The 16 types of nurses

Once upon a time I introduced you the five types of RTs, cfive types of COPD patients, and the 11 types of asthmatics, and the six types of doctors. Now it's time for the 13 types of nurses.

No group of individuals is more vital to good patient care than our beloved nurses. Nurses are great, and I've had the honor of working with nurses on both the receiving end and as fellow professionals.

So, without further adieu, I present to you the 16 nursing types:

Consensus:
 About 80% of RNs fit into this category. These RNs respect, seek out, and listen to the opinions of other members of the staff. They tend to work well together as members of the team to come up with a "consensus" as to what might be wrong with the patient and what to do about it. They are aware that they lack the experience in all areas, that they don't have all the answers, and are willing call upon their coworkers, including doctors and respiratory therapists, to help them to best care for their patients. These are similar to your gallant doctors.

Contents:
These nurses are set in their ways, and prefer not to sway from their routine. They believe they know what needs to be done, and they do it. They tend to not seek out other opinions, and usually don't consider the opinions of others. They consist of about 10% of all nurses. They will often perform procedures (such as increasing oxygen) without seeking expert consultation. These are similar to your goofus doctors.

Prospects:
 These are your newbie RNs or, perhaps, soon to be RNs. Most are eager to learn and are more than willing to go out of their way to help out. Some are mature, independent and trustworthy enough to work on their own, while others have less confidence and need quality assistance. Look at these folks carefully, because in a year or two they will morph to a different type of RN. Some will grow dogmatic and become contents, while others will grow and smile and become consensus. These consist of about 10% of all nurses.

Cordial:
 We all hope that Beginner RNs turn out to be of this type. They know they do not hold all the answers, have a friendly disposition, and are more than willing to take the extra step, even when they're burned out. They tend to smile and lend a helping hand to patients and coworkers. Their ears are always open. They are most often social, may often bring in treats to work to keep the peace, and are likely to remain in one department for several years, if not their entire nursing career. You'll find them mainly on medical/surgical floors, although they generally don't fit in fast pace departments such as critical care and emergency. Some people refer to this type of RN as Happy or even Friendly RN. Most staff and most patients love cordial RNs. They almost seem to be flawless. These usually consist of most LPNs and about 20% of Consensus RNs. Most of them work on the med-surg floors, but a small percentage wander down to the ER and critical care.

Receptive:
 These are your nurses who are constantly looking to become better nurses, read medical journals, magazines, read online sources such as blogs and articles, and are more than willing to listen and retain the wisdom of their fellow workers. They like to learn not just to better themselves, but the institution as well. They tend to be more observant and receptive when it comes to new ideas. They also tend to be proactive (or think quickly) to emergency situations. They can be friendly, but tend to be more serious and bossy under pressure, and may even appear to be condescending at times. They may start their careers on medical/ surgical floors, but generally branch out to more challenging areas such as emergency and critical care. Many are likely to further their careers by earning their bachelor's or even Master's degree, and it is from this group you get your future supervisors, administrators, nurse practitioners, and occasionally doctors. They consist of about 20% of Consensus RNs.

Dogmatic:

This type of RN has a definitive way of doing things. They are relatively laid back in their personality (type b personality) however they have created a set way of doing things to protect themselves from making mistakes. Patients love them because dogmatics tend to be overbearing and attentive to their patent's needs. If a doctor orders for teeth to be brushed every two hours, they will do it every two hours whether it's needed or not, and whether they have to wake the patient or not (patients don't like this part). They are also very particular about specific doctor orders, and call to report even slight variances. For example, if the doctor writes an order to maintain a sat of 92%, they will call the doctor and RT even if the sat is 91%. They will often guilt you into staring at the monitor hoping the vitals improve by your looks alone. Thus, they are known to make a big deal of trivial things. In this way, they tend to irritate doctors and RNs. Although they are so nice it's hard to stay mad at them. However, patients can be guaranteed to get a good wash per shift, to be rotated regularly, have fresh blankets and sheets and towels and a good assessment frequently. Any slight change in lung sounds will be noted. But, the bottom line is, they do this because they legitimately want the best for their patients. Bosses love them too, because, like type A or anal RNs, they are perfectionists with their charting. They make good friends, and are relatively happy except under pressure. Oh, and one more thing, their rooms are spiffy clean. If you leave something laying around they will not say anything, but they will clean it up. They consist of about 10% of Consensus RNs.

Compulsive:
 Like Dogmatic RNs, they are guaranteed to do full assessments, and will do everything the doctor orders to a tee whether they think it's needed or not. They will never question a doctors order. Actually, they are under the belief that if the doctor ordered it, it's needed. If you say something is not needed, they will defend the doctor as a "god." They too will have you staring at monitor values that are "barely" below the accepted range. But if an RT refuses to continue staring at the monitor saying something like "that sats fine," he will get mad at you and tell you that you are not caring for your patient. If you don't follow the rules, or directly follow a doctor's order, he will approach you. He's also prone to writing variances for even the silliest of detail. They are type A personalities, although are generally very precise and attentive to their patients. Yet they too can be overbearing, and tend to be hard to work with. Unlike Macho RNs, they often seek the help of others, but tend to get upset when others disagree with them, or don't provide the answers they want. Therefore, it's easier to pretend to agree with them than to show them how they are incorrect. They expect equal perfection from their coworkers, and are known to look over your back. Sometimes they are referred to as snoops, or sometimes worse. So, when you are working with these RNs, you need to careful. Oh, and one more thing, if you leave your ABG kit lying on the patients bed, they will make you well aware that you messed up their room. These consist about 5% of consensus RNs.

Macho:
These tend to take things in stride, and not make big deals over trifles. They would be content to live with a sat in the mid 80s, will use common sense, and will not call RTs and doctors over such trivial things. They tend to use the word "common sense" a lot. They tend to be cool. They tend to have a dry sense of humor. Many tend to be men, but not all. Nothing seems to bother them, and they do a good job with their patients with the advice of others or without. They tend to have a high degree of intelligence, yet are often seen reading science fiction or mystery novels in their free time as opposed to medical stuff. They tend to hold their own. They tend to work in CCUs, and are very confident. They consist of about 5% of Consensus RNs.

Complainers:
 Nurses do not have as much time to complain as RTs do because they are busier. When RTs complain, they complain about stupid doctor orders or how doctors refuse to give them autonomy. RNs complain not about their job per se, but about the hospital in general -- too many patients, not enough pay, too many rules, change is not needed, paper charting was better, insurance isn't fair, so and so gets treated better by the boss, etc. They tend to be busy bodies while taking care of their duties. When you pass them as you are entering work, they are known to say things like: "You definitely don't want to be here tonight," or, "Welcome to hell," or, "This schedule sucks," or "I hate Michelle, she's always picking her nose." For the most part, complainers tend to be stuck working on med-surge floors, and consist of about 20% of all Consensus RNs.

Busybodies:

These RNs consist of the RNs you never really get to know because they are busy, busy, busy. They are fast moving, going from room to room, chart to chart, and phone to phone. They never run, but walk at a vary fast pace. They tend to be thin. Some of them work on the med-surge floors, but the majority work in the emergency room. The tend to be very business-like, but when you get a chance to sit down with them they are very fun to talk with. Yet they are known to take off mid sentence. Getting a complete conversation in can be a challenge. Likewise, they are not good listeners. Actually, they are awesome nurses and are very knowledgeable. Because they are so busy, some of them tend to skip corners. The RT bosses may complain to them occasionally, but considering they are such great workers, they don't make a big deal about it. These consist of about 10% of Consensus RNs.

Arrogants:

They always have that smirk on the corner of their lips, and walk with their heads high. They are usually friendly and easy to get along with, but they tend to believe that they know everything and don't need to hear from you. Since they know so much, they tend to compete for supervisor jobs, and seek to become RN Bosses. When they do become RN Bosses, they tend to not keep many of their friends. These consist of 15% of Content RNs.

Old-Schoolers:

These are very wise and sagacious RNs. They can pick up on even the most simple thing wrong with the patient. Their patients are usually well taken care of, and they have little need for other members of the team. They are not arrogant by any means, and are usually great teachers. The problem with this type of RN is they are set in their ways, and are not quick to adapt to changes. They tend to believe in old theories such as the hypoxic drive theory, prefer paper charting to computers, and may tend to wine when they are told to break from their routine. If you are not intimidated by them, they can be fun, or at least educational, to work with. About 50% of Contents are Old School.

Content Contents:

They are happy-go-lucky and when we RTs tell them a treatment is not needed they will look at you with crazy eyes. They do this not because they don't like you, but because they don't understand why you just didn't do what you were told. They say things like, "The patient is wheezing. He needs a treatment." They tend to refer to RTs as ancillary staff, and have little use for them other than for them to do what they are told. They are usually opposed to protocols and rapid response teams (RTT) because those elevate RTs to the same level as RNs, and they know that shouldn't be. And, even if a hospital has an RRT, they will never call for one. Attempts to educate them are futile. They are wonderful people and make great friends otherwise, and are great nurses, but they are incapable of learning new things. They consist of 25% of Content RNs.

Besetting:

I'm sorry, but these guys tend to not be happy -- ever. Nobody gets along with them, probably not even the patient. But when all is said and done, they are very good with their patient when it comes to picking up on things early. However, when it comes to little things like brushing their patient's teeth or giving baths, they think those tasks belong to lesser people like Nurses Aids. Unfortunately, these RNs tend to work in Critical Care Units where AIDS are far and few. They have few friends. They hate you and more than likely you can't stand to work with them. If you do something wrong, they will not be nice and give you a warning, they will simply crab to you and make you feel miserable, or they will simply go over your head and write you up. They consist of 5% of Content RNs, so thankfully they're a rare breed.

Boors:

They tend to be very similar to Macho RNs as listed above, except that they have no use for "ancillary staff" other than to provide their duties. They consider anyone besides doctors and nurses as ancillary, so RTs are ancillary. If they ask you to do something, you do it and do it now. If you don't do exactly as you are told, you will have to deal with the consequences. They are usually very quiet, and are very opinionated at the same time if you get them going. They can also be hot heads if you say something they disagree with. They will put you on the spot. If you ask a question, they will ask a question back. They hold grudges, and may go days without talking to you if you said something to irritate him. For example, if you are discussing politics with him, and everybody in the room disagrees with him, he may give you all the cold shoulder. He's modest, smart, quick witted, and can be hard to work with. He has no problems making enemies. But if you are intelligent or important, you may be his best friend. They are rare and far between, or less than 5% of Content RNs.

Chiefs:

Here we lump all levels of RNs from supervisors on up. Usually, but not always, RN bosses come from the ranks of the Receptive (85%) or Arrogant (15%). Arrogant RNs don't necessarily care what people think about them, but Learners do. Learners go out of their way to please. The farther away from the duties of RN work the RN Bosses become, the greater the chance that The Institution moves ahead of The Person. That doesn't mean they won't try to be friendly, but the bottom line is not necessarily keeping the patient load low, but making money for the institution and keeping their own bosses happy and keeping their jobs and the higher wages that come with it. The RN bosses closer to the working staff (the supervisors, the lead RNs), tend to fit in nicely with the other workers. They do not complain. They are very helpful. They tend to be good workers. Yet they are often political, defend policy regardless of usefulness, and generally will tell you what you want to hear and then either ignore you (Arrogant) or make an attempt to help through the general chain of command -- a process that's really slow. As a general rule, they don't like to make waves, and the longer they have their jobs, the smaller the waves become.

The basics of Axis Deviation of the EKG

In this post you'll learn about axis deviation of the EKG, and how you can use it to determine the underlying pathway of the patient.

Axis deviation is the general direction the electrical signal takes from the AV nodes through the ventricles. The direction of depolarization (vector) and size of the QRS arrow (amplitude) change with certain disease processes.

If the axis is not depolarizing normally, this can help clue you in to underlying pathology.

So, to determine axis, check out the hexaxial reference. Examine the QRS complex in the limb leads (I, II and III). Now find the one that has the largest deflection (amplitude). Now determine if it's upright (positive) or downward (negative).

If the largest amplitude is lead II, and the amplitude is positive, then you know you have an axis deviation of about +60, which is normal. If, on the other hand, the amplitude was negative, then the deviation is about -120, which is severe right axis deviation.

Basically, if the QRS is upright (positive) in the lead with the most voltage, the mean axis must be very close to the position of this lead on the circle. If the QRS complex is downward (negative), the mean axis must be located in the opposite direction from the location of this lead on the hexaxial circle.

It's that simple.

To make it even easier (we RTs love to keep things simple), if you look at the standard EKG, the axis will be noted for you, so you shouldn't even have to use this hexaxial reference.

Now determine axis (again, this should be noted on the EKG):

• Normal axis is 0 to +90 degrees.
• Left Axis Deviation is anything between 0 and -90
• Right Axis Deviation is between +90 and 180
• Severe Right Axis Deviation (no man's land) is anything less than -90

22. Right Axis Deviation: (axis between 9 and -90)

• a. QRS negative in lead I
• b. QRS positive in AVF
• c. QRS negative in AVF and lead I if extreme RAD
• d. QRS in V1, V2 isoelectric
• e. Slender person with ventricular heart
• f. Ventricular hypertrophy
• g. Pulmonary disease
• h. MI on left side of heart
• i. Q-wave of inferior MI
• j. Pulmonary embolism
• k. Anteriolateral MI
• l. Emphysema

23. Left Axis Deviation: (axis between +90 and 180)

• a. QRS positive in lead I
• b. QRS negative in AVF
• c. QRS in V5 and V6 are isoelectric
• d. Obese patients
• e. Left Ventricular Hypertrophy
• f. MI right side of heart

24. Severe Right Axis Deviation: (Axis between -90 and -179)

• Called no mans land
• Severe Left Axis Deviation
• Emphysema
• Lead Transposition
• Artificial cardiac pacing
• Ventricular tachycardia

24. Left Ventricular Hypertrophy:

• a. QRS complexes with exaggerated amplitude both in height and depth
• b. S wave in V1 is deep, large R in v5
• c. Height of S in V1 + R in V5 = or greater than35 mm
• d. T wave inversion in V5 and V6 with a gradual downward slope

For more, check out this link to understanding axis deviation. Check out this link to help you determine underlying pathology using this hexaxial reference. For a basic rhythm strip reveiw, click here. See the EKG library here. * Reference for axis deviation hexaxial reference is "Respiratory Disease," ed. by Robert L. Wilkins and James R. Dexter, 1993, page 41. Please note that I'm learning much of this as I research, so if you find something that's not accurate, or have a tip for making the process of learning easier, please let me know.

Hemodynamics made easy

Hemodynamic Monitoring & Normal Values:

1. Blood pressure:

• a. Normal Systolic = 90-140
• b. Normal Diastolic = 60-90
• c. As BP increases CO & CI usually decrease
• b. As BP decreases CO and CI usually increase

2. Pulse Pressure:

• a. Systolic BP minus Diastolic BP
• b. Normal = 40 mmHg
• c. greater than 40 indicates decreased Stroke Volume (SV)

3. SV (Stroke Volume):

• a. Cardiac Output divided by Heart Rate
• b. Normal = 60 – 130 ml/beat
• c. It's the volume ejected per beat

4. CO (Cardiac Output):

• a. Heart Rate times SV
• b. Normal = 4.8 LPM
• c. More reliable than Mean Airway Pressure (MAP)
  

5. CI (Cardiac Index):

• a. Cardiac Output divided by Body Surface Area (BSA)
• b. Normal = 2.5 LPMm2 or simply CO/2
• c. Decreased with shock, dehydration, cardiac fail, PE.
• d. Increased with hypoxia, low BP.
• e. More reliable measurement than CO.

6. EF(Ejection Fraction):

• a. % of blood volume pushed out of heart per beat.
• b. Normal = 65 – 75%
• c. Reduced with ventricular damage

7. MAP (Mean Arterial Pressure):

• a. systolic BP + (Diastolic*2)/3
• b. Normal = 70 – 105

8. Preload: Blood that returns to ventricles at end diastolic, & refers to stretch of myocardial fibers after it is filled with blood. As the preload increases the heart function increases. As preload increases, heart function increases. Basically, it's the stretching of the heart before contraction. The more blood returned to the heart, the more the stretch will be. The means of measuring preload are:

a. PCWP (Pulmonary Capilary Wedge Pressure):

• 1. Measures left heart function
  
• 2. Normal = 5 – 12 mmHg (same as PAP diastolic)
• 3. greater than 18 = edema forming in lungs (if no signs CHF think ARDS)
• 4. greater than 25 = edema in lungs from left heart failure (CHF)
• 5. greater than 5 – 12 + edema = noncardiogenic edema (ARDS)
• 6. greater than 12 may also indicate Mitral valve stenosis

b. CVP (Central Venous Pressure):

• 1. Measures right heart function
  
• 2. Used to monitor systemic venous drainage (fluid levels)
• 3. Normal = 2 – 6 mmHg
• 4. less than 5 = hypovolemia, fluid restriction, diuretics shock, hemorrhage, vasodilators (Nipride, Morphine) blood thinners, peep, ippb
• 5. greater than 7 = hypervolemia, fluid challenge, increased SNS tone (fight or flight), shock, slow HR, decreased ejection fraction (CHF, pump failure, Aortic valve failure, thick blood)

9. Afterload: Resistance heart must work against, or blood that returns & fills the atria. All other values constant, has an inverse relationship with CO, and is indirectly monitored by Blood Pressure. This is measured by:

a. SVR (Sytemic Vascular Resistance):

• 1. Formula: (MAP minus CVP) divided by CO
  
• 2. Normal = 900 – 1400 dynes or les than 20 mmHg/L/min
• 3. Increased = HTN = vasoconstriction, increased SNS tone, cardiac stimulants (EPI, alpha action drugs), thick blood, narrow valves.
• 4. Decreased by vasodilators, decreased WOH, adequate preload, alpha blockers (Regitine, Dibenzylene), decreased SNS tone.

b. PVR (Pulmonary Vascular Resistance):

• 1. (meanPAP – PCWP)/CO
• 2. Normal = 150 – 250 dynes or less than 2.5 mmHg/L/min
• 3. Increased with hypoxia, pulmonary hypertensin, PE

c. PAP (Pulmonary Artery Pressure):

• 1. Monitors blood moving into lungs, afterload of right ventricle
• 2. Normal is 25/8 (mean = 14)
• 3. PAP diastolic can be used to estimate PCWP.

10. Cardiac Electrolytes:

• a. Potassium: Increases and decreases in this result in majority of cardiac arrhythmias.
• b. Magnesium: Low Mg associated with low K. Results in numbness, tingling, contractions, cramps, seizures, & cardiac arrhythmias.

For a printable cheat sheet with this information click here.

For more information, check out Nurse Bob's Hemodynamic Overview.

Graph above compliments of Kettering National Seminar's CRT/RRT Studyguide.

EKG interpretation made easy

This post is meant as a means of using EKGs and rhythm strips in your critical thinking skills. It is not meant to replace a basic course in EKG and rhythm strip interpretation. However, it should help you in that regard.

You should be able to look at an EKG and not just see the basic interpretation, but use that EKG to help you generate a better overall picture of the patient's condition. Whereas #1 on this list shows you how to spot a possible pulmonary embolism.

EKG and rhythm strip interpretations:

1. Pulmonary Embolism:

• a. S wave in lead I
• b. ST depression in lead II
• c. Large Q wave in lead III
• d. T wave inversion in lead III

2. Basics:

• a. ST depression = acute blood loss
• b. Q Wave makes diagnosis of infarct
• c. Q wave one small square is MI
• d. Inverted T-wave is ischemia

3. Posterior wall Infarct:

• a. ST depression in V1 & V2 if acute
• b. Large R in V1 and V2
• c. Maybe Q in V6
• d. Inverted mirror test V1 & V2

4. Lateral wall Infarct:

• a. Q in leads I and AVL (V5, V6)

5. Inferior wall Infarct:

• a. Q in leads II, III, & AVF
• b. ST elevated if acute

6. Anterior wall Infarct:

• a. ST elevation V1 & V2
• b. Q in V1, V2, V3 or V4
• c. V1 & V2 = Anterioseptal
• d. V3 & V4 = Anteriolateral

7. SVT: Narrow QRS & rate of 150-250

8. Left Bundle Branch Block: 2 R waves in V5 & V6

9. Right Bundle Branch Block:

• a. 2 R waves in V1 & V2
• b. QRS wide and looks like an M

10. Acidosis: Smaller amplitude

11. COPD: Small amplitude, Right axis deviation

12. Pulmonary Hypertension: Large P waves. This will also indicate end stage COPD with cor pulmonale or end stage pulmonary fibrosis, etc.

12. 1st degree heart block: (block is when pr interval is greater than five small boxes or 0.2seconds)

• a. Prolonged pr interval and that's it.
• b. For every p wave you have a QRS to follow it.
• c. Rate may be slow, but no missed beats
• d. The ratio of p waves to QRS's is 1:1
• e. electrical conduction slightly delayed
• f. Common in athletes, teens, young adults, heart disease, sarcoidosis, or drugs such as as beta-blockers, diltiazem, verapamil, digoxin, Lanoxin, and amiodarone.
• g. rarely causes symptoms

13. 2nd degree block type or Mobitz I: (electrical conduction intermittenly blocked)

• a. PR interval becomes progressively longer until 1 QRS skipped.
• b. blocked QRS after every 2-5 QRSs
• c. p-QRS usually goes like this: 1:1, 1:1, 1:1 2:1
• c. QRS may be normal or wide if BBB
• d. heart rate slow, irregular or both

14. 2nd degree type II or Mobitz II (Winkebach):

• a. p waves for each QRS at ratio of 2:1, 3:1 or 4:1.
• b. Often wide
• c. Constant p to QRS ratio

15. 3rd degree heart block: (Electrical conduction completely blocked)

• a. no impulses from the atria reach the ventricles
• b. the ventricular rate and rhythm are controlled by the atrioventricular node
• c. Rate = 30-50
• d. p waves do not ever match up with QRS waves (no correlation)
• e. serious arrhythmia that can affect the heart's pumping ability
• f. Fatigue, dizziness, and fainting are common

16. Left Bundle Branch Block:

• a. 2 R waves in V5 and V6
• b. Cannot diagnose infarct
• c. Same as anterior Hemiblock = posterior hemiblock which is also same as biphasicular block

17. Right Bundle Branch Block:

• a. 2 R waves in V1 and V2
• b. QRS is wide and looks like an M

18. Anterior Hemiblock:

• a. Q in lead I and S in III
• b. QRS slightly widened
• c. Occurs in left anterior descending of RCA with MI and heart disease Causes Right Axis Deviation
• d. May be associated with RBBB
• c. 50% of posterior MIs

19. Posterior Hemiblock:

• a. S in 1 and Q in 3
• Normal or slightly widened QRS
• Occurs in Right anterior descending of RCA with MI or heart disease
• Causes Right Axis Deviation
• Rule out other causes of RAD
• Rare, causes AV block, deadly

20. Bifasicular Block:

• a. A combination of blocks
• b. Anterior Hemiblock + RBBB
• c. posterior Hemiblock + RBBB
• d. Anterior Hemiblock + Posterior Hemiblock (also called LBBB)
• May cause intermittent AV block

21. Axis Deviation of the heart*: This is the general direction the electrical signal takes from the AV nodes through the ventricles. The direction of depolarization (vector) and size of the QRS arrow (amplitude) change with certain disease processes.

If the axis is not depolarizing normally, this can help clue you in to underlying pathology. For more, check out this link to understanding axis deviation. Check out this link to help you determine underlying pathology using this hexaxial reference.
So, to determine axis, check out the hexaxial reference. Examine the QRS complex in the limb leads (I, II and III). Now find the one that has the largest deflection (amplitude). Now determine if it's upright (positive) or downward (negative).

If the largest amplitude is lead II, and the amplitude is positive, then you know you have an axis deviation of about +60, which is normal. If, on the other hand, the amplitude was negative, then the deviation is about -120, which is severe right axis deviation.

It's that simple. If you look at the standard EKG, the axis will be noted, so you shouldn't even have to use this hexaxial reference.

Basically, if the QRS is upright (positive) in the lead with the most voltage, the mean axis must be very close to the position of this lead on the circle. If the QRS complex is downward (negative), the mean axis must be located in the opposite direction from the location of this lead on the hexaxial circle.

Now determine axis (again, this should be noted on the EKG):

• Normal axis is 0 to +90 degrees.
• Left Axis deviation is anything between 0 and -90
• Right Axis deviation is between +90 and 180

22. Right Axis Deviation: (axis between 9 and -90)

• a. QRS negative in lead I
• b. QRS positive in AVF
• c. QRS negative in AVF and lead I if extreme RAD
• d. QRS in V1, V2 isoelectric
• e. Slender person with ventricular heart
• f. Ventricular hypertrophy
• g. Pulmonary disease
• h. MI on left side of heart
• i. Q-wave of inferior MI
• j. Pulmonary embolism
• k. Anteriolateral MI
• l. Emphysema

23. Left Axis Deviation: (axis between +90 and 180)

• a. QRS positive in lead I
• b. QRS negative in AVF
• c. QRS in V5 and V6 are isoelectric
• d. Obese patients
• e. Left Ventricular Hypertrophy
• f. MI right side of heart

24. Severe Right Axis Deviation: (Axis between -90 and -179)

• Called no mans land
• Severe Left Axis Deviation
• Emphysema
• Lead Transposition
• Artificial cardiac pacing
• Ventricular tachycardia

25. Left Ventricular Hypertrophy:

• a. QRS complexes with exaggerated amplitude both in height and depth
• b. S wave in V1 is deep, large R in v5
• c. Height of S in V1 + R in V5 = or greater than35 mm
• d. T wave inversion in V5 and V6 with a gradual downward slope

26. Hyperkalemia: Flat p waves, wide QRS, peaked T

27. Hypokalemia: Flat T waves, wide QRS, u waves

28. Hypercalcemia: QT interval shortens

29. Hypocalcemia: Prolonged QT interval

30. Digitalis effect:

• a. PABS early sign
• b. gradual down-sloping of ST segment
• c. Low K enhances Digitalis effect

31. Quinidine Effects: (Anti-arrhythmic)

• a. Widening of p waves and QRS
• b. Often ST depression, prolonged QT
• c. Maybe presence of U wave

32. Atrial Fibrilation:

• a. Quite common in patients with lung diseases.
• b. Due to the excess workload the heart eventually switches to this rythm, such as COPD, CHF, etc.
• c. Irregular rythm, although one p for every QRS

33. Sinus tachycardia: Rate greater than 100 but less than 150 (greater than 150 = SVT)

34. Atrial Flutter: Sawtooth appearance of rythm strip

35. Junctional Rythm: No p waves, or p waves go in various directions.

36. Sinus bradycardia: Rate less than 60

37. Preventricular contraction (PVC):

• a. An abarrently conducted beat generated by the ventricles.
• b. They disrupt the regular rythm.
• c. pt may feel palpitations, or heart flutters
• d. Causes: chemical imbalances, meds, alcohol, caffeine, increased adrenaline (excited), exercise, anxiety, injury to heart muscle, tobacco use,
• e. May be normal, but if canstant may lead to other arythmias

38. Bigeminy: Pre ventricular contraction every other beat

39. Ventricular tachycardia:

• a. Three or more beats of ventricular origin.
• b. Wide comlex
• c. There are no normal-looking QRS complexes.
• d. The rhythm is usually regular, but on occasion it may be modestly irregular

40. Atrial Fibrillation:

• The most common arrhythmia.
• It's caused by the atria quivering in random spots
• Resulting in many p-waves and irregular irregular QRS complexes
• Pulse will also be irregularly irregular
• P-waves may be so fine the baseline appears wavy and fine
• 8% of people over 80 have it (risk increases with age)
• Risk also increases with chronic lung disease due to enlarged atria
• If have large heart, usually becomes chronic and is not treated
• Generally asymptomatic and in itself is not life threatening (often becomes chronic)
• Increased risk of stroke as blood may pool in heart and clot, resulting in a PE
• Often heart rate is greater than 100 but less than 150
• If heart rate less than 120 may be no symptoms
• Fibrillatory waves best seen in leads II, III, and VI
• Common cause is heart failure, alcohol abuse, infections (pneumonia), paricarditis, sick sinus syndrome, pulmonary embolism, recent surgery,
• Treated by treating the cause
• Cardioversion if life threatening (hypotension, pulmonary edema) and young person with normal heart function

41. A-fib with rapid ventricular response:

• Rate is greater than 100 and less than 150
• If patient unstable, cardioversion is necessary
• If stable, treat with digoxin or verapamil
• Goal to reduce rate to between 80 to 100 BPM
• If chronic, calcium antagonists (verapamil or diltiazem) or beta blockers are adjusted to maintain optimal heart rate.

42. Atrial Flutter:

• EKG or rhythm strip has a saw tooth patern
• Heart rate 100-150
• If heart rate less than 120 may be no symptoms
• Occurs most rapidly in patients with cardiovascular disease (hypertension, coronary artery disease, cardiomyopathy)
• Not stable, and frequently changes into atrial fibrillation
• Pooling of blood may result in clots

43. Pre-ventricular contraction (PVC):

• Originates in irritable focus in ventricles
• Produces giant ventricular processes on EKG
• Easily recognized by enormous amplitude in both height and depth
• Most likely cause is hypoxia

44. Ventricular Bigeminy: A PVC occurs every other beat (poor oxygenation)

45. Ventricular Trigeminy: A PVC occurs every third beat. (poor oxygenation)

46. Ventricular Quadrigeminy: A PVC occurs every fourth beat. (poor oxygenation)

47. Supraventricular Tachycardia: Heart rate 150 to 250

• Rapid, PVC like complexes that are narrow (narrow indicates external cause)
• Caused by irritable focus above ventricles
• Causes: stress, smoking, alcohol abuse, pneumonia, heart failure, chronic lung disease, PE, paricarditis, cocaine, digitalis, asthma medicine, cold remedies
• Symptoms: palps, dizziness, SOB, anxiety, chest pain
• May resolve on own or with treatment (cardizem) or with valsalva meneuver, squeezing balls, putting pressure on carotid arteries, ice on balls, etc.
• shockable is symptomatic

48. Ventricular Fibrillation:

• May be coarse or fine
• Does not provide adequate oxygenation to tissues of body
• Is a shockable rythym with 300 joules '
• EKG tracing totally eratic
• Cardiac Arrest

49. Ventricular Tachycardia:

• More than 3 PVCs in a row
• wide complex QRS
• Rate greater than 100
• Causes: heart failure, heart surgery, valve disease
• Is a shockable rhythm with 300 joules during ACLS
• The earlier shocked, the better the results
• Poor perfusion (heart not pumping enough blood to support life)

50. Torsades de Pointes:

• Rapid Ventricular rythym caused by low potassium
• Ventricular complexes twist up and down SSSSSSSssssssSSSSSSsssssSSSSSS
• Rate 250 to 350 per minute
• Polymorphic Ventricular Tachycardia (polymorphic means
• Prolonged QT interval (wide QRS)
• Wide QRS means the cause is within the heart
• Causes are diahrea, alcoholics, hypokalemia, malnourished, poverty
• Treatment is magnesium sulfate
• See picture here

How to determine heart rate:

According to elementary EKG, "You take the duration between two identical points of consecutive ECG waveforms such as the R-R duration. Take this duration and divide it into 60. The resulting equation would be:

"Rate = 60/(R-R interval)"

However, "A quicker way to obtain an approximate rate is to go by the number of 5 small boxes (i.e., the size of one big box or the duration of 0.2 secs) that are in between the two identical points. For example, if the two points were 1 big box away, then the rate is approx 300 beats/min. The rest of the sequence would be as follows:

• 1 big box = 300 beats/min (duration = 0.2 sec)
• 2 big boxes = 150 beats/min (duration = 0.4 sec)
• 3 big boxes = 100 beats/min (duration = 0.6 sec)
• 4 big boxes = 75 beats/min (duration = 0.8 sec)
• 5 big boxes = 60 beats/min (duration = 1.0 sec)"

I use the later, and I've never gotten a question about heart rate wrong on any test.

For a basic rhythm strip reveiw, click here.

For a basic EKG course, click here for the ECG learning center.

See the EKG library here.

* Reference for axis deviation hexaxial reference is "Respiratory Disease," ed. by Robert L. Wilkins and James R. Dexter, 1993, page 41.
Please note that I'm learning much of this as I research, so if you find something that's not accurate, or have a tip for making the process of learning easier, please let me know.
Updated August 2, 2010

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Word of the day: Arcanum: Secret or esoteric knowledge, specialized information, a mystery; a secret and powerful remedy
EKG interpretation is not arcana wisdom known only to doctors.

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