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How can you tell the kidneys aren't being perfused?
- increased BP
- increased BUN/Creatinine
- decreased urine output
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Normal CO, SV and HR
CO 4-8 L or 4,000-8,000L/min
SV and HR are 60-100
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Normal urine output amount
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Primary forces of electrical impulses of the heart go.....
right to left and top to bottom
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S/S of low CO
- Altered LOC
- weak
- prolonged cap refill
- cool extremities
- weak pulse
- SOB....using accessory muscles
- restless
- agitated
- angina
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What does lead II show?
P wave and QRS complex
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What does the PR interval measure?
time from the onset of atrial depolarization to the onset of ventricular depolarization
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Normal time of PR Interval
.12-.20 or 3-5 small boxes
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What does the P wave represent?
atrial depolarization
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What does the QRS complex represent?
ventricular depolarization
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Normal length of QRS complex
0.4-.12 seconds or 1-3 small boxes
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What causes a wider QRS complex?
- MI
- Hypertrophy
- Ischemia
- Bundle Branch Block
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What does the ST segment represent?
early ventricular repolarization....it is isoelectric and is located on the baseline
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What does an elevated and depressed ST segment mean?
- elevated = MI
- depressed = ischemia or dig toxicity
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What does the T wave represent?
ventricular repolarization.....should be larger than the P wave
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What do these irregular T waves mean?
Inverted
Flattened or inverted
Tall or peaked
Notched
- Inverted-ischemia
- Flattened/Inverted-hypokalemia
- Tall/Peaked-hyperkalemia
- Notched-periarditis
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What does the QT interval represent?
the time between the onset of depolarization and the and of repolarization of the venticles
Total duration of ventricular systole
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Normal length of QT interval
.35-.40 seconds or 9-10 small boxes
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Horizontal axis measures
time in seconds and distance in mm
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Vertical axis measures
voltage in mm
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Triplicate method of measurement
- can only be used if you have a regular rhythm
- lines away....
- 1=300
- 2=150
- 3=100
- 4=75
- 5=60
- 6=50
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How do you measure the ventricle rhythm? and what are you noticing? What makes it significant?
- R-R
- is it regular or irregular?
- If there is a difference either way by 3 small boxes, it is a problem
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Atrial and ventricular rates should be
the same
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Look at practicalclinicalskills.com/ekg.aspx
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How do you calculate Mean Arterial Pressure?
1 systolic + 2 diastolic/3
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Drugs for bradycardia
- Atropine
- Dopamine
- Epinephrine
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Due to changes in the cardiac conduction system, older adults are at increased risk for
- dysrhythmias like-
- PAC
- PVC
- A Fib
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When a dysrhythmia is suspected assess patient for
- angina
- hypotension
- heart failure (elderly)
- cerebral perfusion (LOC)
- renal perfusion (UO)
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When you are assessing an older person with dysrhythmias consider the following problems....
- electrolyte imbalances
- hypoxia
- drug toxicity
- heart failure
- myocardia ischemia
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When educating the elderly make sure....
- you know their level of education
- can they hear/see/read
- provide instruction in large easy to read print
- include the family in teaching
- inform of community resources of places to take pulse and bp
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If a patient has bradydysrhythmias what do I teach to help avoid these....
avoid stimulating the vagus nerve.....keep carotid pressure low, dont bear down or stimulate the gag reflex
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How do you teach patients with premature beats or ectopic rhythms?
- stop smoking
- avoid caffeine
- drink with moderation
- manage stress
- take meds and report AE
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What do you teach a patient with ischemic heart disease?
- treat angina promptly with nitro
- if no relief with nitro call 911
- if chest pain is accompanied by sweating, nausea, weakness or palpitations call 911
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What do I teach older patients about drug therapy?
- teach generic and brand name
- teach what each drug does
- clear instructions about dosage, schedule and side effects
- consider physical limitations of older patients...can they see/read/open container
- teach all patients to report dizziness, n/v, sob or chest discomfort....report to Dr.
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HR and the heart.....
teach all clients to take their pulse and report a HR over 100 or below 60 or any increase in irregularity
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Symptoms of hypokalemia
- weakness
- lethargy
- cardiac irregularity (PVC)
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Foods high in K+
- tomatoes
- beans
- prunes
- avocados
- bananas
- strawberries
- lettuce
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Symptoms of hypomagnesia
- weakness
- ventricular irregularities
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Foods high in magnesium
- green leafy vegetables
- nuts
- dried peas
- beans
- whole grains
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What do you teach a patient about a pacemaker?
- take pulse for 1 min every day at the same time. Report a pulse lower than the set pacemaker rate
- report redness/swelling @ insertion site
- keep cell phones 6 in away
- avoid strong electromagnetic fields
- carry a pacemaker id card
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Weird things about a pacemaker.....
- anti theft devices in stores may interfere with their function
- they can set off metal detectors
- if you are close to an electrical or magnetic device and you feel weird...move away and take pulse
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Things to know about ICD's (Implantable cardioverter defibrillatoros)
- cont. with antidysrhythmia meds
- if shocked...site or lie down and call Dr.
- avoid electromagnetic fields
- cell phones kept 6 inch away
- carry ICD ID card
- report any fainting or black outs
- encourage family to learn cpr
- avoid strenuous exercise
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Management
- coordination of resources, such as time, people, supplies, to achieve outcomes.
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- Involves problem solving and decision making processes
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Leadership
the act of guiding or influencing people to achieve desired outcomes; occurs at any time a person attempts to influence the beliefs, opinions or behaviors of an individual or group
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Keys to effective Management **KNOW**
- planning-defining goals and objectives
- organizing-how to communicate, coordinate people, time and work
- staffing-recruit good qualified people
- directing-encourage employees to accomplish goals
- controlling-perform employee reviews and analyze finances and quality of care
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Keys to effective leadership
technical skills-clinical expertise and nursing knowledge
human skills-ability ad judgment to work with people in effective leadership role
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Conceptual skills
the ability to understand the complexities of the overall organization and to recognize how
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Authoritarian
makes all decisions with no staff input and uses the authority of the position to accomplish goals
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Democratic
encourages staff involvement in goal setting, problem solving, and decision making
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Laissez-faire
provides little direction or guidance and forgoes decision making
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Contingency
depending on the situation, the nurse manager may need to use different types of management styles
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Leaders....
attempt to influence beliefs, opinions or behaviors of persons, but may not have formal authority but can still influence others
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Managers have....
a formal line of authority and accountability
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Expert power
- new grads can be intimidating to old nurses
- ....also if I go on a specialized floor go to seminars to learn the new stuff and wow them
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Difference between a transactional leader and a transformational leader
transactional....just concerned with the day to day duties
transformation....has goals and visions for the floor, know charge nurse
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Example when it is ok to be an authoritarian leader
when there is a code....somebody has to be the leader
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Example of a democratic leader
people who are involved with decisions for the floor in goal setting and problem solving
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Give an example of the Laissez-Faire manager....
teacher student relationship like us....we are self motivated and driven, teachers dont need to tell us what to do
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What kind of management does todays health care system need to use?
democratic....but may need to adapt to other styles, depending on the situation
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Staff Developer
offers learning and training opportunities to enhance professional and personal growth for all employees
Accesses resources and plans staff development activities to meet the needs of individual staff members
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What is the key to developing future nursing leaders and managers?
mentors
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What does a corporate supporter do?
he/she is a professional representative for the organization who is committed to the mission, goals and objectives of the employing organization
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There is a strong connection between the nurses .....
work environment and medical errors
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4 key recommendations for nurses **KNOW**
- practice to the full extent of education and training
- achieve a higher level of education
- be full partners w/ physicians and other health care professionals in redesigning healthcare
- engage in effective work force planning and policy making with better data collection and information infrastructure
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