Overview of Atrial Fibrillation and PAC (Nursing)

by Rhonda Lawes, PhD, RN

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    00:01 Hi, welcome to our video series on electrocardiograms.

    00:05 In this one, we're going to talk about the treatment plans for atrial dysrhythmias.

    00:09 So we're going to treat things like atrial fibrillation, premature atrial contractions, or PACs and atrial flutter.

    00:18 Now, if you're looking at the ECG, we do things to diagnose and assess what is really going on.

    00:23 See a basic ECG strip that we're just looking at with like maybe five leads can give us a clue that there's a problem.

    00:31 But we're going to take the next step in seeing what exactly is going on in that patient's heart.

    00:37 Now, that may involve a holter monitor, because have you ever had the experience where you take your car into the mechanic, because it's making this weird noise, but then when you're actually in the mechanic shop, your car refuses to do it? Well, the second thing is with your heart.

    00:54 Oftentimes, patients can be having a dysrhythmia.

    00:57 But it won't necessarily occur when we have them hooked up to a monitor.

    01:01 So a holter monitor is called that because the patient will wear it for at least 24 hours and oftentimes even longer.

    01:09 Now, they used to be big things that you had to strap around their neck, and they were really uncomfortable, but they're much, much smaller now and more comfortable and convenient for the patient.

    01:20 So the reason they wear these for a long period of time is because we have a better chance of seeing the patient experience that dysrhythmia.

    01:29 Now a cardiac stress test, that's a whole another ballgame.

    01:32 That's where we're going to put them on a treadmill and make them walk really fast and then eventually even run.

    01:38 So we are stressing their cardiovascular system.

    01:42 Sometimes that's a trigger for dysrhythmias.

    01:45 We'll also use it with patients who had chest pain, so we can watch ECG changes, while a patient might be having chest pain or is at least stressed.

    01:54 So cardiac stress test takes place with a physician and some other practitioners to observe the patient.

    02:01 It usually involves a treadmill.

    02:03 Unless the patient is not able to walk on a treadmill or be mobile, then they can use some chemicals inserted into an IV that will also stress the patient's cardiovascular system.

    02:15 It's not really fun for the patient because it makes them feel all jazzed.

    02:19 But it will stress the cardiovascular system.

    02:22 And that way the practitioners and the physicians can watch the heart under stress and see how it responds.

    02:29 Now of course, we've got some lab work, we're going to look at their cholesterol and thyroid and electrolyte labs.

    02:34 There's several labs that can help us diagnose and assess what's going on with the heart.

    02:40 Now the last one is a transesophageal echocardiogram.

    02:45 So let's start with that word at the bottom right, echocardiogram.

    02:50 We're going to get some pictures, some images of their heart.

    02:54 But transesophageal means we're going to look through their esophagus so we get that much closer to the heart.

    03:01 So instead of having to go through the chest wall, we put that camera or right down near the heart so we can get a better picture.

    03:10 And that's often done for atrial fib.

    03:13 So let's talk about atrial fib.

    03:15 It is the most common type of abnormal heartbeat.

    03:19 So you'll see this often in your practice.

    03:22 Now it can become a chronic medical condition if it isn't treated.

    03:26 Sometimes we'll get patients in and they're in atrial fib.

    03:29 And they have likely been an atrial fib for a very long time, that's why have really good patient history is important.

    03:37 And if the patient doesn't have it diagnosed by a physician, ask them for more subjective symptoms like, what do you feel like when this rhythm happens? See it on the monitor.

    03:49 Tell me what it feels like.

    03:50 Sometimes people will say, it feels like their heart is gonna burst out of their chest or it feels like it's really fluttery.

    03:56 So then you can ask them.

    03:58 "Have you ever felt that feeling before? How long have you been experiencing that? Has it been just in the last few days, the last few weeks, months or years?" So you are the key to getting really helpful, clinical information.

    04:15 So let's talk about these P words.

    04:17 You've got paroxysmal versus persistent.

    04:20 Okay, so, the cool thing about atrial fib is it comes and goes, that's why a holter monitor can sometimes be helpful.

    04:27 But atrial fib can resolve itself and go back to a sinus rhythm or it can become a chronic issue, really is preferable that it not become a chronic issue.

    04:39 So let's look at paroxysmal, first of all that means it comes and goes.

    04:42 Persistent means it stays for a very long time.

    04:46 So pause the video and see if you can recall the definition of each of those words without looking at your notes.

    04:59 All right now that you have that scaffold of paroxysmal and persistent, let's look at the more complete definitions.

    05:07 So with paroxysmal atrial fib, it's an episode that spontaneously ends.

    05:12 So over seven days, it can end we still consider it paroxysmal, or in shorter periods of times, it can rev up and then resolve.

    05:22 But the idea with paroxysmal atrial fib is that it resolves by itself.

    05:27 We don't have to do anything for it to go back to a sinus rhythm.

    05:31 Now, persistent atrial fib is an episode of atrial fib that sustains itself on longer than seven days.

    05:38 So this atrial fib lasts longer than a week or seven actual calendar days.

    05:45 So this means we've got a bigger problem.

    05:48 Now it makes sense.

    05:49 If someone is having episodes of paroxysmal atrial fib, it could turn into persistent atrial fib.

    05:56 So history, asking your patient clear questions that make sense to them that they can give you the most accurate information will help you get a better treatment plan for them.

    06:09 Now, look at our graphic here, what is going on in the atrium? Alright, it looks a little spastic of there, right? It's disorganized.

    06:20 Look at the ventricle, it's still fairly organized.

    06:24 So, what's going on in your patient's heart when they have atrial fibrillation? It's there a disorganized electrical signals in the heart.

    06:33 And that's what causes the atrium and we call it fibrillate or quiver instead of pumping synchronously with the ventricles.

    06:41 Remember, what we're looking for in a sinus rhythm heart is atrium-ventricles, atrium-ventricles, atrium-ventricles.

    06:51 Look at the difference in this picture.

    06:52 It's a atrium-ventricles, atrium-ventricles, atrium-ventricles.

    06:58 Now, that's not going to be an efficient way to pump blood through the rest of your body.

    07:04 And atrial rate and atrial fib, now that you will be able to measure it on a strip, but think of it as being super fast, it can be like 400-600 a minute due to that just repeated electrical activity.

    07:17 Okay, so when we say the atrial rate is that fast, we just want you to have this picture in mind.

    07:24 There is no way you're going to be able to measure the atrial rate and atrial fib on a strip, because think back to what it looked like.

    07:33 It was just, it's just kind of trashy.

    07:36 There's no discernible ways that you could measure.

    07:40 So let's review the criteria for atrial fib.

    07:43 Heart rate can often be 100-175 bpm.

    07:46 That's considered a rapid ventricular response.

    07:49 However, the heart rate can also be lower than 100 and it's still considered atrial fibrillation if it meets these other criteria.

    07:58 Now the rhythm is irregular like irregularly irregular, right? This is different than PACs.

    08:04 The P wave, we don't have one that's discernible, right? You can't really see it, it just kind of looks like a mess so we can't measure the PR interval.

    08:12 But the QRS looks normal.

    08:15 We just don't have a P wave for every QRS.

    08:18 Premature atrial contractions.

    08:20 The name tells us a lot.

    08:22 If you look at premature that means it's early and atrial contraction that tells us what's going on.

    08:29 Now the official definition is that PACs or premature atrial contractions are contractions of the atria and they're triggered by the atrial myocardium.

    08:39 But they have not originated from the SA node.

    08:44 So let's look at the criteria for sinus rhythm with PACs.

    08:48 Look at the difference in this strip.

    08:51 It looks much more organized than the atrial fibrillation strip.

    08:56 So this is sinus rhythm with PACs.

    08:59 It's fairly ordered and structured.

    09:01 Except for those few beats that are not playing by the rules.

    09:05 The heart rate is consistent.

    09:07 The rhythm is regular and a little bit irregular, just with those exceptional beats.

    09:13 You have P waves that are present before each QRS, they look the same except for those early beats.

    09:19 The PR interval should be within normal range for the sinus beats.

    09:23 And the QRS is normal less than 0.12 seconds.

    About the Lecture

    The lecture Overview of Atrial Fibrillation and PAC (Nursing) by Rhonda Lawes, PhD, RN is from the course Analysis of Abnormal ECG Strips (Nursing).

    Included Quiz Questions

    1. The symptom starts and stops spontaneously.
    2. It typically resolves within 7 days.
    3. The episode continues beyond 7 days.
    4. The episode continues beyond 14 days.
    5. It most often occurs at night while lying.
    1. Electrocardiogram
    2. Holter monitor
    3. Cardiac stress test
    4. PFTs
    5. Cardiac lab work
    1. 100–175 beats/min
    2. 80–100 beats/min
    3. 60–100 beats/min
    4. 100–120 beats/min
    5. 50–80 beats/min
    1. Not able to be measured
    2. 0.12–0.20s
    3. < 0.12s
    4. > 0.20s
    1. < 0.12s
    2. < 0.20s
    3. < 0.16s
    4. < 0.6s

    Author of lecture Overview of Atrial Fibrillation and PAC (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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