SOLUTIONS MANUAL Electrocardiography for Healthcare Professionals 6th Edition By Kathryn A. Booth, T

INSTRUCTOR SOLUTIONS MANUAL Electrocardiography Solution Manual for ForHealthcare Professionals 6th Electrocardiography Healthcare Professionals 6e By Kathryn A. Booth, Thomas Edition ByforKathryn A. Booth, Thomas Edward Edward O'Brien O'Brien All Chapters 1-15 Chapter 1-15 Chapter 1: Electrocardiography Preface/Introduction This chapter includes introductory information about the field of electrocardiography, as well as legal, ethical, communication, and patient education information. In addition, the chapter addresses basic vital signs and troubleshooting. Competency checklists are included to practice checking vital signs.

Learning Outcomes 1.1 Describe the history and the importance of the ECG. 1.2 Identify the uses of an ECG and opportunities for an electrocardiographer.

1.3 Troubleshoot legal, ethical, patient education, and communication issues related to the ECG. 1.4 Perform infection control measures required for the ECG. 1.5 Compare basic vital sign measurements related to the ECG.

Extended Outline I. II.

III.

Outline The ECG and Its History (LO 1.1) Uses of an ECG (LO 1.2) A. In the Hospital (Acute Care) B. Doctor’s Offices and Ambulatory Care Clinics

PowerPoint® Slides Slides 4–9 Slides 10–22 Slide 13 Slide 14

C. Outside of a Healthcare Facility 1. Defibrillators 2. Automatic External Defibrillators 3. Telemedicine D. Opportunities in Electrocardiography Preparing for an ECG (LO 1.3) A. Legal and Ethical Issues 1. Protecting Patient Information: HIPAA 2. Practicing Ethics 3. Professional Liability

Slides 15–17 Slide 16 Slide 16 Slide 17 Slide 18 Slides 23–35 Slide 24 Slide 25 Slide 26 Slide 27

IV.

V.

Outline 4. Slander and Libel 5. Documentation 6. Consent B. Patient Education and Communication Infection Control (LO 1.4) A. Standard Precautions B. Isolation Precautions Vital Signs (LO 1.5) A. Pulse and Respiration 1. Pulse 2. Respiration B. Blood Pressure 1. Factors Affecting Blood Pressure C. Measuring Blood Pressure

PowerPoint® Slides Slide 28 Slide 29 Slide 30 Slide 31 Slides 36–43 Slides 37–38 Slide 39 Slides 44–54 Slide 45–47 Slide 46 Slide 47 Slides 48–50 Slide 49 Slide 50

Teaching Strategies Introduce students to “Electrocardiography” using the following techniques: 1. Have students discuss why they are taking the program and why they think ECG will be necessary for their career objective.

2. Have students visit a clinic, hospital, or outpatient area to discuss with healthcare professionals how ECGs are utilized in their area.

3. Present a variety of equipment that has changed over the last 10 years, such as defibrillators and pacemakers. With the presentation, have students discuss how technology advancements have changed the practice. Examples may include: technology of mobile phones have allowed ECGs to be electronically transmitted to a physician’s computer/phone from the back of an ambulance.

4. Encourage students to discuss their personal stories about how heart disease has affected them, their family, or someone they know. With this discussion, identify the risk factors for heart disease and stroke and ways to prevent them. Suggest identifying differences due to gender or cultural background and how to prevent heart diseases.

5. Have students identify different locations where AEDs (automatic external defibrillators) are used.

6. Relate the importance of and responsibility for performing accurate diagnostic tests.

Suggest that students personalize the concept by stressing that they would expect accurate test results for themselves, a friend, or a significant other.

7. Have students compare and contrast the roles of various healthcare professionals with regard to EGCs. 8. Have students discuss the purpose of ECGs, including common pathology for this test.

9. Emphasize the importance of infection control through hand hygiene, precautions, and use of personal protective equipment.

10. Discuss the necessity of being cognizant of legal and ethical issues, including HIPAA, practicing ethics, liability, slander, obtaining consent, and accurate documentation in the medical record.

In-Class Activities 

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

  

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. They can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students working on Troubleshooting sections in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as obtaining consent, communicating appropriately with patients and other healthcare professionals, and documentation.

Facilitate group discussions in class on various topics, such as legal and ethical considerations, the role of EGCs in healthcare, the importance of HIPAA, preventing the transmission of infection during ECG testing, troubleshooting, the relevance and purpose of vital signs, and communication with patients.

Use the PowerPoint® presentation for Chapter 1 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment    

Using the test bank for Chapter 1, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 1 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 1.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 1.1

Checkpoint Questions 1. Cardiovascular disease 2. Willem Einthoven LO 1.2 Think It Through: Remain Calm Say: “The physician would like me to do a recording of your heart.” Do not show signs of fear or anxiety. Remain calm during the procedure.

Checkpoint Questions 1. Sudden cardiac arrest caused by ventricular tachycardia and ventricular fibrillation.

2. Records the ECG tracing, determines if the ECG tracing is accurate and without abnormalities caused by interference during the recording procedure, and prepares the tracing for the physician’s interpretation.

LO 1.3 Think It Through: Obtaining Consent A family member, legal representative, or witness, but the patient should write an X if possible.

Checkpoint Question 1. Answers will vary; an example is provided here.

Step 1: Identify and define the problem: You have been assigned to perform an ECG, and the patient refuses.

Step 2: Identify possible solutions: a. Do not perform the ECG. b. Insist that the patient allow you to perform the ECG. c. Report the patient to your supervisor. d. Question the patient as to why she does not want the ECG and attempt to gain her cooperation.

Step 3: Select the best solution: d. Question the patient as to why she does not want the ECG and attempt to remove her objection.

Step 4: Implement the selected solution: You question the patient, and she feels uncomfortable about lying exposed on the table during the procedure. You tell her you will cover her and maintain her privacy to the best of your ability.

Step 5: Evaluate the results: The patient allows you to perform the ECG, so the problem is solved.

Step 6: There is no need to return to step 2 because the problem is solved.

LO 1.4

Checkpoint Questions 1. Follow standard precautions and, when necessary, the appropriate isolation precautions.

2. Airborne precautions require special air handling, ventilation, and HEPA or N95 respirator; Droplet precautions requires goggles and masks; Contact precautions require gloves and gowns.

LO 1.5

Checkpoint Questions 1. Pulse, respirations, and blood pressure.

2. Palpated blood pressure is performed by applying the blood pressure cuff to the patient's arm, then placing the fingers on the radial pulse point and inflating the blood pressure cuff. When the pulse disappears, you continue to inflate the cuff an additional 30 mm/Hg, then begin to deflate the cuff slowly in 5mm intervals. When the pulse returns it is an approximation of the systolic blood pressure. Auscultated blood pressure is determined using a stethoscope and provides a more accurate systolic and diastolic blood pressure reading.

Chapter Review Matching 1.

2.

3.

4.

5.

6.

7.

8.

f (LO 1.1) b (LO 1.1) d (LO 1.1) h (LO 1.4) a (LO 1.1) g (LO 1.2) e (LO 1.2) c (LO 1.4)

True/False 9.

10.

11.

12.

(LO 1.1) True.

(LO 1.4) True.

(LO 1.3) False; slander is the act of making derogatory remarks about someone.

(LO 1.2) False; digital monitoring transmits an ECG over the Internet. (OR: A transtelephonic monitor transmits an ECG over the telephone.)

13.

(LO 1.5) False: It may be necessary to wear personal protective equipment when performing an ECG for patients who are in some type of isolation precautions.

Multiple Choice 14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

c (LO 1.5) c (LO 1.1) a (LO 1.2) a (LO 1.2) a (LO 1.2) b (LO 1.2) b (LO 1.2) d (LO 1.5) b (LO 1.3) a (LO 1.2) d (LO 1.3) d (LO 1.5) b (LO 1.4) c (LO 1.3) c (LO 1.5) a (LO 1.5) b (LO 1.5) d (LO 1.5) a (LO 1.4)

Critical Thinking Application: What Should You Do? 33. (LO 1.3) Your favorite uncle should have an ECG as part of a routine physical since he is over 40; however, the physician should order this. You should not perform an ECG on someone without a verbal or written order from an authorized healthcare provider. You may, however, practice an ECG on someone, as long as the individual understands you are not going to interpret it or use it for diagnosis. This must be done with the approval of your supervisor. Question 31 in the text.

34. (LO 1.3) “Mr. Smith, I am not trained to interpret the results of your ECG. As soon as the physician sees it, I am sure he or she will discuss the results with you. How are you feeling right now? Are you having any discomfort or pain? How would you rate your pain on a scale of 1-10, with 0 being no pain and 10 being the most pain?”

35. (LO 1.3) Every patient has the right to privacy. Your co-worker may have just forgotten to close the door and /or drape the patient. You could quietly close the door or curtain in order to provide for privacy. It would be best not to make any statement or comment to your co-worker at this time unless he or she asks.

36. (LO 1.3) You should tell your supervisor how you feel and explain the need to go to the restroom. Do not leave the monitors unattended except for extreme or severe circumstances. You should find someone to view the monitors when you are not there. You have a legal and ethical responsibility to ensure that someone is watching the monitors when you are not there. Hopefully, your supervisor will be able to find someone to take your place in order for you to go home.

Chapter 2: The Cardiovascular System Preface/Introduction This chapter provides a complete introduction and review of the heart and its electrical system. The information focuses on what students need to know to understand and perform an ECG. Specific topics include anatomy of the heart, principles of circulation, cardiac cycle, conduction system and electrical stimulation, and the ECG waveform.

Learning Outcomes 2.1 Explain how circulation occurs in relation to the ECG. 2.2 Recall the structures of the heart including valves, chambers, and vessels.

2.3 Differentiate among pulmonary, systemic, and coronary circulation.

2.4 Explain the cardiac cycle including the difference between systole and diastole.

2.5 Describe the parts and function of the heart and conduction system and how they relate to the ECG.

Extended Outline Outline I. Circulation and the ECG (LO 2.1) II. Anatomy of the Heart (LO 2.2) A. Chambers and Valves B. The Major Vessels to and from the Heart III. Principles of Circulation (LO 2.3) A. Pulmonary Circulation: The Heart and Lung Connection B. Systemic Circulation: The Heart and Body Connection C. Coronary Circulation: The Heart’s Blood Supply D. The Heart as a Pump IV. The Cardiac Cycle (LO 2.4) A. Diastole: Relaxation of the Heart B. Systole: Contraction of the Heart V. Conduction System of the Heart (LO 2.5) A. Unique Qualities of the Heart B. Regulation of the Heart C. Pathways for Conduction Appendix Slides Heart Layers Heart Chambers, Vessels, and Valves Heart Valves Major Vessels to and from the Heart Oxygenated and Deoxygenated Blood Pulmonary and Systemic Circulation Coronary Circulation: Coronary Arteries Coronary Circulation: Coronary Veins Conduction Pathway Appendix

PowerPoint® Slides Slides 4–7 Slides 8–22 Slides 14–15 Slide 16 Slides 22–32 Slide 23, 24 Slide 23, 25 Slides 26–27 Slide 28 Slides 33–39 Slides 34–35 Slides 36–37 Slides 40–54 Slide 41 Slides 42–43 Slides 44–48 Slide 58 Slide 59 Slide 60 Slide 61 Slide 62 Slide 63 Slide 64 Slide 65 Slide 66

Teaching Strategies Introduce students to “The Cardiovascular System” using the following techniques: 1. Have students identify the parts of the cardiovascular system on a diagram or model, including the chambers, valves, blood vessels, and conduction system. The diagram can be drawn using poster board, flip chart, overhead, white board, or PowerPoint® presentation.

2. Have students trace and discuss how the blood flows through the heart, lungs, and body. This can be done by writing each of the structures on a separate sheet of paper. Give each student one sheet of paper. Then have the students line up in the order in which blood flows. Once they are correctly in line, have students discuss the function of the structures they represent.

3. Have students role-play the qualities of the heart, including automaticity, excitability, conductivity, and contractility.

4. Have students compare and contrast how the heart is affected if there are defects or if any area is not functioning normally.

In-Class Activities 

 

    

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to explain cardiac function to a patient, how to communicate to patients and healthcare professionals, and what to do if a patient is excited or upset.

Facilitate group discussions in class on various topics, such as cardiac pathology, anatomy of the heart, how the ECG is affected by heart rhythm, and the role that blood pressure plays in cardiac function.

Have students identify cardiac cycles and ECG components on a rhythm strip and then share with other students for peer review.

Use the PowerPoint® presentation for Chapter 2 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the chapter review in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment    

Using the test bank for Chapter 2, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 2 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 2.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 2.1

Checkpoint Questions 1. The contraction and relaxation of the heart: one contraction and one relaxation equal one cardiac cycle.

2. Diastole is the relaxation of the heart, when the heart chambers fill. Systole is the contraction of the heart, when blood is pumped out. Diastole is passive and systole is active.

LO 2.2

Checkpoint Questions 1. Myocardium.

2. Mitral (bicuspid) valve.

LO 2.3

Checkpoint Questions 1. Coronary arteries.

2. Pulmonary – between the heart and lungs.

Systemic – between the heart and body.

Coronary – the heart’s blood supply.

3. Cardiac output is the volume of blood pumped each minute.

LO 2.4

Checkpoint Questions 1. The contraction and relaxation of the heart: one contraction and one relaxation equal one cardiac cycle.

2. Diastole is the relaxation of the heart, when the heart chambers fill. Systole is the contraction of the heart, when blood is pumped out. Diastole is passive and systole is active.

LO 2.5

Checkpoint Questions 1. SA node, internodal pathways, Bachmann’s bundle, AV node, AV bundle (Bundle of His), bundle branches, Purkinje fibers.

2. Excitability.

3. AV node.

Chapter Review Matching I 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

d i e a j f g b h c

(LO 2.2) (LO 2.2) (LO 2.2) (LO 2.2) (LO 2.2) (LO 2.2) (LO 2.2) (LO 2.2) (LO 2.2) (LO 2.2)

Matching II 11.

12.

13.

14.

15.

16.

17.

18.

f b c g f a h d

(LO 2.5) (LO 2.5) (LO 2.5) (LO 2.5) (LO 2.5) (LO 2.5) (LO 2.5) (LO 2.5)

Multiple Choice 19.

20.

21.

22.

23.

c a a b a

(LO 2. 5) (LO 2. 5) (LO 2. 2) (LO 2. 2) (LO 2. 5)

Matching III 24.

25.

26.

27.

28.

29.

30.

c a h b f e d

(LO 2.2) (LO 2.4) (LO 2.4) (LO 2.3) (LO 2.3) (LO 2.2) (LO 2.4)

31.

g (LO 2.3)

Label the Parts 32.

(Textbook Figure 2-3) (LO 2.2)

33.

(Textbook Figure 2-5B) (LO 2.3)

34.

(Textbook Figure 2-9) (LO 2.5)

A figure shows the label parts of the heart. The labels are sinoatrial (S A) node, internodal pathways, atrioventricular (A V) node, atrioventricular (A V) bundle, purkinje fibers, interventricular septum, apex, right bundle branch, left bundle branch, left ventricle, left atrium, and Bachmann's bundle.

Right or Wrong?

35. a. (LO 2.2) Incorrect—“The valves between the atria and the ventricles are atrioventricular.” b. (LO 2.2) Incorrect—“The ventricles always pump the blood.” c. (LO 2.4) Correct. d. (LO 2.2) Incorrect—“The coronary arteries carry oxygenated blood.” e. (LO 2.2) Incorrect—“The pulmonary arteries carry deoxygenated blood.” f. (LO 2.5) Incorrect—“In general, if you are a man you will have a slower heartbeat rate.” g. (LO 2.2) Incorrect—“The top chambers of the heart are the atria, and the bottom chambers of the heart are the ventricles.” h. (LO 2.2) Incorrect—“The left ventricle is sometimes known as the workhorse of the heart.”

Voyage through the Heart (LO 2.3) 36. a. Superior vena cava. b. Tricuspid valve. c. Pulmonary veins. d. Left atrium. e. Coronary arteries.

Critical Thinking Application: What Should You Do? 37. (LO 2.5) The atrioventricular (AV) node is responsible for slowing the electrical conduction from the atria to the ventricles (acting like a “gatekeeper”). This delay in electrical conduction prevents some of the electrical impulses from stimulating the ventricles and allows the atria to fully contract ejecting blood into the ventricles.

38. (LO 2.5) The sympathetic branch of the autonomic nervous system responded to the stress from the darkness and sound and increased your and your patient’s and your heart rates. Without further stimulation, your patient’s heart rate will return to normal. It would be best to wait for a while until the patient’s heart rate is within normal limits before recording the ECG.

Chapter 3: The Electrocardiograph Preface/Introduction This chapter creates a basic understanding of the ECG, including producing the ECG waveform, the ECG machine, electrodes, and ECG graph paper.

Learning Outcomes 3.1 Explain the three types of leads and how each is recorded.

3.2 Identify the functions of common ECG machines.

3.3 Explain how each ECG machine control is used.

3.4 Recognize common electrodes.

3.5 Describe the ECG graph paper.

3.6 Calculate heart rates using an ECG tracing.

Extended Outline Outline I. Producing the ECG Waveform (LO 3.1) A. Standard Limb Leads B. Augmented Leads C. Chest Leads Placement and Tracing II. ECG Machines (LO 3.2)

PowerPoint® Slides Slides 3–19 Slides 10–11 Slides 12–13 Slide 14 -15 Slides 20-28

Outline A. Functions B. Advancing Technologies III. ECG Controls (LO 3.3) A. Speed B. Gain C. Artifact Filter D. LCD Display E. Heart Rate Limits F. Lead Selector IV. Electrodes (LO 3.4) V. ECG Graph Paper (LO 3.5) A. Measurements VI. Calculating Heart Rate (LO 3.6) A. The 300 Method B. The 1500 Method C. The 6-Second Method Appendix Slides Identifying Lead Wires Einthoven’s Triangle Chest Lead Placement and Tracings Example of Graph Paper Measurements

PowerPoint® Slides Slides 24-25 Slide 26 Slides 29-38 Slide 30 Slide 31 Slide 32 Slide 33 Slide 34 Slide 34 Slides 39-42 Slides 43-49 Slides 46-47 Slides 50-59 Slides 51-52 Slide 53 Slides 54-55 Slide 64 Slide 65 Slide 66 Slide 67

Teaching Strategies Introduce students to “The Electrocardiograph” using the following techniques: 1. Bring to the lab equipment that students can practice placing on each other or a manikin. Equipment should include the ECG electrodes, electrode gel or paste, lead wires, paper, and an ECG machine.

2. Provide each student with ECG paper. Each student should identify how the singlechannel and multi-channel paper are different. Have students identify the components of time and measurement of energy (0.04 second box, 0.20 second box).

3. Since students are often intimidated by math, you may try relating the ECG paper measurements to counting money. Follow these steps.  Write 0.04 on the board or in a PowerPoint® presentation. Then discuss and establish that 0.04 equals four cents.  Ask students to tell you how many stacks of 4 cents will be needed to add up to 20 cents. Once it is established that the answer is 5, show the following.

0.04 cent ×5 cent 0.20

 Next, remove the cents and add a dollar sign in front of the 0.04 and 0.20 and show the following.

$ 0.04 ×5 $ 0.20  Remind students that $0.20 equals two dimes, and ask students how many dimes it would take for 20 cents to become a dollar. Then show the following.

$ 0.04 ×5 $ 0.20 ×5 $1.00  Tell students we are going to make one small change, then add seconds behind the 0.04, 0.20 and 1.00 and remove the dollar signs and show the following.

0.04 seconds ×5 0.20 seconds ×5 1.00 second  At this point, students should make the connection between money and the ECG paper. You can use this as a foundation to demonstrate how we get to 300 large boxes by multiplying 60 seconds by 5 large boxes per second, then multiplying 300 by 5 small boxes per large box to get to 1500.

4. Demonstrate how the ECG machine creates different views of the heart. Using a heart model, have two students or objects represent the + and – electrodes. Move them around the heart to help students visualize the different views of the heart.

Emphasize the anterior, inferior, lateral, and posterior views while doing this activity.

5. Have students run an ECG tracing, changing the sweep speed and gain (magnification) to see how they can modify a normal ECG tracing.

6. Provide students with a number of different ECG tracings, including regular and irregular rhythms. Have students calculate the heart rates using a variety of methods. Have students demonstrate the measurement to each other or in front of the class to ensure that their measurements are accurate.

7. Have students role-play with a variety of scenarios, such as dealing with a difficult patient, communicating to gain cooperation, and troubleshooting.

In-Class Activities 

 



  

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to troubleshoot issues with leads and lead placement, how to use the ECG machine, what to do if using a machine they are not familiar with, communicating with patients about the test, and obtaining patient cooperation.

Facilitate group discussions in class on various topics, such as the importance of proper lead placement, comparing and contrasting different types of ECG machines, and the importance of communication with patients and other healthcare professionals.

Use the PowerPoint® presentation for Chapter 3, for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment    

Using the test bank for Chapter 3, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 3 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 3.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 3.1 Think It Through: Check the Lead Wires Recheck the lead wires to make sure they are placed correctly.

Checkpoint Questions 1.

2.

3.

A 12-lead ECG is done to view the heart from 12 different angles.

10 leads aVL, aVR, aVF

LO 3.2

Checkpoint Questions 1.

2.

Three, and six.

Input, signal processing, output.

LO 3.3 Think It Through: Changing the ECG Tracing Speed Mark the tracing as shown here. Notify the healthcare provider who will be interpreting the tracing, if possible.

Think It Through: Changing the Gain Increase the gain.

Checkpoint Questions 1.

2.

Heart rate is too fast, can’t clearly identify waves because they are too close together, per physician’s orders.

Speed control, lead selector, heart rate limit, LCD display, artifact filter, gain control.

LO 3.4

Checkpoint Questions 1.

Silver electrodes.

LO 3.5 Think It Through: Handle the ECG Report with Care Bring the location of the report to the physician’s attention, remove the charts, or place the ECG recording on top of the charts to protect the ECG recording from damage.

Checkpoint Questions 1.

2.

25 small boxes represent 1 second 1 small box represents 0.04 second

LO 3.6 Think It Through: Counting the Heart Rate There are six complete complexes. The estimated heart rate using the 6-second method is 60 bpm, because the last complex is not complete. R-R (300) method = 75 bpm, 1500 = 71 bpm

Checkpoint Questions 1.

2.

75 (20 small boxes) 63. (24 small boxes)

Chapter Review Matching I 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

c (LO 3.1) b (LO 3.1) a (LO 3.1) a (LO 3.1) b (LO 3.1) c (LO 3.1) c (LO 3.1) c (LO 3.1) b (LO 3.1) a (LO 3.1) c (LO 3.1) c (LO 3.1)

Matching II 13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

j (LO 3.2) k (LO 3.3) c (LO 3.3) b (LO 3.3) e (LO 3.1) f (LO 3.2) g (LO 3.5) d (LO 3.5) i (LO 3.2) a (LO 3.4) h (LO 3.3)

Multiple Choice 24.

25.

26.

27.

28.

29.

30.

31.

a (LO 3.2) b (LO 3.2) c (LO 3.4) b (LO 3.1) a (LO 3.3) d (LO 3.2) a (LO 3.3) c (LO 3.1)

32.

33.

34.

35.

36.

b (LO 3.3) c (LO 3.3) c (LO 3.5) d (LO 3.1) a (LO 3.1)

Matching III 37.

38.

39.

a (LO 3.5) c (LO 3.5) b (LO 3.5)

Matching IV 40.

41.

42.

43.

d (LO 3.1) b (LO 3.1) a (LO 3.1) c (LO 3.1)

Label the Parts 44.

(Textbook Figure 3-2) (LO 3.1)

45.

(Textbook Figure 3-15) (LO 3.5)

46.

(LO 3.6) Boxes between R waves = 3.

300 ÷ 3 = rate of 100 beats per minute.

47.

(LO 3.6) Large boxes between R waves = 1 complete large box = 300 beats per minute. Portions of large boxes are not used.

48.

(LO 3.6) 14 complete complexes × 10 = 140 beats per minute.

49.

(LO 3.6) 4 complexes × 10 = 40 beats per minute.

50.

(LO 3.6) 16 small squares between 2 R waves, 1500 ÷ 16 = 93.75 or 94 beats per

minute.

51.

(LO 3.6) 26 small boxes between R waves 1500 ÷26 = 57.69 or 58 beats per minute.

Critical Thinking Application: What Should You Do? 52. (LO 3.5) The machine is about to run out of paper. You should change the paper before performing the next ECG. 53. (LO 3.4) ECG electrodes dry out. Check to see if the bag has been properly sealed. If so, you may use them if they do not appear to be dried out. Otherwise, it is best to use new electrodes. If you attempt to use the electrodes after you determine they have been properly sealed but you have difficulty with the tracing, you still may need to replace them.

54. (LO 3.1) You have probably attached the lead wires incorrectly. Check each lead color and make sure the leads are properly placed. Since you cannot read the letters, refer to the manufacturer’s directions to identify the correct color for each lead wire.

55. (LO 3.3) Make sure the machine is standardized if that is required of the machine you are using. Check the LCD display. The machine may identify the problem for you. In addition, check the attachment to the patient…skin prep, sensors, then check the cable clips…are they attached to the cables properly and are they grasping the sensors as intended, are they clean without gel buildup. Check the cables themselves…ensure there is no damage to them and that they are inserted into the clips and hub appropriately. Always work from the patient all the way back to the machine. Use the lead selector to repeat the entire 12-lead ECG procedure.

In general, you should be familiar with the controls of the machine you are using.

Review the manufacturer’s directions carefully.

Chapter 4: Performing an ECG Preface/Introduction This chapter describes the procedure for performing an ECG in a simple step-by-step fashion. Each part of the procedure is explained in detail, taking into consideration the latest guidelines. The chapter is divided into the following topics: preparation, communication, safety, anatomical landmarks, applying the electrodes and leads, operating the ECG machine, checking the tracing, reporting results, and equipment maintenance. Extra sections are included regarding pediatric ECG, cardiac monitoring, special patient circumstances, and emergencies. Competency checklists are included to practice performing both an ECG and continuous monitoring.

Learning Outcomes 4.1 Carry out preparation of the patient, room, and equipment for an ECG. 4.2 Describe the communication needed during the ECG procedure, including the actions to take if a patient refuses to allow an ECG to be performed.

4.3 Identify at least three ways to provide for safety during the ECG procedure.

4.4 Demonstrate the procedure for applying the electrodes and lead wires for a 12-lead ECG and cardiac monitoring.

4.5 Describe the procedure for recording and reporting a 12-lead ECG. 4.6 Identify types of artifact and how to prevent or correct them.

4.7 Describe how to report the ECG results.

4.8 Identify the steps for cleaning and caring for the ECG equipment.

4.9 Explain variations for a pediatric ECG procedure.

4.10 Distinguish between a routine ECG and cardiac monitoring.

4.11 Summarize special patient circumstances when performing an ECG. 4.12 Recall the steps for handling an emergency during the ECG.

Extended Outline Outline I. Preparation for the ECG Procedure (LO 4.1) II. Communicating with the Patient (LO 4.2) III. Safety (LO 4.3) IV. Applying the Electrodes and Leads (LO 4.4) A. Placing the Limb Electrodes B. Anatomical Landmarks for the Chest Electrodes C. Placing the Chest Electrodes V. Operating the ECG Machine (LO 4.5) VI. Checking the ECG Tracing (LO 4.6) A. Somatic Tremor B. Wandering Baseline (Baseline Shift) C. Alternating Current (AC) Interference D. Other Problems VII. Reporting ECG Results (LO 4.7) VIII. Equipment Maintenance (LO 4.8) IX. Pediatric ECG (LO 4.9) X. Cardiac Monitoring (LO 4.10) XI. Special Patient Considerations (LO 4.11) XII. Handling Emergencies (LO 4.12) A. Cardiac or Respiratory Arrest B. Seizure Appendix Slides Anatomical Landmarks for Chest Electrodes Posterior 12 Lead ECG

PowerPoint® Slides Slides 4–9 Slides 10–15 Slides 16–19 Slides 20–32 Slide 22 Slide 23 Slides 24–26 Slides 33–36 Slides 37–44 Slide 39 Slide 40 Slide 41 Slide 42 Slides 45–48 Slides 49–51 Slides 52–55 Slides 56–59 Slides 60–66 Slides 67–71 Slide 68 Slide 69 Slide 76 Slide 77

Teaching Strategies Introduce students to “Performing an ECG” using the following techniques: 1. Arrange for a representative from one of the ECG equipment companies or another healthcare professional to visit your class and discuss and demonstrate the ECG procedure. The company representative may bring printed information or other

audiovisuals. If a representative is not available, a previous student or someone who performs ECGs on a regular basis would be a good choice to provide a demonstration.

2. Discuss the different HIPAA violations that may occur when performing a 12-lead ECG. During this discussion, identify ways to ensure that these violations are prevented. For example, protection of the patient’s name, where ECGs are placed, and what students would do if a friend asked about the results.

3. Have students practice on a manikin as the first step in performing a 12-lead ECG tracing. Ensure that the electrodes are placed on the body properly. During this time, have students troubleshoot what they would do in unusual situations; for example: patient with Parkinson’s disease, amputation, cast or splinted arm/leg, mastectomy, or obese patient.

4. Place each of the steps of performing an ECG on a card. Give one card to each student. Then have students organize themselves into the correct order of the procedure.

5. Have students work in pairs to perform a 12-lead ECG on one another. They can use Competency Checklist 4-1, Performing an ECG, for reference. This allows students to provide privacy while performing the ECG and offers them the opportunity to obtain their own 12-lead ECG. Ensure that this practice is not a violation of student policy and/or HIPAA requirements.

6. After completion of student practice, each student should demonstrate how to properly clean and store the equipment.

7. Discuss the importance of properly stocking the 12-lead ECG machine and have each student practice changing the ECG paper.

8. On a student who is willing to have his chest exposed, demonstrate what happens when ECG electrodes have dried out. Emphasize the importance of not leaving a package of ECG electrodes open or having the electrodes connected prior to performing the ECG.

In-Class Activities 

 

 

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to prep a patient, how to communicate to patients and healthcare professionals, how to maintain safety while performing an ECG, emergency management, and troubleshooting.

Facilitate group discussions in class on various topics, such as what to do in a variety of scenarios, best practices for patient preparation, maintaining patient modesty, and professionalism.

Have students continue to identify cardiac cycles and ECG components on a rhythm strip and then share with other students for peer review.

   

Have students identify artifacts, including potential causes and remedies.

Use the PowerPoint® presentation for Chapter 4 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment 

   

Have the students practice the ECG procedure from beginning to end. Students should take turns being the technician and the patient and practice all the steps of Competency Checklist 4-1 Recording an Electrocardiogram. After practice, observe and evaluate each student. During your evaluation, have the students react to different comments or situations that can occur during an electrocardiogram such as a patient who is afraid or uncooperative or a patient who has a seizure or some other type of medical emergency.

Using the test bank for Chapter 4, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 4 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 4.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 4.1

Checkpoint Questions 1.

2.

The experience should be pleasant, it should not produce anxiety, it must be done correctly, and the tracing must be accurate.

Patient name, date of birth, identification number such as a Social Security or medical record number, age, sex, race, current medication being taken, weight and height, special condition or position of the patient, and the location, date, and time of the recording.

LO 4.2

Checkpoint Questions 1.

2.

Indicate to the patient that you are providing for his or her privacy during the procedure.

Determine why he or she is refusing the ECG. Explain the procedure. Report the refusal to your supervisor.

LO 4.3

Checkpoint Questions 1.

2.

Refer to Table 4-2.

To protect yourself from injuries when moving or lifting patients or other large or awkward items.

LO 4.4 Think It Through: The Midclavicular Line The midclavicular line may not run through the nipple line. Use the clavicle as the landmark, not the nipple.

Checkpoint Questions 1.

2.

3.

4.

Midaxillary line It is a ridge about an inch below the suprasternal notch where the main part of the sternum and the manubrium attach.

Check the manufacturer’s directions in the operator’s manual for optimum connection techniques.

Attach the limb leads first because the ECG will not run at all without the limb leads attached. However, the ECG machine will run if the limb leads are attached and the chest leads are not. This is important in the event that a patient is having a cardiac crisis. A tracing from the frontal plane is better than nothing. The

physician could be looking at this tracing while you connect the precordial leads to run the full 12-lead ECG. LO 4.5

Checkpoint Questions 1.

2.

You should identify and communicate with the patient, prepare the patient and the room, provide for patient privacy and safety, locate, and check the equipment, load ECG paper if needed, and attach the electrodes and leads.

For an automatic ECG, simply press the Run or Auto button and check the LCD display for errors. For a manual ECG machine, standardize the equipment and set to lead I. Follow the operator’s manual and/or facility policy.

LO 4.6 Think It Through: Multiple ECGs You can look for marks on the patient’s chest or consult your supervisor.

Think It Through: Handling a Flatline Tracing Calm the patient by explaining that something might just need to be reattached. Then check the lead wires, electrodes, and cables for any loose connections.

Checkpoint Questions 1.

2.

AC interference Too loose or incorrect electrode application, old or dried out electrode gel or solution, oil, lotion, or pulling the electrodes from unsupported lead wires

LO 4.7

Checkpoint Questions 1.

2.

Results should be given immediately to your supervisor or the physician, and a printed copy is placed on top of the chart.

To ensure that you are doing the ECG on the correct patient, to verify what medications the patient may be taking. To ensure that the patient is charged for the procedure.

LO 4.8

Checkpoint Question So that the ECG machine is available to record a tracing; so that the equipment is in good condition at all times and will not transmit diseases to other patients LO 4.9

Checkpoint Questions 1.

2.

Their fast heart rates make the tracing difficult to evaluate at the standard speed.

Document the change on the ECG tracing.

LO 4.10

Checkpoint Question Continuous monitoring is typically done in lead II or modified chest lead. There are only three electrodes, and the monitoring lasts more than 30 seconds. A routine ECG has 10 electrodes and monitors all 12 leads.

LO 4.11

Checkpoint Questions 1.

2.

Record the first 12-lead tracing with all the leads in normal position, record the second 12 leads with the chest leads moved to new positions, and indicate on the second tracing what the new lead labels are.

A right-side or posterior ECG. Dextrocardia is a condition in which the heart is in the right side of the thoracic cavity. This technique would more directly capture the electrical activity of the heart.

LO 4.12

Checkpoint Question 1.

Protect the patient from harm, call for help, and record the ECG tracing after the patient’s seizure has stopped.

Chapter Review Matching I 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

d b c a e b f d a c c b a

(LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4) (LO 4.4)

Multiple Choice 14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

a a c d b b b c c a a a c b a b d a

(LO 4.4) (LO 4.2) (LO 4.4) (LO 4.4) (LO 4.3) (LO 4.1) (LO 4.4) (LO 4.6) (LO 4.6) (LO 4.6) (LO 4.5) (LO 4.6) (LO 4.6) (LO 4.6) (LO 4.4) (LO 4.10) (LO 4.9) (LO 4.5)

True/False 32.

33.

(LO 4.6) True (LO 4.10) True

Matching II 34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

d g k m h a e l b i f c n j

(LO 4.4) (LO 4.4) (LO 4.11) (LO 4.4) (LO 4.6) (LO 4.11) (LO 4.4) (LO 4.6) (LO 4.4) (LO 4.6) (LO 4.6) (LO 4.4) (LO 4.10) (LO 4.4)

Identification 48.

49.

(LO 4.4) a. Manubrium b. Body of the sternum c. Suprasternal notch d. Clavicles e. Fourth ICS f.

Fifth ICS g. Midclavicular line h. Anterior axillary line i.

Midaxillary line (LO 4.4) a. V1—fourth intercostal space, right sternal border b. V2—fourth intercostal space, left sternal border c. V3—halfway between V2 and V4 (“skip” and placed after V4) d. V4—fifth intercostal space at the midclavicular line e. V5—on the same horizontal level with V4, at the anterior axillary line f.

V6—on the same horizontal level with V4 and V5, at the midaxillary line

Critical Thinking Application: What Should You Do? 50.

51.

52.

53.

(LO 4.10) Do not panic. Check the patient to make sure he or she is breathing and has a pulse. If so, you will need to check all of your electrodes and lead wires for proper connection. If the patient is not breathing or does not have a pulse, report a Code Blue and initiate CPR immediately.

(LO 4.6) Parkinson’s disease produces fine tremors. The patient is probably experiencing somatic tremor. You may have the patient place the hands palms down under the buttocks to reduce the tremor. If the tremor is still noticeable, you should note on the tracing that the patient has Parkinson’s disease.

(LO 4.11) Report this to your supervisor immediately. If instructed, complete the ECG procedure, observing the patient carefully. Note on the ECG that the patient was experiencing chest pains during the procedure.

(LO 4.7) Explain to the patient that you are not allowed to give a copy and that he or she should ask the physician or request the medical records department for a copy.

Chapter 5: Rhythm Strip Interpretation Preface/Introduction This chapter describes how the heart produces the ECG waveform. It introduces the five-step criteria for rhythm classification approach to rhythm interpretation that will be utilized throughout Chapters 6 through 10.

Learning Outcomes 5.1 Describe the heart activity that produces each part of the ECG waveform 5.2 Explain the process of evaluating ECG tracings and determining the presence of dysrhythmias.

5.3 Describe the criteria used to classify dysrhythmias, including rhythm, rate, P wave morphology, PR interval measurement, and QRS duration measurement.

Extended Outline Outline

PowerPoint® Slides

II.

Electrical Stimulation and the ECG Waveform (LO 5.1) A. What Each Part of the Waveform Represents Rhythm Interpretation (LO 5.2)

Slides 3–21 Slides 6–16 Slides 22-25

III.

Identifying the Components of the Rhythm (LO 5.3)

Slides 26-40

I.

A. Step 1: Determining the ECG Rhythm or Regularity

Slides 28-29

B. Step 2: Determining the Atrial and Ventricular Rates 1. Regular Rhythm 2. Irregular Rhythm C. Step 3: Identifying the P Wave Morphology

Slide 30 Slide 30 Slide 30 Slide 31

Outline

PowerPoint® Slides

D. Step 4: Measuring the PR Interval

Slides 32-33

E. Step 5: Measuring the QRS Duration and Analyzing the Morphology

Slides 34-36

Teaching Strategies

1.

2.

3.

4.

5.

Introduce students to “Rhythm Strip Interpretation” using the following techniques: Have students identify components of P, Q, R, S, T, and U waves on a variety of rhythm strips. The rhythm strips should be obtained in different lead selections to have QRS complexes with both positive and negative deflections.

Discuss how the QRS complex still represents the ventricular depolarization regardless of whether the QRS complex has a positive or negative deflection.

Have students discuss or role-play the actual mechanical movement of the heart during each of the P, Q, R, S, and T waves.

Review the steps in “Identifying the Components of the Rhythms” by dividing the class into five groups, one for each of the steps. Have each group review the step and present it to the class by discussing what the step involves and also by demonstrating how to perform that step on an ECG strip.

In pairs, have students demonstrate how to identify each component of an ECG tracing to one another.

In-Class Activities 

      

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to read rhythm strips properly, how to communicate abnormalities to patients and healthcare professionals, and identifying the various dysrhythmias.

Facilitate group discussions in class on various topics, such as the importance of accurate identification of dysrhythmias, causes of dysrhythmias, and the role that they have in the identification of dysrhythmias.

Have students identify dysrhythmias on a rhythm strip and then share with other students for peer review.

Use the PowerPoint® presentation for Chapter 5 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment •

Obtain or create examples of different ECG tracings, then number and put them in random order in different skill stations in the lab. Rotate each student through the lab identifying the components of each tracing.

• • • •

Using the test bank questions for Chapter 5, create a test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 5 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 5.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 5.1

Checkpoint Questions 1.

2.

3.

Depolarization.

P wave represents atrial depolarization, T wave represents ventricular repolarization.

Ischemia occurs when there is a sudden loss or reduction in blood supply (oxygen) to a region of the heart tissue due to the presence of atherosclerotic plaque, a blood clot, emboli, or vascular spasm.

LO 5.2

Checkpoint Question 1.

Waves, segments, and intervals on the ECG tracing

LO 5.3

Checkpoint Questions 1.

2.

3.

Rhythm, rate, P wave morphology, PR interval measurement, and QRS. 79 beats per minute Are all the QRS complexes of equal duration? What is the actual measurement, and is it within normal limits? Do all QRS complexes look alike, and are any unusual QRS complexes premature or ectopic in nature?

Chapter Review Matching 1.

2.

3.

4.

5.

6.

7.

8.

9.

d e a g i c f b h

(LO 5.1) (LO 5.1) (LO 5.1) (LO 5.1) (LO 5.1) (LO 5.3) (LO 5.3) (LO 5.1) (LO 5.1)

Multiple Choice 10. b 11. c 12. d 13. a 14. a 15. a 16. b 17. b

(LO 5.1) (LO 5.1) (LO 5.1) (LO 5.1) (LO 5.1) (LO 5.3) (LO 5.3) (LO 5.3)

Label the Parts 18. (LO 5.1)

Critical Thinking Application: What Should You Do? 19.

(LO 5.2) The process of determining the type of cardiac dysrhythmia can be challenging. The best approach in determining the actual rhythm is to take on the role of a detective. Detectives gather all the information they can before determining who is the suspect or how something has happened. The process of ECG analysis is similar. First you gather all the data regarding the different waveforms and their patterns. The next step is to match all the information to the specific ECG rhythm criteria in order to classify the various cardiac dysrhythmias.

Chapter 6: Sinus Rhythms Preface/Introduction In this chapter the user learns to interpret the sinus rhythms, including criteria for classification, how the patient may be affected, basic patient care, and treatment.

Learning Outcomes 6.1 6.2 6.3 6.4 6.5 6.6

Analyze normal sinus rhythm and its effect on the patient, including basic patient care and treatment.

Analyze sinus bradycardia and its effect on the patient, including basic patient care and treatment.

Analyze sinus tachycardia and its effect on the patient, including basic patient care and treatment.

Analyze sinus dysrhythmia and its effect on the patient, including basic patient care and treatment.

Analyze sinus arrest and its effect on the patient, including basic patient care and treatment.

Analyze sinus exit block and its effect on the patient, including basic patient care and treatment.

Extended Outline I.

II.

III.

IV.

Outline Rhythms Originating from the Sinus Node (LO 6.1) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Sinus Bradycardia (LO 6.2) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Sinus Tachycardia (LO 6.3) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Sinus Dysrhythmia (LO 6.4) A. Criteria for Classification

PowerPoint® Slides Slides 3-11 Slides 6-8 Slide 9 Slides 12-19 Slide 13-14 Slide 15 Slides 21-26 Slide 21-22 Slides 23-24 Slides 28-32 Slide 28-29

V.

VI.

Outline B. How the Patient Is Affected and What You Should Know Sinus Arrest (LO 6.5) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Sinus Exit Block (LO 6.6) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know

PowerPoint® Slides Slide 30 Slides 34-40 Slides 35-36 Slide 37 Slides 41-46 Slides 42-43 Slide 44

Teaching Strategies Introduce students to “Sinus Rhythms” using the following techniques: 1. Divide the class into five groups, one for each dysrhythmia discussed in the chapter. Have each group review one of the dysrhythmias and present it to the class, discussing its distinguishing characteristics and presenting examples of ECG strips that show the rhythm.

2. In pairs, have students demonstrate how to identify the components of each sinus rhythms on an ECG tracing.

3. Search the Internet or other resources for various ECG strips representing different dysrhythmias. Certain ECG machines can print abnormal strips as examples.

Provide practice sessions by passing the strips around or projecting them in class and reviewing each one. Start by just differentiating the different strips. First introduce the easiest strips; then introduce more complex strips with each practice session.

4. Play a matching game by having students match the unique feature with each rhythm identified in the book. You can do this in presentation format or by creating index cards for each feature.

In-Class Activities •

• •

•

• •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to read rhythm strips properly, how to communicate abnormalities to patients and healthcare professionals, and identifying the various dysrhythmias.

Facilitate group discussions in class on various topics, such as the importance of accurate identification of dysrhythmias, causes of dysrhythmias, and the role that they have in the identification of dysrhythmias.

Have students identify dysrhythmias on a rhythm strip and then share with other students for peer review.

Use the PowerPoint® presentation for Chapter 6 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

• •

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment •

• • • •

Obtain or create examples of different sinus tracings, then number and put them in random order in different skill stations in the lab. Rotate each student through the lab identifying each rhythm or dysrhythmia.

Using the test bank questions for Chapter 6, create a test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 6 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 6.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 6.1 Think It Through: Report the Patient Condition and the Tracing Report the situation to your supervisor immediately. The patient is showing signs of decreased cardiac output, which includes pale skin and respiratory difficulty.

Checkpoint Question 1.

B; All five steps are within normal limits.

LO 6.2

Checkpoint Question 1.

B; The heart rate is less than 60, and all other measurements are within normal limits.

LO 6.3

Checkpoint Question 1.

A; The heart rate is greater than 100, and all other measurements are within normal limits.

LO 6.4

Checkpoint Question 1.

A; Irregular rhythm; the P-P and R-R intervals progressively widen and narrow; other steps are normal.

LO 6.5 Think It Through: Sinus Arrest Asystole is considered a life-threatening dysrhythmia that requires immediate CPR. You should follow the facility policy for a cardiac arrest, sometimes referred to as a Code Blue.

Checkpoint Question 1.

B; Irregular rhythm due to the pause, rhythm appears regular both before and after the pause, the other steps are normal. (Remember to measure the duration of the pause.)

LO 6.6

Checkpoint Question 1.

B; The length of the R-R interval of the pause is a direct 3:1 ratio of the P-P interval.

Chapter Review Matching 1.

2.

3.

4.

5.

6.

7.

8.

9.

b d e i g f h c a

(LO 6-1) (LO 6-1) (LO 6.4) (LO 6-4) (LO 6-1) (LO 6.2) (LO 6-4) (LO 6-1) (LO 6-4)

Multiple Choice 10.

11.

12.

13.

14.

15.

a b a c d c

(LO 6.1) (LO 6.2) (LO 6.3) (LO 6.3) (LO 6.1) (LO 6.6)

Fill in the Blank 19.

20.

21.

22.

23.

(LO 6.3) Exercise.

(LO 6.5) Cardiac arrest, Code Blue, medical emergency.

(LO 6.1) Normal sinus rhythm.

(LO 6.2) Sinus bradycardia, sinus tachycardia.

(LO 6.4) Sinus dysrhythmia.

Critical Thinking Application: Rhythm Identification 24.

(LO 6.2) Rhythm (regular or irregular): Regular

Rate: 35 P wave: Upright and uniform PRI: 0.16 second QRS complex: 0.08 second Interpretation: Sinus bradycardia 25.

(LO 6.6) Rhythm (regular or irregular): Irregular

Rate: 30 P wave: Upright and uniform PRI: 0.16 second QRS complex: 0.08 second Interpretation: Sinus exit block 26.

(LO 6.2) Rhythm (regular or irregular): Regular

Rate: 49 P wave: Upright and uniform PRI: 0.16 second QRS complex: 0.06 second Interpretation: Sinus bradycardia 27. (LO 6.4) Rhythm (regular or irregular): Irregular with widening P-P and R-R intervals Rate: 60 (cannot count last cardiac complex—incomplete) P wave: One for each QRS PRI: 0.12 to 0.20 second QRS complex: 0.06 to 0.10 second

Interpretation: Sinus dysrhythmia 28.

(LO 6.1) Rhythm (regular or irregular): Regular

Rate: 71 P wave: Rounded and upright PRI: 0.16 second QRS complex: 0.08 second Interpretation: Normal sinus rhythm 29.

(LO 6.6) Rhythm (regular or irregular): Irregular

Rate: 50 P wave: Upright and uniform PRI: 0.14 second QRS complex: 0.10 second Interpretation: Sinus exit block 30.

(LO 6.2) Rhythm (regular or irregular): Regular

Rate: 36 P wave: Rounded and upright PRI: 0.16 second QRS complex: 0.08 second Interpretation: Sinus bradycardia 31.

(LO 6.1) Rhythm (regular or irregular): Regular

Rate: 65 P wave: Round, upright, and uniform PRI: 0.20 second QRS complex: 0.10 second Interpretation: Normal sinus rhythm

32.

(LO 6.3) Rhythm (regular or irregular): Regular

Rate: 136 P wave: Upright and uniform PRI: unable to measure (beginning of P wave covered by end of T wave) QRS complex: 0.08 second Interpretation: Sinus tachycardia 33.

(LO 6.2) Rhythm (regular or irregular): Regular

Rate: 35 P wave: Round, upright and uniform PRI: 0.20 second QRS complex: 0.10 second Interpretation: Sinus bradycardia 34.

(LO 6.5) Rhythm (regular or irregular): Irregular

Rate: 40 (cannot count last cardiac complex—incomplete) P wave: Round, upright, and uniform PRI: 0.18 second QRS complex: 0.08 second Interpretation: Sinus exit block rhythm (pause 2.0 seconds) Note: 50 small boxes multiplied by 0.04 seconds = 2.0 seconds 35.

(LO 6.1) Rhythm (regular or irregular): Regular

Rate: 79 P wave: Round, upright, and uniform PRI: 0.16 second QRS complex: 0.08 second Interpretation: Normal Sinus Rhythm (NSR)

36.

(LO 6.4) Rhythm (regular or irregular): Irregular

Rate: 50 P wave: Round, upright, and uniform PRI: 0.18 second QRS complex: 0.08 second Interpretation: Sinus arrest

Chapter 7: Atrial Dysrhythmias Preface/Introduction This chapter provides an introduction to interpretation of the atrial dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment.

Learning Outcomes 7.1 Summarize the similarities and differences among atrial dysrhythmias.

7.2 Analyze premature atrial complexes and their effect on the patient, including basic patient care and treatment.

7.3 Analyze wandering atrial pacemaker and its effect on the patient, including basic patient care and treatment.

7.4 Analyze multifocal atrial tachycardia and its effect on the patient, including basic patient care and treatment.

7.5 Analyze atrial flutter and its effect on the patient, including basic patient care and treatment.

7.6 Analyze atrial fibrillation and its effect on the patient, including basic patient care and treatment.

Extended Outline I. II.

III.

IV.

Outline Introduction to Atrial Dysrhythmias (LO 7.1) Premature Atrial Complexes (LO 7.2) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Wandering Atrial Pacemaker (LO 7.3) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Multifocal Atrial Tachycardia (LO 7.4) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know

PowerPoint® Slides Slides 3–6 Slides 7–14 Slides 9–11 Slide 12 Slides 15–19 Slide 16 Slide 17 Slides 20–25 Slide 20 Slide 21

Outline V.

VI.

Atrial Flutter (LO 7.5) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Atrial Fibrillation (LO 7 .6) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know

PowerPoint® Slides Slides 26–33 Slides 29–30 Slide 31 Slides 34–40 Slides 36–37 Slide 38

Teaching Strategies Introduce students to “Atrial Dysrhythmias” using the following techniques: 1. Divide the class into five groups, one for each dysrhythmia discussed in the chapter. Have each group review one of the dysrhythmias and present it to the class, discussing its distinguishing characteristics and presenting examples of ECG strips that show the rhythm.

2. In pairs, have students demonstrate how to identify the components of each atrial dysrhythmia on an ECG tracing.

3. Search the Internet or other resources for various ECG strips representing different atrial dysrhythmias. Certain ECG machines can print abnormal strips as examples.

Provide practice sessions by passing the strips around or projecting them in class and reviewing each one.

4. Play a matching game by having the students match the unique features with each atrial dysrhythmia identified in the book. You can do this in presentation format or by creating index cards for each feature.

In-Class Activities •

• •

•

• • • •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to read rhythm strips properly, how to communicate abnormalities to patients and healthcare professionals, and identifying the various dysrhythmias.

Facilitate group discussions in class on various topics, such as the importance of accurate identification of dysrhythmias, causes of dysrhythmias, and the role that they have in the identification of dysrhythmias.

Have students identify dysrhythmias on a rhythm strip and then share with other students for peer review.

Use the PowerPoint® presentation for Chapter for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment •

• • • •

Obtain or create examples of different atrial dysrhythmia tracings, then number and put them in random order in different skill stations in the lab. Rotate each student through the lab identifying each dysrhythmia.

Using the test bank for Chapter 6, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 7 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 6.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 7.1

Checkpoint Question 1.

P wave.

LO 7.2

Checkpoint Question 1.

A; Irregular rhythm— The P wave of the early complex is upright with QRS measurement within normal limits.

LO 7.3

Checkpoint Question 1.

B; Three or more different-shaped P waves.

LO 7.4

Checkpoint Question 1.

B; Three or more different-shaped P waves with a heart rate greater than 100.

LO 7.5

Checkpoint Question 1.

A; F waves have replaced P waves.

LO 7.6

Checkpoint Question 1.

B; P waves replaced by chaotic electrical activity referred to as f waves, irregular R-R intervals.

Chapter Review Matching 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

c f e g h d k l i b j a

(LO 7.1) (LO 7.2) (LO 7.2) (LO 7.1) (LO 7.5) (LO 7.5) (LO 7.2) (LO 7.6) (LO 7.2) (LO 7.6) (LO 7.6) (LO 7.6)

Multiple Choice 13.

14.

15.

16.

17.

18.

19.

20.

a b b d c b b d

(LO 7.3) (LO 7.4) (LO 7.6) (LO 7.5) (LO 7.6) (LO 7.3) (LO 7.2) (LO 7.1)

Fill-in-the-Blank 21.

22.

(LO 7.4) Atrial fibrillation.

(LO 7.5) Atrial flutter with ratio 4:1.

Short Answer 23. (LO 7.1) If the PACs are frequent, you would expect the patient to experience signs of low cardiac output.

24. (LO 7.5) Oxygen therapy and careful monitoring to watch for the rhythm to change to sinus rhythm or progress to atrial fibrillation.

25. (LO 7.6) Chaotic atrial activity(f waves) with irregular R-R intervals.

26. (LO 7.3, 7.4) MAT is considered more serious because it is usually caused by underlying disease, such as emphysema, CHF, or acute mitral regurgitation. WAP is a common occurrence in children, older adults, and well-conditioned athletes.

Critical Thinking Application: Rhythm Identification 27.

(LO 7.2-7.6) Rhythm: Irregular Rate: 50 P wave: Upright and rounded, early complexes - biphasic P waves PRi: 0.18 QRS: 0.10 Interpretation: Sinus Bradycardia with PAC's

28.

(LO 7.2-7.6) Rhythm: Regular Rate: V, 71; A, 213; multiply the ratio of F waves by V rate P wave: Absent, F waves PRI: Absent QRS: 0.08 second Interpretation: Atrial flutter 3:1

29.

(LO 7.2-7.6) Rhythm: Irregular Rate: V, 90; A, unable to determine P wave: Absent, f waves PR Interval: Absent QRS: 0.08 second Interpretation: Atrial fibrillation

30.

(LO 7.2-7.6) Rhythm: Irregular Rate: V, 100; A, unable to determine

P wave: Absent, f waves PR Interval: Unable to determine QRS complex: 0.08 second Interpretation: Atrial fibrillation 31.

(LO 7.2-7.6) Rhythm: Regular Rate: V, 71; A, 284; multiply the ratio of F waves by V rate P wave: F waves PR Interval: Absent QRS complex: 0.06 second Interpretation: Atrial flutter 4:1

32.

(LO 7.2-7.6) Rhythm: Irregular Rate: V, 40; A, absent P wave: Absent, F waves PR Interval: Absent QRS complex: 0.08 second Interpretation: Atrial fibrillation

33.

(LO 7.2-7.6) Rhythm: Irregular Rate: V 120 P wave: f waves PR Interval: Absent QRS: 0.06 second Interpretation: Atrial Fibrillation

34.

(LO 7.2-7.6) Rhythm: Irregular Rate: 75 P wave: Variable PRI: None QRS: 0.08 Interpretation: Wandering atrial pacemaker

35.

(LO 7.2-7.6) Rhythm: Regular Rate: V- 83 Atria 332 P wave: Absent, F waves PRI: None QRS complex: 0.06 second (multiply the ratio of f waves by the ventricular rate.)

Interpretation: Atrial flutter 4:1

36.

(LO 7.2-7.6) Rhythm: Irregular Rate: 50 P wave: Variable PRI: Variable QRS: 0.10 second Interpretation: Wandering atrial pacemaker

37.

(LO 7.2-7.6) Rhythm: Irregular Rate: 70 P wave: Absent, f waves

PR Interval: Absent QRS: 0.10 second Interpretation: Atrial fibrillation

Chapter 8: Junctional Dysrhythmias Preface/Introduction This chapter provides an introduction and interpretation of the junctional dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment.

Learning Outcomes 8.1 Describe the various junctional dysrhythmias.

8.2 Analyze premature junctional complexes and their effect on the patient, including basic patient care and treatment.

8.3 Analyze junctional escape rhythm and its effect on the patient, including basic patient care and treatment.

8.4 Analyze accelerated junctional rhythm and its effect on the patient, including basic patient care and treatment.

8.5 Analyze junctional tachycardia rhythm and its effect on the patient, including basic patient care and treatment.

8.6 Analyze supraventricular tachycardia rhythm and its effect on the patient, including basic patient care and treatment.

Extended Outline I. II.

III.

IV.

V.

VI.

Outline PowerPoint® Slides Introduction to Junctional Dysrhythmias (LO 8.1) Slides 3–9 Premature Junctional Complex (PJC) (LO 8.2) Slides 10–16 A. Criteria for Classification Slides 12–13 B. How the Patient Is Affected and What You Should Know Slide 14 Junctional Escape Rhythm (LO 8.3) Slides 17–23 A. Criteria for Classification Slides 19–20 B. How the Patient Is Affected and What You Should Know Slide 21 Accelerated Junctional Rhythm (LO 8.4) Slides 24–29 A. Criteria for Classification Slides 25–26 B. How the Patient Is Affected and What You Should Know Slide 27 Junctional Tachycardia (LO 8.5) Slides 30–35 A. Criteria for Classification Slides 31–32 B. How the Patient Is Affected and What You Should Know Slide 33 Supraventricular Tachycardia (SVT) (LO 8.6) Slides 36–43 A. Criteria for Classification Slides 38–39 B. How the Patient Is Affected and What You Should Know Slide 40

Teaching Strategies Introduce students to “Junctional Dysrhythmias” using the following techniques: 1. Divide the class into five groups, one for each dysrhythmia discussed in the chapter. Have each group review one dysrhythmia and present it to the class, discussing its distinguishing characteristics and presenting examples of ECG strips that show the rhythm.

2. In pairs, have students demonstrate how to identify the components of each junctional dysrhythmia on an ECG tracing.

3. Search the Internet or other resources for various ECG strips representing different junctional dysrhythmias. Certain ECG machines can print abnormal strips as examples. Provide practice sessions by passing the strips around or projecting them in class and reviewing each one.

4. Play a matching game by having the students match the unique features with each junctional dysrhythmia identified in the book. You can do this in presentation format or by creating index cards for each feature.

In-Class Activities 

 



  

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, reading and interpreting rhythm strips, identifying junctional dysrhythmias, and how to respond when junctional dysrhythmias are identified.

Facilitate group discussions in class on various topics, such as how junctional dysrhythmias can be identified, how a healthcare professional should respond when identifying junctional dysrhythmias, how junctional dysrhythmias affect patients, and the importance of accurately interpreting ECG rhythm strips.

Use the PowerPoint® presentation for Chapter 8 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment     

Obtain or create examples of different junctional dysrhythmia tracings, then number and put them in random order in different skill stations in the lab. Rotate each student through the lab identifying each dysrhythmia.

Using the test bank for Chapter 8, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 8 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 8.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 8.1

Checkpoint Question 1. With junctional rhythms, electrical impulses are coming from the AV node instead of the SA node. These electrical impulses cause depolarization of the atria to flow retrograde, or backward. This reverse flow of electrical activity causes the inverted P wave.

LO 8.2

Checkpoint Question 1. B; note the “inverted” P wave on the early complexes.

LO 8.3

Checkpoint Questions 1. A; note the inverted waves.

2. Junctional rhythm has a rate between 40 and 60 bpm. A PJC rate is based on the underlying rhythm combined with the number of PJCs. The P-P and R-R intervals in junctional rhythms are regular. PJCs are premature, interrupting the cadence of the underlying rhythm and causing it to be irregular.

LO 8.4

Checkpoint Question 1. A; note the missing P waves, normal QRS, and rate between 60 to 100 beats per minute.

LO 8.5

Checkpoint Question 1. B; note the inverted P waves after the QRS complex and rate in excess of 100 bpm LO 8.6

Checkpoint Questions 1. Greater than 150 bpm. Electrical impulses or the loci of stimulation come from above the ventricles.

2. The practitioner might ask you to increase the paper speed in an effort to expose the P waves and analyze the tracing more carefully.

3. Racing, fluttering, “not feeling right,” dizziness, “heart racing in my chest”

4. B 5. Narrow QRS and rate over 150 bpm.

Chapter Review Multiple Choice 1. b 2. c 3. b 4. a 5. d 6. a 7. c 8. d 9. b

(LO 8.1) (LO 8.6) (LO 8.6) (LO 8.6) (LO 8.6) (LO 8.6) (LO 8.2) (LO 8.3) (LO 8.4)

Short Answer 10.

(LO 8.1) Where the Electrical impulses are generated from in the junctional tissue region of the heart will determine where the P wave is located (before, during or after the QRS complex). The P wave is inverted due to backward (retrograde) depolarization of the atria. The coordination of the P and QRS complex has to do with the locus of stimulation within the AV junction causing depolarization of the atria and ventricles.

Critical Thinking Application: Rhythm Interpretation 11. (LO 8.2–LO 8.6) Rhythm: Regular Rate: 41 P wave: Inverted PR Interval: 0.08 second QRS: 0.06 second Interpretation: Junctional escape rhythm 12. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 52

P wave: Inverted, following the QRS complex PR Interval: unable to determine QRS: 0.10 second Interpretation: Junctional escape rhythm 13. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 64 (23.5 sm. boxes) P wave: Inverted PR Interval: 0.10 QRS: 0.10 Interpretation: Accelerated Junctional Rhythm 14. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 115 P wave: Inverted following the QRS PR Interval: Unable to determine QRS: 0.08 second Interpretation: Junctional tachycardia 15. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 42 P wave: Absent PR Interval: Absent QRS: 0.08 second Interpretation: Junctional escape rhythm

16. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 167 P wave: Upright, partially buried by previous T wave, due to rate PR Interval: Unable to determine QRS: 0.08 second Interpretation: SVT, this is not junctional tachycardia because of evidence of upright P waves.

17. (LO 8.2-LO 8.6) Rhythm: Irregular Rate: 80 P wave: Upright and uniform, absent on early complexes PR Interval: 0.18 second QRS: 0.08 second Interpretation: Sinus rhythm with PJCs 18. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 54 P wave: Absent PR Interval: Absent QRS: 0.10 second Interpretation: Junctional escape rhythm 19. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 29 P wave: Inverted, after QRS complex

PR Interval: Absent QRS: 0.10 second Interpretation: Junctional escape rhythm 20. (LO 8.2-LO 8.6) Rhythm: Irregular Rate: 70 P wave: Upright and uniform, missing on early complex PR Interval: 0.16 second QRS: 0.10 second Interpretation: Sinus rhythm with PJC 21. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 188 P wave: Absent PR Interval: Absent QRS: 0.08 second Interpretation: Supraventricular tachycardia 22. (LO 8.2-LO 8.6) Rhythm: Regular Rate: 83 bpm P wave: Inverted PR Interval: 0.08 sec QRS: 0.08 sec Interpretation: Accelerated Junctional Rhythm

Chapter 9: Heart Block Dysrhythmias Preface/Introduction This chapter provides an introduction to interpretation of the heart block dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment.

Learning Outcomes 9.1 Describe the various heart block dysrhythmias.

9.2 Analyze first degree atrioventricular (AV) block and its effect on the patient, including basic patient care and treatment.

9.3 Analyze second degree atrioventricular (AV) block, Mobitz I, and its effect on the patient, including basic patient care and treatment.

9.4 Analyze second degree atrioventricular (AV) block, Mobitz II, and its effect on the patient, including basic patient care and treatment.

9.5 Analyze third degree atrioventricular (AV) block and its effect on the patient, including basic patient care and treatment.

Extended Outline Outline I. Introduction to Heart Block Dysrhythmias (LO 9.1) II. First Degree Atrioventricular (AV) Block (LO 9.2) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know III. Second Degree Atrioventricular(AV) Block, Type I ( Mobitz or Wenckebach) (LO 9.3) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know IV. Second Degree Atrioventricular (AV) Block, Type II (Mobitz II) (LO 9.4) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know V. Third Degree Atrioventricular (AV) Block (Complete) (LO 9.5) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know Appendix Slides First Degree AV Block Second Degree AV Block, Type I Second Degree AV Block, Type II

PowerPoint® Slides Slides 4–6 Slides 7– 16 Slides 10–11 Slide 12 Slides 17– 27 Slides 21–22 Slide 23 Slides 28– 35 Slides 30–31 Slide 32 Slides 36– 45 Slides 39–41 Slides 42-43 Slide 50 Slide 51 Slide 52

Outline Comparing Heart Blocks

PowerPoint® Slides Slide 53

Teaching Strategies Introduce students to “Heart Block Dysrhythmias” using the following techniques: 1. Divide the class into four groups, one for each dysrhythmia discussed in the chapter. Have each group review one dysrhythmia and present it to the class, discussing its distinguishing characteristics and presenting examples of ECG strips that show the rhythm.

2. In pairs, have students demonstrate how to identify the components of each heart block dysrhythmia on an ECG tracing.

3. Search the Internet or other resources for various ECG strips representing different heart block dysrhythmias. Certain ECG machines can print abnormal strips as examples. Provide practice sessions by passing the strips around or projecting them in class and reviewing each one.

4. Play a matching game by having the students match the unique features with each heart block dysrhythmia identified in the book. You can do this in presentation format or by creating index cards for each feature.

In-Class Activities •

• •

•

• • •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, reading and interpreting rhythm strips, identifying heart block dysrhythmias, and how to respond when heart block dysrhythmias are identified.

Facilitate group discussions in class on various topics, such as how heart block dysrhythmias can be identified, how a healthcare professional should respond when identifying heart block dysrhythmias, how heart block dysrhythmias affect patients, and the importance of accurately interpreting ECG rhythm strips.

Use the PowerPoint® presentation for Chapter 9 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment •

• • • •

Obtain or create examples of different heart block tracings, then number and put them in random order in different skill stations in the lab. Rotate each student through the lab identifying each dysrhythmia.

Using the test bank for Chapter 9, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 8 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 9.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 9.1

Checkpoint Question 1. The electrical current has difficulty traveling down the normal conduction pathway.

LO 9.2

Checkpoint Question 1. B; PR interval greater than 0.20 second LO 9.3

Checkpoint Question 1. A; prolonging PR interval, missing QRS, then prolonging PR interval pattern starts over.

LO 9.4

Think It Through: Mobitz I vs. Mobitz II For a Mobitz I (Wenckebach), the PR interval in front of the dropped QRS complex will be longer than the PR interval after the dropped QRS complex. Type I has a cyclical pattern of prolonging PR intervals, then a dropped QRS complex. lengthen, lengthen drop…

Checkpoint Question 1 A; Missing QRS complexes; wherever a P wave is with a QRS complex, the PR interval always measures the same.

LO 9.5

Checkpoint Question 1. B; regular P-P and R-R intervals but firing at different rates. Variable PR interval, some P waves buried within QRS complexes or T waves

Chapter Review Multiple Choice 1. a 2. b 3. c 4. d 5. c 6. d 7. c 8. b 9. a 10. c

(LO 9.2) (LO 9.3) (LO 9.4) (LO 9.5) (LO 9.2–9.5) (LO 9.5) (LO 9.2) (LO 9.3, 9.4, 9.5) (LO 9.2) (LO 9.4)

Short Answer 11.

(LO 9.2–9.5) First degree, second degree type I (Wenckebach), second degree type II, and third degree (complete) heart block. Third degree is most serious, due to atria and ventricles being electrically separated (dissociated) from one another.

12.

(LO 9.3, 9.4) In Mobitz I, PR interval is in a progressively prolonging pattern followed by a missing QRS, then the pattern resets and starts over again.

In Mobitz II has missing QRS complexes, but wherever a P wave is with the QRS complex, the PR interval will always measure the same.

13.

(LO 9.5) Always check the patient first! Watch for signs of low cardiac output. The patient may be unconscious. Contact the practitioner by calling a code. This patient may need to be treated with medication, pacemaker, or both, depending upon the patient’s ability to tolerate the rhythm. Rhythm strips are always obtained, labeled, and placed in the patient’s medical record.

Critical Thinking Application: Rhythm Interpretation 14.

(LO 9.2–9.5) Rhythm: Regular Rate: 83 P wave: Upright and uniform PR Interval: 0.24 sec QRS: 0.10 Interpretation: First Degree Heart Block

15.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Irregular Rate: Atria - 60, Ventricles - 50

P wave: Upright and uniform PR Interval: Variable prolonging pattern QRS: 0.06 sec Interpretation: Second Degree Heart Block Mobitz Type I 16.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: Atria - 125, Ventricles - 42 P wave: Upright and uniform PR Interval: 0.14 sec QRS: 0.06 sec Interpretation: Second Degree Heart Block Type II, 3:1

17.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: Atria - 79, Ventricles - 28 P wave: Upright and uniform PR Interval: Variable without pattern QRS: 0.06 sec Interpretation: Third Degree Heart Block

18.

(LO 9.2–9.5) Rhythm: V, irregular; A, regular Rate: V, 60; A, 68 P wave: Rounded and upright PR Interval: Variable “cycle” QRS: 0.08 second Interpretation: Second degree block, type I, Mobitz

19.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: 57 P wave: Upright and uniform PR Interval: 0.36 second QRS: 0.10 sec Interpretation: Bradycardic First Degree Heart Block

20.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: V, 34; A, 100

P wave: Rounded and upright PR Interval: 0.14 second QRS: 0.08 second Interpretation: Second Degree Type II heart block, 3:1 21.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: V, 35; A, 100 P wave: Round and upright PR Interval: Variable QRS: 0.16 second Interpretation: Third degree (complete) heart block

22.

(LO 9.2–9.5) Rhythm: V, irregular; A, regular Rate: V, 70; A, 94 P wave: Upright and uniform PR Interval: Progressive, prolonging pattern QRS: 0.08 second Interpretation: Second degree heart block type I

23.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: V, 38; A, 107 P wave: Upright and uniform, some buried PR Interval: Variable QRS: 0.14 second Interpretation: Third degree (complete) heart block

24.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: 42 P wave: Upright and uniform PR Interval: 0.26 second QRS: 0.10 Interpretation: First degree heart block

25.

(LO 9.2–9.5) Rhythm: V, irregular; A, regular Rate: V, 60; A, 71

P wave: Upright and uniform PR Interval: Variable prolonging pattern QRS: 0.08 second, wide and bizarre Interpretation: Second degree heart block type I 26.

(LO 9.2–9.5) Rhythm: Atria - Regular, Ventricles - Regular Rate: V, 33; A, 100 P wave: Upright and uniform PR Interval: Variable QRS: 0.10 second Interpretation: Second degree heart block type II

Chapter 10: Ventricular Dysrhythmias Preface/Introduction This chapter provides an introduction and interpretation of the ventricular dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment.

Learning Outcomes 10.1 Describe the various ventricular dysrhythmias.

10.2 Analyze PVCs and their effect on the patient, including basic patient care and treatment.

10.3 Analyze agonal rhythm and its effect on the patient, including basic patient care and treatment.

10.4 Analyze idioventricular rhythm and its effect on the patient, including basic patient care and treatment.

10.5 Analyze accelerated idioventricular rhythm and its effect on the patient, including basic patient care and treatment.

10.6 Analyze ventricular tachycardia and its effect on the patient, including basic patient care and treatment.

10.7 Analyze ventricular fibrillation and its effect on the patient, including basic patient care and treatment.

10.8 Analyze asystole and its effect on the patient, including basic patient care and treatment.

Extended Outline Outline I. Introduction to Ventricular Dysrhythmias (LO 10.1) II. Premature Ventricular Complexes (PVCs) (LO 10.2) A. Criteria for Classification

PowerPoint® Slides Slides 4–7 Slides 8–27 Slides 22–24

Outline B. How the Patient Is Affected and What You Should Know III. Agonal Rhythm (LO 10.3) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know IV. Idioventricular Rhythm (LO 10.4) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know V. Accelerated Idioventricular Rhythm (LO 10.5) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know VI. Ventricular Tachycardia (LO 10.6) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know VII. Ventricular Fibrillation (LO 10.7) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know VIII. Asystole (LO 10.8) A. Criteria for Classification B. How the Patient Is Affected and What You Should Know

PowerPoint® Slides Slide 25 Slides 28–33 Slides 29–30 Slide 31 Slides 34–39 Slides 35–36 Slide 37 Slides 40–46 Slides 41–42 Slide 43 Slides 46–53 Slides 49–50 Slide 51 Slides 54–58 Slide 55 Slide 56 Slides 59–64 Slide 60 Slide 61

Teaching Strategies Introduce students to “Ventricular Dysrhythmias” using the following techniques: 1. Divide the class into seven groups, one for each dysrhythmia discussed in the chapter. Have each group review one dysrhythmia and present it to the class, discussing its distinguishing characteristics and presenting examples of ECG strips that show the rhythm.

2. In pairs, have students demonstrate how to identify the components of each ventricular dysrhythmia on an ECG tracing.

3. Search the Internet or other resource for various ECG strips representing different ventricular dysrhythmias. Certain ECG machines can print abnormal strips as examples. Provide practice sessions by passing the strips around or projecting them in class and reviewing each one.

4. Play a matching game by having the students match the unique features with each ventricular dysrhythmia identified in the book. You can do this in presentation format or by creating index cards for each feature.

5. Discover what is included in a crash cart by creating a mock crash cart, identifying items in a crash cart with pictures, or visiting a local facility and reviewing the items in the crash cart with permission from the staff.

In-Class Activities •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by

• •

•

• • •

providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, reading and interpreting rhythm strips for ventricular rhythms, identifying ventricular rhythms, and how to respond when ventricular rhythms are identified.

Facilitate group discussions in class on various topics, such as how ventricular rhythms can be identified, how a healthcare professional should respond when identifying ventricular rhythms, how ventricular rhythms affect patients, and the importance of accurately interpreting ECG rhythm strips.

Use the PowerPoint® presentation for Chapter 10 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment •

• • • •

Obtain or create examples of different ventricular tracings, then number and put them in random order in different skill stations in the lab. Rotate each student through the lab identifying each dysrhythmia.

Using the test bank for Chapter 10, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 10 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 10.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 10.1

Checkpoint Question 1. Because the current is initiated within the Purkinje fibers and the electrical stimulation occurs from ventricular cell to cell.

LO 10.2

Checkpoint Question 1. B; both rhythms contain an early complex; however, the early complex in B has a missing P wave and the QRS appears wide and bizarre, measuring 0.12 second or greater.

LO 10.3

Checkpoint Question 1. A; QRS complexes that appear wide and bizarre, measuring 0.12 second or greater, missing P waves, rate is less than 20.

LO 10.4

Checkpoint Question 1. A; QRS complexes that appear wide and bizarre, measuring 0.12 second or greater, with missing P waves. The ventricular rate is between 20 and 40 beats per minute.

LO 10.5

Checkpoint Question 1. A; QRS complexes that appear wide and bizarre, measuring 0.12 second or greater, missing P waves, rate is between 40 and 100 bpm.

LO 10.6 Think It Through: PVCs A PVC is an ectopic impulse that occurs early or “escapes” from the ventricles, causing the ventricles to depolarize.

Checkpoint Question 1. B; QRS complexes that appear wide and bizarre, measuring 0.12 second or greater, missing P waves, rate is greater than 100 bpm.

LO 10.7

Checkpoint Question 1. B; chaotic electrical activity, absence of P waves and QRS complexes.

LO 10.8

Checkpoint Question 1. A; absence of electrical activity—no waveforms present.

Chapter Review Multiple Choice 1. f 2. c 3. e 4. b 5. d 6. d 7. c 8. d

(LO 10.2–10.8) (LO 10.5) (LO 10.3) (LO 10.4) (LO 10.1) (LO 10.1) (LO 10.7) (LO 10.2)

Short Answer 9. (LO 10.4, 10.5) Idioventricular rate is 20 to 40 bpm. Accelerated idioventricular rate is 40 to 100 bpm.

10. (LO 10.8) Both rhythms are life-threatening and require basic and advanced life support measures.

11. (LO 10.6, 10.7) Ventricular tachycardia is described as three or more PVCs in a row at a rate exceeding 100 bpm. Ventricular fibrillation is chaotic electrical activity with only fibrillatory waves.

Matching 12. f (LO 10.1, 10.2) 13. j (LO 10.1, 10.2) 14. c (LO 10.1, 10.2) 15. b, j (LO 10.1, 10.2) 16. d (LO 10.1, 10.2) 17. h (LO 10.1, 10.2) 18. i (LO 10.1, 10.2) 19. g (LO 10.1, 10.2) 20. a, e, f, g, h, I (LO 10.1, 10.2)

21. l (LO 10.1, 10.2) 22. k (LO 10.1, 10.2)

Critical Thinking Applications: Rhythm Identification (Caution students to double-check the rhythm strip length to ensure that they are six-seconds long) 23. (LO 10.2–LO 10.8) Rhythm: Unable to determine because the tracing contains only two complexes Rate: V, 20 (this may be interpreted as 20, due to the absence of a third complex to determine actual regularity/rate. This tracing would require greater than a six second strip for the most accurate interpretation) A, absent P wave: Absent PR Interval: Absent QRS: 0.20 second, wide and bizarre Interpretation: idioventricular, (may be interpreted as agonal) 24. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 70 P wave: Upright and uniform (absent on early complexes) PR Interval: 0.16 sec QRS: 0.10 sec, early complexes wide and bizarre Interpretation: Sinus Rhythm with Frequent, Multifocal PVCs 25. (LO 10.2–LO 10.8) Rhythm: Regular Rate: V, 150 A, absent P wave: Absent PR Interval: Absent QRS: Unable to determine, wide and bizarre

Interpretation: Ventricular tachycardia 26. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: Unable to determine P wave: Absent PR Interval: Absent QRS: Chaotic electrical activity Interpretation: Ventricular fibrillation 27. (LO 10.2–LO 10.8) Rhythm: Absent Rate: 0 P wave: Absent PR Interval: Absent QRS: Absent Interpretation: Asystole 28. (LO 10.2–LO 10.8) Rhythm: Ventricular tachycardia, regular; ventricular fibrillation, irregular Rate: V-tach, 150; V-fib, unable to determine; A, absent P wave: Absent PR Interval: Unable to determine QRS: Greater than 0.12 second Interpretation: Ventricular tachycardia, paroxysmal ventricular fibrillation 29. (LO 10.2–LO 10.8) Rhythm: Unable to determine because the tracing contains only two complexes.

Rate: V, 14 (this may be interpreted as 20, due to the absence of a third complex to determine actual regularity/rate. This tracing would require greater than a six second strip for the most accurate interpretation) A, absent

P wave: Absent PR Interval: Absent QRS: Greater than 0.12 second Interpretation: Idioventricular, (may be interpreted as agonal) 30. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: V, 70 (last complex is incomplete); P wave: Rounded and upright in underlying rhythm, absent in PVCs PR Interval: 0.18 second QRS: Underlying rhythm, 0.08; –PVCs, greater than 0.12 second Interpretation: Sinus rhythm with non-sustained run of ventricular tachycardia, or salvo PVCs 31. (LO 10.2–LO 10.8) Rhythm: Regular Rate: V, 35; A, absent P wave: Absent PR Interval: Absent QRS: Greater than 0.12 second Interpretation: Idioventricular rhythm 32. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 70 P wave: Round and upright in underlying rhythm; absent in PVCs PR Interval: 0.16 second in underlying rhythm; P wave is absent in PVCs QRS: 0.08 second in underlying rhythm; greater than 0.12 second in PVCs Interpretation: Sinus rhythm with multifocal couplet PVCs

33. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 60 P wave: Round and upright in underlying rhythm; absent in PVCs PR Interval: 0.16 second in underlying rhythm; P wave is absent in PVCs QRS: 0.08 second in underlying rhythm; greater than 0.12 second in PVCs Interpretation: Sinus rhythm with bigeminy unifocal PVCs 34. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 70 (first complex incomplete) P wave: Upright and uniform, missing on early complexes PR Interval: 0.16 second in underlying rhythm, absent on early complexes QRS: 0.10 second in underlying rhythm, early complexes wide and bizarre Interpretation: Sinus rhythm with trigeminy unifocal PVCs 35. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 100 P wave: Upright and uniform, missing on early complexes PR Interval: 0.14, absent on early complexes QRS: 0.10 second in underlying rhythm, early complexes wide and bizarre Interpretation: Sinus tachycardia with two unifocal PVCs 36. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 60 P wave: Upright and uniform

PR Interval: 0.16 sec QRS: 0.06 sec, early complexes wide and bizarre Interpretation: Sinus rhythm with trigeminy unifocal PVCs 37. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 140 P wave: Upright and uniform, missing on early complexes PR Interval: 0.16 second, absent on early complexes QRS: 0.08 second in underlying rhythm, early complexes wide and bizarre Interpretation: Sinus tachycardia with three 4-beat runs of ventricular tachycardia 38. (LO 10.2–LO 10.8) Rhythm: Regular Rate: V, 54; A, absent P wave: Absent PR Interval: None QRS: 0.24 second, wide and bizarre Interpretation: Accelerated idioventricular rhythm 39. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: 90 P wave: Upright and uniform, missing on early complexes PR Interval: 0.16 second, absent on early complexes QRS: 0.08 second in underlying rhythm, early complexes wide and bizarre Interpretation: Sinus rhythm with 2 unifocal couplet PVCs 40. (LO 10.2–LO 10.8)

Rhythm: Irregular Rate: 100 (last complex incomplete) P wave: Upright and uniform, missing on early complexes PR Interval: 0.16 second in underlying rhythm, absent on early complexes QRS: 0.06 second in underlying rhythm, early complexes wide and bizarre Interpretation: Sinus tachycardia with trigeminy unifocal PVCs 41. (LO 10.2–LO 10.8) Rhythm: Irregular chaotic Rate: Unable to determine P wave: Absent PR Interval: None QRS: Absent Interpretation: Ventricular fibrillation 42. (LO 10.2–LO 10.8) Rhythm: Regular Rate: V, 200; A, absent P wave: Absent PR Interval: None QRS: Wide and bizarre Interpretation: Ventricular tachycardia 43. (LO 10.2–LO 10.8) Rhythm: Irregular Rate: V, 190, A, absent P wave: Absent PR Interval: None

QRS: Wide, bizarre, and twisted Interpretation: Multifocal Ventricular tachycardia or Torsades de Pointes

Chapter 11: Pacemaker Rhythms Preface/Introduction This chapter introduces pacemaker rhythms, evaluation of pacemaker function, and complications related to the ECG tracing.

Learning Outcomes 11.1 Identify the various types and functions of pacemakers.

11.2 Analyze pacemaker rhythms and their effect on the patient, including basic patient care and treatment.

11.3 Summarize pacemaker complications relative to the ECG tracing.

Extended Outline Outline I. Introduction to Pacemakers (LO 11.1) A. Pacemaker Function

PowerPoint® Slides Slides 3–12 Slides 5–7

B. Types of Pacemakers II. Evaluating Pacemaker Function (LO 11.2) A. Pacing Spike B. Chamber Depolarization Characteristics C. AV Delay

Slides 8–9 Slides 13–25 Slides 17-18 Slide 19 Slides 20-21

D. Evaluating a Pacemaker ECG Tracing III. Pacemaker Complications Relative to the ECG Tracing (LO 11.3)

Slides 22-23 Slides 26–31

Appendix Slide Pacemaker Placement

Slide 34

Teaching Strategies Introduce students to “Pacemaker Rhythms” using the following techniques: 1. Present a variety of pacemaker devices: atrial, ventricular, atrioventricular, atriobiventricular, as well as typical ECG strips from patients who have each device.

Have students discuss how each type of pacemaker works.

2. Obtain pictures or examples of actual pacemaker devices and discuss each type, how it is connected and what type of tracing would be expected when each of the devices are used.

3.

4.

Have the student search the Internet for the newest types of pacemaker devices and present these devices including how they are implanted, how they work and what type of pacemaker tracing would be seen with the device.

Consider a guest speaker such a medical professional or even a patient who recently had a Placement inserted to discuss the latest types of pacemakers, how they function, how they are inserted, how they are maintained, and how they are monitored.

In-Class Activities •

• •

•

• • •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to evaluate a pacemaker ECG tracing and how to communicate abnormalities to patients and healthcare professionals.

Facilitate group discussions in class on various topics, such as the importance of pacemaker functions, the purpose of pacemakers, and possible complications of pacemakers on ECG tracings.

Use the PowerPoint® presentation for Chapter 11 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment •

•

• • • •

Obtain a variety of pacemaker rhythm strips, mix them up, number them, then place them at skill stations in the lab and rotate your students through as they identify each rhythm.

If available use a rhythm simulator, and randomly present tracings for interpretation. This can be done, one-on-one or in a group review format or as a competition.

Using the test bank for Chapter 11, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 11 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 11.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 11.1

Checkpoint Questions 1. Atrial pacing is used alone when the conduction system from the atrioventricular node through the ventricles is intact and functioning.

2. The atrioventricular pacing option mimics the normal cardiac conduction system and allows the atria to contract completely prior to the ventricles, which allows for an atrial kick.

3. A rate-responsive pacemaker is one that monitors the sinus node rate, breathing, and blood temperature and can adjust the pacing speed to speed up or slow down the heart based on the metabolic demands of the body.

LO 11.2

Checkpoint Questions 1.

2.

3.

4.

B; presence of a pacing spike prior to the P wave A; presence of a pacing spike prior to the QRS complex B; presence of a pacing spike prior to the P wave and QRS complex B; presence of a pacing spike prior to the P wave and two closely timed pacing spikes prior to the QRS complex

LO 11.3

Checkpoint Question 1. Malfunction—failure to pace; malsensing—failure to sense; loss of capture— failure to depolarize; oversensing—perceiving electrical current impulses from sources other than the heart; and undersensing—inability to detect electrical activity and never turning off.

Chapter Review Multiple Choice 1. a and c (LO 11.2) 2. b and c (LO 11.2) 3. d (LO 11.2) 4. b (LO 11.2) 5. b (LO 11.2) 6. d (LO 11.3) 7. b (LO 11.3)

8. c (LO 11.1) 9. b (LO 11.1) 10. a (LO 11.1)

Matching 11.

12.

13.

14.

15.

16.

17.

18.

19.

i c d h e g f a b

(LO 11.3) (LO 11.3) (LO 11.3) (LO 11.3) (LO 11.3) (LO 11.3) (LO 11.3) (LO 11.3) (LO 11.3)

Critical Thinking Application: Rhythm Interpretation 20.

(LO 11.2)

Rhythm: Regular Rate: 75 P wave: Rounded, upright with spike PR Interval: 0.14 second QRS: 0.08 second Interpretation: Atrial paced rhythm 21.

(LO 11.2)

Rhythm: Regular Rate: 79 (19 small boxes) P wave: Rounded, upright with spike PR Interval: 0.18 second QRS: 0.16 second Interpretation: AV sequential paced rhythm 22.

(LO 11.2)

Rhythm: Regular Rate: 80 P wave: Rounded and upright PR Interval: Unable to determine QRS: Preceded by a pacing spike Interpretation: Ventricular paced rhythm 23.

(LO 11.2)

Rhythm: Irregular Rate: 70 P wave: Absent PR Interval: Unable to determine QRS: Greater than 0.12 second Interpretation: Ventricular paced rhythm with failure to capture 24.

(LO 11.2)

Rhythm: Regular Rate: 100 P wave: Upright when seen PR Interval: Variable QRS: 0.14 second, wide and bizarre with spike Interpretation: Ventricular pacemaker rhythm 25.

(LO 11.22) Rhythm: Regular Rate: 81 (18.5 small boxes) P wave: Variable with intermittent spikes PR interval: 0.12 second

QRS: 0.12 sec and uniform with 2 spikes Interpretation: Atriobiventricular paced rhythm 26.

(LO 11.2) Rhythm: Regular Rate: 71 (21 small boxes) P wave: Variable with intermittent spikes PR interval: 0.10 second QRS: 0.18 second and uniform with 2 spikes Interpretation: Atriobiventricular paced rhythm

27.

(LO 11.2) Rhythm: Regular Rate: 65 (23 small boxes) P wave: Upright and uniform with spike PR interval 0.16 second QRS: 0.10 second Interpretation: Atrial paced rhythm

28.

(LO 11.2) Rhythm: Regular Rate: 75 (20 small boxes) P wave: Absent PR interval: Unable to measure QRS: 0.16 second and uniform with spike Interpretation: Ventricular paced rhythm

29.

(LO 11.2) Rhythm: Regular

Rate: 83 (18 small boxes) P wave: Upright and uniform with spikes PR interval: 0.18 second QRS 0.14 second and uniform with spike Interpretation: Atrioventricular paced rhythm 30.

(LO 11.2) Rhythm: Regular Rate: 42 (36 small boxes) P wave: Upright with dimple and uniform PR interval: 0.32 (prolonged) QRS: 0.24 second and uniform, wide and bizarre with RSR morphology and two spikes Interpretation: Biventricular paced rhythm

31.

(LO 11.2) Rhythm: Regular Rate: 83 (18 small boxes) P wave: Upright with dimple and uniform PR interval: 0.14 second QRS: 0.12 second and uniform with RSR morphology and two spikes Interpretation: Biventricular paced rhythm

Chapter 12: Cardiac Stress Testing Preface/Introduction This chapter provides the information necessary to assist with the exercise electrocardiography procedure. The competency checklist provides the step-by-step procedure for practice and developing proficiency at the skill.

Learning Outcomes 12.1 Describe exercise electrocardiography and identify its other names.

12.2 Identify uses of exercise electrocardiography.

12.3 Describe other types of cardiac stress testing.

12.4 Prepare a patient for exercise electrocardiography.

12.5 Summarize safety measures that are used before, during, and after exercise electrocardiography.

12.6 Explain the responsibilities of a healthcare professional during exercise electrocardiography.

12.7 Compare common protocols followed in exercise electrocardiography.

12.8 Explain the responsibilities of a healthcare professional after exercise electrocardiography.

Extended Outline Outline I. Cardiac Stress Testing (LO 12.1) II. Why Is Exercise Electrocardiography Used? (LO 12.2) III. Other Types of Cardiac Stress Testing. (LO 12.3) IV. Preparing the Patient for Exercise Electrocardiography (LO 12.4) V. Providing Safety (LO 12.5) VI. Performing Exercise Electrocardiography (LO 12.6) VII. Common Protocols (LO 12.7) VIII. After Exercise Electrocardiography (LO 12.8)

PowerPoint® Slides Slides 4–9 Slides 10–15 Slides 16–21 Slides 22–31 Slides 32–37 Slides 38–43 Slides 44–54 Slides 55–62

Teaching Strategies Introduce students to “Cardiac Stress Testing” using the following techniques: 1. Briefly review how exercise affects the heart and cardiovascular system.

Compare and contrast maximal and submaximal exercise and when each is used.

Discuss the basic formula followed for each, as shown below.

Note: Current technology automatically calculates THR once the patient’s date of birth is entered into the stress test monitor as part of the software program. This does not relieve the technician of the responsibility for double-checking the number and knowing the appropriate formula based upon testing protocol and facility policy.

2. Have students figure their own target heart rate based on their age and a variety of common multipliers (such as .60, .75, and .85).

Calculating Target Heart Rate (THR) Standard Exercise (Maximal Heart Rate) 220 – age = heart rate 220 – 20 = 200 bpm Exercise Stress Testing (220 – age) × .85 = heart rate (220 – 46) × .85 = 174 × .85 = 147.9 bpm or 148

Based on a 20-year old

Based on a 46-year old

3. Arrange for a representative from one of the ECG equipment companies or another healthcare professional to visit your class and discuss cardiac stress testing.

The company representative may bring printed information or other audiovisuals. If a representative is not available, a previous student or someone who performs ECGs on a regular basis would be a good choice to initiate a discussion.

4. Arrange a trip to a local healthcare facility that performs cardiac stress testing. If possible, have students view the equipment and watch an exercise electrocardiography test in progress.

5. Have students role-play a variety of scenarios, such as patient instruction, communication to gain cooperation, and troubleshooting.

6. Have students complete “Cardiac Crossword Chapter 12” and review the answers in class.

Cardiac Crossword Chapter 12 1

2

3

4

5 6

7

9

8

10

11

12

13

14

15

16

17

Word Bank ANGINA CONGESTIVE HEART FAILURE HYPERVENTILATE

ANGIOGRAM

BETA BLOCKERS

ECHOCARDIOGRA M INVASIVE ST SEGMENT DEPRESSION

FALSE POSITIVE NONINVASIVE THALLIUM STRESS TEST

Across 3. Most important responsibility to the patient in exercise 6. Drugs used to treat hypertension 7. Procedure that does not require entrance into a body cavity, tissue, or blood vessel 9. High blood pressure 11. A physician who specializes in the study of the heart

CARDIOLO GIST HYPERTEN SION SAFETY THR

13. A diagnostic test indicates the presence of disease but, in reality, no disease is present 15. Failure of the heart to pump an adequate amount of blood to the body tissue 16. A noninvasive diagnostic test that uses sound to study the heart and blood vessels; also known as cardiovascular ultrasound 17. An invasive type of exercise electrocardiography in which thallium, a radiopaque substance, is injected into the body to permit viewing the vessels around the heart Down 1. Myocardial ischemia may cause this change on an ECG tracing during exercise stress testing 2. To breathe at an increased rate and depth of inhalation and exhalation 4. Pain around the heart radiating to the arm, caused by a lack of oxygen to the heart muscle 5. Accumulation of plaque and fatty deposits in the arteries that supply oxygen to the heart 8. An invasive procedure during which a radiopaque substance is injected and x-rays are taken of the blood vessels 10. Target heart rate; common abbreviation accepted in medical practice 12. Procedure that requires entrance into a body cavity, tissue, or blood vessel 14. A rough piece of material used to abrade (scrape) the skin prior to electrode placement

Cardiac Crossword Chapter 12 (Answers) G

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Across 3. SAFETY – Most important responsibility to the patient in exercise 6. BETA BLOCKERS – Drugs used to treat hypertension 7. NONINVASIVE – Procedure that does not require entrance to a body cavity, tissue, or blood vessel 9. HYPERTENSION – High blood pressure 11. CARDIOLOGIST – A physician who specializes in the study of the heart 13. FALSE POSITIVE – A diagnostic test indicates the presence of disease but, in reality, no disease is present 15. CONGESTIVE HEART FAILURE – Failure of the heart to pump an adequate amount of blood to the body tissue 16. ECHOCARDIOGRAM – A noninvasive diagnostic test that uses sound to study the heart and blood vessels; also known as cardiovascular ultrasound

S E

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17. THALLIUM STRESS TEST – An invasive type of exercise electrocardiography in which thallium, a radiopaque substance, is injected into the body to permit viewing the vessels around the heart Down 1. ST SEGMENT DEPRESSION – Myocardial ischemia may cause this change on an ECG tracing during exercise stress testing 2. HYPERVENTILATE – To breathe at an increased rate and depth of inhalation and exhalation 4. ANGINA – Pain around the heart radiating to the arm, caused by a lack of oxygen to the heart muscle 5. CORONARY ARTERY DISEASE – Accumulation of plaque and fatty deposits in the arteries that supply oxygen to the heart 8. ANGIOGRAM – An invasive procedure during which a radiopaque substance is injected and x-rays are taken of the blood vessels 10. THR – Target heart rate; common abbreviation accepted in medical practice 12. INVASIVE – Procedure that requires entrance into a body cavity, tissue, or blood vessel

In-Class Activities •

• •

• • •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to instruct patients on preparation for exercise electrocardiography, how to maintain patient safety during exercise electrocardiography, and how to communicate with patients and providers.

Facilitate group discussions in class on various topics, such as the purpose of exercise electrocardiography, proper protocols, and how to follow up.

Use the PowerPoint® presentation for Chapter 12 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Assessment •

• • • •

Have the students practice the stress test procedure from beginning to end including cool down. Students should take turns being the technician and the patient and practice all the steps of Competency Checklist 12-1 Assisting with Exercise Electrocardiography (Stress Testing). After practice, observe and evaluate each student. During your evaluation, have the students explain different aspects of the procedure including things such as why different protocols are used, instances when chemical stress testing is desired or recommended, what is watched for during the pre-test, testing and cool down. Note: If students actually get on the treadmill be very careful to ensure they have no medical conditions that would present as a danger and watch for other aspects of their safety.

Using the test bank for Chapter 12, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 12 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 12.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through/Law & Ethics LO 12.1

Checkpoint Questions 1.

The testing does not require entrance into a body cavity, tissue, or blood vessel.

2. (any three) Safety, education, and preparation of the patient; attaching electrodes; instruction for reporting of patient symptoms; monitoring of blood pressure; and performing 12-lead ECG LO 12.2

Checkpoint Question 1.

Cause of chest pain, functional capacity of the heart, heart disease, limitations for an exercise program, abnormal heart rhythms induced by exercise, the effectiveness of heart medication, how well blood pressure is maintained during exercise, and patient risk of myocardial infarction LO 12.3

Checkpoint Question 1.

Because the patient is not able to exercise or the physician wants images of the heart LO 12.4 Law & Ethics: Informed Consent Because informed consent is mandatory, you must solve the problem before beginning the procedure. Start by identifying why the patient is resisting, and then use possible solutions from Table 11-3 to troubleshoot the situation.

Checkpoint Questions 1.

Because of the risks and complications involved in the procedure 2.

Because certain medications can affect the results of the test. All medications, including vitamins and herbal preparations that the patient is taking, should be reported to the physician.

LO 12.5

Checkpoint Question 1.

Not everyone can have a standard stress test. Conditions that limit the patient include heart aneurysm, uncontrolled disturbances in the heartbeat, inflammation surrounding the heart or heart muscle, severe anemia, uncontrolled hypertension, unstable angina, and congestive heart failure.

LO 12.6 Think It Through: Reporting Problems Stop treadmill, Check the pulse and respiration, and begin emergency procedures as appropriate.

Checkpoint Question 1.

Skin prep solution, gauze, chest electrodes, stress test unit, lead wires, treadmill or stationary bike, adhesive tape belt or mesh vest, crash cart LO 12.7

Checkpoint Questions 1. a. Naughton b. Bruce c. Modified Bruce 2. 103 to 145 beats per minute (depending on the percentage multiplier) LO 12.8

Checkpoint Question 1. (any three) Rest for several hours, avoid extreme temperature, avoid stimulants, no hot shower or bath for 2 hours, discuss the results with the physician

Chapter Review Multiple Choice 1. a 2. c 3. a 4. d 5. a 6. b

(LO 12.5) (LO 12.5) (LO 12.3) (LO 12.6) (LO 12.5) (LO 12.5)

7. d 8. c

(LO 12.6) (LO 12.4)

Patient Education 9. (LO 12.4) Incorrect:. The patient should not consume alcohol or caffeine for 24 hours prior to the test and should not use tobacco on the day of the test.

10. (LO 12.6) Correct.

11. (LO 12.8) Correct.

12.

(LO 12.8) Incorrect: The physician should discuss the results of exercise electrocardiography with the patient as soon as the results are available.

13. (LO 12.4) Correct.

14.

(LO 12.6) Incorrect: Check the manufacturer’s directions and the diagram provided with the test machine for correct placement of the leads for exercise electrocardiography.

15.

(LO 12.6) Correct.

Matching 16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

m k j a f b d e c g h i l

(LO 12.3) (LO 12.2) (LO 12.5) (LO 12.4) (LO 12.3) (LO 12.2) (LO 12.7) (LO 12.3) (LO 12.5) (LO 12.2) (LO 12.3) (LO 12.8) (LO 12.7)

Lead Placement (LO 12.6) 29.

True or False 30.

(LO 12.1) False – An invasive procedure requires entrance into a body cavity, tissue, or blood vessel.

31.

(LO 12.7) False – A Bruce protocol is most commonly utilized for a stress test.

32.

(LO 12.7) False – A chemical stress test is used for patients with their exercise capacity limited by cardiac disease.

33.

(LO 12.7) False – A 12-lead ECG is obtained toward the end of each stage of exercise electrocardiography.

34.

(LO 12.8) True.

35.

(LO 12.1) True.

Critical Thinking Application: What Should You Do? 36.

(LO 12.4) Because the chart does not indicate whether the patient should omit any medications prior to exercise electrocardiography, you should check with the physician. Atenolol is a beta blocker, so it is particularly important that you determine whether this medication should be taken. Ask the licensed practitioner or physician whether medication should be held on the day of the test. When asking, be certain to provide him or her with a list of all the medications the

patient is taking. If the patient is in a hurry, you could obtain the answer and call him prior to the day of the test. However, if the patient is not available by phone or the test is scheduled for the next day, you will need to inform him of the medication changes before he leaves.

37.

(LO 12.6)Turn the treadmill off, then Determine whether the patient is responsive. If so, evaluate the patient, including the blood pressure. Keep in mind that a physician will be present. If the patient is not responsive, provide emergency support as required (not all unresponsive patients are pulseless and apneic) immediately. If CPR has already been started, obtain the emergency equipment and additional personnel to assist. A Code Blue or 911 emergency will be initiated.

38.

(LO 12.8) After exercise electrocardiography, the patient is instructed to avoid extreme temperatures and nicotine products. These things cause stress on the heart. Discuss this information with the patient and encourage her to wait at least 3 hours before smoking and to remain inside the air-conditioned facility until her husband arrives.

39.

(LO 12.4) You should explain to the patient that the thallium stress test requires 3 to 4 hours of his time and that he should plan to miss work for at least one afternoon. Do not forget to explain to him the necessary preparation for the test.

Chapter 13: Ambulatory Monitoring Preface/Introduction This chapter includes the latest information about various types of ambulatory monitors and includes what you need to know to apply and remove a monitor. A procedure checklist is also provided for this skill.

Learning Outcomes 13.1 Identify the purpose and function of ambulatory monitoring.

13.2 Explain why ambulatory monitoring is used in addition to the 12-lead ECG. 13.3 Summarize the common types of ambulatory monitoring.

13.4 Educate the patient about ambulatory monitoring.

13.5 Prepare a patient for application of an ambulatory monitor.

13.6 Describe the procedure for applying an ambulatory monitor correctly.

13.7 Describe the procedure for removing the ambulatory monitor and reporting the results.

Extended Outline Outline I. What Is Ambulatory Monitoring? (LO 13.1) II. How Is Ambulatory Monitoring Used? (LO 13.2) III. Types of Ambulatory Monitoring (LO 13.3)

PowerPoint® Slides Slides 4–9 Slides 10–14 Slides 15–25

Outline IV. Educating the Patient (LO 13.4) A. The Patient Diary V. Preparing the Patient (LO 13.5) VI. Applying an Ambulatory Monitor (LO 13.6) A. Before the Procedure B. Placing the Electrodes VII. Removing an Ambulatory Monitor and Reporting Results (LO 13.7) Appendix Slides Mobile Cardiac Outpatient Telemetry (MCOT) Apply the Monitor

PowerPoint® Slides Slides 26–34 Slides 27-28 Slides 35–38 Slides 39–47 Slides 39–40 Slides 41–42 Slides 48–54

Slide 59 Slide 60

Teaching Strategies Introduce students to “Ambulatory Monitoring” using the following techniques: 1. Have students identify the types of ambulatory monitors and their functions.

2. Have students discuss the uses for ambulatory monitors.

3. Have students compare and contrast the uses and variations of ambulatory monitoring.

4. Have students discuss or role-play patient education for ambulatory monitoring.

5. Discuss patient preparation of an ambulatory monitor.

6. Have students describe and demonstrate the procedures for applying and removing an ambulatory monitor.

7. Discuss and role-play the procedure for reporting ambulatory monitor results.

8. Arrange for a representative from an ECG equipment company or another healthcare professional to visit your class and discuss ambulatory monitoring.

9. Arrange a trip to a local healthcare facility that performs ambulatory monitoring.

If possible, have students view the equipment.

10.

Have students role-play teaching the patient how to fill in an ambulatory monitor diary. Then have each student complete a “pretend” diary for 24 hours and return to the class. Discuss the diary entries in class and how difficult it was for the students to remember to record each activity. Relate their feelings to the patients in their care.

11.

Have the students complete “Cardiac Crossword Chapter 13” and review the answers in class.

Cardiac Crossword Chapter 13 1 2

3

4 5

6

7 8

9

10

11 12

13

Word Bank AMBULATE

ANTI-ARRHYTHMIC ELECTRODE EVENT MARKER HOLTER OSCILLOSCOPE PALPITATION POSTSYMPTOM EVENT TRANSTELEPHONIC

DIARY LOOP MEMORY MONITOR STRESS ECG

SYNCOPE

Across 2. This type of device is attached to the chest with two lead wires. The device memory can hold 5 minutes or more of information. Commonly used for patients with a history of syncope. Can provide the physician with an ECG tracing of the heart before, during, and after the episode.

7. Proper name given to one type of ambulatory monitor; named after the inventor of the procedure and machine 8. Another name for exercise electrocardiography 11. Over the phone line 13. Fast or irregular heartbeat sensation felt by the patient; may or may not be associated with chest pain Down 1. To walk 3. This type is used when a patient is experiencing symptoms 4. Type of medication given to prevent cardiac rhythm abnormalities 5. A monitor or TV-type device used to view electrical tracing of the heart or ECG images 6. The disposable paper or plastic adhesive device containing conductive media that is attached to the patient’s skin 9. Fainting spells 10. Patients activate this when they experience symptoms such as chest pain, dizziness, and indigestion during ambulatory monitoring 12. Holter monitor should not be removed unless the patient brings this to the clinic at the end of the test

Cardiac Crossword Chapter 1 (Answers) 1 2

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Across 2. LOOP MEMORY MONITOR – This type of device is attached to the chest with two lead wires. The device memory can hold 5 minutes or more of information.

Commonly used for patients with a history of syncope. Can provide the physician with an ECG tracing of the heart before, during, and after the episode.

7. HOLTER – Proper name given to one type of ambulatory monitor; named after the inventor of the procedure and machine 8. STRESS ECG – Another name for exercise electrocardiography 11. TRANSTELEPHONIC – Over the phone line 13. PALPITATION – Fast or irregular heartbeat sensation felt by the patient; may or may not be associated with chest pain

G

Down 1. AMBULATE – To walk 2. POSTSYMPTOM EVENT – This type is used when a patient is experiencing symptoms 3. ANTI-ARRHYTHMIC – Type of medication given to prevent cardiac rhythm abnormalities 5. OSCILLOSCOPE – A monitor or TV-type device used to view electrical tracing of the heart or ECG images 6. ELECTRODE – The disposable paper or plastic adhesive device containing conductive media that is attached to the patient’s skin 9. SYNCOPE – Fainting spells 10. EVENT MARKER – Patients activate this when they experience symptoms such as chest pain, dizziness, and indigestion during ambulatory monitoring 12. DIARY – Holter monitor should not be removed unless the patient brings this to the clinic at the end of the test

In-Class Activities •

• •

•

• • • • 

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as how to explain ambulatory monitoring to a patient, how to educate patients and communicate with healthcare professionals, and how to report results.

Facilitate group discussions in class on various topics, such as the purpose of ambulatory monitoring, the procedure for applying ambulatory monitors, and how to prepare a patient for the procedure.

Have students identify appropriate situations for ambulatory monitoring and then share with other students for peer review.

Use the PowerPoint® presentation for Chapter 13 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and Learn Smart assignments. These can be assigned as practice opportunities or graded work for submission.

Using the Procedure Checklist 13-1 Applying an Removing an Ambulatory (Holter) Monitoring have each student practice the procedure, including education and communication that is needed.

Assessment • • • • •

Have the students practice applying different ambulatory monitors with different application locations to one another, including stress loops.

Using the test bank for Chapter 13, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 13 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 13.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 13.1

Checkpoint Question 1.

Providing patient education, applying and removing the monitor, distinguishing artifact, scanning the digital disk, ensuring the placement of the results.

LO 13.2

Checkpoint Questions 1.

The healthcare provider who interprets the results needs to compare the activities in the diary with the ECG tracing to link symptoms or events with any abnormalities captured in the recording LO 13.3

Think It Through: Patient Problems Tell the patient he or she needs to check the electrodes because one or more of them may have become loose. If the electrodes are in place, check the cable connections to the sensors and the monitoring unit, then check any batteries or other electronic components to be sure they are functioning correctly.

Checkpoint Question 1.

Real-time monitoring means that during the monitoring a person is viewing the ECG tracing as it occurs.

LO 13.4 Think It Through: Patient Instructions Explain to the patient that although he is encouraged to continue all of his daily activities, the electrodes and monitor cannot be immersed in water. This includes showering, taking a tub bath, and—unfortunately—participating in a swim meet.

Checkpoint Question 1.

For comfort and convenience, to reduce artifact in the tracing, and to provide access to the chest.

LO 13.5

Checkpoint Question 1.

“Let me check with my supervisor to ensure that I answer this question correctly” or “Give me a second; I will ask the doctor to be certain I answer correctly.”

LO 13.6

Checkpoint Question 1.

Leads or wires become loose or detached, or are pulling. The monitor, wires, or electrodes get wet.

LO 13.7 Think It Through: No Diary Ask the patient to return with the diary before removing the monitor.

Checkpoint Questions 1.

Improper lead attachment, incomplete patient diary, failure of patient to maintain normal routine.

Chapter Review Ordering 1. 4 (LO 13.6) 2. 1 (LO 13.6) 3. 3 (LO 13.6) 4. 2 (LO 13.6) 5. 13 (LO 13.6) 6. 6 (LO 13.6) 7. 11 (LO 13.6) 8. 10 (LO 13.6) 9. 5 (LO 13.6) 10. 9 (LO 13.6) 11. 12 (LO 13.6) 12. 8 (LO 13.6) 13. 7 (LO 13.6)

Matching 14. d 15. g 16. h 17. e 18. i 19. f 20. c 21. a

(LO 13.1) (LO 13.2) (LO 13.1) (LO 13.2) (LO 13.2) (LO 13.1) (LO 13.3) (LO 13.3)

22. b

(LO 13.2)

Patient Education 23.

(LO 13.4) Incorrect – The patient is instructed to participate in his or her normal activities during the monitoring.

24.

(LO 13.4) Correct.

25.

(LO 13.4) Incorrect – Mr. Booth should not take a tub bath or shower during the monitoring. He may take only sponge baths. The monitor should not get wet under any circumstances.

26.

(LO 13.4) Correct.

27.

(LO 13.4) Incorrect – Patients should take their medications as normally scheduled unless specifically instructed not to by the physician.

Multiple Choice 28. c 29. d 30. b 31. b 32. a

(LO 13.3) (LO 13.3) (LO 13.4) (LO 13.3) (LO 13.3)

Holter Diary 33.

The student should complete the right side of the form: Check the “24 hr” box Patient’s Name: Sam McDaniel Patient’s Addr.: (Student can make something up) Age: 54 Sex: Male Phone: (Student can make something up) Medications: Plavix 75 mg daily, Lipitor 20 mg daily Date of recording: (Student can make something up or use current date) Started: 8:00 a.m. (yesterday’s date should be added) Connected by: (Student’s name, or a name made up by the student) Ended: 4:20 p.m. (today’s date should be added) Disconnected by: (Student’s name)

34.

The patient completed the diary correctly

35.

If the diary was not complete, your supervisor or the licensed practitioner would be notified and the monitoring may need to be rescheduled and repeated. The patient should be given additional, clear instructions about completing the diary

before the procedure is repeated. Follow the guidelines at your place of employment.

Critical Thinking Application: What Would You Do? 36.

(LO 13.6) Monitors are expensive and easily damaged. The first thing you should do is examine the monitor for obvious cracks or breaks. If you do not find any damage, insert the batteries and test to see if it functions properly. If it does not work, you may need to contact the manufacturer for repair. Most importantly, you should report the incident to your supervisor and use a different monitor for ambulatory monitoring while the original monitor is being serviced.

37.

(LO 13.7) It appears that your patient was not given the proper instructions, did not understand the instructions, or was unable or unwilling to write in the diary.

You can question the patient to see if he or she remembers some of the activities during the 24- to 48-hour period and attempt to fill in the blanks. You would need to make note of this on the diary. You may want to show the physician or your supervisor the diary to determine if the monitoring should be repeated or continued. It may be wise to do this prior to removing the monitor, in case the physician decides to continue the monitoring. Most importantly, if the monitoring is going to occur again, you should ensure that the patient understands and is able to complete the diary. Proper patient education is important. You may also be able to enlist the help of a family member if the patient is unable or unwilling to complete the diary.

38.

(LO 13.4) For some reason, Mr. Hernandez is not willing to complete the diary. Try to understand his reason by discussing it with him. Ask him questions to gain a better understanding of the problem. He may be illiterate, not understand English or just be uncooperative. In either case, you will need to enlist the cooperation of a family member to ensure that the diary is complete. Ambulatory monitoring will not be effective unless the patient completes the diary.

39.

(LO 13.7) When the ambulatory monitor is in place, the patient is instructed to avoid magnets, metal detectors, high-voltage areas, and electric blankets. At most courthouses, all individuals are required to walk through a metal detector. Ms. Lin should call the courthouse in advance to determine if alternate screening arrangements can be made. If not, consult with the physician to see if the monitoring can be delayed until after Ms. Lin’s court appearance.

Chapter 14: Clinical Presentation and Management of the Cardiac Patient Preface/Introduction This chapter expands on the anatomy of the coronary arteries and relates them to typical and atypical cardiac symptoms. STEMI, non-STEMI, and heart failure are

introduced. The chapter also includes a section about sudden cardiac death as compared to myocardial infarction, and finishes with assessment, immediate care, and continued treatment of the cardiac patient.

Learning Outcomes 14.1 Describe the structure and location of arteries, including the coronary arteries.

14.2 Describe typical cardiac symptoms and unstable angina.

14.3 Summarize atypical patient types and presentation.

14.4 Compare ST segment elevation and non-ST segment elevation.

14.5 Explain heart failure.

14.6 Identify assessment and immediate treatment needed for the cardiac patient.

14.7 Discuss treatment modalities for the cardiac patient.

Extended Outline Outline I. Coronary Arteries (LO 14.1) II. Cardiac Symptoms (LO 14.2) A. Unstable Angina III. Atypical Patient Presentation (LO 14.3) A. Women B. Diabetes C. Elderly Patients IV. Acute Coronary Syndrome (LO 14.4) A. ST Segment Elevation MI (STEMI) B. Non-ST Segment Elevation (NSTEMI) V. Heart Failure (LO 14.5) A. Left Ventricular Failure B. Right Ventricular Failure VI. Cardiac Patient Assessment and Immediate Treatment (LO 14.6) A. O-P-Q-R-S-T B. S-A-M-P-L-E C. Immediate Care D. Additional Cardiac Tests VII. Treatment Modalities for the Cardiac Patient (LO 14.7) A. Thrombolytic or Fibrinolytic Therapy (Clot Busters) B. Angioplasty and Stents C. Coronary Artery Bypass Graft (CABG) Surgery D. Left Ventricular Assist Devices E. Coumadin Clinic F. Enhanced External Counter Pulsation (EECP) Therapy Appendix Slides Blood Vessel Layers

PowerPoint® Slides Slides 4–9 Slides 10–16 Slide 14 Slides 17–23 Slide 18 Slides 19–20 Slide 21 Slides 24–29 Slide 25-26 Slide 27 Slides 31–39 Slides 33–34 Slides 35–37 Slides 40–48 Slide 41 Slide 43 Slide 44 Slide 46 Slides 49–59 Slides 50-51 Slides 52–53 Slide 54 Slide 55 Slide 56 Slide 57 Slide 64

Outline ST Segment Elevation MI (STEMI) Appendix Clinical Triad Appendix O-P-Q-R-S-T Visual Pain Scale

PowerPoint® Slides Slide 65 Slide 66 Slide 67 Slide 68

Teaching Strategies Introduce students to “Clinical Presentation and Management of the Cardiac Patient” using the following techniques: 1. Arrange for a healthcare professional to visit your class and discuss clinical management of cardiac patients. The speaker may bring printed information or other audiovisuals.

2. Have students work in groups to research and report out on treatment modalities.

3. Have students identify each type of heart failure by comparing and contrasting right versus left heart failure.

4. Have student research patient presentation of MI and role-play their expected presentation. Review each presentation type and discuss treatment needs.

5. Research the various anticoagulants as treatment and determine the advantages and disadvantages of each.

In-Class Activities •

• • •

• • • • •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Provide scenarios for students to role-play in a variety of situations, such as atypical patient presentations, patient assessment, and patient treatment.

Facilitate group discussions in class on various topics, such as how to identify heart failure and coronary syndromes, treatment for the cardiac patient, and cardiac patient assessment.

Have students identify acute coronary syndrome.

Use the PowerPoint® presentation for Chapter 14 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students use the Competency Checklist 14-1 to simulate practicing Immediate Care for a Cardiac Patient.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment • • • •

Using the test bank for Chapter 14, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 14 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 14.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 14.1

Checkpoint Questions 1. Tunica adventitia keeps the vessel open.

Tunica media dilates and constricts the vessel.

Tunica intima has direct contact with the blood.

LO 14.2

Checkpoint Questions 1.

Because it is better to treat for the most serious cause of the problem rather than overlook a cardiac problem that could cause severe consequences or even death of the patient.

LO 14.3

Checkpoint Questions 1. b; diabetics, women, and elderly people 2.

The symptoms they experience are not classic and vary depending on the type of the patient.

LO 14.4

Checkpoint Questions 1.

a. ST depression b. T wave inversion (either order)

LO 14.5

Checkpoint Questions 1.

When the left pump fails, it causes blood to back up into the right heart, which in turn causes right heart failure. When the left pump (ventricle) fails, blood will stall and back up in the lungs, often causing pulmonary edema. Respiratory assessment will often reveal noisy, “wet”-sounding lungs, referred to as rales (crackles). Additional signs and symptoms of left heart failure include:  Shortness of breath or trouble breathing  Fatigue (tiredness)  Tachycardia  Confusion  Shortness of breath  Anorexia

 Decreased or absent urine production  Pallor Left heart failure always leads to right heart failure.

2.

The clinical triad includes three symptoms (normal breath sounds, hypotension, and jugular vein distention) and is a ominous sign of right-sided heart failure.

LO 14.6

Checkpoint Questions 1.

Assess the pain level; check the vital signs, including pulse oximetry, start oxygen at 4 liters/min; obtain 12-lead ECG immediately and with each set of vital signs; notify the physician or treating practitioner of a patient with chest pain; practitioner interprets the ECG. 2.

These mnemonics help ensure that you approach all cardiac patients in the same way and that your assessment of each patient is complete and thorough.

LO 14.7

Checkpoint Questions 1.

Clot busters are used to prevent or break down clots. Thrombolytic agents convert plasminogen to plasmin which in turn breaks down the fibrin that is in a clot. Fibrinolytic agents destroys the fibrin in a clot. Fibrin is necessary for a clot to form.

2.

Stents are placed during coronary angioplasty to help keep the coronary artery open.

Chapter Review True/False 1. (LO 14.2) False; not all chest pain is cardiac in origin. Patients may experience chest pain due to inflammation of the costal cartilage or lungs, gastric or esophageal irritation, gallbladder, or dental pain, to name a few.

2. (LO 14.2) True 3. (LO14.4) False – acute myocardial infarction does not always present with ST segment elevation.

4. (LO 14.6) False – the “A” in S-A-M-P-L-E refers to allergies.

5. (LO 14.5) True 6. (LO 14.7) False – fibrinolytic agents are not always appropriate and should not be used with certain medical conditions.

7. (LO 14.6) True

8. (LO 14.1) False – the circumflex artery supplies blood to the left atrium and ventricle.

Multiple Choice 9. d 10.b 11.d 12.d 13.b 14.c 15.a 16.c 17.a 18.d 19.d 20.d 21.d 22.d 23.d 24.c 25.d

(LO 14.1) (LO 14.1) (LO 14.2) (LO 14.2) (LO 14.3) (LO 14.3) (LO 14.3) (LO 14.4) (LO 14.4) (LO 14.5) (LO 14.5) (LO 14.6) (LO 14.6) (LO 14.6) (LO 14.6) (LO 14.7) (LO 14.7)

Fill in the Blank 26.

27.

28.

29.

(LO 14.6) a. Assess pain level: quality, duration, location, radiation. b. Check vital signs, including pulse oximetry (SpO2). c. Start oxygen at 4 L/min nasal cannula (or per local protocol). d. Obtain 12-lead ECG immediately and with each set of vital signs. e. Notify physician or treating practitioner of patient with chest pain. f. Physician or treating practitioner interprets ECG. (LO 14.6) CBC, electrolytes, PT/PTT or PT/INR, lipid panel, and cardiac enzymes, such as troponin and CK-MB (LO 14.7) Widow maker (LO 14.7) Any two of the following: saphenous vein (SV), internal mammary artery (IMA), internal thoracic artery (ITA), radial artery (RA), right gastroepiploic artery (RGEA), ulnar artery (UA), splenic artery, inferior epigastric artery.

Critical Thinking Application: What Should You Do? 30.

(LO 14.2, 14.3, 14.6)

a. unstable angina, When in doubt about pain you should always “Think the Worst.” In this case it is likely that her stable angina has changed to unstable angina. The pain is now waking her up at night and lasts more than 20 minutes. b. See Table 14-1 c. Because the pain is lasting longer, coming more frequently, and waking her up at night.

31.

(LO 14.1, 14.6) a.

The LAD (left anterior descending) artery supplies blood to both of the ventricles. It is called the widowmaker because a complete blockage in of this artery can result in sudden death. b. aspirin and Plavix (clopidogrel) or Effient (prasugrel) c. A DES (drug eluting stent) releases medication that helps prevent restenosis, however in some cases the stent itself can cause a thrombus (blood clot) to form and long-term dual antiplatelet therapy is given to prevent this.

32.

(LO 14.2, LO 14.6) a.

Yes b.

He could be low on oxygen as well, and anxious because of his family history. c.

Assess pain level: quality, duration, location, radiation. Check vital signs, including pulse oximetry (SpO2). Start oxygen at 4 L/min. by nasal cannula (or per local protocol). Obtain 12-lead ECG immediately and with each set of vital signs.

Notify physician or treating practitioner of patient with chest pain. Physician or treating practitioner interprets ECG. d.

To ensure that the patient is thoroughly evaluated and to prevent him from having damage or to reduce the damage to his heart if the problem is caused by ischemia e.

He may or may not be having cardiac symptoms. After the evaluation, it may be determined that he is having gallbladder pain.

Chapter 15: Basic 12-Lead ECG Interpretation Preface/Introduction This chapter provides an introduction to 12-lead ECG interpretation. It includes anatomical views of the coronary arteries and correlates the arteries with the leads and views obtained on a 12-lead ECG. It also identifies the morphologic changes in the tracing that occur as a result of ischemia, injury, and infarction. Bundle branch block dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment and how to differentiate between left and right bundle branch block is included. Axis deviation and left ventricular hypertrophy round out the chapter concepts. The last section helps users put all these concepts together for 12lead interpretation.

Learning Outcomes 15.1 Discuss the anatomic views represented on a 12-lead ECG and the coronary artery that commonly supplies each region of tissue.

15.2 Identify common morphologic changes associated with ischemia, injury, and infarction.

15.3 Analyze bundle branch block and its effect on the patient including basic patient care and treatment.

15.4 Differentiate between left and right bundle branch blocks and how they relate to the 12 lead ECG. 15.5 Define axis deviation, and list the steps utilized to determine the presence of axis deviation.

15.6 Describe left ventricular hypertrophy (LVH) and list the steps to determine the presence of LVH.

Extended Outline Outline I.

The Views of a Standard 12-Lead ECG and Major Vessels (LO 15.1) II. Ischemia, Injury, and Infarction (LO 15.2) A. Bundle Branch Block B. Criteria for Classification III. How the Patient Is Affected and What You Should Know IV. IV. Differentiate between left and right bundle branch blocks V. Electrical Axis (LO 15.5) VI. Left Ventricular Hypertrophy (LO 15.6) Appendix Slides Typical 12 Lead ECG Coronary Arteries Viewed in 12 Lead ECG Inferior Infarction Lateral Infarction Right Bundle Branch Block Appendix Left Bundle Branch Block Appendix Electrical Axis Deviation

PowerPoint® Slides Slides 4–13 Slides 14–23 Slides 24-34 Slides 29-31 Slides 32 Slides 35-40 Slides 41-48 Slides 49-57 Slide 62 Slide 63 Slide 64 Slide 65 Slide 66 Slide 67 Slide 68

Teaching Strategies 1. Introduce students to “Basic 12-Lead ECG Interpretation” using the following techniques: 2. Have students identify the portions of the heart viewed on a variety of 12-lead ECG tracings.

3. Have students compare and contrast ischemia, injury, and infarction.

4. Provide normal and abnormal rhythm strips and 12-ECG’s to the students and have them determine presence of BBB in the rhythm strips and have them determine left or right BBB or normal ventricular conduction in the 12-Lead ECG’s.

5. In pairs, have students demonstrate how to identify bundle branch block on an ECG tracing.

6. Search the Internet or other resource for various ECG strips that show bundle branch block. Certain ECG machines can print abnormal strips as examples. Provide practice sessions by passing the strips around or projecting them in class and reviewing each one.

7. Have students identify components of P, Q, R, S, T, and U waves on a variety of 12lead ECGs, including tracings that show axis deviation and other abnormalities.

In-Class Activities •

• •

• • • •

Encourage students to complete the Checkpoint Questions throughout the chapter and check their answers. You can use the Checkpoint Questions as practice by providing the answer key, or as a graded assignment. Students can also work on Checkpoint Questions in small groups for reporting out or group discussion.

Have students work on instructor-driven discussion questions in groups and report the responses out to the class for discussion.

Facilitate group discussions in class on various topics, such as axis deviations and other 12-lead ECG abnormalities. Have students research symptoms that would accompany these conditions.

Have students identify cardiac cycles and abnormalities on a rhythm strip and then share with other students for peer review.

Use the PowerPoint® presentation for Chapter 15 for a class lecture and/or review.

Use the Apply Your Knowledge questions for discussion.

Have students complete and check the Chapter Review questions in preparation for the final chapter evaluation.

Have students complete Connect and LearnSmart assignments. These can be assigned as practice opportunities or graded work for submission.

Assessment •

• • • •

Gather 12-lead ECGs with a variety of pathologies and place them randomly at skill stations in the lab. Number each of them and rotate the students through the lab to practice and apply their analysis and interpretation skills.

Using the test bank for Chapter 15, create a written test in two versions for a final evaluation of student proficiency.

Have students complete LearnSmart and Connect activities, as assigned.

Create a Chapter 15 test or quiz in Connect to evaluate student proficiency.

Have students write and submit a reflection of key concepts for Chapter 15.

Submission can also be via an uploaded assignment through Connect.

Answer Key Checkpoint Questions/Think It Through LO 15.1

Checkpoint Question 1.

In order to view either the right ventricle or the posterior wall of the heart; also for dextrocardic patients.

LO 15.2

Checkpoint Questions 1.

Wandering baseline makes it difficult to analyze the ST segment. This could give the appearance of ST elevation or depression when this is not the case or may allow the interpreter to miss ST elevation or depression.

2.

Low oxygen level to a region of cells in the heart that occurs when there is a reduction or interruption in blood flow and oxygen to the myocardium.

3.

ST segment elevation.

4.

Two or more views looking at the same part of the heart, or two numerically consecutive chest leads.

5.

A Q wave that measures 0.04 second or greater in width and/or greater than or equal to 1/3 the height of the R wave in that lead.

LO 15.3

Checkpoint Questions 1. Electricity will flow as it normally does down the unaffected side; the affected side will depolarize in a cell-by-cell manner, causing the QRS complex to widen and reflecting the longer depolarization period. If both ventricles are blocked, the patient could possibly end up with a complete heart block (medical emergency).

2. RBBB—Electricity passes down the left bundle as it normally does; the right bundle is blocked, causing a cell-by-cell depolarization. Electrical evidence on a 12lead would be viewed best in lead V1. There will still be a P wave, but the ventricular depolarization will measure 0.12 second or greater and the QRS is positively deflected.

LBBB—Electricity passes down the right bundle as it normally does; the left bundle is blocked, causing a cell-by-cell depolarization. Electrical evidence on a 12-lead would be viewed best in lead V1. There will still be a P wave, but the ventricular depolarization will measure 0.12 second or greater and the QRS is negatively deflected.

3. A; QRS complex measures greater than or equal to 0.12 second

LO 15.4

Checkpoint Questions 1. a. Left BBB—P wave is present and there is a negatively deflected ventricular depolarization (QS complex) measuring 0.12 second or more. b. Right BBB—P wave is present and there is a positively deflected ventricular depolarization (RSR complex) measuring 0.12 second or more LO 15.5

Checkpoint Questions 1.

2.

3.

I and aVF QRS complex Left axis deviation

LO 15.6

Checkpoint Questions 1. Yes. Step 1: Analyze V1 and V2. Measure from the isoelectric line down to the tip of the deepest QS complex. (32 mm) Step 2: Analyze V5 and V6. Measure from the isoelectric line up to the tip of the tallest R wave. (29 mm) Step 3: Combine the deepest QS complex measurement with the tallest R wave measurement. If the combined numbers measure 35 mm or greater, clinically you must suspect left ventricular hypertrophy. (32 + 29 = 61 mm)

Chapter Review Matching 1. h (LO 15.5) 2. i (LO 15.2) 3. a (LO 15.6) 4. e (LO 15.3) 5. c (LO 15.2) 6. g (LO 15.2) 7. b (LO 15.2) 8. j (LO 15.4) 9. c (LO 15.2) 10. f (LO 15.2) 11. d (LO 15.1) 12. n (LO 15.4) 13. k (LO 15.4) 14. m (LO 15.4)

Multiple Choice 15. d 16. b 17. a 18. c 19. d 20. c 21. a 22. b 23. c 24. a 25. d 26. c 27. a 28. c 29. d 30. b 31. c 32. c 33. d

(LO 15.1) (LO 15.1) (LO 15.1) (LO 15.1) (LO 15.1) (LO 15.1) (LO 15.1) (LO 15.1) (LO 15.2) (LO 15.2) (LO 15.2) (LO 15.5) (LO 15.5) (LO 15.5) (LO 15.5) (LO 15.5) (LO 15.6) (LO 15.6) (LO 15.4)

34. d 35. c 36. a 37. d

(LO 15.4) (LO 15.4) (LO 15.4) (LO 15.4)

Short Answer 38.

(LO 15.2) Plaque and thrombus or clot.

39.

(LO 15.2) Two or more leads looking at the same part of the heart or numerically consecutive chest leads.

40.

(LO 15.4) In a bundle branch block (the) duration or width of the QRS is increased on the tracing. With hypertrophy, the amplitude or voltage of the QRS is affected increased.

41.

(LO 15.4) Evidence of atrial activity (P wave). Remember, the problem is within the ventricles, so we must see a P wave to tell us that the electrical activity was initiated above the ventricles. QRS complex that measures 0.12 second or more in duration.

42.

(LO 15.4) Presence of atrial activity. If the majority of ventricular depolarization is negative or a QS complex is present measuring greater than 0.12 seconds, it is an LBBB. 43.

(LO 15.4) Presence of atrial activity and a classic RSR pattern in V1

Matching II 44.

45.

46.

47.

48.

49.

(LO 15.4) Right Bundle Branch Block (LO 15.4) Left Bundle Branch Block (LO 15.4) Right Bundle branch Block (LO 15.4) Right Bundle Branch Block (LO 15.4) Left Bundle branch Block (LO 15.4) Right Bundle branch Block

Critical Thinking Application Rhythm Identification 50.

51.

52.

53.

54.

55.

56.

(LO 15.2) ST depression and T wave inversion in V1-V6 and aVL; there are also some changes in V1-V4. Anterior, lateral and septal ischemia.

(LO 15.2) Pathologic Q wave noted in leads III and aVF. Old Inferior wall MI. (LO 15.2) ST elevation in inferior leads II, III and aVF. Inferior wall MI. (LO 15.2) Lateral ST elevation noted in leads V2, V3, V4, V5, V6, I and aVL; ST depression in leads III and aVF. Anterolateral MI with septal extension (III and aVF are reciprocal changes).

(LO 15.3) Normal axis - Lead I up, aVF up.

(LO 15.3) Left axis - lead I up, aVF down.

(LO 15.3) Extreme right axis - lead I down, aVF down.

57.

58.

59.

60.

61.

62.

63.

64.

(LO 15.4) Yes, measurement combined is approximately 40 mm. Add the S wave measurement in V1 with the R wave measurement of V5.

(LO 15.4) Rhythm: Regular Rate: 54 P wave: Upright and uniform PR interval: 0.16 seconds QRS: 0.20 second Interpretation: Sinus bradycardia with Right Bundle Branch block (LO 15.4) Rhythm: Regular Rate: 58 P wave: Upright and uniform PR interval: 0.20 seconds QRS: 0.16 second Interpretation: Sinus bradycardia with Left Bundle Branch block (LO 15.4) Rhythm: Regular Rate: 88 P wave: Upright and uniform PR interval: 0.12 seconds QRS: 0.12 second Interpretation: Sinus rhythm with Right Bundle Branch block (LO 15.4) Rhythm: Regular Rate: 91 P wave: Upright and uniform PR interval: 0.18 seconds QRS: 0.16 second Interpretation: Sinus rhythm with Left Bundle Branch block (LO 15.4) Rhythm: Irregular Rate: 60 P wave: Upright and uniform PR interval: 0.20 seconds QRS: 0.16 second Interpretation: Sinus rhythm with Right Bundle Branch block (LO 15.4) Rhythm: Regular Rate: 68 P wave: Inverted and uniform PR interval: 0.10 seconds QRS: 0.14 second Interpretation: Accelerated junctional rhythm with Right Bundle Branch block (LO 15.4) Rhythm: Regular Rate: 94 P wave: Biphasic and uniform PR interval: 0.14 seconds QRS: 0.16 second Interpretation: Sinus rhythm with Right Bundle Branch block