Sinus Tachycardia

· Rhythm is regular
· Rate is between 101 and 150 beats/min
· PR Interval is 0.12-0.20 seconds
· Upright P wave
· QRS is 0.12 seconds or less
· Is considered SVT when greater than 150 unless in children
· ATRIAL FLUTTER
Atrial Flutter
· Rhythm may be regular or irregular
· Atrial rate is 230-350 beats/min
· Ventricular rate varies
· PR Interval is usually nonexistent
· Flutter waves replace the P waves; they resemble a “saw tooth”
· QRS is 0.12 seconds or less
· Will see the saw tooth waves across the baseline
Atrial Fib
· Rhythm is irregular and usually erratic
· Atrial rate is 350-400 beats/min
· Ventricular rate varies
· There is usually no PR Interval
· P waves are erratic and baseline appears “wavy”
· QRS is 0.12 seconds or less
· If on medications, can see a slower atrial rate but still a-fib

VENTRICULAR TACHYCARDIA
· Rhythm is usually regular
· Ventricular rate is greater than 100 beats/min
· QRS is wide and is greater than 0.12 seconds
· There is no P wave
· Can be stable or unstable
· Can have a pulse or no pulse
· If have more than 3 is a run of v-tach
VENTRICULAR FIBRILLATION
· Rhythm is chaotic and no regularity noted
· No identifiable QRS complexes
· No P waves
· Total chaotic electrical activity creates the baseline
· Can be coarse or fine
· No pulse
ASYSTOLE
· No PQRST
· Baseline straight or slightly wavy
· Must be confirmed in 2 leads
· No pulse
Peripheral Vascular Disease
Definition

· Intermittent claudication due to an inadequate oxygen supply.

· It occurs when the patient is walking, exercising, etc. Patient will get leg pain and cramps.
· SMOKING IS THE NUMBER ONE REASON FOR PVD
Inspection
· Assess skin color, hair distribution, and venous blood flow.
· Extremities should be assessed for thromophlebitis, varcoise veins, and lesions such as stasis ulcers.
· Check capillary refills, edema, pulses
· Homan’ s sign: Presence of calf pain during sharp dorsiflexion of foot. This is nonspecific and can be
elicited from any painful condition of the calf.

Pulses
· 0- absent
· 1t= weak, thready
· 2t= normal
· 3t= full, bounding
Auscultation
· If the artery is narrowed or bulging it will create an abnormal buzzing sound (BRUIT).
Other things you can hear:
· Bounding: sharp and brisk rising pulse
· thready: weak, slow rising pulse
· Thrill: vibration

Things that can occur

Pulmonary Embolism

· most common pulmonary complication in hospitalized patients.

· Estimated that about 500,000 die each year for PE.
· Most arise in the deep veins of the legs.
· Other sites are the right side of the heart (AFIB), upper ext. (rare) and pelvic veins (especially after
childbirth).
Emboli
· Mobil clot that generally do not stop moving until they lodge at a narrowed part of the circulatory
system.
· The lungs are an ideal location for emboli to lodge because of their extensive arterial and capillary
network.The presence of a deep vein thrombosis is usually unsuspected until a pulmonary embolism
occurs.
· Thrombi in the deep vein can dislodge spontaneously.
Assessment of DVT: a warm, reddish blue extremity.
· More common mechanism that throws a clot is sudden standing and changes of the rate of blood flow,
such as valsalva’ s maneuver.

Clinical Manifestations
This depends on the size of the emboli and the number of blood vessels occluded.
· Sudden onset of unexplained dyspnea
· Tachypnea
· Tachycardia
· Cough
· Chest pain
· hemoptysis
· crackles
· fever
· changes in mental status

Massive Emboli
The patient will suddenly collapse and experience.
· shock, pallor, have sever dyspnea, and crushing chest pain.
· Pulse is rapid and weak
· BP is low
When rapid obstruction of 50% or more occurs, acute Cor Pulmonale may result because of right
ventricle can no
longer pump blood into the lungs.
Death occurs in over 60% of patients.
Medium-sized emboli
Can cause pleuritic chest pain accompanied by:
· Dyspnea
· slight fever
· productive cough with blood streaked sputum
· Tachycardia
· Friction rub

Small emboli
· Undetected or produce vague, transient symptoms.
Complications

Pulmonary Infarction
· Death of lung tissue occurs in less than 10% of patients with emboli.
· It is more likely to occur in patients with:
occlusion of a large or medium-sized pulmonary vessel (<2mm)
Insufficient collateral blood flow from the bronchial circulation
Preexisting lung disease
Pulmonary Hypertension
· Occurs when more than 50% of the area of the pulmonary bed is compromised.
· Also results form hypoxemia.
· Only if the emboli is massive will this occur.
· But small to medium emboli that are recurrent can cause pulmonary hypertension.
Diagnostic test
· History and physical
· Venous studies (venous Doppler’s, lung scans, pulmonary arteriogram).
· CXR
· ABG’ s
· CBC
Collaborative care
· Oxygen mask or cannula.
· IV site
· IV heparin
· Bed rest
· Narcotics for pain
· Thrombolytic agents
· Vena cava filter
· Pulmonary embolectomy
Drug therapy
· Diuretics (if heart failure occurs).
· Heparin
· Coumadin
HEPARIN
· It is an anticoagulant.
· Should be started immediately.
· The dosage of heparin is adjusted according to its effect on the PTT.
· Normal PTT is 35-45
· Bolus is always given first
· PTT should be one and half to two and half times normal to be therapeutic.
Coumadin
· Anticoagulant
· PT is monitored
· Doc adjusted according to PT levels. The most significant is the INR.
· PT is always drawn with the INR.

Nursing management
· Health promotion
· Bed rest
· Semi-fowler’ s position.
· IV line for medications and fluid therapy.
· Careful monitoring of ABG’ s, ECG, and lung sounds.
· Nurse should explain the situation to patient/family.
Education
Educate patient with s/s and explain what is going on because they feel:
· Pain
· sense of doom
· inability to breathe
· explain situation and provide emotional support.
Ambulatory and home care
· Emotional support
· teach, teach, teach
Diagnosis
· Adequate tissue perfusion.
· Adequate cardiac output
· Increased level of comfort

Arterial Blood gases

Normal ABG Values
Ph- 7.35-7.45
Sat- 95-100%
PaO2- 80-100
pCO2- 35-45
HCO3- 22-28
· Use pH, pCO2 and HCO3 components to determine acid-base balance.
· Begin at pH. Based on you answer to questions, follow the sequence of the diagram.
· Determine what you primary disturbance is. Be sure to check all components (remember you have 2
primary disturbances I.e., metabolic and respiratory acidosis)
· Once the primary disturbance is identified, determine if compensation is present.
Ask yourself is the pH normal
· YES: then ask is the pCO2 WNL
· YES: Normal-acid base balance
Is the pH normal
· NO: if decreased it is acidosis and if it’ s increased it’ s alkalosis.
Now ask if the pH is not normal:
pH is decreased (acidosis) look at the pCo2. If it is HIGH it is Respiratory Acidosis if the HCO3 is also
High then it is Respiratory acidosis compensated with Metabolic acidosis.
· pH is decreased: acidosis now look at the HCO3 if low it is metabolic acidosis if the pCO2 is low. It is
metabolic acidosis compensated with respiratory alkalosis.
· IF pH is elevated (ALKALOSIS)
· look at pCO2 if low = Respiratory alkalosis
and if HCO3 is low it is respiratory alkalosis compensated with metabolic acidosis.
· If HCO3 is high= metabolic alkalosis
and pCO2 is high=metabolic alkalosis compensating with respiratory acidosis.
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· Ongoing monitoring