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Get prepared to celebrate certified nurses with free resources and recognition ideas. Remember Me. Lead II: ground electrode on the left shoulder, negative electrode on right shoulder, and positive electrode on the left lower rib cage. Right and left arm electrodes are placed on the shoulders and right and left leg electrodes are placed low on the thorax or on the hips.
To monitor in MCL1, select lead I on the bedside monitor. Adapted from Drew BJ. Bedside electrocardiogram monitoring. Standard placement is shown here on wrists and ankles. B Chest electrode placement.
There are 25 little boxes between these two R waves. There are little boxes in a second strip. Heart rate can also be determined for a regular rhythm counting large boxes between R waves.
There are large boxes in a second strip. B Heart rate determination for a regular or irregular rhythm using the number of RR intervals in a 6-second strip and multiplying by There are seven RR intervals in this exam- ple.
Electrocardiography and vectorcardiography. Cardiac Nursing 3rd ed. When present, they precede every QRS complex and are consistent in shape. When the sinus node fails to form impulses, there is no heart rate.
PACs necessary. Very early procainamide can be used PACs may find the AV junction still partially refractory and unable to conduct at a normal if necessary. Conduction through the AV node, bundle branches, and ventricles is usually normal unless the PAC is very early. PACs conducted normally in the ventricle.
PACs conducted abnormally in the ventricle. At least three different P-wave shapes use atropine. Conduction through the bundle branches and ventricles is usually normal.
QRS complex but may be hidden in preceding T wave. In atrial rate. Ventricular rhythm may be regular or irregular of arrhythmia. One F wave is usually hidden in the QRS complex, and when output. Atrial activity is chaotic with no formed atrial impulses visible. Most of the atrial impulses are blocked within the AV junction. Those impulses successful. If an atrial impulse reaches the bundle branch system during its refractory period, aberrant intraventricular conduction can occur.
Sinus rhythm is usually not interrupted by the used, but, if desired, lidocaine, premature beats, so sinus P waves can often be seen occurring regularly amiodarone, procainamide, throughout the rhythm. May vary in morphology size, shape if they originate from more than one focus in the ventricles. Impulses originating in the ventricles conduct via muscle cell-to-cell conduction, resulting in the wide QRS complex. If sinus rhythm is the underlying basic rhythm, regular P waves or magnesium should are often buried within QRS complexes.
Ventricles are not contracting. IV antiarrhythmic that facilitates conversion to prevent recurrence. There is no conduction into the ventricles.
Ventricular conduction is normal. Some P waves are not conducted to the ventricles, but only one rate, and symptoms. The PR interval preceding the ventricular rate.
Conduction ratios can vary, with ratios as low as every blockers, and calcium channel other P wave is blocked , up to high ratios such as every 15th P wave blockers.
Periodically a P wave is not followed by a QRS complex. The PR interval preceding the pause is the same as that following the pause. Conduction through the ventricles is abnormally slow due to associated bundle branch block.
Conduction ratios can vary from to only occasional blocked beats. Two or more consecutive atrial impulses fail to conduct to the ventricles.
Ventricular conduction is normal in type I and abnormally slow in type II advanced blocks. All impulses are blocked at the AV node or in the bundle branches, so there is no conduction to the ventricles. Conduction through the ventricles is normal if a junctional escape rhythm occurs, and abnormally slow if a ventricular escape rhythm occurs.
Control of heart rate using either a beta-blocker or nondihydropyridine CCB in most cases for patients with persistent or permanent AF Level B. Administration of AV nodal blocking agents is recommended to achieve heart rate control in patients who develop postoperative AF Level B. In the absence of preexcitation, IV administration of beta-blockers esmolol, metoprolol, or propranolol or nondihydropyridine CCBs verapamil, diltiazem to slow ventricular response to AF in the acute setting, exercising caution in patients with hypotension or HF Level B.
IV administration of digoxin or amiodarone to control heart rate in patients with AF and HF who do not have an accessory pathway Level B. Oral digoxin is effective to control heart rate at rest and is indicated for patients with HF, LV dysfunction, or for sedentary individuals Level C.
Preventing Thromboembolism 1. Antithrombotic therapy is recommended for all patients with AF except those with lone AF or contraindications Level A.
For patients without mechanical heart valves at high risk of stroke prior stroke, TIA, or systemic embolism; rheumatic mitral stenosis , chronic oral anticoagulant therapy with a vitamin K antagonist is recommended in a dose to achieve the target INR of 2. INR should be determined at least weekly during initiation of therapy and monthly when anticoagulation is stable Level A. Aspirin mg daily is an alternative to vitamin K antagonists in low-risk patients or those with contraindications to anticoagulation Level A.
For patients with mechanical heart valves, the target intensity of anticoagulation should be based on the type of prosthesis, maintaining an INR of at least 2. Oral anticoagulation INR: 2. Cardioversion of Atrial Fibrillation 1. Immediate electrical direct-current cardioversion is recommended for patients with AF involving preexcitation when very rapid tachycardia or hemodynamic instability occurs Level B.
When a rapid ventricular response does not respond promptly to pharmacologic measures in patients with myocardial ischemia, symptomatic hypotension, angina, or HF, immediate R-wave-synchronized cardioversion is recommended Level C.
Electrical cardioversion is recommended in patients without hemodynamic instability when symptoms of AF are unacceptable to the patient. In case of early relapse of AF after cardioversion, repeated electrical cardioversion attempts may be made following administration of antiarrhythmic medication Level C. Electrical cardioversion is recommended for patients with acute MI and severe hemodynamic compromise, intractable ischemia, or inadequate rate control with drugs Level C.
There are no Class I recommendations for pharmacologic conversion of atrial fibrillation. Maintenance of Sinus Rhythm 1. An oral beta-blocker to prevent postoperative AF is recommended for patients undergoing cardiac surgery unless contraindicated Level A.
Before initiating antiarrhythmic drug therapy, treatment of precipitating or reversible causes of AF is recommended Level C. Level of Evidence Definitions: Level A: Data derived from multiple randomized clinical trials or meta-analyses. Level B: Data derived from a single randomized trial or nonrandomized studies. Level C: Only consensus opinion of experts, case studies, or standard of care. Cir- culation. Adenosine Level A 3. Flecainide Level B 2. Ibutilide Level B 3. Procainamide Level B 4.
Procainamide Level B 2. Sotalol Level B 3. Amiodarone Level B 4. Amiodarone Level B 2. Lidocaine Level B 3. Catheter ablation Level B 2. Vagal maneuvers Level B 2.
Pill-in-the-pocket single-dose oral diltiazem plus propranolol Level B 3. Reverse digitalis toxicity Level C 2. Correct hypokalemia Level C 3.
Vagal maneuvers for single or infrequent episodes Level B 3. Electrical cardioversion if hemodynamically unstable Level B 2. Beta-blockers, verapamil, diltiazem for rate control in absence of digitalis therapy Level C Prophylactic Therapy: 1. Catheter ablation for recurrent symptomatic or incessant AT Level B 2.
Level C 2. Electrical cardioversion with sedation is recommended with hemodynamically unstable sustained monomorphic VT Level C. Contraindicated: Calcium channel blockers verapamil, diltiazem should not be used to terminate wide QRS tachycardia of unknown origin, especially with history of myocardial dysfunction. Polymorphic Ventricular Tachycardia 1. Electrical cardioversion with sedation is recommended for sustained PVT with hemodynamic compromise Level B.
IV beta-blockers are useful if ischemia is suspected or cannot be excluded Level B. Urgent angiography and revascularization should be considered with PVT when myocardial ischemia cannot be excluded Level C.
Torsades de Pointes 1. Withdrawal of any offending drugs and correction of electrolyte abnormalities are recommended for TdP Level A. Acute and long-term pacing is recommended for TdP due to heart block and symptomatic bradycardia Level A. Incessant Ventricular Tachycardia 1. Revascularization and beta blockade followed by IV antiarrhythmic drugs such as procainamide or amiodarone are recommended for recurrent or incessant PVT Level B.
The small arrow 1 shows the initial direction of depolarization through the septum, followed by the di- rection of ventricular depolarization, indicated by the larger arrow 2. A Normal sequence of depolarization through the heart as recorded by each of the frontal plane leads. Used with permission, Alexander R, Pratt C. Diagnosis and management of acute myocardial infarction. History of ischemic-like symptoms 2.
Changes on serial ECGs 3. Other indicators:a,b 1. New LBBB. ST-segment depression that resolves with relief of chest pain. Rarely feasible due to delay in treatment-seeking behavior.
Fibrinolytic agent should be initiated within 30 minutes of arrival if no contraindication 2. Fibrinolytics not recommended 2.
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