Non-Invasive Hemodynamic Patient Monitoring Self ... - ePOPS

Document Coversheet for ePOPS NON-INVASIVE HEMODYNAMIC PATIENT MONITORING SELF-INSTRUCTIONAL LEARNING PACKAGE

DOCUMENT TYPE: REFERENCE TOOL

CW.01.04 Published Date: 12-Jul-2018 Review Date: 12-Jul-2021

This is a controlled document for BCCH& BCW internal use. Refer to online version. Print copy may not be current. See Disclaimer at the end of the document.

Document Owner: BC Children’s Hospital Clinical Nurse Educators

Purpose of Document(s): The learning package was created to introduce nurses to the patient monitoring system used

throughout the TECK Acute Care Centre. It provides an overview of the Philips central monitoring

system and outlines the bedside nurse’s role and responsibilities when applying and monitoring a

patient. It also covers the essentials of assessing ECG’s for normal sinus rhythm.

Applicability

BC Children’s Hospital Teck Acute Care Centre

Version History DATE DOCUMENT NUMBER and TITLE ACTION TAKEN

26-Jun-2018 CC.03.49 Non-invasive Hemodynamic Patient Monitoring Self-Instructional Learning Package

Approved at: BC Children’s Hospital Best Practice Committee

DISCLAIMER This document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part as per the Terms of Use on the website.

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Professional Development Specialty Pediatric Nursing Practice

Non-Invasive Hemodynamic Patient Monitoring

Self-Instructional Learning Package

BC Children’s Hospital Clinical Nurse Educators

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Non Invasive Monitoring

In the TECK ACC all patient areas (with exception of the OR) use Philips IntelliVue

monitoring systems to provide hemodynamic monitoring. The system provides in room

monitoring, as well as central monitoring for each patient. Central overview stations are

located in each team care station. The Comm center also provides an overview of the

two nearest team care stations.

Philips monitors can be both mounted in the rooms (hard wired) or on roll stands for

portable use. When they are not mounted in the room the system uses wireless

technology to display information on the central monitoring system. There is wireless

coverage in all areas of the TECK ACC, excluding the elevators and outdoor areas.

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There are 4 components to the Philips system.

The compact X2

The large screen MX450 monitor

The Central Monitor

The cables, probes and leads attached to the patient

X2

Is the main console of the monitoring system. Connects with the MX450’s.

X2’s have a battery life of 3 hours.

MX450

Mirrors the information gathered from the X2.

The touch screen is fragile and

scratches easily. PLEASE USE THE PADS OF YOUR FINGERS to make selections and not your fingernails or

objects such as pens or pencils!

Central

12 sectors per central in the team care stations.

24 sectors in the Comm centers.

Cables

& Cords

Cables: are the thick white cords that attach the leads to the X2 monitor.

Leads: are the coated wires that attach to the electrodes. We use a 3 lead

system.

Electrodes: are the sticky disks applied to the patient’s skin.

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Accessing Information Cardiologists and other attending physician groups have remote access to any patient information on any Philips in the TECK ACC. Nurses can access patient information from a central monitor to display on a computer by using the PIIC iX icon on the desktop (see below). This allows the nurse to observe multiple patients on the same computer screen in an alcove.

Follow the process below to request PIIC iX web viewer access.

call or email the Service Desk at 604-675-4299 with the following information: o Request - please grant me access to the PIIC iX Multipatient Web Viewer

(https://piicixweb.phsa.ca/(S(l4tayd452x111m45h4odc2fl))/logon.aspx?ReturnUrl=%2fPatientSelection.aspx) and provide the following information:

Name

Title (e.g. Nurse or Physician or Unit Clerk)

Department (e.g. NICU/PICU/ER/etc)

Do you have approval for this access from your manager/supervisor (include his/her name)?

Contact Information - phone/email/cell (how can we contact you to test your access)

Location where this information will be viewed (e.g. alcove PC, team care station PC, Citrix, remote access from home, laptop etc). This will help determine your access rights and if further configuration is required.

All of the information collected on every Philips monitor is saved on our hospital ‘server’ for 7 days – this includes patient data, events and alarms. To ensure this data is saved when discharging a patient, please select “end case” and press “confirm” on the bedside monitor. If you notice any problems, such as dropped signals or unusually displayed items, please let the charge nurse know and call the Philips 24/7 Hotline @ 1-800-323-2280 to report your observations. The staff at the Philips hotline will provide both clinical and technical support. Your call is logged and a case reference number is assigned. Please e-mail the reference number and a short description of the event/problem/situation to your leadership team to facilitate appropriate follow up.

https://piicixweb.phsa.ca/(S(l4tayd452x111m45h4odc2fl))/logon.aspx?ReturnUrl=%2fPatientSelection.aspx)

https://piicixweb.phsa.ca/(S(l4tayd452x111m45h4odc2fl))/logon.aspx?ReturnUrl=%2fPatientSelection.aspx)

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Learning Activity #1:

Philips has a great 20-30 minute e-learning activity that introduces the main features of the monitors. Please check out www.theonlinelearningcenter.com and work through the tutorial.

Features to focus on:

Introduction Overview Alarms ECG monitoring Arrhythmia Monitoring Set up

Respiratory monitoring Monitoring SpO2 Pulse monitoring BP monitoring Trends

http://www.theonlinelearningcenter.com/

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Electrodes, Leads and Cables All of the cardiac monitors have the ability to monitor the heart’s electrical activity in a variety of different leads. The six standard leads are I, II, III, aVr, aVI, and aVf. Leads I, II, III are called bipolar because they monitor the electrical activity occurring between two electrodes, a positive and a negative. A separate electrode, the ground, is used to eliminate any interference which may occur. Lead II is the most commonly used; therefore inpatient monitors have been configured to default to lead II. Lead II produces tall, upright deflections that are the easiest to see and measure. The electrodes are placed in the following manner:

1. White on the right upper chest (also labeled RA for right arm). This is the negative electrode when in lead II.

2. Black on the left upper chest (LA for left arm). This is the ground electrode. 3. Green on the left lower chest (LL for Left lower, or diaphragm of baby). This is

the positive electrode. It must be in a place where you can see the rise and fall of the chest.

The electrodes must be placed correctly on the child’s body for proper electrical activity to be sensed by the monitor. A good tracing can only happen if the electrodes are placed in the appropriate areas and the monitor leads are attached to the correct electrodes. ALWAYS ENSURE THAT THESE ARE CORRECT DURING YOUR INITIAL PATIENT ASSESSMENT.

Lead Position- The ECG is a graphic representation of the sequence of the myocardial depolarization and repolarization. ECG tracings are obtained through a system of 3 electrodes placed on the trunk of the patient, usually in a triangle configuration

American Heart Association, 2006 & PICU Orientation manual, 2009

Best practice tip: Print an ECG strip at the time of initial assessment …this will give you a baseline to refer back to throughout the shift.

TIP: White on the Right; Smoke over Grass.

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The child’s skin must be dry when the electrodes are applied. The electrodes may need to be changed frequently if the child is diaphoretic. The entire surface of the electrode needs to be in direct contact with the skin surface for the best tracing. The electrodes can dry out very quickly and peel away from the skin. When this happens the monitor struggles to pick up the signal and your patient is no longer being safely monitored. The monitor also alarms for the whole unit to hear and contributes to nuisance alarms.

Best practice tip: If the electrode is not sticking well, consider washing and drying the skin area and replacing with a new electrode. Do not apply tape over the electrode.

A good time to change the electrodes is during bath time. Electrodes left on the child for too long may cause skin irritation. Please change the electrodes and provide skin care at least every 24 hours. Sometimes a “batch” of electrodes is dry and unusable. Place the unusable batch in a small plastic bag with the packaging containing the LOT number and leave them in the CNE/CRN office with a description of the problem. They are returned to stores and replaced (for free) by the manufacturer. Little hands, burping, or feeding activities can easily dislodge the electrodes from the body or the leads from the electrodes…always check to make sure everything is connected…otherwise you may be monitoring the inside of a sleeper!! In any event, when in doubt always check the child first. When you observe something unusual, go back to your original assessment of the child’s cardiac function… What is the patient’s color? What are the pulses like? What is the cap refill/peripheral temperature?

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Terminology Learning how to work with the monitors may feel like you are learning another language! Below are a few key terms that you may find helpful to define:

PROFILES: Profiles are settings that determine the monitor’s behavior, alarm settings and measurement settings. They are configured to provide the appropriate default settings and are based on age. We followed the Provincial PEWS recommendations and have a total of 7 different age groups. Each group has its own profile. When admitting a patient you will be asked to select the appropriate profile for that specific patient.

SCREEN: A screen is just a display. Choosing a screen allows you to choose

how you want your monitor to look. A profile comes with pre-programmed default settings; screen selection allows you to choose how you want the patient information to be displayed on the bedside monitor screen. There are four screen options to choose from. You may choose different screen selections based on your preferences. Changing the screen will change how your monitor looks but it doesn’t change the profile default settings. The “change screen” icon is located at the top right corner of the screen. It will tell you what mode you are currently in (ie: 4 wave, or big numbers, etc.).

Main Screen Closes all open menus and windows and returns to the Main Screen. Disabling Touchscreen Operation • To temporarily disable touchscreen operation of the monitor, press and hold the Main Screen permanent key. A padlock will appear on the Main Screen permanent key. • Press and hold the Main Screen permanent key again to re-enable the touchscreen operations Switching to a Different Screen Screens define the selection, size and position of waves. 1. To switch to a different Screen, select the monitor info line and then select Change Screen, or select the Change Screen

Switching to a Different Profile Profiles are predefined monitor configurations that enable you to quickly change the configuration of the whole monitor to adapt to different monitoring situations. 1. Select the monitor info line and then select Profiles, or select the Profiles SmartKey. 2. In the Profiles menu, select Profile. 3. Choose a profile from the pop-up list. 4. Select Confirm.

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SECTORS: Each central monitor has 12 boxes that are linked to a patient room.

These boxes are called sectors. Choose the Sector by using the mouse to hover

over the room you want to see and select <Manage Patient> to Admit,

Discharge, Change Parameters or view Reports/Trends.

SMART KEYS: Frequently used buttons along the bottom of the touch screen.

NUISANCE ALARMS: Unnecessary extraneous alarming. Evidence proves that nuisance alarms are dangerous; nurses will start to disregard ALL alarms over time, even the life threatening kind. Customize your alarm settings for your patient. Ask for an order if necessary - REQUESTING PHYSICIANS TO ORDER INDIVIDUAL ALARM PARAMETERS IS YOUR RESPONSIBILITY!!!

TRENDS – Vital sign trends and/or graphic trends. Trending is the ability to go

back in time and pull off the history of patient’s vitals or graph trends for all monitored parameters. Trends are stored data that can be retrieved and viewed.

Viewing Vital Signs Trends Trends are patient data collected over time and displayed in graphic or tabular form. Select the Vitals Trend SmartKey for tabular trends. When you open the vitals trend window, a selection of pop-up keys appear to let you navigate through the stored trend data: • Select Group to see a pop-up list of trend groups and select a group for viewing. Pop-up keys to scroll up and down the screen to see measurement trends that do not fit in the current view. • Select Interval to see a pop-up list of time interval choices from 12 seconds to 1 hour for viewing the trend data. Pop-up keys move the cursor one time interval to the left or right to navigate through the trends database timeline. Pop-up keys move the cursor one page to the left or right to navigate through the trends database timeline. Pop-up keys jump to the beginning or the end of the trends database to see the most recent or oldest trend information stored.

Best Practice Tip: Avoid over monitoring! There is a difference between continuous cardio-

respiratory monitoring (ECG, Respiratory rate, SPO2), Telemetry (ECG),

and continuous O2 sat monitoring (SPO2 only). Check specifically what

is ordered for your patient.

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ALARM HISTORY – Documents all the alarms the patient has had and provides the ability to pull those up to review and print at any time.

Best Practice tip: Check your patients alarm history after a break.

WAVE REVIEW- Records ‘real’ time storage of waves (like a video). Information is stored for 7days. For example: Your patient has an unusual rhythm/event at 02:10. Wave review allows you to go back and pull up the real time waves to view and print.

YELLOW Versus RED Alarms – Yellow can be silenced at the bedside or central monitor, and are ‘non-latched’, meaning that if the patient self corrects then the alarm turns off. Red on the other hand is considered life threatening and are ‘latched’ meaning you must visit and acknowledge the bedside monitor to silence the alarm while physically assessing the patient.

Color Coded Alarms • Red *** alarms are high priority alarms. They include life-threatening situations such as asystole. • Yellow ** alarms are lower priority alarms. • INOP alarms are technical alarms and have the lowest priority. They let you know that the monitor cannot measure or detect.

- Yellow alarms occur when the patient’s measurement violates the set

measurement parameters.

- Red Heart Rate (HR) alarms occur when the measure violates

parameters by 25 or greater above the set HR limit or 20 or more

below the lower HR limit indicating possible life-threating events

(apnea, desat, invasive pressure disconnects).

BLUE alarm: technical INOP’s -- meaning there is a connection deficit and the monitor cannot pick up the signal. For example, if the SpO2 probe is loose, an electrode is peeling off, or a lead is removed.

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ALARM SETTINGS FOR DEFAULT

As previously mentioned, the Philips clinician (Larissa) has programmed the default alarm settings into each Philips monitor. The parameters were determined in consultation with the cardiology group and align with PEWS. These are very general settings - You are able to apply the patients individualized alarm settings/parameters at any time.

IT IS THE EXPECTATION THAT THE NURSE CHECK AND SET EACH PATIENT’S INDIVIDUAL ALARM SETTINGS (INCLUDING BP) AT THE BEGINNING OF EACH SHIFT

PACED - The monitor needs to know when a patient has a pacemaker so it can adjust how and what data it collects. It is the nurse’s responsibility to ensure the pacemaker function is activated when monitoring a child with a pacemaker.

Changing the Pacing Status When monitoring patients with pacemakers, it is important to set the paced status correctly. Change the paced status: • Via the Setup ECG menu, select Paced and then select from the pop-up list. • Via the monitor info line. Select Paced and then select from the pop-up list. • Via the Patient Demographics menu, select Paced and then select from the pop-up list.

FREEZE THAT FRAME! When looking at the bedside monitor you can freeze the screen to take a closer look….

Freezing Waves You can freeze waves on the screen and measure parts of the wave using cursors. The waves are frozen with a history of 20 seconds. Freeze an individual wave by 1. Entering the wave menu for the measurement by selecting the wave on the screen 2. Select Freeze Wave Releasing Frozen Waves To release frozen waves: 1. Select a frozen wave. 2. Select Unfreeze Waves All frozen waves are released

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Admitting and Discharging

All patients need to be admitted into the monitoring system. This attaches the

physiological information gathered to both a person and a location.

TO ADMIT:

Select <Patient Demogr.>

Select <Patient Name> and input the 3 categories with asterisk: Last Name, MRN,

Birthday

Select <Confirm>

(Fields with an asterisk are required before you can confirm)

The next step, (that you CANNOT do from the Central Monitor) is to set the Patient

Profile. Find the “Profile button” or find the age range displayed and select the

appropriate setting for each patient.

Select <Confirm>

To SET/CHANGE PARAMETERS:

Remember: See It, Touch It, Change It

Each alarm has a corresponding audio alarm of different speeds that will be heard from

in room as well as at the Central Stations and a visual indicator.

TO DISCHARGE:

Select <Discharge> or <End Case>

Select <Confirm>

Patient is now discharged. Patient data will remain in the system for 7 days.

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Transferring a patient on a monitor

When a patient is transferred to another area within the TECK ACC the X2 monitor and

attached cables, leads and probes goes with them. This allows for uninterrupted patient

physiological monitoring. Do not forget to remove the X2 and pack it up with the patient

when transferring!

Once at the new location remove the clean, unused X2 and connect the patient’s X2 to

the large screen monitor. Select <Continue X2> when prompted, and verify that the

settings for patient profile are correct.

Take the clean X2 and its cords to the previous location so that monitoring is available

for the next admission.

Printing There are 2 different types of recordings that you can obtain from the monitor. You can print trends/reviews or you can record a strip that can be attached to the daily flowsheet. Print: Printing trends and wave reviews can only be done at the team care station using letter sized paper. Please ensure the printer has enough paper and is turned on. Contact BIOMED should you encounter a problem with the printer. Record a strip: There are a couple of ways to record a strip. You can press ‘delayed record’ from the bedside monitor, or you can use the mouse at the central monitor to choose the sector and press record. The strip will print at the central strip printer located in each Comm center.

General Maintenance CLEANING – it is the SSA’s and RN’s responsibility to clean the monitors.

Please use Oxivir TB wipes. They are the best way to clean the monitors and are safe to use on the touch screens.

EQUIPMENT problems – Our Biomed department – Local 6740/2064

SERVICING and QUALITY CONTROL – Please call:

Philips 24/7 hotline 1-800-323-2280

** Note: The customer service number is also embedded in the central. Click on the Philips icon at the top left of any central – the number will be there.

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It’s time to look at putting it all together and initiating cardio-respiratory monitoring on yourself or a partner. Don’t forget to admit, choose a profile and set your limits! Getting everything programmed and the patient settled can be a challenge. Over time you will find a method with short cuts and preferences that work for you. As you learn how to navigate the system questions may come up. To best support your learning and get the most from the monitors a practice partner can mentor you along the way. Please use the cardio-respiratory monitor core competency table attached to keep track of your successes. We ask that a colleague provide feedback and sign in the space at the bottom of the page.

Cardio-respiratory Monitor Competency Required

Confident Competent Need Practice

Monitor set up prior to use:

Ensures monitor is clean

Previous pt data cleared

Cables, equipment appropriate size (Neonate, child, small adult cuff), disposable versus non-disposable purple leads set, (infant, child, adult)

Appropriate profile chosen

Electrode placement:

Appropriate size leads

Skin prep done

Leads applied in correct location (RA, LA, LL)

Patient and family teaching done (when to call for help, how long monitoring anticipated, limits, what to do when monitor alarms, leads changed daily or prn,)

Demonstrates safe use of central monitor:

Admits pt. using correct demographic information (Last name, MRN, BD)

Understands default settings, difference between yellow and red alarms

Determines individual settings and seeks direction from physician to personalize settings to reduce nuisance alarms

Sets monitor to pacemaker mode (if appropriate)

Able to silence and print

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Monitoring unit:

Sets monitor for resp monitoring only

Prints vital signs

Explores trends

Adjusts monitor alarm volume, brightness, modes

Sets automode for B/P (if appropriate) for frequent cycles

Please ask your practice partner supporting your learning to sign below. Supported by: __________________ Date:

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Once the patient is properly admitted and attached to the monitor we can safely gather important information that is easily viewed, reviewed and recorded. The longer we monitor the patient the more likely we encounter various alarms. There are a couple of ways to address the audio alarms from both the patient and central monitors. Please review the Philips Quick Guide and the Philips Monitor Quick Reference Guide located online and in the appendix of this package and answer the following questions: What is the difference between silencing and pausing an alarm? How long does each function last? Silence: _____________________________________________________________ Pause alarm: _________________________________________________________ What does the Monitor Standby feature do? _________________________________ Is it possible to switch individual alarms off? _________________________________

Silence Acknowledges all active alarms by switching off audible alarm indicators and lamps. <Silence> buttons will silence an active alarm for ~30 sec, but a new alarm will break through Duration: ~ 30 sec

Pause Alarms Pausing alarms prevents the monitor from indicating any alarm. No alarm sounds or alarm messages are shown. Pause duration depends on monitor configuration. Select again to immediately re-enable alarm indicators. <Pause Alarms>

prevents any active

alarms to break

through for a longer

amount of time.

Avoid choosing this

option unless staying

at the bedside.

Duration: 2min 59sec

Using Monitor Standby Standby mode suspends patient monitoring and all waves and numerics disappear from the display. All settings and patient data information are retained. You can place the monitor in standby: • Via the Monitor Standby SmartKey. • Via the Main Setup key then selecting Monitor Standby. Duration: Until the screen is touched

Switching Individual Alarms On/Off When an alarm is turned off, you will see the alarms off symbol next to the measurement numeric. 1. Select the measurement numeric to enter its measurement setup menu. 2. Select Alarms to toggle between On or Off. Duration: Until you turn it back on it will remain off ** Please note: it is never acceptable to turn off alarms for patients who have monitoring ordered. Always ask the question, does my patient need to be on monitoring if I’m unconcerned when it rings.

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Introduction to ECG’s

ECG interpretation is an important skill for all nurses working with cardio-respiratory monitors. The idea of interpreting an ECG may seem overwhelming, complicated and complex at first. The hope of this module is to provide a systematic approach to looking at strips, and offer clarity on roles and responsibilities around ECG interpretation and documentation. Consider looking at the information gathered on an ECG strip in the same light as info gathered when doing and documenting vital signs on your patient. All the info gathered contributes to the overall assessment and is part of the whole clinical picture. The nurse’s responsibility is to gather the information, document measurements and share anything unusual or uncertain with the other members of the team. Much in the same way a change in a patient’s baseline temperature is communicated and shared. The physicians focus is around diagnosis and action plan. How to interpret findings is a skill that develops over time.

It is an unrealistic expectation to think everything about ECG’s can be learned in a workshop or course in a short period of time. PLEASE ALLOW YOURSELF TIME TO DEVELOP COMPETENCIES AND CELEBRATE SUCCESSES AS YOU BUILD ON WHAT YOU ALREADY KNOW!

“The first ECG was introduced by Willem Einthoven, a Dutch physiologist, in the early 1900s. No matter how sophisticated the cardiac monitor, no matter how many additional features the monitor may include, the ECG is simply a display of the electrical activity recorded on the body's surface (Aehlert, 2005)”.

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ECG monitoring may be used to:

• Monitor a patient's heart rate

• Evaluate the effects of disease or injury on heart function

• Evaluate pacemaker function

• Evaluate the response to medications

• Obtain a baseline recording before, during, and after a medical procedure

The ECG can provide information about:

• The orientation of the heart in the chest

• Conduction disturbances

• Electrical effects of medications and electrolytes

• The mass of cardiac muscle

• The presence of ischemic damage

The ECG does not provide information about the mechanical (contractile) condition of the myocardium. To evaluate the effectiveness of the heart's mechanical activity, you must assess the patient's pulse and blood pressure.

If you are not sure about what you are seeing on the monitor than you need to assess your patient! Evaluate the ABC’s. Signs and symptoms of impaired cardiac output include changes in:

Level of Consciousness

Heart rate (tachycardia or bradycardia)

Pulses

Capillary refill time

Skin Color

Skin temperature

Blood pressure Urine output

American Association PEARS Provider Manual. ECG’s provide information about time and voltage of electrical events of the heart. The ECG tells you what is happening in that heart at that moment of time. Before reading the ECG strip of paper it is important to review a couple of details about a cardiac cycle.

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Quick Review

There are three systems that must work together for the heart to beat efficiently:

1) Circulatory – the continuous network of vessels through which the heart mechanically pumps the blood

2) Conduction – the electrical wiring system that stimulates the heart to pump

3) Coronary – the arteries and veins that provide oxygenated blood to meet the metabolic needs of the heart itself.

The heart has two types of cells:

Myocardial cells; contractile units that allow the cell to contract when the cell is stimulated electrically

Pacemaker cells; specialized cells that can spontaneously generate and conduct electrical impulses

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How is the heart stimulated to beat?

The heart’s own internal pacemaker is called the sinoatrial (SA) node, stimulates the heart to beat. The SA node is a specialized

bundle of nerve fibers located at the top of the right atrium.

The lower parts of the conduction system ARE NOT accustomed to initiating impulses. This can lead to unstable rhythms, some of which can be life threatening.

The SA node fires by a process called depolarization. The firing of the SA node stimulates both the left and right atria to contract. SA node has the fastest rate of automaticity. The impulse then travels through a network of tracts to the AV node. The AV node is located on the floor of the right atrium. Once at the AV node it is delayed for a short time (0.04 sec) to allow the ventricles to fill. Then the impulse travels down from the AV node to a pathway called the Bundle of His and splits into two branches the left and right bundle branch. Purkinji fibers extend from the bundle branches into the endocardium and deep into the myocardial tissue. Conduction of the electrical stimulus to the myocardial cells causes the ventricles to contract.

A HEARTBEAT THAT IS INITIATED ANYWHERE OTHER THAN THE SA NODE IS CALLED ECTOPIC BEAT AND IS NOT A SINUS RYTHYM!

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Electrocardiography

The ECG Complex represents the electrical activity in one cardiac cycle, meaning that it represents the conduction of electrical impulses from the atria to the ventricles.

The ECG complex is broken down into parts or waveforms which are labeled using the letters p through u

Each wave form represents specific electrical activity with in the heart.

ALL HEARTBEATS PRODUCE AN ECG WAVE AND ALL ECG’S HAVE THE SAME

BASIC ELEMENTS: A set of P-QRS-T waves

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P Wave – Atrial Depolarization

(contraction)

The first wave in the cardiac cycle is the P wave. The first half of the P wave reflects

stimulation of the right atrium. The downslope of the P wave reflects stimulation

of the left atrium.

The beginning of the P wave is recognized as the first abrupt or gradual deviation from the baseline. Its end is the point at which

the waveform returns to the baseline.

PR Interval – Atrial Depolarization and

Delay in AV node This interval starts from the beginning of the

P wave to the beginning of the QRS complex

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QRS Complex – Ventricular Depolarization (contraction)

The QRS Complex reflects the impulse from the Bundle of His to the Purkinje Fibers

yielding ventricular contraction.

This is measured from the beginning of the Q wave to the end of the S wave. It should be 2-3 times the amplitude of the P and T

waves.

Q Wave – Depolarization in the Septum

R Wave – Electrical stimulus through ventricular walls

The R wave represents the electrical stimulus as it passes the main portion of the ventricular walls. The wall of the ventricles are very thick and therefore require more

voltage.

S Wave – Depolarization in Purkinje Fibers

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ST Segment – Absolute Refractory

Period The ST segment extends from the end of

the QRS to the beginning of the T wave. It is not usually measured in time but in

amplitude.

T Wave – Ventricular Repolarization The T wave represents the relative

refractory period. It follows the QRS – ST segment, and is the time during the cycle where the heart is most vulnerable to fatal

arrhythmias.

QT Interval – Ventricular Depolarization and Repolarization

The QT interval represents one complete ventricular depolarization and repolarization. It is the distance from the beginning of the

QRS complex to the end of the T wave.

U wave – Recovery of Purkinje Fibers The U wave is not always (rarely) seen, but

represents the recovery period of the Purkinje Fibers.

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ECG Paper

ECG’s are a graphical representation of the heart's electrical activity. When you place electrodes on the patient's body and connect them to an ECG, the machine records the voltage (potential difference) between the electrodes. This recording is made on ECG paper.

ECG paper is graph paper made up of small and large boxes measured in millimeters. The smallest boxes are 1-mm wide and 1-mm high. The horizontal axis of the paper corresponds with time. Time is used to measure the interval between or duration of specific cardiac events. Time is stated in seconds (Aehlert, 2005).

The horizontal axis represents time. The vertical axis represents amplitude or

voltage.

The monitors in the med/surg inpatient areas are set to the standard paper speed of 25 mm/sec. Each horizontal 1-mm box represents 0.04 sec (25 mm/sec × 0.04 sec = 1 mm).

Look closely at the boxes in the diagram - the lines after every five small boxes on the paper are heavier. The heavier lines indicate one large box. Because each large box is the width of five small boxes, a large box represents 0.20 sec.

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Normal Sinus Rhythms

It is considered a foundational nursing competency to recognize normal sinus rhythm (NSR). Normal sinus rhythm records an impulse that starts in the sinus node and progresses to the ventricles through a normal conduction pathway – from the sinus node to the atria and AV node, through the bundle of His, to the bundle branches and on to the Purkinje fibers.

NORMAL SINUS RHYTHM IS THE STANDARD AGAINST WHICH ALL OTHER RHYTHMS ARE COMPARED.

Characteristics of Normal Sinus Rhythm:

Rate is WNL (within normal limits) for age The rhythm is regular All intervals are within normal limits There is a P for every QRS and a QRS for every P The P waves all look the same

It is the nurse’s responsibility to assess an ECG strip each shift for patients on monitoring. The medical/surgical inpatient areas use the 4 step method to assess a strip. Please record a strip for each patient on monitoring at the beginning of each shift and attach it with double sided tape onto the space allotted on the daily flow sheet. A minimum of one strip per 12 hour shift is required. Alternatively, you can print a strip report using the computer printer – this provides a 8x11 (letter sized) strip that can be added to the patients chart.

Please print and attach any additional strips to the nurses notes whenever:

You notice a change from baseline

The patient condition/status changes

Before and after invasive procedures

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Other Sinus Heart Rhythms

The following are referenced from the book, “ECG Interpretation Made Incredibly Easy.”

Published by Lippincott Williams & Wilkins 2011. A free pdf copy of this textbook is

available on line. Simply google “ECG Interpretation Made Incredibly Easy” for a copy of

your own.

This addresses adult patients however the principle remains the same.

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The 4 Step Method The 4 step method to reviewing ECG strips is just one of many different ways to approach looking at the information on the paper. This method is outlined on the ECG lanyard card that is available from your friendly CNE/CRN.

Review of the steps:

1. Determine the rate. There are a couple of methods to determine atrial and ventricular heart rate. The easiest way to calculate the rate is to use the “10 times” method. You will notice that the ECG paper is marked in increments of 3 seconds (or 15 large boxes). To figure out the rate – obtain a 6 second strip and count the R waves and then multiple by 10. Ten 6-second strips represent one minute.

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Find the hash marks along the horizontal edge. Each mark equals 3 seconds. Count the waves from one mark to the third mark for a 6 second period.

What is the rate in the strip above? ______________

2. Determine the rhythm. There are a couple of ways to determine if the rate is regular or irregular. It is important to notice if the strip is the patient’s baseline rhythm or different from their norm.

Place a blank piece of scrap paper on top of the strip with the straight edge near the peak of the R wave. Mark the paper at the R waves of two consecutive QRS complexes. Move the paper across the strip, aligning the two marks with succeeding R-R intervals. If the distance is the same the rhythm is regular. If the distance varies it is irregular. Use the same method to measure the distance between the P waves (P-P interval) and determine whether the atrial rhythm is regular or irregular.

** Compare R-R and P-P intervals in several cycles. These should occur regularly – you may see very small variances associated with respirations. **

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3. Assess P waves and PR interval. When looking at the strip ask yourself….

Are P waves present before every QRS (1:1)?

Do all P waves look alike in size and shape?

Are they upright and round?

Do they occur at regular intervals (P-P)?

IS THE PR INTERVAL CONSTANT?

Does the PR interval fall within normal ECG standards as listed on the back of the lanyard?

4. Assess QRS waves.

Are they the same size and shape?

Any changes from prior QRS shape?

Is the QRS duration appropriate for age?

That’s it! Time for some practice

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Determine the rate

Determine the rhythm

Assess the P waves and PR interval

Assess the QRS

Determine the rate

Determine the rhythm

Assess the P waves and PR interval

Assess the QRS

Non-Invasive Hemodynamic Patient Monitoring Self ... - ePOPS

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