRegularRate 88 bpmP wavesUnable to determine PR interval Unable to determine QRS duration 0.06 sec Identification Atrial flutter with ST-segment depression

53Lets PracticeRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

RhythmRegular except for PVCs (irregular)Rate 107 bpmP wavesround and upright present before every QRS except at the PVCsPR interval 0.20 sec (sinus beats) QRS duration 0.08 sec (sinus beats) Identification Sinus tachycardia with uniform PVCs

54Lets PracticeRhythmRateP WavePR IntervalQRS ComplexInterpretationTreatment

Rhythm Regular Rate60 bpm/regular PR interval 0.20 sec QRS duration 0.06 sec Identification Sinus rhythm 55ReferencesBorgelt, E., & Overmyer, A. (2006). Basic cardiac rhythms: Identification and response. Mosby, Inc.Ignatavicius, D. & Workman, M.L. (2013). Critical Thinking Study Guide to Accompany Medical-Surgical Nursing. (7th ed.). St. Louis, MO: Mosby Elsevier.