HEART RHYTHM 101..
WHAT YOU REALLY NEED TO
KNOW IN A NUTSHELL…
Tara Cypher, RN MSN
WHY IS THIS SOMETHING TO WORRY
ABOUT???
According to the NHI, approx 1 in 18 or 14.4
million people in USA have a diagnosis of an
irregular heart rhythm
 In order to understand when something is wrong,
we need to know how the heart works
 We have hands on time and the opportunity to
recognize changes in our patients condition.
 We need to recognize what is “normal” and what
is a potential problem

THE ANATOMY OF THE HEART
PHYSIOLOGY OF THE HEART…HOW DOES
THE MAGIC HAPPEN???

TWO important concepts:

1. Electrical activity in the heart

2. Mechanical contraction of the heart
BLOOD FLOW THROUGH THE HEART

http://youtu.be/7XaftdE_h60
BLOOD FLOW THROUGH THE HEART
Deoxygenated blood from the Superior and
Inferior Vena cava enter the RIGHT ATRIUM
 Blood Flows from the Right Atrium through the
TRICUSPID valve into the Right Ventricle
 Blood is pumped from the RIGHT VENTRICLE
through the PULMONARY VALVE to the
Pulmonary Arteries
 The Pulmonary Arteries bring blood to the lungs
to be oxygenated

BLOOD FLOW THROUGH THE HEART
Oxygenated blood comes back to the heart from
the PULMONARY VEINS
 The Pulmonary Veins enter the LEFT ATRIUM
 The oxygenated blood passes through the
MITRAL (BICUSPID) Valve to the Left Ventricle
 The LEFT VENTRICLE pumps blood through
the AORTIC valve into the AORTA
 The Aorta is our largest artery, branching off to
deliver oxygenated blood to our body
 Capillaries serve as small exchange vessels
between arteries and veins where nutrients and
gasses diffuse

The heart consists of
two parallel pumps.
• The right ventricle pumps blood
through the lungs.
• The left ventricle pumps blood
through the systemic
circulation– the body
THE HEART AS A PUMP

http://youtu.be/84PrHxJri9Q
THE HEART AS A PUMP
The RIGHT and LEFT side are pumping at the
SAME time…
 The right pumps to the lungs
 The left pumps to the body
 When we listen to the heart, TWO sounds should
be heard
1. S1: LUB: Tricuspid and Mitral Valve closing

o
2. S2: DUB: Pulmonary and Aortic Valve closing
Any extra heart sounds are called a MURMER
HOW DOES THE HEART PUMP???
The
heart needs “electricity’
to start the pump
The heart is made of
specialized muscle tissue to
conduct electricity
The heart as special nodes,
branches and fibers so the
signals can pass quickly
through the heart
THIS IS WHERE THE ION CHANNELS COME
IN….
Like all muscle cells in the body, the heart
depends K, Na, and Ca channels for
contraction…
 The pacemakers of the heart (the SA node, AV
node, Bundle of HIS and Purkinge Fibers) have
specialized cells to make heart muscle
contraction more efficient
 All have specific “refractory” periods when they
will not get “excited” or depolarize and cause
contraction of heart muscle

IONS AND THE HEART
ELECTRICAL ACTIVITY IN THE
HEART

http://youtu.be/v3b-YhZmQu8
NORMAL SINUS RHYTHM
THE HEART WORKS BEST WHEN
THE SINUS NODE RUNS THE SHOW
All cells in the heart are capable of electrical
activity…but the heart works much better when
the SINUS NODE (the fastest internal
pacemaker) takes the lead and the heart
contracts in an organized fashion
 Normal Sinus Rhythm is meant to depolarize the
atria uniformly, gives the AV valves time to close,
then depolarize the ventricles evenly to the lungs
and the body…but this is not a perfect world
 Arrythmias are common

EXAMPLES OF PROBLEMS WHEN THE
ELECTRICAL ACTIVITY IS OUT OF WHACK…
Premature beats…we all have them!
 Atrial Fibrillation….the most common
 Atrial Tachycardia
 Junctional Rhythm
 SVT
 Heart blocks
 Ventricular Tachycardia
 Ventricular Fibrillation

PREMATURE BEATS

Premature Atrial Contractions
PREMATURE BEAT

Premature Ventricular Contraction
ATRIAL FIBRILLATION

Nothing regular about it…
ATRIAL TACHYCARDIA

The atria are contracting 1, 2, 3, 4, etc times for
each ventricular contraction
SUPRAVENTRICULAR TACHYCARDIA

Its just too fast…
JUNCTIONAL RHYTHM
FIRST DEGREE HEART BLOCK
SECOND DEGREE HEART BLOCK: II

Mobitz Type 2
SECOND DEGREE HEART BLOCK: I

Mobitz Type 1: Wenckebach
THIRD DEGREE HEART BLOCK

Complete Heart Block.....BAD NEWS
VENTRICULAR TACHYCARDIA

Get ready to shock ladies and gentleman…
VENTRICULAR FIBRILLATION

The heart is just quivering…ouch
ASYSTOLE

Nothing good…but always check your leads!
WHAT ARE THE BIG THINGS I NEED TO
LOOK OUT FOR???




1. Heart rate and pulse
2. Common medications that slow down or speed
up the heart
3. Common problems with abnormal heart
rhythms…like clots!
4. Many medications or conditions that increase
or decrease K, Na or Ca COULD AFFECT THE
HEART
MEDICATIONS THAT SPEED UP THE HEART




Keep in mind, pacemakers are usually placed for
slow heart rhythms
In an emergency, IV medications are given to
speed up heart rate
Many medications may speed up heart rate as a
side effect…when in doubt, look it up!
Cold medications, Caffiene, Allergy Medications,
Diet medications, some cough medications,
thyroid medications, some blood pressure
medications
MEDICATIONS THAT BLOCK IMPULSES




Na Channels: Procainamide, Quinidine,
Lidocaine, Flecainide
Beta nerve impulses: Atenolol, Metoprolol,
Carvedilol, Nadolol, Esmolol, etc
Potassium: Amiodarone (Cordarone®), Dofetilide
(Tikosyn®), Ibutilide (Corvert®), Sotalol
(Betapace®), Tedisamil
Calcium: Diltiazim (Cardizem®), Verapamil
HEART RATE VS PULSE




The heart rate is the electrical impulses, the
pulse is the mechanical output
Need to listen/feel how that beat is pumping
blood
Not all beats are created equally
TAKE HOME MESSAGE: Electrical activity
does not always mean good mechanical
contraction of the heart
WHAT DOES THIS MEAN TO ME?

Check the HR and pulse BEFORE giving any drug for
the heart

Check with the patient…how is the mental status,
how are their other vital signs??

Double check the orders…when to hold the
medication, etc.

Anything fast or slow NEEDS TO BE ADDRESSED.
Document and tell someone.

When in doubt, ASK. ALWAYS. Medications are
hard to take back.
POP QUIZ!
You enter Mrs. X’s room at your rehab facility to
pass evening medications. She is 81 yrs old,
recovering from hip surgery. She has had a fever
and a “cold” for the last 2 days. She is ordered to
receive Sudafed to relieve nasal congestion.
 Mrs. X states she is feeling very weak. She
sounds short of breath with minimal exertion.
 As a diligent LPN, you check her pulse and her
blood pressure
 Her BP is 88/60, her pulse is 160 and feels
thready. Her temperature is 99.9, her oxygen
saturation is 91% but it is difficult to get a good
reading.

WHAT DO YOU DO FOR MRS. X???




A. Give her the cold medicine and a glass of
water. She could be dehydrated.
B. Ask her if she would like Tylenol for her fever,
as she has a standing order for this medication
C. Notify the charge nurse/MD that Mrs. X
needs immediate attention.
D. Write down the vital signs and come back to
Mrs. X when you are finished with your other
patients?
C. NOTIFY THE CHARGE NURSE/MD
ON CALL

Mrs. X needs immediate intervention, as she
potentially unstable in a fast arrythmia!!
Upon returning from lunch, you receive report
that one of your patients has been “confused” and
“agitated”
 The Nursing Assistant reports that Mr. Q’s blood
pressure is 180/109 and his heart rate is 55 on
the cardiac monitor
 You enter the room of Mr. Q, and find him trying
to get out of bed. He does not recognize you.
 He is sweating and appears pale. He is
grimacing and rubbing his left shoulder and
chest
 You can feel a pulse but it is weak.

WHAT DO YOU DO FOR MR. Q




A. Try to get an order for restraints. He is at
high risk for falls
B. Bring in his daughter to see if he recognizes
her. He has a history of dementia.
C. Give him is scheduled blood pressure
medication
D. Call the physician and ask for help
D. CALL THE PHYSICIAN AND GET HELP

Mr. Q is unstable, with a symptomatic
bradycardia– Possible heart attack!
BONUS ROUND!!

NAME THAT RHYTHM!!!
THE GOOD
THE BAD
AND THE UGLY!!!
THANK YOU FOR YOUR TIME!