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Cardiovascular assessment and cardiac rhythms

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Cardiovasular AssessmentStudy Plan by Diane ChamberlainLearning OutcomesUpon successful completion of this section, you should be able to:describe the principles and practice of cardiac assessmentconduct an accurate process for cardiac assessmentdemonstrate an understanding of the principles of electrophysiologydemonstrate a systemic approach to the assessment of arrhythmiasdescribe the physiological effect of different arrhythmiasidentify signs and symptoms of general hypoperfusion.VideosThe Circulatory System anatomy and physiology revision –Cardiovascular HistoryCardiac patients who are acutely ill require a different initial history than do cardiac patients with stable or chronic conditions. A patientexperiencing a myocardial infarction requires immediate, and possibly life-saving, medical and nursing interventions (e.g., relief of chestdiscomfort and treatment of arrhythmia) rather than an extensive interview. For this patient, asking a few, well-chosen questions regardingchest discomfort using the patient’s descriptors are important. In addition, associated symptoms (such as shortness of breath orpalpitations), drug allergies and reactions, current medications, history of cardiac and other major illnesses, and smoking history should bedetermined while assessing vital signs (heart rate and rhythm and blood pressure) and starting an intravenous line. As the patient’scondition stabilizes, a more extensive history should be obtained.A comprehensive cardiovascular assessment includes clinical assessment of perfusion of all organs (skin colour, temperature,clamminess, nausea and vomiting or diarrhoea, inattention and delirium, anxiety, respiratory insufficiency, dyspnoea, decreased urineoutput, abdominal and chest pain, muscle pain). All of these signs and symptoms are the result of different organs response to hypoperfusion.In addition the following are part of a comprehensive cardiovascular assessment.assessment of skin colour (peripheral and central), respiratory effort, respiratory and heart ratemeasurements of blood pressureprecordial examination by inspection and palpationcardiac auscultationauscultation of lung fieldsabdominal palpationpalpation of peripheral pulses.044 How Blood Flows Through the Heart3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 4/14Core text readings – a choice (not feasible to read them all)Cardiovascular Care Made Incredibly Visual!, 2nd Edition. (n.d.). Lippincott Williams & Wilkins.Chapter 1, Anatomy and PhysiologyChapter 2, Assessment – Click here [Full text ebook through the library]ORCurtis, K., & Ramsden, C. 2015. Chapter 22, Cardiovascular Emergencies in Emergency and trauma care for nurses and paramedicSciences.ORAitken, A, Marshall, A, & Chaboyer, W.,2015, ACCCN’s critical care nursing, 3nd edn, Elsevier, Australia, Chapter 9, pp. 231-248, 3and chapter 27 ‘Paediatric considerations in critical care, pp. 885-888.ACCCN National Adult Advanced Life Support Program Manual – Section 4; pp 25-46ACCCN National Paediatric Advanced Life Support Program Manual – Section 5: pp 40-64VideosCardiac Physical Exam –The cardiovascular physical assessme…Heart Sounds3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 5/14Understanding basic electrophysiologyIt is important that you have a basic understanding of the physiology of the cardiac cell and the action potential. This information should befound in your text book or other Tphysiology or ECG text. This preliminary work will assist you to build knowledge toward assessing ECG’sand arrhythmias as well as your understanding of medications which act on the cardiovascular system. Complete the following questionsand activities and include the information in your workbook in your own words for future reference.Core text readingDavies, A., & Scott, A. (2015). Starting to Read ECGs. London: Springer London. pp. 1-140 (Chapters 1 -6) – Click here [Full text ebook through the library]ActivityReview the four basic properties of the cardiac cell.Describe the depolarisation and repolarisation process in cardiac cells.What is meant by the terms transmembrane potential and resting membrane potential?Name the two different types of cardiac cell and give their function.Define cardiac action potential. Describe the four phases of the cardiac action potential in the typical cardiac cell. What ismeant by unipolar and bipolar leads?Where is the best place to attach the limb leads?Draw the leads and conduction pathways of Einthoven’s triangle in relation to the planes of the body. Describe the mainprinciples of the triangle. Explain the relationship between the triangle concept, your lead placements and the direction ofthe electrical impulse.Take a strip of ECG paper and identify the time (m/secs) and height (m/V) of one small square and one large square.Identify on your strip of paper how many seconds are between the hatch marks at the top of the strip. Relate this to thecalculation of heart rate from an ECG.Describe the effect of artefact on the ECG trace and identify ways to prevent it.Cardiac rhythm assessmentAnalysis of the cardiac rhythm is one vital component of cardiovascular clinical assessment. Despite the rhythm analysis it is important todetermine its effect on patient in terms of haemodynamics and stability—so a primary survey is important when a patient cardiac rhythmchanges. The aim of this week’s learning is to revise cardiac rhythm assessment. Here are some main points for revision.This is the process for rhythm analysisTo determine the rhythm ask yourself, what is the rate?The heart rate can be determined by using the 6-second count method, a heart rate calculator ruler, the R-R interval method, or thetriplicate method.The 6-second count methodThe 6-second count method is the simplest way of determining the heart rate and is generally considered the fastest, with the exception ofthe heart rate calculator ruler method. The 6-second count method, however, is the least accurate. This method can be used when therhythm is either regular or irregular.The short, vertical lines (or some other similar marking) at the top of most ECG papers divide the ECG paper strip into 3-second intervalswhen the paper is run at a standard speed of 25 mm per second. Two of these intervals are equal to a 6-second interval. When the ECGstrip is run at 50 mm per second, four of these ‘3-second’ intervals are equal to a 6-second interval.Cardiac cell action potential3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 6/14ActivityWhere is the best place to attach the limb leads?Draw the leads and conduction pathways of Einthoven’s triangle in relation to the planes of the body. Describe the mainprinciples of the triangle. Explain the relationship between the triangle concept, your lead placements and the direction of theelectrical impulse.Take a strip of ECG paper and identify the time (m/secs) and height (m/V) of one small square and one large square. Identifyon your strip of paper how many seconds are between the hatch marks at the top of the strip. Relate this to the calculation ofheart rate from an ECG.Describe the effect of artefact on the ECG trace and identify ways to prevent it.Cardiac Rhythm Analysis ProcessIs the rhythm regular or irregular?Measure the intervals between the R waves (0.12 seconds variation is normal)Is the R-R Interval consistent?What is the assessment of the P waves?Are P waves present?Is there one, and only one, before each QRS?Is their shape normal?What is the measurement of the PR interval?Measure from the beginning of the P wave to the beginning of the QRS (normal is 0.10-0.20 seconds)Is it consistent?What is the measurement of the QRS interval?Measure from the beginning of the Q wave to the end of the S wave (normal is 0.05–0.10 seconds)Do all the QRS complexes look alike?What is the ST segment?Between the S wave and T wave (should be on the isoelectric line)What is the assessment of the T wave?The T wave normally deflects in the same direction as the QRST waves that follow ventricular ectopics often deflect in the opposite directionWhat is the rhythm?Analyse the rhythm with all the data that you have, keeping in mind the normal conduction pathwayFigure 1.1: 6-second count method(Adapted from ECG Workbook 2011, 2nd edn, M&K Update Ltd, p. 15.)Videos1.2.Basic Rhythm Interpretation, part 5 – Th…3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 7/143.4.1.2.Basic Rhythm Interpretation, part 5 – Th…Basic Rhythm Interpretation, parr 5 – Th…Basic Rhythm Interpretation, part 5 – Th…Normal Sinus Rhythm3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 8/143.4.5.6.Sinus BradycardiaJunctional BradycardiaAccelerated Junctional RhythmAtrial Fibrillation3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 9/147.8.9.Atrial FlutterAtrial TachycardiaPulseless Ventricular Tachycardia (pVT)Ventricular Fibrillation3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 10/14Lifespan considerationsLifespan considerationsPaediatric FocusResource Reading [ACCCN National Paediatric Advanced Life Support Program Manual – Section 5 has similar}Davies, A., & Scott, A. Chapter: The Pediatric ECG (2015). Starting to Read ECGs. London: Springer London. pp. Click hereClinical assessment is also an important skill to possess when caring for paediatric patients. Children may deteriorate or respond to treatment rapidly and sometimesCaring for infants in an Intensive Care setting will provide many challenges. Infants are simply not ‘little adults’ and the anatomical and physiological differences betwCompensatory mechanisms in children will often mask the signs of severe illness. It is therefore imperative that age specific parameters are known so that deterioratthey will deteriorate rapidly as their reserve capacity is lower than that of an adult.The aims and processes of assessment in the seriously ill child centre aroundIdentifying any physiological abnormalitiesIdentifying the most appropriate ways of correcting the abnormalities andDiagnosing the underlying problem(Paediatric Basic (2014). Basic Assessment and Support in Paediatric Intensive Care.Below are some of the major cardiovascular differences between adults and children.Heart RateIn children, heart rate will vary with age and clinical condition . Between the ages of 1 week to 16 years, there is a wide range of normal heart rate. See table below.AGE Awake heart rate (beats/min) Sleeping heart rate (beats/min)Neonate (96hrs) 100-205 90-160Infant (1-12 months) 100-180 90-160Toddler (1-2yrs) 98-140 80-120Preschool (3-5yrs) 80-120 65-100School age (6-7yrs) 75-118 58-90Adolescent 60-100 50-90Table adapted from Hazinski, M.F (2013) Nursing Care of the Critically Ill Child. Elsevier. 3rd Edition. MissouriCardiac OutputNormal cardiac output is higher per kg in children compared to adults. In neonates and infants stroke volume is fixed. In order for infants to increase their cardiac ouof a compromised cardiac output and once the ability to compensate has been exhausted, the patient may begin to exhibit an age appropriate bradycardia. This is aBlood PressureCirculating blood volume in children is higher per kg of body weight but their actual blood volume is small. This is important to take into consideration when administelower arterial blood pressure than adults (see table below), therefore, smaller changes in blood pressure may be more significant than they are in adults. Hypotensioabsent in a child with signs of inadequate tissue perfusion such as cold peripheries, decreased capillary refill, oliguria and decreased conscious level.Age Systolic blood pressure(mmHg)Diastolic bloodpressure (mmHg)Mean Arterial Pressure(mmHg)Neonate (96hrs) 67-84 35-53 45-60Infant (1-12 months) 72-104 37-56 50-621-2 years 86-106 42-63 49-623-5 years 89-112 46-72 58-696-7 years 97-115 57-76 66-7210-12 years 102-120 61-80 71-7912-15 years 110-131 64-83 73-84Table adapted from Hazinski, M.F (2013) Nursing Care of the Critically Ill Child. Elsevier. 3rd Edition. MissouriOlder Adult FocusReadingStrait, J.B. & Lakatta, E.G. (2012) Aging-Associated Cardiovascular Changes and Their Relationship to Heart Failure. Heart Failure Clinics, 8(1), 143-164. C3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 11/14Review activitiesCardiac Rhythm Review activitiesCardiac Rhythm Questions and AnswersReview Questions notes to go with video clip – click hereRhythm StripsRevise your rhythm analysis. Answers will be posted after Week 2 for you to check.Review activity 1Review activity 2Review activity 3Review activity 4Cardiac rhythm review3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 12/14Review activity 5Review activity 63/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 13/14Answers to review activitiesActivity 1Rate: 53 beats/minute.Rhythm: Irregular.P Waves: Present; the first, second, fourth, fifth, and sixth P waves are followed by QRS complexes.PR Int:0.22 to 0.46 second. The PR intervals progressively increase until a QRS complex fails to follow the Pwave.QRS: 0.08 second.Intrp: Sinus rhythm with second-degree, type I AV block (Wenckebach).Activity 2Rate: 61 beats/minute.Rhythm: Irregular.P Waves: Present; precede each QRS complex.PR Int: 0.12 second.QRS: 0.14 second.Intrp: Sinus arrhythmia with widened QRS.Activity 3Rate: 26 beats/minute.Rhythm: Regular.P Waves: Present; the first, third, and fifth P waves are followed by QRS complexes. AV conduction ratio is 2:1.PR Int: 0.19 second.QRS: 0.10 second.Intrp: Sinus rhythm with 2:1 AV block.Activity 4Rate: 62 beats/minute.Rhythm: Irregular.P Waves:Present; precede the second, fourth, fifth, sixth, and seventh QRS complexes. The P waves areabnormal (0.16 second in duration and notched).PR Int: 0.26 second.QRS: 0.12 second (all QRS complexes except the third QRS complex); 0.14 second (third QRS complex).Intrp: Sinus rhythm with first-degree AV block, and an isolated premature ventricular contraction.Activity 5Rate: 82 beats/minute.Rhythm: Regular.P Waves: Present; precede each QRS complex. The P waves are abnormally wide.PR Int: 0.16 second.QRS: 0.16 second.Intrp: Normal sinus rhythm with widened QRS.3/24/2020 Study Plan Week 2 – Cardiovascular assessment and cardiac rhythmshttps://flo.flinders.edu.au/mod/book/tool/print/index.php?id=2585800 14/14Activity 6Rate: 70 beats/minute.Rhythm: Regular.P Waves: Present; precede each QRS complex.PR Int: 0.16 second.QRS: 0.06 second.Intrp: Normal sinus rhythm.The post Cardiovascular assessment and cardiac rhythms appeared first on My Assignment Online.

  

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