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Step 1b: Assessing the Heart Rhythm (Nursing)

by Prof. Lawes

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    00:01 Now, the second part of one is: b) assess the heart rhythm.

    00:07 Now, I don't really mean this kind of rhythm.

    00:09 But what we're talking about here is, there is something from a long ago past.

    00:14 See that instrument at the top? Those are called calipers. And back when I graduated, we were so excited to get our first pair.

    00:23 But I cannot tell you how many times I punctured my thigh because I would carry them around in my pocket.

    00:29 And they are very sharp.

    00:31 Now, in practice, you have electronic calibers.

    00:35 You don't actually have to carry these around.

    00:37 But it was pretty cool when I got my first ones in nursing school.

    00:41 Remember what that felt like, when you got your first stethoscope? This was kind of the same thing.

    00:46 So for thinking about rhythm, we definitely want it to be all together, right? So what you're going to do is look at the distance between the R waves and make sure that it's consistent.

    00:56 Like if you've ever really seen me dance, it is not very consistent, nor is it pretty.

    01:01 But we want the heart to have a beautiful, consistent rhythm.

    01:06 So when you look up here, we put those old fashioned calipers up there to show you, we're measuring these to make sure the distance between the first and second QRS is the same between the second and third, and between the third and fourth that those are all the same distance.

    01:24 That would mean we have a regular ventricular rhythm.

    01:29 Now, let's look at the distance between the P waves.

    01:32 We also want that to be consistent.

    01:34 So you see that from the calipers, we've drawn a line down for you to remind you, there's the P wave, and we're looking at the distance between those P waves and making sure they're the same all along the strip.

    01:45 Now, we just use this as a representation, right.

    01:48 This is not really a six second strip.

    01:50 We just wanted to give you an idea of what you would do if you're looking at a real ECG strip.

    01:54 And we wanted to make sure you made the connection.

    01:58 You measure the distance from P to P to P to make sure the atrial rhythm is regular because that's what the P wave represents.

    02:06 And you measure the distance between the QRS, to QRS, to QRS, to make sure the ventricular rhythm is regular.

    02:14 So part one, we got two parts, right? 1A, we looked at the right took a six second strip.

    02:20 We multiply it by 10. So you'll get a minute.

    02:23 1B, we're looking at the rhythm.

    02:25 So we're making sure that it's the same distance between each of the QRS complexes, the same distance between the P, to P, to P.

    02:35 And we want to make sure there's a P for every QRS.

    02:39 That is a quick way for us to know the atrium and ventricle, atrium and ventricle, atrium and ventricle are working together.

    02:47 The way we want them to pump blood around your body to perfuse your tissues.

    02:51 Whoa. whoa. Okay, what is this? This is just here as a placeholder.

    02:59 Okay, as you move through this series, you will talk about all these things.

    03:03 But let me show you what the takeaway point is here.

    03:07 First, look at the dyrhythmic type that left hand column.

    03:11 Now, you see, this means difficult. Rhythmic means rhythms.

    03:15 So this is anything that is not normal.

    03:17 Anything's that is not sinus rhythm is technically considered a dysrhythmia.

    03:23 So you've got sinus tachycardia, sinus bradycardia, atrial flutter, atrial fibrillation, PAT, AV, we've got all those things listed there.

    03:32 Don't worry about it.

    03:34 What I want you to see is look at the second and third column.

    03:38 Let's look at sinus tachycardia.

    03:40 Okay, so you have an atrial rate anywhere between 100 to 200.

    03:44 You have a ventricular rate between 100 and 200 and the rhythm is regular.

    03:50 So this is why it matters that you start very first step one, know the rate and know the rhythm.

    03:57 The only difference between sinus rhythm and sinus tachycardia, is how fast it is? If the heart rate is 100 or over, then it's considered sinus tachycardia.

    04:09 So I did not mean for you to go, "Oh my lanta.

    04:13 what am I going to do with this?" No, no. I just want you to understand.

    04:19 Don't skip step one.

    04:20 It's really important that you take that look at the strip and see if it's regular or not. And what the rate is? Because I want you to count down until you see atrial fibrillation.

    04:34 Now, we have the atrial rate listed there.

    04:36 But when we walk through that specific rhythm, you'll see, you don't see P waves. You just see this word.

    04:41 It's just a bunch of trash before the QRS.

    04:45 But look at the rhythm.

    04:47 Yeah, so when you're thinking about the rhythm, what does it say? Yeah, very irregular.

    04:54 So you won't be able to measure P to P, to P, to P because you got, going on in the atrium.

    05:00 Because it's like fireworks are going off in there.

    05:03 It's not a really consistent, SA node, AV node, doesn't go like that.

    05:08 The atrium is kind of really a mess.

    05:11 But the ventricle, right? QRS...

    05:14 Because that conduction is getting through irregularly in atrial fibrillation, your QRS complexes will be very irregular.

    05:24 If you try to measure from this QRS to the second QRS, and then try to check that with the second in the third, they will not be the same.

    05:32 So that was the whole purpose in showing you this chart. Right? You can look at that, that's super ventricular things that happen outside of the ventricle.

    05:42 Those are the first ones, then the last three are ventricular rhythms. Yeah.

    05:47 Ventricular Tachycardia.

    05:50 If you have seen one episode of Grey's Anatomy, you know, that is no bueno. Right? That is no good.

    05:57 So ventricular tachycardia.

    05:59 The rate? Atrial, is likely going to be buried in there.

    06:02 Won't really know it.

    06:04 The ventricular rate is real fast, because your ventricle just...

    06:07 <fast heartbeat sound> Might be rea pretty irregular, might be irregular.

    06:11 Either way, it's life threatening.

    06:15 Ventricular fibrillation.

    06:17 You're not going to be able to tell what an atrial rate is because your ventricles are now doing the fib, right? Your ventricles are just... that's what's going on.

    06:26 And ventricular fibrillation.

    06:29 This is obviously, a much more serious and life threatening dysrhythmia.

    06:34 Now, the other one is an AV block.

    06:37 We've got a ventricular rate of less than 50.

    06:40 They were SA node, AV node, we have a block there.

    06:43 So things aren't moving through the heart like they're supposed to.

    06:47 So I don't want you to spend time memorizing this chart, or panicking.

    06:53 Memorizing is not learning.

    06:55 It's more important that you look at this and say, "Ah, some dysrhythmias look just like a normal rhythm, but they're fast.

    07:05 So what rhythm on this chart looks just like sinus rhythm, except the rate is faster.

    07:14 If you send sinus tachycardia, you're rocking and rolling.

    07:18 What rhythm looks just like sinus rhythm? Sinus rhythm, but it is slower.

    07:26 The heart rate is slower.

    07:29 Sinus bradycardia. You got it.

    07:31 Name one irregular rhythm.

    07:34 What's an example of a rhythm that is irregular? Let's say specifically, a supraventricular rhythm that is irregular.

    07:43 Right? Atrial fib. In fact, we told you, it's very irregular.

    07:49 So that's the purpose of the chart to have you rock solid on why step one, A and B, rate and rhythm are the most important place to start.

    08:01 Now, have you thought about that word depolarization and repolarization? I know we use it a lot in our videos, but I want to make sure you are very clear, because this is how the heart knows to pump and to pump efficiently.

    08:14 It's these electrical signals as they move through the heart it what causes it or allows it to be a mechanical pump.

    08:21 Now, two words depolarization and repolarization.

    08:27 So, depolarization is when the electrical signal of depolarization reaches the contractile cells, the muscle wall will contract in the heart.

    08:36 So when we say depolarization, you think, contraction.

    08:41 Now the second word is repolarization.

    08:45 When the repolarization signals reaches myocardial cells, they relax.

    08:50 So you're thinking depolarization, repolarization, depolarization, repolarization. Got it.

    08:57 Depolarization, repolarization. Both are critically important.

    09:03 But you need to know those terms, solid.

    09:06 When you're looking and studying the heart, these are really important basic terms that you should know.

    09:12 Now, this is really cool.

    09:14 I love what we have put together for you here.

    09:18 You're gonna see the picture progress.

    09:21 So let's start, we're gonna have a total of six graphics for you to take a look at.

    09:26 And you're gonna see the heart, what's happening in the heart, and the ECG, and then I'm going to explain to you what's happening.

    09:33 So, atrial depolarization. That's what the P wave represents.

    09:38 So look at our picture of the heart. You see it depolarizing.

    09:43 Look at the picture of the ECG.

    09:45 That's what that first upward, boom, positive is. See it.

    09:51 So follow of your finger there.

    09:53 We've got the isoelectric line right before the P wave.

    09:56 And we have that first bump, right, that is the atrial depolarization.

    10:01 So what's going on in the heart? Well, the atrium is depolarizing.

    10:06 So that would mean it's going to...

    10:10 Right, contract.

    10:12 Now, after the P wave, let's show you the next picture.

    10:15 When you see the P wave, there's that little flat piece of line.

    10:19 What's going on there? Well, the impulse is delayed at the AV node.

    10:25 Remember, the AV node is SA node, AV node, and then it goes down into the ventricles, through the rest of the system.

    10:34 So we slow it down. Well, we don't even have to think about it.

    10:37 We don't do it.

    10:39 It slows down a little bit at the AV node to let the atrium contract and the ventricle receive all the blood, right? Because when the atrium contracts, it increases the pressure in that chamber in the upper chamber of the heart, which shoves all the blood through that tricuspid valve into the ventricle for talking about the right side of the heart.

    11:01 So it needs a little bit of a breather there for everything to catch up.

    11:05 So P wave, atrial depolarization, flat part back to the isoelectric line, that's where the impulse is delayed to let the atrium empty and the ventricle fill.

    11:17 Now, we've got another picture for you.

    11:19 This is ventricular depolarization.

    11:23 And when the ventricles are depolarizing, right, when they're contracting, the atrium are repolarizing.

    11:30 So they're relaxing, while the ventricle pushes everything through That is the QRS complex.

    11:38 So take a look at our ECG clip right there.

    11:43 You see the P wave.

    11:44 We already know, that's atrial depolarization, because we're really good at this right? Then you see the little space there. That's the isoelectric line.

    11:52 Well, of course, we know that's the impulse delay through the AV node.

    11:56 Then we see a giant positive spike, right? Goes up like that. We call that the QRS.

    12:03 And that's when the ventricles are depolarizing, or contracting, and the atrium at the same time are relaxing, or repolarization.

    12:14 Okay, that's how the heart works better, who and there's a little bit of delay between the atrium and the ventricle.

    12:20 So you've been with me through the first three steps.

    12:22 Now, let's head into the last half.

    12:25 Now, step four, you'll see this spot we have mark there, cool.

    12:29 It's the isoelectric line there.

    12:31 We see that little line back it, no activity.

    12:35 That's where the ventricle depolarization is complete.

    12:39 Look, what's going on in the ventricle.

    12:42 See it there? So, in the third step, we had that ventricle depolarizing, contracting.

    12:48 Now, in four, we have the ventricle depolarize is complete.

    12:53 Now, picture five. The ventricle repolarization starts.

    12:58 That's the T wave.

    12:59 So look at the picture, see what's going on ventricle.

    13:02 We know that repolarization is relax.

    13:06 That's a good thing.

    13:07 And it starts, there you go, you see the repolarization starting. You've got the T wave.

    13:13 Now, picture six, the sixth one, our last stop, the ventricular repolarization is complete.

    13:20 Okay, so see it? We're right back down, even there with the isoelectric line.

    13:25 Before you go on from this section, this would be a really good time for you to pause the video, stop here, and really think through these six steps.

    13:39 And make sure, you're very clear on how what is going on with each of the P wave, the QRS, the T wave, the isoelectric lines? So I would encourage you to stop, and spend some time here, pausing and recalling.

    13:53 Now, if you just read this, you're gonna think you have it, right? It's gonna seem like, yeah, yeah, yeah, she just said that.

    13:58 But if you really want to get things into your long term memory, if you will put the effort in now, make sure this legit makes sense to you, by covering your notes, looking away, trying to ask yourself questions. What does a P wave represent? When is the ventricular depolarization done? Spend some time with this.

    14:19 I promise you, interpreting ECGs is going to be, much easier for you as you move through the rest of this course.


    About the Lecture

    The lecture Step 1b: Assessing the Heart Rhythm (Nursing) by Prof. Lawes is from the course The Basics of ECG Strips (Nursing).


    Author of lecture Step 1b: Assessing the Heart Rhythm (Nursing)

     Prof. Lawes

    Prof. Lawes


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