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Diploma in Nursing
Integrated Nursing Sciences 2. 1

ECG and Arrhythmia

Learning Objectives
1. Remember and recollect important principles of ECG.
2. List the characteristics and interpret the ECG.
3. Identify the treatment plan from the case study, integrating evidences gathered
from patient’s history and investigative results to the patient’s diagnosis.
4. Describe the nursing interventions with rationale to prepare patient for cardiac
procedures.
5. Develop and prioritize an individualized plan of care for the patient post
procedure. Include 1 important nursing diagnoses and describe 4 nursing
interventions with rationale for each nursing diagnosis.
6. Role-play the discharge planning (INS1) for the patient in the scenario. To
include necessary props to aid the understanding of the patient and /or
caregivers.

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Watch for conduction pathway overview: https://youtu.be/Kdh7mTjVaso

Think-Pair-Share: Important principles of ECG

1) Identify the basics of ECG rhythm and what each area indicates:

P P-wave: indicates the atrial depolarization which leads to contraction of the 2 atrial
chambers of the heart. The impulses were triggered by the firing of the SA node. (
QRS QRS Complex: indicates ventricular depolarization and contraction which is cause by
the impulse from the Bundle of His that travels throughout the Ventricular muscles. It
measures less than 0.12 sec (from 0.04 to 0.12 sec) / less than 3 small squares in the
ECG paper.
ST ST segment: Signifies the beginning of Ventricular repolarization and relaxation.

T T wave: indicates Ventricular Repolarization and Relaxation, which no associated

activity of the ventricular muscle. It is a resting phase of the whole Cardiac cycle.
QT QT interval: Represents electrical depolarization and repolarization of the ventricles.

2) List the systemic approach in analyzing ECG Rhythm:

1) Calculate Heart Rate

2) Determine regularity

3) Assess P waves

4) Determine PR interval

5) Determine QRS duration

3) There are two ways of calculating HR:

1st Method (For all 6 seconds strip multiplied by 10.

rhythms)
2nd Method The number of small boxes in between the Typical R-R interval/
(For regular rhythms distance between the QRS complexes from 1 cardiac cycle to
only) another divided by 1500.

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ACTIVITY FOR ALL

To start on the ECG interpretation activity, the student should have completed the activity of Understanding
Basic ECG: Understanding Basic ECG - Understanding Basic ECG and ABG (polite.edu.sg)

The steps and criteria for identifying cardiac rhythms are as follow:
Steps How to NSR SB ST AF VT VF PVCs
count/describe
The heart rate Count the number Calculate Rate: Ventricula Calculate Too rapid NA as
for this rhythm of QRS complexes (number of QRS in 6-sec strip x10) r Rate to count/ interprete
is in a 6-second strip x Rate (number > 300- d with
10 (number of QRS in 600bpm other
of QRS in 6 sec strip rhythms
6 sec strip x10)
x10)

If 60-100 If If
bpm < 60 bpm >100 bpm

The rhythm is ● Regular Regular Irregular Regular Irregular

● Irregular
The P wave is ● Present and Present and normal Absent Absent/ Absent/
normal Fibrillator Not Not
/upward & y Identifiabl Identifiabl
rounded e e
● Absent /
Not
Identifiable
● Fibrillatory
The QRS ● Present and
complex is < 0.12 seconds Present & < 0.12 seconds Present & >0.12 Bizarre, >0.12
● >0.12 seconds < 0.12 seconds varying in seconds
● Between 0.12- seconds Bizarre shape and Bizarre
0.20 seconds shape direction shape
● (Count the
number of
small boxes X
0.04 secs)
● Bizarre,
varying in
shape and
direction
Interpret the ECG Normal Sinus Sinus Atrial Ventricular Ventricular Premature
Sinus Bradycardia Tachycardia Fibrillation Tachycardia Fibrillation Ventricular
Rhythm Contraction

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ACTIVITY FOR GROUPS

A. State four (4) characteristics of the ECG rhythm and interpret the ECG
B. Identify the immediate treatment

ECG Characteristics
Rate:
Rhythm:
P wave:
QRS Complex:
Interpret:

Immediate treatment: Monitor ECG rhythm, Treat underlying Group 1

disorder
Rate:
Rhythm:
P wave:
QRS Complex:
Interpret:

Immediate treatment: Monitor ECG rhythm, treat underlying Group 2

disorder, if symptomatic then IV atropine/cardiac pacing
Rate: NA as interpreted with
other rhythms.
Rhythm: Irregular
P wave: NA as interpreted
with other rhythms
QRS Complex: Bizarre and
varying in shape and sizes
Interpret: Premature
Ventricular Contractions
Immediate treatment: Group 3

Rate:
Rhythm:
P wave:
QRS Complex:
Interpret:

Group 4
Immediate treatment:

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Ventricular rate:
Rhythm:
P wave:
QRS Complex:
Interpret:

Immediate treatment:

Rate:
Rhythm:
P wave:
QRS Complex:
Interpret:

Group 1

Rate: 180bpm
Rhythm: Regular
P wave: Present, Rounded
and upward. Normal.
QRS Complex: Present, <0.12
sec
Interpret: Sinus Tachycardia

Immediate treatment: Monitoring of diet, especially eliminating

possible trigger such as, Caffeine, Nicotine etc.. Inform doctor and
recommend Calcium- Channel blockers/ Beta-blockers to slow
down heart rate. BONUS

Source for images: Clinical Skills Education, LLC.  EKG Academy. Retrieved Oct 6, 2020 from
https://ekg.academy

SBL Arrhythmia

Roger is a 75-year-old man who presents to the doctor for evaluation and follow-up of his medical
problems at the specialist clinic.

The Symptoms

I noticed the first sign of symptoms (a feeling of nerve activity within the chest) whilst gardening one
day. I was used to doing a very physical job and had done so all my working life. The feeling of the
nerve action across my chest lasted for about 15 minutes the first time, but I started to experience
this on two or three more days over the next month. I suffered these symptoms for five months
before I first went to my G P. I explained the symptoms to him and his first reaction was that it may
be a heart problem. I remember being quite shocked, as there had been no history of heart problems
within the family and being a relatively fit person, I found myself asking, “how could that possibly

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be?”. The GP was very reassuring, he felt my pulse to check for any irregular beat and then
recommended a referral to the local hospital for further investigation

The Diagnosis

Within eight weeks I had received an appointment with a heart specialist at the local hospital. During
the consultation I showed him the record I had kept of all the episodes I had experienced since my first
visit to the GP and his first reaction was that it could be a heart rhythm disturbance.

Helio.(2018). ECG Review.[Image].Retrieved from https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-archive/atrial-fibrillation-with-rvr-ecg-5

1. State four (4) characteristics of Roger’s ECG rhythm and interpret the ECG taken on arrival.

Rate 180 bpm

Rhythm is The distance between 2 successive R waves aren’t the same. Therefore,
irregular.
The P Wave is P waves is absent
ORS Complex is QRS Complex present that appears different, successive R waves consists of 3
small squares. However 1 particular R waves appears to have 6-7 small
squares. More than 0.12 secs. Therefore, widened QRS complex is present in
this case. It appears bizarre and varying in shape and directions.
Interpretation Abnormal heart rate and ECG reading. Irregular rhythm which may be caused
by the irregularity of the QRS complex that appears in different duration that is
out of a normal range (0.04 – 0.12 sec). Therefore, Ventricular Fibrillation.

View: Atrial Fibrillation Overview - ECG, types, pathophysiology, treatment, complications

Video: https://youtu.be/wxJuP-i9Jx0

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Figure 1: AHA.(2017). Treatment Guidelines of Arrhythmia.[Image]. Retrieved from

http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Treatment-Guidelines-of-Atrial-Fibrillation-AFib-or-
AF_UCM_423779_Article.jsp?appName=WebApp

2. Refer to Figure 1 for the CHA2DS2-VASc Risk Score

(a) What is the purpose CHA2DS2-VASc Risk Score?

The CHA2DS2-VASc Risk Score evaluates ______

(b) What is Roger’s CHA2DS2-VASc Risk Score?

(https://clincalc.com/Cardiology/Stroke/CHADSVASC.aspx)
Roger’s CHA2DS2-VASc Risk Score total points is _________

(c) Based on the score in (b) is there a need to administer aspirin or anticoagulant? As Roger’s
thromboembolism risk is 2 (age ≥75 years) Based on the 2012 ESC Guidelines, __________

(d) Briefly explain the relationship between stroke and the ECG in figure 1.
_____________________________________________________________--

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The Treatment

During the next month I had two ECG’s, an Echocardiogram and a seven-day event recorder. On the next visit
to the heart specialist he confirmed the diagnosis of a heart rhythm disturbance. The issue with the
medications ordered was that they were only effective for a short period of time, which meant that when the
effect of the tablets wore off the abnormal heart rhythm would restart. Sadly, this occurred most days by
then. The heart specialist then recommended a referral to a hospital that had an Electrophysiological
Cardiologist.

A Referral to an Electrophysiological Cardiologist

Within two months I received an appointment to see a cardiology consultant at a specialist heart hospital.
At the consultation the specialist referred to a procedure called electrophysiological study (EPS) and
catheter ablation, suggesting that it may be able to cure the problems I was experiencing. He put the
probability of success at that time as 70%.

The Ablation
I received a letter from the hospital with the date the procedure was to be performed and a week before
this date I had to visit the hospital for a pre-admission check. I was given a 45-minute information session
about the procedure. I thought this was very good and it put my mind a rest.

3. What is EPS and catheter ablation? How would it treat arrhythmia? [include a picture with your
answer to aid with the explanation of the procedure]
Electrophysiology studies (EPS)

Catheter ablation

Link for reference:

https://youtu.be/_WkTQB4ARfM
https://www.mayoclinic.org/tests-procedures/cardiac-ablation/about/pac-20384993

4. Describe five (5) nursing considerations in the preparation of Roger for EPS study and ablation?
Provide a rationale for each answer.

Nursing Consideration Rationale

To prevent nausea and gastric aspiration.

To reduce the possibility of infection from

microscopic nicks in the skin that can become
bacterial breeding ground
To ensure that the advanced consent given by
patient remains legitimate for the procedure.

To assess risk of bleeding.

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To decrease risk of bleeding and to allow the

identification of arrhythmic site during the EPS
studies.

The following week I arrived at the hospital for the procedure that was called Pulmonary Vein
Isolation. The catheters were fed up into the heart from veins at the top of both legs, there was no
pain and the time seemed to go very quickly. A blood pressure monitor on my arm was taking
measurements every 15 minutes and as I recall, the only real discomfort I experienced was with the
vibration of the ablation, which I felt in my teeth. The consultant and nurses were excellent and I felt
reassured when they kept checking on my welfare during the procedure. It was all over in less than
three hours but it actually only felt like 30 minutes. I was taken to the high dependency unit to
recover for the first few hours and I was being checked constantly.

5. Develop and prioritize an individualized plan of care for Roger in the case scenario post procedure.
Include 1 important nursing diagnoses and describe 4 nursing interventions with rationale for each
nursing diagnosis

Risk for bleeding related to pulmonary vein isolation procedure and administration of
anticoagulation.

Nursing intervention Rationale

1. Monitor vital signs including heart rate, blood

pressure, respiratory rate, and SpO2 hourly

2. To check the puncture site hourly.

3. To monitor the patient for presence of chest

pain radiating to the neck, shoulders or back,
dyspnoea, tachycardia, hypotension

4. To keep the affected leg straight for 6 hours

post removal of the sheath

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The Recovery
I made an uncomplicated recovery from the procedure and was allowed to go home the next day. For
the first two weeks, I had home rest.

6. Describe and role-play the discharge planning for the patient after pulmonary vein isolation in the
scenario. Provide a rationale for your answer.

Health Education Rationale

These symptoms are all normal and should subside
within 5 to 7 days after the procedure. To seek
medical attention if symptoms are prolonged or
severe.

To monitor changes in ECG rhythm from home

To prevent blood clots and reduce the incidence of

stroke.

To prevent and monitor for infection at the exit site.

To allow the puncture sites to heal.

The Conclusion
It has been almost two years since the ablation procedure and at the moment the “fast heartbeat”
seems to be very much improved. I have had a couple of very small episodes of the condition that
have probably lasted 45 minutes in total. This is a vast improvement to the 23 hours which was the
worst episode I ever experienced.

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INDIVIDUAL
Case Study Summary for INS2.1

Patient’s Name Roger

Diagnosis

Issues

Roger’s CHA2DS2-VASc Risk

Score & recommendation

Pre and Post EPS and

catheter ablation
(most important focus)

Health Education

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