Email : kimberly@avancelearning.com


  Contact : 813-508-1511

All posts by Kimberly

tn_16References

References

References

Aehlert, B.  (2002) ACLS Quick Review Study Guide.  St Louis, MO: Mosby, Inc.

Allen, D., Bekken, & N., Crisfulla, K., et al.  (2011) ECG Interpretation Made Incredibly Easy (5th ed.).  Philadelphia, PA: Wolters Kulwer/Lippincott Williams & Wilkins.

Brose, J. A., Auseon, J. C., Waksman, D., & Jarosick, M. J.  (2000) The Guide to EKG Interpretation, Revised Edition.  Athens, OH:  Ohio University Press.

Cason, L., Grbach, W., & Groban, M., et al.  (2013) ACLS Review Made Incredibly Easy (2nd ed.).  Philadelphia, PA: Wolters Kulwer/Lippincott Williams & Wilkins.

Ellis, K. M. (2002) EKG in a Heartbeat.  Upper Saddle River, NJ: Prentice Hall.

Hazinski, M. F., Cummins, R. O., & Field, J. M. (Eds.) (2002) Handbook of Emergency Cardiovascular Care for Healthcare Providers.  Dallas, TX:  American Heart Association.

Hodges, R. K., Garrett, K. M., Chernecky, C., & Schumacher, L.  (2005) Real-World Nursing Survival Guide: Hemodynamic Monitoring.  St Louis, MO:  Elsevier Saunders.

Huff, J. (2012) ECG Workout: Exercises in Arrhythmia Interpretation (6th ed.).  Philadelphia, PA: Wolters Kulwer/Lippincott Williams & Wilkins.

Schumacher, L. & Chernecky, C.  (2005) Real-World Nursing Survival Guide: Critical Care and Emergency Nursing.  St Louis, MO:  Elsevier Saunders.

Resources

Texas Heart Institute

http://www.texasheartinstitute.org

American College of Surgeons Online

http://www.acssurgery.com

American Association of Critical Care Nurses

http://www.aacn.org

Read More
chiefs

Course Evaluation Form

Understanding EKG.com Course Evaluation Form
Course Title: Understanding EKG Technical Telemetry Course
Course Date:
The purpose of this form is to provide you with an opportunity to provide feedback on the course that you just completed.
Your input is important to us as it gives information on how to improve our course in the future.
**For the measures below, please provide a number evaluation of how well you feel the measure was met using the following scale:

4- Excellent, 3- Good, 2- Fair, 1- Poor

* indicates required field
Read More
chiefs

Technical Telemetry Course Post Test

Understanding EKG.com Technical Telemetry Course

Post-Test
Instructions: Pick only one answer for each of the following questions:
* indicates required field
























































Note: Measure PR interval, QRS, rate, and regularity to determine each rhythm strip below.
>>Click here to print out rhythm strips for easier measuring if needed.<<<






































Read More
tn_15evaluation

Course Evaluation Form

Understanding EKG.com Course Evaluation Form
Course Title: Understanding EKG Clinical Telemetry Course
Course Date:
The purpose of this form is to provide you with an opportunity to provide feedback on the course that you just completed.
Your input is important to us as it gives information on how to improve our course in the future.
**For the course objectives listed below, please provide a number evaluation of how well you feel the objective was met using the following scale:

4- Excellent, 3- Good, 2- Fair, 1- Poor

* indicates required field
Read More
tn_14exam

Clinical Telemetry Exam

Understanding EKG.com Clinical Telemetry Course

Post-Test
Instructions: Pick only one answer for each of the following questions:
* indicates required field




















































































Note: Measure PR interval, QRS, rate, and regularity to determine each rhythm strip below.
>>Click here to print out rhythm strips for easier measuring if needed.<<<






































Read More
chiefs

Need Contact Hours?

If you would like to take this EKG course to earn 11.0 contact hours... here's what to do:

1) Submit your payment through our  secure online payment system here.

2) You then get a login and password to access our UnderstandingEKG.com course here.

3) Study the clinical course and do the practice strips at the end of each section.

4) Complete the post-test and submit. We will score your test.  You must score 80% or higher to pass.Re-take as much as you need to. We will coach you!

5) Once a passing score is achieved, we will send your certificate of completion via email.

How does the course work? Check out our intro video here:

Read More
tn_12Answers

Answers to Practice Strips

5-1

Regularity: R-R equal, regular
Rate: 83
P waves: Upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08

5-2

Regularity: R-R equal at beginning of strip and narrows at end of strip but still equal to each other at end, regular
Rate: 90- speeding up to 100 at end of strip
P waves: Upright, uniform, one before every QRS
PRI: 0.12
QRS: 0.08

5-3

Regularity: R-R equal, regular
Rate: 81
P waves: Upright, uniform, one before every QRS
PRI: 0.14
QRS: 0.06

6-1 (Sinus rhythm)

Regularity: R-R equal, regular
Rate: 62
P waves: Upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.06

6-2 (Sinus tachycardia)

Regularity: R-R equal, regular
Rate: 142
P waves: Upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.06

6-3 (Sinus bradycardia)

Regularity: R-R equal, regular
Rate: 43
P waves: Upright, uniform, one before every QRS
PRI: 0.20
QRS: 0.10

6-4 (Sinus rhythm)

Regularity: R-R equal, regular
Rate: 75
P waves: Upright, uniform, one before every QRS
PRI: 0.18
QRS: 0.08

7-1 (Atrial fibrillation)

Regularity: R-R not equal, irregularly irregular
Rate: 90
P waves: fibrillating, indiscernible
PRI: N/A
QRS: 0.06

7-2 (Sinus rhythm with premature atrial contraction)

Regularity: R-R equal except for one early beat, slightly irregular
Rate: 70
P waves: Upright, uniform, one before every QRS except for premature beat
PRI: 0.18 except premature beat
QRS: 0.10
Premature beat: p wave not seen because it is hidden in T wave of previous complex. QRS is 0.08.

7-3 (Wandering atrial pacemaker)

Regularity: R-R not equal, irregularly irregular
Rate: 40
P waves: Upright, not uniform, one before every QRS
PRI: varies with each complex
QRS: 0.08

7-4 (Atrial flutter)

Regularity: R-R equal, regular
Rate: 75
P waves: Upright, sawtooth, more P waves than QRS
PRI: not measured
QRS: 0.08

8-1 (Accelerated junctional rhythm)

Regularity: R-R equal, regular
Rate: 94
P waves: inverted, uniform, one before every QRS
PRI: 0.16
QRS: 0.08

8-2 (Junctional rhythm with wide QRS)

Regularity: R-R equal, regular
Rate: 51
P waves: Not seen, possibly inverted after QRS
PRI: N/A
QRS: 0.12

8-3 (Sinus rhythm with two PJC’s)

Regularity: R-R equal except for two early beats, slightly irregular
Rate: 70
P waves: Upright, uniform, one before every QRS, except premature beats
PRI: 0.16 except premature beats
QRS: 0.06
Premature beats: both have missing P waves, QRS is 0.06

8-4 (Junctional tachycardia)

Regularity: R-R equal, regular
Rate: 107
P waves: inverted, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Premature beats: both have missing P waves, but QRS is 0.06

8-5 (Junctional rhythm)

Regularity: R-R equal, regular
Rate: 47
P waves: not seen
PRI: not measured
QRS: 0.08

10-1 (2nd degree AV block Type II)

Regularity: R-R equal, regular
Rate: 35
P waves: upright, uniform, but not all followed by QRS
PRI: 0.16 on conducted beats- only every third beat
QRS: 0.06

10-3 (2nd degree AV block Type I)

Regularity: R-R slightly irregular
Rate: 90
P waves: upright, uniform, but not all followed by QRS
PRI: progressively widening until one P wave have no QRS, then cycle restarts
QRS: 0.06

10-4 (Sinus bradycardia with first degree AV block)

Regularity: R-R, regular
Rate: 54
P waves: upright, uniform, all followed by QRS
PRI: 0.24
QRS: 0.10

10-5 (3rd degree AV block with narrow QRS (junctional focus))

Regularity: R-R, regular
Rate: 75
P waves: upright, uniform, but not all followed by QRS
PRI: immeasurable as there is no relationship with QRS complexes
QRS: 0.08

11-1 (Idioventricular vs agonal)

Regularity: R-R, regular
Rate: 25
P waves: none
PRI: N/A
QRS: 0.16

11-2 (Sinus rhythm with PVC’s, bigeminy)

Regularity: R-R regularly irregular
Rate: 80
P waves: upright, uniform, but not one before every QRS
PRI: 0.18
QRS: 0.08 except for premature beats
Premature beats: No P wave before then, wide QRS, occur every other beat

11-3 (Atrial fibrillation with rapid ventricular response and PVC)

Regularity: R-R irregularly irregular
Rate: 180
P waves: fibrillating, indiscernible
PRI: N/A
QRS: 0.08 except for premature beat
Premature beat: No P wave before it, wide QRS, is a single beat

11-4 (Sinus rhythm/sinus tachycardia with unifocal PVC’s)

Regularity: R-R slightly irregular
Rate: 100
P waves: upright, uniform, but not one before every QRS
PRI: 0.14
QRS: 0.04 except premature beats
Premature beats: No P waves before them, similar in appearance, no pattern of occurrence

11-5 (Ventricular tachycardia)

Regularity: R-R regular
Rate: 150
P waves: none seen
PRI: N/A
QRS: 0.34

11-6 (Accelerated idioventricular)

Regularity: R-R regular
Rate: 58
P waves: none seen
PRI: N/A
QRS: 0.12

11-7 (Ventricular fibrillation)

Regularity: R-R not measurable
Rate: not measurable
P waves: none
PRI: N/A
QRS: not measurable

12-1 (Atrial fibrillation)

Regularity: R-R irregularly irregular
Rate: 90
P waves: fibrillating, not measurable
PRI: N/A
QRS: 0.10

12-2 (Sinus bradycardia with 1st degree AV block and wide QRS)

Regularity: R-R regular
Rate: 56
P waves: upright, uniform, one before every QRS
PRI: 0.24
QRS: 0.16

12-3 (Sinus rhythm/sinus tachycardia with PJC’s)

Regularity: R-R regularly irregular
Rate: 100
P waves: upright, uniform, except for premature beats
PRI: 0.14
QRS: 0.06
Premature beats: No P waves seen, QRS 0.08

12-4 (Atrial and ventricular paced rhythm)

Regularity: R-R regular
Rate: 95
P waves: pacer spike before each
PRI: N/A because there is a pacer spike before QRS also
QRS: 0.12 with pacer spike before each

12-5 (Sinus tachycardia)

Regularity: R-R regular
Rate: 115
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08

12-6 (Sinus bradycardia)

Regularity: R-R regular
Rate: 52
P waves: upright, uniform, one before every QRS
PRI: 0.14
QRS: 0.08

12-7 (SVT)

Regularity: R-R regular
Rate: 205
P waves: not seen, may be hidden in T wave
PRI: N/A
QRS: 0.08

12-8 (Sinus rhythm with PVC’s (bigeminy))

Regularity: R-R regularly irregular
Rate: 80
P waves: upright, uniform, not one before every QRS
PRI: 0.18 except premature beats
QRS: 0.10 except premature beats
Premature beats: no P wave before them, occurs every other beat, similar in appearance, QRS 0.16

12-9 (Idioventricular rhythm)

Regularity: R-R regular
Rate: 38
P waves: none
PRI: N/A
QRS: 0.18

12-10 (Accelerated junctional rhythm)

Regularity: R-R regular
Rate: 75
P waves: none seen
PRI: N/A
QRS: 0.08

12-11 (Ventricular Tachycardia)

Regularity: R-R regular
Rate: 175
P waves: none
PRI: N/A
QRS: 0.20

12-12 (2nd degree AV block Type I)

Regularity: R-R slightly irregular
Rate: 70
P waves: upright, uniform, not all followed by QRS
PRI: progressively widening until one P wave have no QRS, then cycle restarts
QRS: 0.10

12-13 (Wandering atrial pacemaker)

Regularity: R-R slightly irregular
Rate: 80
P waves: upright, but not uniform- appearance differs toward end of strip, one before every QRS
PRI: varies
QRS: 0.04

12-14 (Sinus bradycardia)

Regularity: R-R regular
Rate: 52
P waves: upright, uniform, one before every QRS
PRI: 0.20
QRS: 0.08

12-15 (Sinus rhythm with a run of 3 PVC’s)

Regularity: R-R slightly irregular
Rate: 90
P waves: upright, uniform, one before every QRS except premature beats
PRI: 0.16 except premature beats
QRS: 0.10 except premature beats
Premature beats: No p waves before QRS, 3 in a row, similar in appearance, QRS 0.12

12-16 (Atrial flutter)

Regularity: R-R regular
Rate: 83
P waves: sawtooth
PRI: not measured
QRS: 0.06

12-17 (2nd degree AV block Type II with wide QRS)

Regularity: R-R regular
Rate: 37
P waves: upright, uniform, not every one is followed by QRS
PRI: 0.32 on conducted beats
QRS: 0.12

12-18 (Sinus rhythm with 1st degree AV block and wide QRS)

Regularity: R-R regular
Rate: 63
P waves: upright, uniform, and one before every QRS
PRI: 0.36
QRS: 0.16

12-19 (3rd degree AV block with narrow QRS (junctional focus))

Regularity: R-R regular
Rate: 45
P waves: upright, uniform, no relationship with QRS
PRI: immeasurable
QRS: 0.08

12-20 (Junctional rhythm)

Regularity: R-R regular
Rate: 60
P waves: none
PRI: N/A
QRS: 0.06

12-21 (SVT)

Regularity: R-R regular
Rate: 190
P waves: not seen
PRI: N/A
QRS: 0.08

12-22 (2nd degree AV block Type I)

Regularity: R-R slightly irregular
Rate: 70
P waves: upright, uniform, but not all followed by QRS
PRI: progressively widening until one P wave have no QRS, then cycle restarts
QRS: 0.08

12-23 (Sinus rhythm)

Regularity: R-R regular
Rate: 79
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08

12-24 (Idioventricular rhythm)

Regularity: R-R regular
Rate: 34
P waves: none
PRI: N/A
QRS: 0.12

12-25 (Ventricular fibrillation)

Regularity: Immeasurable
Rate: Immeasurable
P waves: none seen
PRI: Immeasurable
QRS: Immeasurable

12-26 (2nd degree AV block Type II)

Regularity: R-R regular
Rate: 65
P waves: upright, uniform, but not all followed by QRS
PRI: 0.26 on conducted beats
QRS: 0.06

12-27 (Ventricular paced rhythm)

Regularity: R-R regular
Rate: 65
P waves: upright, uniform, but not one before every QRS
PRI: not measured
QRS: pacer spike before every one

12-28 (Sinus rhythm with PVC)

Regularity: R-R slightly irregular
Rate: 70
P waves: upright, uniform, one before every QRS, except premature beat
PRI: 0.16 except premature beat
QRS: 0.08 except premature beat
Premature beat: no P wave before it, only one, QRS 0.16

12-29 (Ventricular tachycardia)

Regularity: R-R regular
Rate: 140
P waves: none
PRI: N/A
QRS: 0.36

12-30 (Sinus tachycardia)

Regularity: R-R regular
Rate: 110
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08

12-31 (Sinus bradycardia)

Regularity: R-R regular
Rate: 50
P waves: upright, uniform, one before every QRS
PRI: 0.12
QRS: 0.04

12-32 (3rd degree AV block with narrow QRS (junctional focus))

Regularity: R-R regularly irregular
Rate: 45
P waves: upright, uniform, no relationship with QRS
PRI: N/A
QRS: 0.10

12-33 (SVT changing into atrial fibrillation with rapid ventricular response at the end)

Regularity: R-R regular at the beginning of strip then irregular toward the end
Rate: 140
P waves: not measurable
PRI: N/A
QRS: 0.08

12-34 (Sinus rhythm with PAC)

Regularity: R-R slightly irregular- one early beat
Rate: 70
P waves: upright, uniform, one before every QRS
PRI: 0.16
QRS: 0.08
Premature beat: Upright P wave before QRS, only one occurance, QRS 0.08

12-35 (Accelerated junctional)

Regularity: R-R regular
Rate: 75
P waves: not seen
PRI: N/A
QRS: 0.08

12-36 (3rd degree AV block)

Regularity: R-R regular
Rate: 35
P waves: upright, uniform, no relationship with QRS
PRI: N/A
QRS: 0.20

12-37 (Sinus rhythm)

Regularity: R-R regular
Rate: 68
P waves: upright, uniform, one before every QRS
PRI: 0.14
QRS: 0.08

12-38 (Atrial flutter)

Regularity: R-R regular
Rate: 75
P waves: sawtooth
PRI: not measured
QRS: 0.08

12-39 (Sinus rhythm with PAC)

Regularity: R-R slightly irregular, one early beat
Rate: 65
P waves: upright, uniform, one before every QRS, except P wave appearance different in premature beat
PRI: 0.18
QRS: 0.08
Premature beat: Upright P wave before QRS, one occurrence, QRS 0.08

12-40 (Sinus rhythm with PJC)

Regularity: R-R slightly irregular- one early beat
Rate: 60
P waves: upright, uniform, one before every QRS except for premature beat
PRI: 0.16
QRS: 0.04
Premature beat: No P wave before QRS seen, one occurrence, QRS 0.04

12-41 (Sinus tachycardia)

Regularity: R-R regular
Rate: 105
P waves: upright, uniform, one before every QRS
PRI: 0.12
QRS: 0.08

12-42 (Atrial flutter with variable conduction rate)

Regularity: R-R slightly irregular, a few early beats
Rate: 80
P waves: sawtooth
PRI: not measured
QRS: 0.08

Read More
tn_10PacedRhythms

Paced Rhythms

Pacemakers

Pacemakers can be temporary or permanent. Temporary are used in emergencies and usually used only a few days at most. They inserted transvenously (inserted through a vein) or applied transcutaneously (on the skin).

Transvenous Pacemaker

transvenous pacemaker 1

Transvenous Pacemaker

transvenous pacemaker 2

Transcutaneous Pacing

transcutaneous pacing

Permanent Pacemaker (Dual Chamber)

Dual chamber permanent pacemaker

What does a pacemaker do to an EKG rhythm strip?
... it creates pacer spikes.

pacer spike example

a. Types of Pacing Response

Example EKG strip with Triggered pacing

(12-27) vent paced 1

1) Triggered- Fixed rate. Fires according to a predetermined program regardless of patient’s underlying heart rate or rhythm. (i.e. pacer is programmed to send 75 impulses to the ventricles every minute regardless of what the atria are doing as in the strip below).

Example EKG strip with Inhibited pacing

demand paced 2

2) Inhibited- Fires only when needed. Senses patient’s own rhythm and inhibits its impulse until needed (i.e. the ventricle or atria stop beating or are beating too slow, etc). In the strip below, you can see the pacer only kicks in after the patient's ventricles fail to beat.

Can be both: Triggered atrial, (this means the pacer sends an impulse to the atria regardless of how the atria are beating) and inhibited ventricular (this means it senses ventricular beats and fires only when ventricles need it to).

b. Common Kinds of Inhibited Pacers

1) Single chamber- Senses and stimulates either atria or ventricles but not both

2) Dual chamber-Works on both chambers simultaneously. Most common is DDD-Dual pacing for both chambers, Dual chamber activity sensing, and Dual response (triggering and inhibition).

c. Assessment
Always check your patient to assure the mechanical and electrical are both working.

1) Things to assess
· Does each pacer spike capture and get followed by either a P wave or QRS (depending on the type of pacer)?

(In the picture below, there are way more pacer spikes than QRS's, not every pacer spike is followed by a QRS meaning that even though the pacer is firing as programmed, the heart is not responding appropriately.)

failure_to_capture

· Is the rate reasonable? (Usually 60-100)

· Are the pacer spikes competing with the patient’s underlying rhythm or falling near T waves? (Spikes falling near T waves can throw a patient into Vtach or Torsades)

· Is pacer firing consistently and reliably?

d. Common Malfunctions

pacer competition

1) Failure to Capture- pacer firing, creating pacer spikes, but heart does not respond (no P wave or QRS after)

2) Failure to Pace- Pacer fails to deliver correct number of stimuli or sometimes any stimulus at all.

3) Competing with patient’s own intrinsic rhythm- can be for two reason and either of these can be bad if the depolarized beat falls near the T wave of the previous beat

Read More