Assignment in Critical Care Nursing

Submitted to:

Prof. Janeirah Q. Manalundong-Mamowalas, MANc, MN, RN

Submitted by:

Shereen D. Al-Obinay

Date of submission: October 26, 2018

Sinus rhythm
A sinus rhythm is any cardiac rhythm where depolarization of the cardiac muscle begins at the sinus
node. It is characterized by the presence of correctly oriented P waves on the electrocardiogram (ECG).

Rate: 60-100
Rhythm: regular
P wave: similar; 1:1 with QRS
PR interval: 0.12 to 0.20; constant
QRS complex: < 0.1 sec
Characteristics of normal sinus rhythm

1. Normal heart rate (classically 60 to 100 beats per minute for an adult).
2. Regular rhythm, with less than 0.16 second variation in the shortest and longest durations between
successive P waves.
3. The sinus node should pace the heart – therefore, P waves must be round, all the same shape, and
present before every QRS complex in a ratio of 1:1.
4. Normal P wave axis (0 to +75 degrees)
5. Normal PR interval, QRS complex and QT interval.
6. QRS complex positive in leads I, II, aVF and V3–V6, and negative in lead aVR.
Sinus bradycardia

 Sinus bradycardia is a sinus rhythm with a rate that is lower than normal.

Rate: Less than 60 beats per minute.

Rhythm: Regular
P waves: Upright, consistent, and normal in morphology and duration.
PR interval: Between 0.12 and 0.20 seconds in duration.
QRS complex: Less than 0.12 seconds in width, and consistent in morphology.

Sinus tachycardia
Sinus tachycardia (also colloquially known as sinus tach or sinus tachy) is a sinus rhythm with an
elevated rate of impulses, defined as a rate greater than 100- 140 beats/min (bpm) in an average adult.
200 beats/min during exercise
Rate: Greater than or equal to 100.
Rhythm: Regular.
P waves: Upright, consistent, and normal in morphology (if no atrial disease)
P–R interval: Between 0.12–0.20 seconds and shortens with increasing heart rate
QRS complex: Less than 0.12 seconds, consistent, and normal in morphology.

Heart Block
Heart block, also called atrioventricular block or A-V block, is an abnormality of the spread or flow of
electrical activity from the upper heart chambers, the atria, to the lower heart chambers, the ventricles.

First-degree heart block:

Rate: approximately 80/ within normal range

Rhythm: regular
Regularity: Atrial rhythm regular, ventricular rhythm regular
P Wave: each P wave is followed by QRS complex (Normal)
PR interval: > 0.2 but constant
QRS complex: 0.06 to 0.10 , Normal, <0.12

Second-degree heart block:

 Type I second-degree heart block, also called Mobitz Type I heart block

Rate: atrial exceeds ventricular rate; both remain within normal limits
Rhythm: atrial-regular; ventricular-irregular
P Wave: Normal
PR interval: Progressively prolonged (see shaded areas) until P wave appears w/o QRS complex
QRS complex: 0.06 to 0.10
Type II second-degree heart block, also called Mobitz Type II block

Rate: atrial within normal limits; ventricular slower than atrial but may be within normal limits
Rhythm: atrial-regular; ventricular-irregular
P Wave: Normal
PR interval: constant for conducted beats
QRS complex: within normal limits; absent for dropped beats

Third-degree heart block: Also called complete heart block.

Rate: atrial and ventricular beats independently; atrial- 60 to 100 beats/min; ventricular- 40 to
60 beats/min intranodal block, <40 beats/min infranodal block
Rhythm: regular
P Wave: Normal
PR interval: varied; not applicable or measuarble
QRS complex: normal or widened
Atrial Arrhythmias
- Atrial arrhythmia is an abnormality that occurs in one of the two upper chambers of the
heart, the left or right atrium.

Atrial fibrillation.
The electrical signal that circles uncoordinated through the muscles of the atria (the upper chambers of
the heart), causing them to quiver (sometimes more than 400 times per minute) without contracting.
The ventricles (the lower chambers of the heart) do not receive regular impulses and contract out of
rhythm, and the heartbeat becomes uncontrolled and irregular.
Rhythm: irregularly irregular

Rate: atrial –usually >400 beats/min ventricular- varies

P Wave: absent; replaced by fine fibrillatory waves, or f waves
PR interval: indiscernible
QRS complex: 0.06 to 0.10 seconds

Premature atrial contraction (PAC or premature atrial impulses)

- A common and benign arrhythmia, a PAC is a heartbeat that originates away from the sinus
node, which sends electrical signals through the upper chamber. A PAC can cause a feeling
of a skipped heartbeat.

Rhythm: irregular
Rate: varies with underlying rhythm
P Wave: premature and abnormally shaped with premature atrial contractions
PR interval: usually within normal limits, but varies depending on ectopic focus
QRS complex: 0.06 to 0.10 seconds
Supraventricular tachycardia (SVT)
Characterized by a rapid heart rate that ranges between 100 and 240 beats per minute. It is an
abnormally fast heart rhythm arising from improper electrical activity in the upper part of the heart.

Atrial flutter
- Atrial flutter is a coordinated rapid beating of the atria.
Type I normally causes the heart rate to increase to and remain at 150 beats per minute. Rarely,
the rate may reach 300 beats per minute; sometimes it decreases to 75 beats per minute.
Type II increases the atrial rate faster, so the ventricular rate may be 160 to 170 beats per minute.
As with atrial fibrillation, atrial flutter increases the risk of stroke.

Rhythm: atrial-regular; ventricular- typically irregular

Rate: atrial-250 to 400 beats/min; ventricular- usually 60-100 beats/min; ventricular rate
depends on degree of atrioventricular block
P Wave: classic sawtooth appearance
PR interval: unmeasurable
QRS complex: 0.06 to 0.10 seconds
Atrial tachycardia.

Rhythm: regular
Rate: 150 to 250 beats/min; ventricular rate depends on atrioventricular conduction rates
P Wave: hidden in the preceding T wave
PR interval: not visible
QRS complex: 0.06 to 0.10 seconds

Sick sinus syndrome (SSS).

- Is an improper firing of electrical impulses caused by disease or scarring in the sinus or
Sinoatrial node (SA node).

Wolff-Parkinson-White syndrome (WPW).

WPW syndrome occurs when electrical signals fail to pause in the atrioventricular node because
an extra pathway allows the impulse to "bypass" the normal pathway; and the syndrome is
sometimes called bypass tract. WPW syndrome causes heart rates approaching 240 beats per
minute.
Junctional rhythm

Premature junctional contraction (PJCs)

Rhythm: irregular atrial and ventricular rhythms during PJCs

Rate: reflects the underlying rhythm
P Wave: usually inverted and may occur before or after or be hidden within the QRS complex
(see shaded area)
PR interval: <0.12 second if P wave precedes QRS complex; otherwise unmeasurable
QRS complex: 0.06 to 0.10 seconds

Junctional escape rhythm

Rhythm: regular
Rate: 40-60 beats/min
P Wave: usually inverted and may occur before or after or be hidden within the QRS complex
PR interval: <0.12 second if P wave precedes QRS complex; otherwise unmeasurable
QRS complex: 0.10 seconds
 Accelerated junctional rhythm

Rhythm: regular
Rate: 60 to 100 beats/minute
P Wave: usually inverted and may occur before or after or be hidden within the QRS complex
PR interval: <0.12 second if P wave precedes QRS complex; otherwise unmeasurable
QRS complex: 0.06 to 0.10 seconds

Ventricular Arrhythmias
Premature ventricular contractions (PVCs)
- (PVCs) are extra heartbeats that begin in one of your heart's two lower pumping chambers (ventricles).

Rhythm: irregular
Rate: reflects the underlying rhythm
P Wave: none with PVC, but P wave present with other QRS complexes
PR interval: unmeasurable except in underlying rhythm
QRS complex: early, with bizarre configuration and duration if > 0.12 seconds; QRS complexes
are normal in underlying rhythm
Ventricular fibrillation

is when the heart quivers instead of pumping due to disorganized electrical activity in the ventricles

Rhythm: chaotic
Rate: can’t be determined
P Wave: absent
PR interval: unmeasurable
QRS complex: indiscernible

Ventricular tachycardia

- Ventricular tachycardia (VT) is a rapid heart rate that originates in the lower chambers of the heart,
or ventricles.

Rhythm: regular
Rate: Fast (100-250 bpm)
P Wave: absent
PR interval: not measurable
QRS complex: wide (o.10 sec), bizarre appearance

Monomorphic Ventricular Tachycardia EKG Strip

Rhythm: regular
Rate: Fast (100-250 bpm)
P Wave: absent
PR interval: not measurable
QRS complex: Wide (> 0.10 sec, bizarre looking)

Ventricular Tachycardia Torsade de Pointes EKG Strip

Rhythm: irregular
Rate: Fast (200-250 bpm)
P Wave: absent
PR interval: not measurable
QRS complex: Wide (> 0.10 sec, bizarre looking)
Asystole

Rhythm: atrial- usually indiscernible; ventricular- absent

Rate: atrial- usually indiscernible ; ventricular – absent
P Wave: may be absent
PR interval: unmeasurable
QRS complex: absent or occasional escape beats

Cardiac arrest
 Is a sudden state of circulatory failure due to a loss of cardiac systolic function.
 It is the result of 4 specific cardiac rhythm disturbances:
Ventricular fibrillation (VF)
Pulseless ventricular tachycardia (VT)
Pulseless electrical activity
Asystole.
 DEMOGRAPHIC DATA

Name: Patient Why Admission area: Emergency ward

Age: 50 Admitting date: November 01 2009
Gender: Female Admitting time: 1:12 AM
Diagnosis: Hypertensive Cerebrovascular disease
Allergies: None
DNR/DNI: NONE

ICU Admission date: November 02 2009 ICU Admission time: 8:00 am

ASSESSMENT

I. Neurology
 GCS : E3M4V1T = 9
 Pupil reaction: 2
II. Respiratory
Ventilator: CPAP (Continuous Positive airway Pressure) mode, 10cm H20
ABG values: ph=7.38 PO2=69mmHg pCO2=32mmHg HCO3=22mEq/L
SPO2 =96%
 Intubated due for protection of airway secondary to decrease level of LOC
 Amount of Secretion: Large
Characteristic of secretion: Thick Color of secretion: Greenish
Frequency of suctioning: 2x hourly
Response to ventilation: patient fighting ventilator
III. Cardiac
Heart rate: 66bpm, sinus rhythm
Blood pressure: 136/74mHg
CVP:
IV. GI
 Patient on NGT feeding: Bolus feeding type
 Residual volume: 40mL
 No bowel movement
V. GU
 FBC
 Total output: 900mL/hr
Urine Output: 40ml/hr
 Total intake: 1200mL/hr
 Balance: 300mL
VI. Skin integrity
 Edema scale: +1
BLOOD WORKUP

Result:
 Positive Staph. aureus bacterium
 Hemoglobin 118 g/L
 WBC – Monocyte 0.10
DIAGNOSTIC RESULT:
 CXR to follow up
 MRI on November 15 2009

MEDICATIONS
o N-acetylcysteine
o Piperacilin + Tazobactam
o Omerprazole
o Nicardipine
o Mannitol