Telemetry Interpretation

Anatomy and Physiology Review

Heart Atria Ventricles Valves Cardiac Cycle

Electrophysiology
Electrical
Automaticity
Ability to initiate an electrical impulse spontaneously and repetitively (pacemaker)

Excitability
Ability of non-pacing cells to respond to electrical impulse and to depolarize

Conductivity
Ability to transmit an electrical stimulus from cell to cell leading to rapid succession of depolarization (contraction)

Mechanical
Contractility
Ability of atria and ventricles to contract (shorten muscle fiber length in response to electrical stimulation, generate pressure to propel blood forward)

Electrical Conduction
Electrical Conduction
SA Node Internodal Pathways Intra-atrial Pathways (Bachmanns Bundle) AV Node Bundle of His Bundle Branches
Left and Right

Purkinje Fibers

Monitoring
Types
Continuous Intermittent

Leads
I, II, III, avF, avr, avl, mcl 12 leads (V1, V2, V3, V4, V5, V6)

Standard Limb Leads

Lead Placement
5-Lead 12-Lead

Monitoring
Electrodes
Applied to non-bony surfaces Avoid hairy areas Gel

Batteries Artifact

EKG Paper Layout

Hash mark to hash mark equals 3 seconds (depending on telemetry paper used) Thick line to thick line equals 0.20 sec Small box to small box equals 0.04 sec

Rhythm Strip Components

P wave P-R Interval QRS Complex ST Segment T Wave U Wave

P-wave
P-wave represents atrial depolarization (contraction)
Smooth and round Upright Precedes each QRS complex

Present or absent Does every p-wave have a QRS complex following it?

PR Interval
Measured from the beginning of the P wave to the beginning of the QRS complex (AV conduction) Interval 0.12 0.20 seconds Intervals greater than 0.20 seconds is indicative of a heart block

QRS Complex
QRS complex represents ventricular depolarization (contraction)
Measured from Q-wave to S-wave at the baseline Normal time interval 0.04-0.12 sec Longer interval could be result of medication or cardiac disease (MI)

Is there a QRS complex after EVERY P-wave?

ST Segment
ST segment represents the end of ventricular depolarization and the beginning of repolarization Measured from the end of the S-wave to the beginning of the T-wave
Normal time interval 0.08-0.12 sec Slight upward shape (slope) However, time is not as significant as the shape and direction
Elevation or depression could be the result of infarction, ischemia or electrolyte imbalances

T wave
T wave represents ventricular repolarization (recovery/relaxation)
Measured from the beginning of the T-wave to the return of the T-wave to the baseline Round, smooth, slightly asymmetrical and upright Larger than a P wave Abnormalities
Inversion Tall and peaked Flat

Other Wave Forms

QT Interval
Total time required for ventricular depolarization and repolarization Measure from beginning of QRS to the end of the T wave Normal time interval < 0.44 seconds

U-wave
When present follows the T wave Seen more often in Lead 3 Suggest electrolyte imbalance (K)

EKG Strip Interpretation

Things to consider: Rhythm
Regular or irregular

Rate P-wave
Present for every QRS complex Shape

PR Interval QRS length **Others if needed QT interval or U wave Interpretation

Determining Rhythm
Examine the distance between wave forms and then determine if regularly spaced
Atrial Rhythm
Measure the P-P interval

Ventricular Rhythm **
Measure the R-R interval

Any variation the rhythm is irregular

**Most commonly used

Rate
SA node
Pacemaker of the heart Rate 60-100 Sympathetic and Parasympathetic

AV node
Back up pacemaker Rate 40-60 Sympathetic and Parasympathetic

Bundle of His and Purkinje fibers

Rate 20-40 Sympathetic only

Determining Heart Rate (Method 1)

If the rhythm is regular Count the number of QRS complexes in a 6 second strip, multiply by 10

3 hash marks (6 second strip)

Determining Heart Rate (Method 2)

If the rhythm is irregular Count the number of small boxes between QRS complexes and divide into 1500
Must use the longest and shortest complexes to determine heart rate range 1500 # small boxes from 1 QRS complex to the next complex

Determining Heart Rate (Method 3)

One large box, the heart rate is 300 BPM (300/1) Two large boxes, the heart rate is 150 BPM (300/2) Three large boxes, the heart rate is 100 BPM (300/3) Four large boxes, the heart rate is 75 BPM (300/4)

Rhythm Patterns

Sinus Rhythms
Rhythm regular (R-R and P-P) Rate
60 - 100

P Wave
Round, smooth, upright, precedes each QRS complex

PR Interval
0.12 0.20 seconds

QRS Complex
0.04 -0.12 seconds

Treatment
None, unless symptomatic

Normal Sinus Rhythm

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Sinus Tachycardia

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Sinus Bradycardia

Rhythm Rate P Wave PR Interval QRS Complex Interpretations

Sinus Rhythms

An older client has been taking metoprolol (Toprol) for hypertension for the past 3 days. Her daughter states that she has become confused, dizzy, and weak since starting the drug. How will the telephone triage nurse respond to the daughters concerns?

Shes getting older, so confusion is common with aging. Did your mother pass out at any time in the past few days? Tell your mother to stop taking the metoprolol for a week. Tell your mother to only take half of the drug today.

25%

25%

25%

25%

Atrial Rhythms
Rhythm
Regular, irregular or irregularly irregular

Rate
40-60 beats/minute (can be as high as 250-300 beats/minute)

P Wave
Saw tooth (F) or irregularly shaped (f)

PR Interval
Not measurable

QRS Complex
0.04 0.12 seconds

Atrial Flutter

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Atrial Fibrillation

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Other Atrial Rhythms

Other Common Dysrhythmias

Premature Atrial contractions (PACs)

Ventricular Rhythms
Rhythm
Regular or irregular

Rate
Greater than 150 beats/minutes, may not be measurable

P Wave
Absent

PR Interval
Absent

QRS Complex
Wide, bizarre

Ventricular Tachycardia

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Ventricular Fibrillation

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Ventricular Asystole

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Other Common Dysrhythmias

Premature Ventricular contractions (PVCs)

Bigeminy

Couplets

A client is on a cardiac monitor. The nurse suddenly notices there are no ECG complexes and the alarm sounds. What is the priority action of the nurse?

Call a code blue and 25% shout for help. Begin chest compressions and ventilations. Assess the client and check lead placement. Press the record button to get an ECG strip.
1

25%

25%

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Heart block and Pacers

Pacemaker spike

Pacemakers
Uses Type
Temporary Permanent

Maintenance Nursing Responsibility

A client reports not feeling well for the past week after taking digoxin (Lanoxin), which was prescribed a month ago. Which statement by the client indicates possible digoxin toxicity?

I am short of breath and my hands are swollen. I have chest pain and tingling in my fingers. I am constipated and have trouble sleeping. I have double vision and feel sick to my stomach.

25%

25%

25%

25%

LETS PRACTICE

Lets Practice

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Lets Practice

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Lets Practice

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Lets Practice

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Lets Practice

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

Lets Practice

Rhythm Rate P Wave PR Interval QRS Complex Interpretation Treatment

References
Borgelt, E., & Overmyer, A. (2006). Basic cardiac rhythms: Identification and response. Mosby, Inc. Ignatavicius, D. & Workman, M.L. (2013). Critical Thinking Study Guide to Accompany Medical-Surgical Nursing. (7th ed.). St. Louis, MO: Mosby Elsevier.