Introduction

Anatomy and Physiology Update

Assessment Techniques

Recording the Physical Assessment Findings

Cardiovascular Assessment in Specific Disease Conditions

Electrical Activity of the Heart Related to Normal EKG

References

Course Exam

Electrical Activity of the Heart Related to the Normal EKG, Con't.

Assessment of the MI Patient

 As a review, we remember that an MI myocardial infarct is death of the heart muscle tissue. The area of infarct can be small or large depending upon the amount of the blood supply which was cut off. 

The treatment for the MI patient is divided into two phases.  First, the acute stage where the patient is in the ICU. The second phase of medical treatment is the rehabilitation stage.  The person is placed on the nursing care until where rehabilitation starts.

Assessment During the Acute Phase (Day 1 – 4)

1. Assess for possible complications of the MI
1. Arrhythmias
2. Congestive heart failure
3. Carcinogenic shock
4. Mitral regurgitation
5. Ventricular septal rupture
6. Pericarditis
7. Ventricular aneurysm
8. Dressler’s syndrome (post MI syndrome)
2. Progressive activity
   Starting with self-care items, then progress as per the individual’s capability, MD will order activity levels.
   

Assessment During the Rehabilitation Phase (semi acute 4 – 10 days):

1. Up to bathroom and assess patient for any arrhythmia which is still a concern at this time, bedside activities only also assess vital signs regularly, especially after activity.
2. Daily care – assess short walks in room and hallway, can usually do all hygiene activates at this time.

Assessment during late Rehabilitation Stage:

1. Counseling on discharge – does the patient return to their same job and lifestyle?
2. Patient teaching – the patient should be taught what to look for; any adverse symptoms should be reported to the physician immediately, careful assessment before discharge is important.

These are only guidelines to assessing the MI patient.  Each person will progress differently and must be assess on their own merits.  Their individual programs will be worked out with their cardiologist. The nurse should be familiar with each individual’s program so that it can be followed carefully.  Continually asses for the above complications which can occur at any time during the rehabilitation phase of the MI patient.  Complications such as arrhythmias, CHF, shock, and angina will always slow the recovery of the patient.  These persons with complications will have to be assessed even more carefully to prevent life threatening further complications.

Assessment of Patient with CHF

Congestive heart failure, or cardiac decompensation, whatever the cause, results in lowered cardiac output.  In addition to this problem, blood backs up behind the heard causing hypertension and a variety of similar conditions. In assessing this patient, first keep in mind emergency procedures in case of a crisis.  CHF can lead to pulmonary edema very quickly so be prepared to act quickly.

Assessment of CHF:

1. Vital Signs
   
   Baseline vital signs are important here as well as for our other assessments, including an apical pulse; history is also important.
2. Cardiovascular
   Assess heart rhythm, and strength of the heartbeat.  Assess pulses, skin color, tugor and blanching.
3. Respiratory
   Assess lung sounds for congestion, rales
4. General Medical
   Neuro assessment, lethargy, restlessness, skin color, extremities for reduced circulation

Drugs for treating CHF:

1. Digoxin
   Used to strengthen the force of contraction and increases cardiac output, can be used to reduce all the symptoms of even severe CHF, watch for signs of toxicity – nausea and gastritis.
2. Diuretics
   Either thiazide type or loop type; helps to reduce fluid volume over load and reduce pulmonary symptoms.
3. Vasodilators
   Can help reduce volume that ventricles must pump, thus reducing eh workload.  (arterial dilators)

The above guide assumes that the patient is stable.  If the patient is in a crisis situation, such as pulmonary edema, they will need emergency care in the form of intravenous digoxin and/or diuretics. In addition, the patient will require supplemental oxygen (1-3 L/min), sometimes needs oxygen via ventilator and endotracheal tube, under pressure, and in high concentrations.  In this acute state of emergency it is important to continually monitor the vital signs and lab test values.  The patient must be maintained with adequate oxygen and blood supply until the heart can begin again to pump sufficient supplies of blood into circulation, and the lungs can clear of the excess fluid.  Digoxin is a cardiotonic drug that increased the force of the contraction of the heart, increasing cardiac output.

With most vasodilators, the blood pressure will be lowered and the pulse rate will be increased as will the respiratory rate be increased. The nurse must relax the patient as much as possible and make them comfortable as possible so as to reduce the work load of the heart.  Pulmonary assessment in these emergencies is also important as cardiovascular assessment. 

Artificial Pacemakers

There are many different types of cardiac pacemakers.  They can be external or internal artificial pacemakers.  Earlier in the text, it was mentioned that pacemakers can be used to treat many of the Brady (slow) arrhythmias.  The EKG tracing illustrated, shows a normally functioning pacemaker.  The pacemaker can be the demand type, where the pacemaker will automatically start again if the patient’s rate falls below a certain preset rate.  There are also pacemakers which are preset to give a constant pulse, no matter what the patient’s heart rate is.  Note the pacemaker “spikes” on the sample EKG.  Each of these spikes represents an electrical stimulation of the heart. 

Cardiovascular Disease and the EKG

The above is merely a guide to possible complications with certain cardiac related disorders. There can also be others.  If the patient is being monitored in the ICU or other such unit, any of the arrhythmias will be detected rapidly.  If they are on a medical/surgical unit, and not monitored, the nurse must be acutely aware of arrhythmias. Look for indications as change in level of consciousness, dizziness, pallor, confusion, lowered urinary output, sudden development of edema and other signs/symptoms which might indicate an arrhythmia.  Of course, nothing will take the place of careful and accurate recording of vital signs.  A sudden or even insidious change in the vial signs can be the first indication of an arrhythmia.

Interpretation of the EKG

This is perhaps the most important section of this course.  Interpretation of the EKG must be performed in a logical sequence in order to best serve the patient.  There are many different approaches to the interpretation of the EKG, but in this section we will present a “common sense” approach.  If you are responsible for a patient who is being monitored, you want to be able to recognize any arrhythmia which may be life-threatening.  You want to be able to do that as fast as possible; it may save the life of your patient.  As you read through these steps, remember that they may not apply to every patient in every situation, but always be deliberate and methodical when you interpret the EKG.

Step I: Assessment

1. Assess patient symptoms, if any, and vital signs.
2. Assess leads to the patient (must be in proper place)
3. Assess obvious abnormalities of EKG (rate, rhythm)

In this phase, the nurse must quickly note any adverse symptoms.  The symptoms will determine if the arrhythmia is severe or not.  The vital signs are important.  At the same time, you are assessing the patient, look at the EKG to determine if there are any gross arrhythmias, such as no rhythm, or grossly irregular rhythm.  After these are determined, the nurse can then take the appropriate action.  If the patient needs immediate resuscitation or if they can wait for treatment. 

Step II: EKG Components

1. Examine the individual components of the EKG tracing.
2. Are any of the components missing
3. Are any of the components present but altered

Examine each of the waves of the EKG.  Make sure that there is a P wave, QRS complex, etc.  if all of the components are present, are they normal in configuration.  They should all be identical in shape, and in timing.

Step III: Determine the Arrhythmia

1. Atrial arrhythmia
2. Ventricle arrhythmia

Once you have identified the abnormal component on the EKG, you then name the arrhythmia.  If the abnormality is in the atria (P wave), then identify the arrhythmia.  If the abnormality is in the ventricle, then identify the arrhythmia.

Step IV: Action

1. Immediate action
2. Long-term action/intervention

As we stated above, if the arrhythmia is immediately life-threatening, then immediate action must be taken.  However, in the most nursing situations, the action will involve notifying the physician and then treating the arrhythmia with the appropriate drug.  As you proceed through each of the above steps, you must continually be aware of the changes in the patient’s condition and of possible intervention. Each hospital will have a different protocol for dealing with arrhythmias.  Always consider your hospital’s policy and procedure and use your common sense when dealing with these potentially fatal arrhythmias.

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