NCMB 418 LEC AND RLE
Basic ECG
ECG (Electrocardiography)
- A graphical recording of the heart’s electrical
activities
- 1st diagnostic test done when cardiovascular
disorder is suspected
12-LEAD ELECTROCARDIOGRAM
- Printed in a standard four-column format
- ECG machine reads three leads
simultaneously for 2.5 to 3 seconds until all
12 leads are obtained and then prints out the
12-lead ECG
- ECG electrodes are color-coded; each is
identified by a specific code that refers to its
intended placement. There are two coding
systems currently in use:
o American Heart Association (AHA)
system
o International Electrotechnical
Commission (IEC) system.
Reading the electrocardiogram:
1. Beginning on the left-most column, the printout
contains the standard limb leads I, II, and III. The
12-lead ECG machine then uses the limb leads
and, with the creation of Wilson’s central
terminal, creates the augmented leads, aVR,
aVL, and aVF.
2. Moving from the limb leads to the precordial
leads, the machine reads and records the
precordial leads, starting with V1, V2, and V3,
then reads and records V4, V5, and V6
Anatomy of the ECG
 P wave – atrial depolarization
 PR-Segment – 0.04 sec delay by AV Node for
completion of ventricular filling
 QRS Complex- ventricular depolarization
 ST segment – early ventricular repolarization
 T wave – ventricular repolarization
 U wave – repolarization of the mid-myocardial
cell
 PR-Interval – transition of impulse from SA node
to Purkinje fibers
 QT-interval – duration time from ventricular
depolarization to ventricular repolarization
BSN4YA-3 |1st Semester | Midterms | A.Y. 2022-2023
Common Pathologic Waves in an Electrocardiogram
1. T-wave inversion – may be due to ischemia
- Cause: myocardial repolarization is
altered and delayed
2. ST-segment changes – injured myocardial cells
depolarize normally but repolarize more
rapidly than normal, causing ST-segment to rise
at least 1mm above the isoelectric line
- Elevation in the ST-segment in two
continuous leads is a KEY DIAGNOSTIC
indicator of MI
3. Abnormal/Pathologic Q-wave – develops within
1-3 days (there is no depolarization current
conducted from necrotic tissue)
- May occur without ST or T-wave
changes (indicates a previous MI
SKILLS PROCEDURE
IMPORTANT! Ensure all your equipment and materials
are at hand before going to the client.
Materials needed: ECG machine, clean gloves (1 pair),
soap & water or alcohol-based wipes / cotton balls with
alcohol, hair clipper, if needed
Placement of Leads
 FIRST: Introduce self and identify the client
by asking for at least 2 identifiers (e.g. name,
birthday, age, etc.). Wash hands and don PPE, if
appropriate
 Briefly explain what the procedure will involve
using the appropriate language.
 Gain consent to proceed with the ECG recording
Assessment:
1. Verify the doctor’s order for obtaining an ECG
for the client.
2. Review client’s chart for medical history and/or
contraindications.
3. Assess client’s vital signs and mobility.
4. Assess client’s skin around the areas where
leads are to be placed, the client’s temperature
and pain sensitivity.
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NCMB 418 LEC AND RLE
5. Assess client’s skin hair near the wrist and ankle
areas and the chest.
6. Check and ensure the room is at a comfortably
warm temperature (This will prevent muscular
tension or movements from producing
unnecessary tracings on the ECG recording).
7. Assess client and family’s awareness,
understanding of the procedure, and related
safety factors.
Planning:
1. Identify expected outcomes
2. Assemble and prepare the equipment and
supplies needed.
Implementation (Note: AHA coding system is used in this
procedure.)
 Ensure to provide privacy at all times.
A. Placement of chest electrodes:
1. Explain the procedure and purpose to
the client, sensations the client would
feel and precautions to prevent client
discomfort.
2. Skin preparation. If the patient’s skin is
dirty, clean with soap and water, and
then dry. If the skin is oily or the patient
applied any creams or lotions, use an
alcohol wipe to clean each electrode
placement site
3. Ask the patient to lay on the clinical
examination couch with the head of the
couch at a 45° angle.
4. Adequately expose the client’s chest for
the procedure (offer a blanket to allow
exposure only when required). Exposure
of the patient’s lower legs and wrists is
also necessary to apply the limb leads.
5. Apply V1 at the 4th intercostal space at
the right sternal edge
6. Apply V2 at the 4th intercostal space at
Evaluation
the left sternal edge
7. Apply V3 midway between the V2 and
V4 electrodes
8. Apply V4 at the 5th intercostal space in
the midclavicular line
9. Apply V5 at the left anterior axillary line
at the same horizontal level as V4
Recording and Reporting: Record, document, and report
10. Apply V6 at the left mid-axillary line at
all pertinent information of the procedure performed.
the same horizontal level as V4 and V5.
BSN4YA-3 |1st Semester | Midterms | A.Y. 2022-2023
B. Limb electrode and lead placement
1. Apply the red lead on the ulnar styloid
process of the right arm
2. Apply the yellow lead on the ulnar
styloid process of the left arm
3. Apply the green lead on the medial or
lateral malleolus of the left leg
Placement of ECG Leads
4. Apply the red lead on the ulnar styloid
process of the right arm
5. Apply the black lead on the medial or
lateral malleolus of the right leg
C. Recording the trace
1. Turn on the ECG machine and ensure
ECG paper has been loaded.
2. Double-check all the electrodes are
attached in the appropriate locations.
3. Politely ask the client to remain still and
not talk during the recording as muscle
activity can cause an artefact which
obscures the ECG trace of myocardial
activity
4. Press the appropriate button on the ECG
machine to record the ECG trace. If the
ECG trace is poor, double-check the
connections to ensure there is good skin
contact.
5. Once an ECG trace has been obtained,
switch off the ECG machine.
6. Detach the ECG leads from the
electrodes and then remove the
electrodes carefully, warning the
patient this may feel uncomfortable.
7. Explain to the client that the procedure
is now finished.
8. Thank the client for their time.
9. Dispose of PPE appropriately and wash
your hands.
10. Label the ECG with the patient's details,
i.e., client’s name, age, gender, date &
time the tracing was obtained.
1. Inspect the body part or wound condition and
sensitivity.
2. Ask client to describe level of comfort and
burning sensation following the treatment.
3. Identify any unexpected outcome.
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NCMB 418 LEC AND RLE
Coronary Artery Diseases
Physiologic Changes of Aging
 Aorta & arteries tend to become less distensible
 Heart becomes less responsive to
catecholamines
 Maximal exercise heart rate declines
 Decreased rate of diastolic relaxation (↑in BP is
 more pronounced for systolic BP than diastolic
BP)
- Note that hypertension is NOT a normal
age-related process
 Compensatory mechanism are
delayed/insufficient = orthostatic hypotension is
common
 Thickness of LV wall may increase with age due
to blood vessel changes.
CORONARY ARTERY DISEASE (CAD)
 Also known as coronary HEART disease (CHD)
 Describes heart disease caused by impaired
coronary blood flow
 Common cause: atherosclerosis
 CAD can cause the following:
- Angina
- Myocardial Infarction (MI) = heart attack
- Cardiac dysrhythmias
- Conduction defects
- Heart failure
- Sudden death
 Men are more often affected than women
 Approximately 80% who die of CHD are 65+ y/o
Physical Assessment:
 Inspection:
- Skin color
- Neck vein distention (jugular vein)
- Respiration
- Peripheral edema
 Palpation:
- Peripheral pulses
 Auscultation:
- Heart sounds (presence of S3 in adults &
S4)
- Murmurs – audible vibrations of the
heart & great vessels produced by
turbulent blood flow
- Pericardial friction rub – extra heart
sound originating from the pericardial
sac
- May be a sign of inflammation,
infection, or infiltration
BSN4YA-3 |1st Semester | Midterms | A.Y. 2022-2023
- Described as a short, high-pitched
scratchy sound.
Common Clinical Manifestations
 Dyspnea
- Dyspnea on exertion – may indicate
decreased cardiac reserve
- Orthopnea – a symptom of more
advanced heart failure
- Paroxysmal nocturnal dyspnea – severe
SOB that usually occurs 2-5hrs after
onset of sleep
 Chest Pain – may be due to decreased coronary
tissue perfusion or compression & irritation of
nerve endings
 Edema – increased hydrostatic pressure in
venous system causes shifting of plasma
resulting to interstitial fluid accumulation
 Syncope – due to decreased cerebral perfusion
 Palpitations
 Fatigue
Diagnostics
 ECG (Electrocardiography) – graphical recording
of the heart’s electrical activities; 1st diagnostic
test done when cardiovascular disorder is
suspected
- Waves: P wave – atrial depolarization
(contraction/stimulation)
 QRS complex – ventricular
depolarization (changes are
irreversible)
 ST segment – ventricular
repolarization (changes are
reversible)
 U wave – hypokalemia
- PR interval (time for impulse to travel) =
0.12-0.20s (3-5 squares) √ for AV block
 QRS = 0.10s or (<2squares) √ for
electrolyte
 Abnormalities:
a) absent P wave = atrial fibrillation
b) saw-tooth pattern = atrial flutter
c) elevated ST segment = MI
d) 3rd degree heart block = prolonged PR
then progressively prolonged.
 Cardiac Enzymes (Cardiac Markers): 1st:
Myoglobin
a) urine = 0 – 2mg/dL (↑within 30mins –
2hrs after MI)
b) blood = <70mg/dL
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NCMB 418 LEC AND RLE
2nd: Troponin* - regulates calcium-mediated
contractile process released during MI (Troponin
T & I)
- blood = <0.6mg/dL - ↑ within 3-6hrs
after MI & remains elevated for 21 days
upon onset of attack
3rd: Creatinine kinase (CK) – intracellular
enzymes found in muscles converting ATP to
ADP
- CK-MB – specific to myocardial tissue
(↑within 4-6hrs & decreases to normal
within 2-3days)
o male = 12-70 mg/dL
o female = 10-55 mg/dL
4th: LDH (specifically LDH1- most sensitive
indicator of myocardial damage) = 45-90mg/dL -
↑within 3-4 days
 Stress Test / Treadmill Test (Treadmill Stress Test)
– ECG monitoring during a series of activities of
patient on a treadmill
Purposes: identify ischemic heart disease
- evaluate patients with chest pain
evaluate effectiveness of therapy
- develop appropriate fitness program
- Instructions to patient: get adequate
sleep prior to test
- avoid: caffeinated beverages, tea,
alcohol, smoking, nitroglycerine on the
day before until the test day
- wear comfortable, loose-fitting clothes
& rubber-soled shoes on the test day
- light breakfast on the day of the test
- inform physician of any unusual
sensations during the test
- rest after the test
 Pharmacologic Stress Test – use of intravenous
injection of pharmacologic vasodilator
(dipyridamole, adenosine, or dobutamine) in
combination of radionuclide myocardial imaging
o To evaluate presence of significant CHD
for patients contraindicated in TST
o Dipyradamole blocks cellular re-
absorption of adenosine (endogenous
vasodilator) & increases coronary blood
flow 3-5x above baseline levels
 If with CHD, the resistance
vessels distal to the stenosis
already are maximally dilated to
maintain normal resting flow,
thus, further vasodilatation does
not produce increased
bloodflow
BSN4YA-3 |1st Semester | Midterms | A.Y. 2022-2023
 Dobutamine – used in patients
with bronchospastic pulmonary
disease
 Echocardiography – uses ultrasound to assess
cardiac structure & mobility.
 Doppler U/S – to detect blood flow of artery &
vein specifically of lower extremities (No
smoking 1hr before the test)
 Holter Monitoring – portable 24hr ECG
monitoring which attempts to assess activities
which precipitate dysrhythmias & its time of the
day
 MRI – magnetic fields & radiowaves are used to
detect & define abnormalities in tissues (aorta,
tumors, cardiomyopathy, pericardiac disease)
- shows actual beating & blood flow;
image over 3 spatial dimensions
o Secure consent
o Assess for claustrophobia
o Remove metal items (jewelries,
eyeglasses)
o Instruct client to remain still
during the entire procedure
o Inform client of the duration
(45-60mins)
o CI: clients with pacemakers,
prosthetic valves, recently
implanted clips or wires
Angina Pectoris / Myocardial Ischemia
 Ischemia – suppressed blood flow
 Angina – to choke
 Occurs when blood supply is inadequate to meet
the heart’s metabolic demands
 Symptomatic paroxysmal chest pain or pressure
sensation associated with transient ischemia
TYPES:
A. Stable angina – the common initial manifestation
of a heart disease.
 Common cause: atherosclerosis
(although those with advance
atherosclerosis do not develop angina)
 Pain is precipitated by increased work
demands of the heart (i.e.. physical
exertion, exposure to cold, & emotional
stress)
 Pain location: precordial or substernal
chest area
 Pain characteristics:
 constricting, squeezing, or
suffocating sensation
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NCMB 418 LEC AND RLE
 Usually steady, increasing in  IV (Nitro-Bid)
intensity only at the onset &  Β-adrenergic blockers:
end of attack  Propanolol (Inderal)
 May radiate to left shoulder,  Atenolol (Tenormin)
arm, jaw, or other chest areas  Metoprolol (Lopressor)
 Duration: < 15mins  Calcium channel blockers:
 Relieved by rest (preferably  Nifedipine (Calcibloc,
sitting)  Adalat)
B. Variant/Vasospastic Angina (Prinzmetal Angina)  Diltiazem (Cardizem)
 1st described by Prinzmetal &  Lipid lowering agents – statins:
Associates in 1659
 Simvastatin
 Cause: spasm of coronary arteries
 Anti-coagulants:
(vasospasm) due to coronary artery
 � ASA (Aspirin)
stenosis
 � Heparin sodium
 Mechanism is uncertain (may be from
 � Warfarin (Coumadin)
hyperactive sympathetic responses,
Classification
mishandling defects of calcium in
A. Class I – angina occurs with strenuous, rapid, or
smooth vascular muscles, reduced
prolonged exertion at work or recreation
prostaglandin I2 production)
B. Class II – angina occurs on walking or going up
 Pain Characteristics: occurs during rest
the stairs rapidly or after meals, walking uphill,
or with minimal exercise
walking more than 2 blocks on the level or going
o commonly follows a cyclic or
more than 1 flight of ordinary stairs at normal
regular pattern of occurrence
pace, under emotional stress, or in cold
(i.e.. Same time each day usually
C. Class III – angina occurs on walking 1-2 blocks on
at early hours)
the level or going 1 flight of ordinary stairs at
 If client is for cardiac cath, Ergonovine
normal pace
(nonspecific vasoconstrictor) may be
D. Class IV – angina occurs even at rest
administered to evoke anginal attack &
Nursing Management
demonstrate the presence & location
1. Diet instructions (low salt, low fat, low
C. Nocturnal Angina - frequently occurs nocturnally
cholesterol, high fiber); avoid animal fats
(may be associated with REM stage of sleep)
 E.g.. White meat – chicken w/o skin, fish
D. Angina Decubitus – paroxysmal chest pain occurs
2. Stop smoking & avoid alcohol
when client sits or stands up
3. Activity restrictions are placed within client’s
E. Post-infarction Angina – occurs after MI when
limitations
residual ischemia may cause episodes of angina
4. NTGs – max of 3doses at 5-min intervals
Dx: detailed pain history, ECG, TST, angiogram may be
 Stinging sensation under the tongue for
used to confirm & describe type of angina
SL is normal
Tx: directed towards MI prevention
 Advise clients to always carry 3 tablets
- Lifestyle modification (individualized regular
 Store meds in cool, dry place, air-tight
- exercise program, smoking cessation)
amber bottles & change stocks every
- Stress reduction
6months
- Diet changes
 Inform clients that headache, dizziness,
- Avoidance of cold
flushed face are common side effects
- PTCA (percutaneous transluminal coronary
 Do not discontinue the drug.
- angioplasty) may be indicated if with severe
 For patches, rotate skin sites usually on
- artery occlusion
chest wall
 Instruct on evaluation of effectiveness
Drug Therapy
based on pain relief
 Nitroglycerin (NTGs) – vasodilators: 5. Propanolols causes bronchospasm &
 patch (Deponit, Transderm-NTG) hypoglycemia, do not administer to asthmatic &
 sublingual (Nitrostat) diabetic clients
 oral (Nitroglyn)

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NCMB 418 LEC AND RLE
6. Heparin – monitor bleeding tendencies (avoid Shortness of breath, profuse
punctures, use of soft-bristled toothbrush); perspiration
monitor PTT levels; used for 2wks max; do not Feeling of impending doom
massage if via SC; have protamine sulfate  Complications: death (usually within 1 hr of
available onset)
7. Coumadin – monitor for bleeding & PT; always Heart failure & cardiogenic shock –
have vit K readily available (avoid green leafy profound LV failure from massive
veggies). resulting to low cardiac output
Thromboemboli – leads to immobility &
Myocardial Infarction impaired cardiac function contributing
 Unstable Angina/Non ST-Segment Elevation MI – to blood stasis in veins
a clinical syndrome of myocardial ischemia. Rupture of myocardium
 Causes: atherosclerotic plaque disruption or Ventricular aneurysms – decreases
significant CHD, cocaine use (risk factor) pumping efficiency of heart & increases
 Defining guidelines: (3 presentations) work of LV
1) Symptoms at rest (usually prolonged, Tissue Changes after MI
i.e.. >20mins) Time after Onset Type of Injury & Gross
2) New onset exertional angina (increased Tissue Changes
in severity of at least 1 class – to at least 0-0. 5hrs Reversible injury
class III) in <2months
3) Recent acceleration of angina to at least 1-2hrs Onset of irreversible
class III in <2months injury
 Dx: based on pain severity & presenting 4-12hrs Beginning of coagulation
symptoms, ECG findings & serum cardiac necrosis
markers 18-24hrs Continued necrosis; gross
 When chest pain has been unremitting for pallor of infected
>20mins, possibility of ST-Segment Elevation MI tissue
 ST-Segment Elevation MI (Heart Attack) 1-3days Total necrosis; onset of
 Characterized by ischemic death of acute inflammatory
myocardial tissue associated with process
atherosclerotic disease of coronary 3-7days Infarcted area becomes
arteries soft with a yellow-brown
 Area of infarction is determined by the affected center & hyperemic
coronary artery & its distribution of blood flow edges
(right coronary artery, left anterior descending 7-10days Minimally soft & yellow
artery, left circumflex artery) with vascularized edges;
 Dx: based on presenting S/Sx, serum markers, & scar tissue generation
ECG (changes may not be present immediately begins (fibroplastic
after symptoms except dysrhythmias; activity)
PVCs/premature ventricular contractions are 7-10days Complete scar tissue
common after MI) replacement
 Typical ECG changes: ST-segment elevation, Q
wave prolongation, T wave inversion Management of MI
M.I  Initial Management: OMEN
 Manifestations:
 O2 therapy via nasal prongs
chest pain – severe crushing,
 adequate analgesia (Morphine via IV –
constricting, “someone sitting on my
also has vasodilator property)
chest”
 ECG monitoring
 substernal radiating to left arm,
 sublingual NTG (unless contraindicated;
neck or jaw
IV may be given to limit infarction size &
 prolonged (>35mins) & not
most effective if given within 4hrs of
relieved by rest
onset)

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NCMB 418 LEC AND RLE
 Thrombolytic Therapy – best results occur if
initiated within 60-90mins of onset
(Streptokinase & Urokinase – promote
conversion of plasminogen to plasmin)
 Anti-arrhythmics: lidocaine, atropine, propanolol
 Anticoagulants & antiplatelets: ASA, heparin
 Stool softeners
 Surgery:
1. Revascularization
 PTCA
 Coronary stent implantation
 Coronary Artery Bypass Graft
(CABG) – no response to
medical treatment & PTCA
2. Resection – aneurysm
Nursing Management
 Promote oxygenation & tissue perfusion (place
client on semi-fowler’s, O2 via nasal cannula,
monitor v/s changes, remind client on his
activity limitations & restrictions)
 Promote comfort & rest
 Monitor the ff perimeters: v/s, ECG, rate &
rhythm of pulse, effects of ADLs on cardiac
status
 Diet: low salt, low cholesterol, low calories,
avoid alcohol & smoking
 Take prescribe meds at regular basis
 Stress management
 Resume sexual activity after 4-6wks from
discharge or when client can go up 2 flights of
stairs without difficulty
 Assume less tiring position (non-MI
partner takes active role).
 Perform sexual activity in a cool, familiar
place.
 Take prescribed NTG before sexual
activity
 Refrain from sexual activity after a large
meal or during a tiring day.
 Moderation should be observed if
palpitations, dizziness or dyspnea is
observed
CARDIAC CATHETERIZATION
What to expect during a Cardiac Catheterization
1. You’re given an IV and anesthetic
2. Tube (cath) is inserted through groin or
arm to reach heart’s blood vessels.
3. Dye is injected into blood vessels so
they’ll appear on x-ray
4. Doctor will look for blockages and any
other issues
BSN4YA-3 |1st Semester | Midterms | A.Y. 2022-2023
5. Catheter can also be used to clear
blockages and make repairs.
Nursing Interventions for Cardiac Catheterization
 Before Procedure:
 Check consent form
 Check for allergies to seafood & iodine
 NPO post-midnight
 Baseline V/S
 Explain that warm or flushing sensation
may be felt upon administration of the
dye; “fluttering” sensation may be felt
as catheter enters the heart
 Administer sedatives as ordered
 Have the client void prior to transport to
cath lab
 After Procedure:
 Bed rest upper extremity catheter =
until stable v/s, HOB not more than 30
30°
o lower extremity = 24hrs, flat on
bed for 6hrs
 Apply pressure (5lb sand bag) over
puncture site & monitor for bleeding
 Monitor v/s q15 for 1st 2hrs then q1
until stable v/s, esp. peripheral pulses
 Immobilize affected extremity in
extension for adequate circulation
 Monitor for color & temperature
changes of extremities
 Instruct client to report tingling
sensations
DYSRYTHMIAS
 An arrhythmia (also called dysrhythmia) is an
irregular or abnormal heartbeat.
WHAT IS MY PULSE?
 Your pulse indicates your heart rate, or the
number of times your heart beats in one minute.
Pulse rates vary from person to person.
 Your pulse is slower when you are at rest and
increases when you exercise, since more
oxygen- rich blood is needed by the body during
exercise.
HEART RHYTHMS ON ECG
 The heart’s electrical system triggers the
heartbeat. Each beat of the heart is represented
on the electrocardiogram (EKG or ECG) by a
wave arm.
 The normal heart rhythm (normal sinus rhythm)
shows the electrical activity in the heart is
following the normal pathway. The rhythm is
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NCMB 418 LEC AND RLE
regular and the node is normal (about 50 to 100
beats per minute).
 Tachycardia: fast heart rhythm (greater than 100
beats per minute)
 Bradycardia: slow heart rhythm (less than 60
beats per minute)
THE TYPES OF ARRHYTHMIAS
1. Tachycardia: A fast heart rhythm with a rate of
more than 100 beats per minute.
2. Bradycardia: A slow heart rhythm with a rate
below 60 beats per minute.
3. Supraventricular arrhythmias: Arrhythmias that
begin in the atria (the heart’s upper chambers).
“Supra” means above; “ventricular” refers to the
lower chambers of the heart, or ventricles.
4. Ventricular arrhythmias: Arrhythmias that begin
in the ventricles (the heart’s lower chambers).
5. Bradyarrhythmias: Slow heart rhythms that may
be caused by disease in the heart’s conduction
system, such as the sinoatrial (SA) node,
atrioventricular (AV) node or His-Purkinje
network.
TYPES OF SUPRAVENTRICULAR ARRHYTHMIAS
Supraventricular arrhythmias begin in the atria
1. Premature atrial contractions (PACs) – Early,
extra heartbeats that originate in the atria.
2. Paroxysmal supraventricular tachycardia (PSVT) –
A rapid but regular heart rhythm that comes
from the atria. This type of arrhythmia begins
and ends suddenly.
3. Accessory pathway tachycardias (bypass tract
tachycardias) – A fast heart rhythm caused by an
extra, abnormal electrical pathway or
connection between the atria and ventricles.
The impulses travel through the extra pathways
as well as the usual route. This allows the
impulses to travel around the heart very quickly,
causing the heart to beat unusually fast
(example: Wolff- Parkinson-White syndrome)
4. AV nodal re-entrant tachycardia (AVNRT) – A fast
heart rhythm caused by the presence of more
than one pathway through the atrioventricular
(AV) node.
5. Atrial tachycardia – A rapid heart rhythm that
originates in the atria.
6. Atrial fibrillation – A very common irregular
heart rhythm. Many impulses begin and spread
through the atria, competing for a chance to
travel through the AV node. The resulting
rhythm is disorganized, rapid and irregular.
Because the impulses are traveling through the
BSN4YA-3 |1st Semester | Midterms | A.Y. 2022-2023
atria in a disorderly fashion, there is a loss of
coordinated atrial contraction.
7. Atrial flutter – An atrial arrhythmia caused by
one or more rapid circuits in the atrium. Atrial
flutter is usually more organized and regular
than atrial fibrillation.
TYPES OF VENTRICULAR ARRHYTHMIAS
1. Premature ventricular contractions (PVCs)
 Early, extra heartbeats that originate in
the ventricles.
 Most of the time, PVCs don’t cause any
symptoms or require treatment.
 This type of arrhythmia is common and
can be related to stress, too much
caffeine or nicotine, or exercise.
 They can be also be caused by heart
disease or electrolyte imbalance.
 People who have several PVCs and/or
symptoms associated with them should
be evaluated by a cardiologist (heart
doctor).
2. Ventricular tachycardia (V-tach)
 A rapid heartbeat that originates in the
ventricles.
 The rapid rhythm keeps the heart from
adequately filling with blood, and less
blood is able to pump through the body.
 V-tach can be serious, especially in
people with heart disease, and may be
associated with more symptoms than
other types of arrhythmia.
 A cardiologist should evaluate this
condition.
3. Ventricular fibrillation (V-fib)
 An erratic, disorganized firing of
impulses from the ventricles.
 The ventricles quiver and cannot
generate an effective contraction, which
results in a lack of blood being delivered
to the body.
 This is a medical emergency that must
be treated with cardiopulmonary
resuscitation (CPR) and defibrillation
(delivery of an energy shock to the heart
muscle to restore a normal rhythm) as
soon as possible.
4. Long QT
 The QT interval is the area on the ECG
that represents the time it takes for the
heart muscle to contract and then
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NCMB 418 LEC AND RLE
recover, or for the electrical impulse to
fire and then recharge.
 When the QT interval is longer than
normal, it increases the risk for “torsade
de pointes,” a life-threatening form of
ventricular tachycardia.
TYPES OF BRADYARRHYTHMIAS
1. Sinus node dysfunction – Slow heart rhythms
due to an abnormal SA node.
2. Heart block – A delay or complete block of the
electrical impulse as it travels from the sinus
node to the ventricles. The level of the block or
delay may occur in the AV node or His-Purkinje
system. The heartbeat may be irregular and
slow.
SYMPTOMS OF AN ARRHYTHMIA
 Palpitations: A feeling of skipped heartbeats,
fluttering, "flip-flops" or feeling
 that the heart is "running away"
 Pounding in the chest
 Dizziness or feeling lightheaded
 Shortness of breath
 Chest discomfort
 Weakness or fatigue (feeling very tired)
CAUSES ARRHYTHMIAS
 Coronary artery disease
 High blood pressure
 Changes in the heart muscle (cardiomyopathy)
 Valve disorders
 Electrolyte imbalances in the blood, such as
sodium or potassium
 Injury from a heart attack
 The healing process after heart surgery
 Other medical conditions
Dx Tests:
1. Electrocardiogram (ECG or EKG): A picture of the
electrical impulses traveling through the heart
muscle. An ECG is recorded on graph paper,
through the use of electrodes (small, sticky
patches) that are attached to your skin on the
chest, arms and legs.
2. Stress test: A test used to record arrhythmias
that start or are worsened with exercise. This
test also may be helpful in determining if there
is underlying heart disease or coronary artery
disease associated with an arrhythmia.
3. Echocardiogram: A type of ultrasound used to
provide a view of the heart to determine if there
is heart muscle or valve disease that may be
causing an arrhythmia. This test may be
performed at rest or with activity.
4. Cardiac catheterization: Using a local anesthetic,
a catheter (small, hollow, flexible tube) Is
BSN4YA-3 |1st Semester | Midterms | A.Y. 2022-2023
inserted into a blood vessel and guided to the
heart with the help of an X-ray machine.
5. Electrophysiology study (EPS): A special heart
catheterization that evaluates your heart’s
electrical system. Catheters are inserted into
your heart to record the electrical activity. The
EPS is used to find the cause of the abnormal
rhythm and determine the best treatment for
you. During the test, the arrhythmia can be
safely reproduced and terminated.
6. Treatment options include medications, lifestyle
changes, invasive therapies, electrical devices or
surgery.
LIFESTYLE CHANGES
 If you smoke, stop.
 Limit your intake of alcohol.
 Limit or stop using caffeine. Some people are
sensitive to caffeine and may notice more
symptoms when using caffeinated products,
such as tea, coffee, colas and some over-the-
counter medications.
 Avoid using stimulants. Beware of stimulants
used in cough and cold medications and herbal
or nutritional supplements. Some of these
substances contain ingredients that cause
irregular heart rhythms. Read the label and ask
your doctor or pharmacist which medication is
best for you.
 Your family may also want to be involved in your
care by learning to recognize your symptoms
and how to start CPR if needed.
 If you notice that your irregular heart rhythm
occurs more often with certain activities, you
should avoid them.
INVASIVE THERAPIES
 Electrical cardioversion Patients with persistent
arrhythmias, such as atrial fibrillation, may not
be able to achieve a normal heart rhythm with
drug therapy alone.
 Catheter ablation: During ablation, energy is
delivered through a catheter to tiny areas of the
heart muscle.
 Permanent pacemaker: A device that sends
small electrical impulses to the heart muscle to
maintain a normal heart rate.
 Implantable cardioverter-defibrillator (ICD): A
sophisticated electronic device used primarily to
treat ventricular tachycardia and ventricular
fibrillation — two life-threatening abnormal
heart rhythms.
 Arrhythmia surgery may also be recommended
if you need surgery, such as valve surgery or
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NCMB 418 LEC AND RLE
bypass surgery, to correct other forms of heart
disease. The Maze and modified Maze
procedures are two surgeries used to correct
atrial fibrillation
Heart Failure
 Results in intravascular and interstitial volume
overload and poor tissue perfusion
 The most common is CAD, but it also occurs in
infants, children, and adults with congenital and
acquired heart defects
 4 general categories: LSHF, RSHF, Systolic
dysfunction, Diastolic dysfunction
 RISK FACTORS
1) Hypertension
2) Diabetes mellitus
3) Congenital heart defects
4) Lifestyle: cigarette/tobacco smoke,
alcohol use
5) Obesity, overweight
6) Valvular heart disease
 Left-sided heart failure – Fluid may back up in
your lungs, causing shortness of breath.
 Right-sided heart failure – Fluid may back up into
your abdomen, legs and feet, causing swelling.
 Systolic heart failure – The left ventricle can’t
contract vigorously, indicating a pumping
problem.
 Diastolic heart failure (also called heart failure
with preserved ejection fraction) – The left
ventricle can’t relax or fill fully, indicating a filling
problem.
TREATMENT
1) Oxygenation
2) Pharmacologic – inotropes, vasodilators, ACE
inhibitors, diuretics
3) Surgery – pacemaker, mechanical heart pump,
heart transplant
4) Nursing Management: Prevention: (focus = risk
reduction)
 Maintenance of physical functioning
(promotion of cardiac wellness)
 Adherence to treatment regimen
 Weight monitoring
 Diet and lifestyle modification; limit
sodium intake
 Smoking cessation
 Read labels (medication and food)
 Limit alcohol intake
 Rest period allotment;
reducing/managing stress
 Controlling blood pressure
Phases of action potential
 The resting potential, threshold, the rising
phase, the falling phase, and the recovery phase.
We begin with the resting potential, which is the
membrane potential of a neuron at rest.
 phase 0, upstroke or rapid depolarization
 phase 1, early rapid repolarization
 phase 2, plateau
 phase 3, final rapid repolarization
 phase 4, resting membrane potential and
diastolic depolarization
 Step 1 - Resting Potential. Sodium and potassium
channels are closed. ...
 Step 2 - Depolarization. Sodium channels open in
response to a stimulus. ...
 Step 3 - Repolarization. Na+ channels close and
K+ channels open. ...
 Step 4 - Resting Conditions. Na+ and K+ channels
are closed.
COMPLICATIONS
1. Kidney damage / failure – due to reduced blood
flow to the kidneys
2. Valvular problems - valves of the heart may not
function properly if it is enlarged or if the
pressure is very high
3. Arrythmias / dysrhythmias
4. Liver problems – CHF leads to a buildup of fluid
that puts too much pressure on the liver
Normal sinus rhythm
 Ventricular and atrial rates of 60 to 100
beats/minute
 Regular and uniform QRS complexes and P
waves
 PR interval of 0.12 to0.20 second
 QRS duration < 0.12 second
 Identical atrial and ventricular rates, with
constant PR intervals
CARDIAC ARRHYTMIAS
Causes:
 congenital defects
 Myocardial ischemia or infarction
 organic heart disease
 drug toxicity
 degeneration of the conductive tissue
 Connective tissue disorders
 Electrolyte imbalances
 Hypertrophy of the heart muscle
 Acid-base imbalances
 Emotional stress
Cardiac arrhythmias may result from

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NCMB 418 LEC AND RLE
 Enhanced or depressed automaticity
 Altered conduction pathways
 Abnormal electrical conduction
Tests
1. ECG
2. Laboratory testing may reveal electrolyte
abnormalities , hypoxemia or acid-base
abnormalities or drug toxicities
3. Exercise testing
4. Electrophysiologic testing to identify the
mechanism and location of accessory pathways
and to assess effectiveness of drugs
Treatment
1. Anti-arrythmic drugs
2. Electrical conversion with defibrillation and
cardioversion
3. Valsalva’s maneuver
4. Temporary of permanent placement of
pacemaker to maintain heart rate
5. Implantable cardioverter-defribrillator
6. Surgical removal or cryotherapy of an irritable
ectopic focus to prevent recurring arrhythmias
7. Management of underlying disorder such as
correction of hypoxia
Caring for patient
1. Evaluate patient’s ECG and assess hemodynamic
parameters
2. Life threatening, assess LOC, pulse and RR,
hemodynamic parameters, may initiate CPR
3. Administer oxygen, analgesics
4. Assess predisposing factors such as fluid and
electrolyte imbalance, signs of drug toxicity,
especially with digoxin
5. Prepare to assist with or perform cardioversion
or defibrillation if indicated
6. If a temporary pacemaker needs to be inserted
make sure fresh battery is installed and secure
the external catheter wires and the pacemaker
box
7. After pacemaker insertion, monitor pulse rate
regularly and WOF pacemaker failure and
decrease cardiac output

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