N124

Prof. MAG Batalla

6/28/12
ETHICS
Ethics
- Study of morality
- What is right, what is wrong
Bioethics
- Ethics in health sciences
- Including nursing
Nursing Ethics
- Ethics in nursing practice
- Some argue that it is a subset of bioethics;
others say that it is part of nurses judgment
Covers:
Nurses specific roles and responsibilities
Relationships
Approaches
1. Consequentialism
a. Utilitarianism
2. Deontological/non-consequentialism
a. Virtue ethics based on virtues,
morals
b. Principalism based on personal
principles
What will help us when we are faced with an ethical
problem?
- Ethical principles
- Professional guidelines
- Personal values
- Judgment
E.g. removing an ET (doctors order)
Principles of bioethics
1. Autonomy
o Right to self-determination
o Make decisions yourself
2. Nonmaleficence
o Do no harm to your patient
3. Beneficence
o Do good to your patient
4. Justice
o Do what is fair to the patient
5. Veracity

o Being truthful; honest

6. Fidelity
o Be loyal to your patient
o Do your role as a nurse
Ethical decision making within a nursing process
model
ADPIE
o Evaluation what you learned,
insights
NURSING NEGLIGENCE IN CRITICAL CARE
Nursing legislation
- The making of laws, or body of laws, already
enacted, affecting the science of the art and
practice of nursing
Nursing jurisprudence
- Applying of laws into nursing practice
Tort
-

A wrongful act committed against a person or

his or property independent of a contract
Classifications
o Unintentional
o Intentional
o Quasi-intentional

Unintentional Torts
Negligence omission or commission of an
act that a reasonalble and prudent person
would perform in a similar situation
4 elements which must all be present in
making a claim of negligence:
1. A duty was owed to the client
(professional relationship
2. The professional violated the duty and
failed to conform to the standard of care
3. The failure to act by the professional was
the proximate cause of the resulting
injuries (casualty)
4. Actual injuries resulted from breach of
duty (damage)
Kinds of negligence:
a. Non feasance failure to perform their
duty
b. Malpractice aka professional negligence
indicated professional misconduct or
unreasonable lack of skill
Some causes of malpractice

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Leaves foreign objects inside a client

during surgery
Failing to assess and observe a client
as directed
Failing to report a change
Failing to obtain proper consent
Failing to report another HCPs
negligence or incompetence
Failing to take actions to provide
safety
Failing to provide client with sufficient
and appropriate education before
discharge

Intentional Torts
1. Assault
o Occurs when another person fears,
expects, or is apprehensive about
being touched in an offensive,
insulting, or physical injurious manner
2. Battery
o Actual harmful or unwarranted contact
with another person without his or her
consent
3. False imprisonment
o Not applicable in situations wherein
the use of restraints will maintain the
safety of another person from injuring
himself or others
o The unjustified detention of a person
without the legal right to confine that
person
4. Intentional inflictment of emotional distress
3 necessary elements:
a. The conduct exceeds what is usually
accepted by society

Quasi-intentional Torts
A voluntary act that directly causing injury or
distress without intent to injure or cause
distress

A violation of persons right to

protection against unreasonable and
unwarranted interference with ones
personal life
E.g. taking pictures of a patient
without permission

3. Breach of confidentiality
o A form of invasion of privacy
concerned with the facts presented in
the medical world
o E.g. revealing patient records without
a legal permit
LEGAL DOCTRINES
- Framework of rules
SKIPPED!
Reading assignment:
Selected laws affecting nursing practice and
administration
1. RA 9173
2. RA 6425
3. Presidential Decree No. 856
4. Memorandum Circular No. 2006-144
of DILG

PREVENTION OF LAWSUITS
1. Maintain an accurate and complete medical
record
Kung hindi mo sinulat, hindi mo ginawa
a. Medications
b. Physician comm.
c. Formal issues in charting
2. Establish rapport with the client and the family
through honest and open communication
3. Keep nursing knowledge and skills current
4. Know the client (e.g. reading medical
records)

1. Defamation of character
a. Slander spoken communication in which
one person discusses another that will
harm another persons reputation
b. Libel written communication that will
harm another persons reputation
2. Invasion of privacy

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ECG INTERPRETATION

Stimulate the cardiac cells

contraction of muscles

Review of cardiac tissue function

Repolarization
Movement of electrolytes
across a cell membrane in
which the inside of the cell is
returned to its negative charge
Cell stops the flow of Na into
the cell and K out of the cell
Stop contraction of the
cardiac muscles rest

Types of cardiac cells

1. Myocardial
o Atria and ventricles
o Cells responsible for contraction
o Working or mechanical cells
2. Pacemaker
o SA node
o Responsible for conduction of
impulses
Phases
Properties
- Rhythmicity
o Automaticity generated at regular rate
- Automaticity
o Ability of certain cells to
spontaneously depolarize
- Excitability
o Ability of a cell or tissue to depolarize
in response to an stimulus
- Conductibility
o Ability to conduct impulses
- Contractability
o Ability of cardiac myofibrils to contract
or depolarize
- Refractoriness
o State of cell or tussue during
repolarization when the cell or tissue
cannot depolarize REST
Cardiac Action Potential
Resting membrane potential
o
- 80 to -90 mV
o Intracellular K levels is very high
o Intracellular Na levels is very low
o Extracellular Ca is much higher than
intracellular Ca
Action potential
o Graphic representation of
depolarization and repolarization
Depolarization
Movement of electrolytes
across the cell membrane
causing the inside of the cell
to become positive
Changes in intra and
extracellular electrolytes

Phase 0: Depolarization
- Cell is stimulated and cell membrane
becomes MORE PERMEABLE TO SODIUM
- Begins when the cell receives an impulse
o Na moves into the cell
o K goes out
o Negative to positive (upward stroke in
ECG)
- Cell depolarizes, contraction begins
- Responsible for QRS
Phase
-

1: Early repolarization
Na channels partially close
Brief outward movement of K
Results in fewer positive electrical charges
within the cell

Phase
-

2: Plateau
Slow inward movement of Ca
Slow outward movement of K
Depolarized state is maintained
Responsible for ST segment

Phase
-

3: Final rapid repolarization

K flows quickly out of the cell
Entry of Ca and Na stops
Responsible for T wave

Phase 4: Return to resting state

- Heart is polarized
- Goes back to resting membrane potential
(intracellularly negative)
Medication
Ca channel blockers (verapamil, diltiazem)
affects Phase 2
Sodium affects Phase 1

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AR cells in the SA node fire their action potential

Spreads to the neighboring cardial muscle cells
Runs back throughout the atrial syncytium triggers
atrial systole P wave
*cardiac conduction system
SA node atrial syncytium junctional
fibers AV node AV bundle bundle
branches
The ECG
- Records electrical changes in heart muscle
caused by an action potential
- Functions:
o Orientation of heart
o Conduction disturbances
o Electrical effects of medications and
electrolytes
ECG cannot provide information of
mechanical (contractile) condition of
myocardium (dapat pulse or BP)
Electrodes
- Have a conductive media that conducts skin
surface voltage changes through cardiac
wires to a cardiac monitor
Lead
- A record of electrical activity between 2
electrodes
- Each lead records the average current flow at
a specific time in a portion of the heart
Planes
Frontal
o View the heart from the front of the
body as if it were flat
o Directions: superior, inferior, right, left
Horizontal
o View the heart as if the body were
sliced in half horizontally
o Direction: posterior, anterior, right, left

12-lead ECG
Frontal plane leads
- Bipolar/standard limb lead
o A lead the consists of a positive and
negative electrode
o Leads I, II, III

o
o
o

Superior (+), inferior (-), right

(+), left - (-)
Right arm electrode is always negative
Left leg is always positive

Einthovens triangle
-

Unipolar
o A lead the consists of a single positive
electrode and a reference point
o Leads: right arm (aVR), left arm
(aVL), left foot (VF)

Horizontal plane leads/Chest leads

- Leads II, III, aVF inferior wall of LV
- Leads I and aVL lateral wall of LV
- Leads V5 and V6 lateral wall of LV
- Leads V3 and V4 anterior wall of LV
- Leads V1 and V2 septal wall
Lead
II, III, aVF
I, aVL, V5, V6
V3, V4
V1, V2

Surface
Inferior
Lateral
Anterior
Septal

if there is MI, both leads should show

changes, not just one lead

P wave atrial contraction/depolarization (from

SA node)
QRS depolarization and repolarization of
ventricle
T wave repolarization and relaxation of
ventricles

P-R segment conduction delay through the AV

node
P-R interval atrial depolarizon and conduction delay
through the AV node; more important that P-R
segment
S-T segment isoelectric; ventricles are still
depolarized
Q-T interval ventricular repolarization; how long
contraction was before resting
2 big boxes of 5 mm 1 mV
1 small box 0.04 sec
5 small boxes 0.2 sec

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5 large boxes 1 sec

15 large boxes 3 sec
30 large boxes 6 sec
Steps in ECG interpretation
1. Identify the complexes and make your initial
survey
a. Are the PQRST complexes present?
b. Examine the P waves (upright?
Present in all complexes? Look alike?
Equidistant?)
c. Do all QRD complexes look alike and
unchanging?
Normal P wave
o Smooth and rounded
o No more than 2.5 mm in height
o No more than 0.1 sec in duration
o Upright leads I, II, aVF, and V2
through V6
2. Determine the rhythm
a. Is the rhythm regular?
b. P-P cycle: length equal?
c. R-R: length equal?
o

Distance between 2 P waves or 2 R

waves

3. Calculate the heart rate

HR = 1500/# 0.4 sec squares between 2
complexes
HR = 300/#.20 sec squares between 2
complexes

if the rhythm is irregular:

o Count the number of P-P or R-R
cycles in a 6 second strip (or count 30
big boxes)
o Multiply the number by 10

4. Determine the P-R interval

o # of small squares between P and R x
0.04
o Normal= .12 - .20 sec
5. Determine the QRS duration
o # of small squares x 0.04 sex
o Normal = 0.04 0.1 sec

The Q Wave
- First negative or downward deflection
following the P wave
o Always a negative waveform
- Represents depolarization of intraventricular
septum
- Normal Q wave
o Less than 0.04 sec
o Less than 1/3 the height of R wave in
that lead
- Abnormal (pathologic)
o More than 0.,04
o More than 1/3 the height of the
following R wave in the lead
The R Wave
- The first positive or upward deflection
The S Wave
- A negative waveform after the R wave
o Always negative
o R and S depolarization of ventricles
6. Note whether the S-T segment is along the
baseline
a. An elevation of 1 small square is
considered significant
S-T segment
point at which the QRS complex and the S-T
segment meets
- J point/junction
S-T segment elevation
o May represent a normal variant
myocardial injury, pericarditis, or
ventricular aneurysm
S-T segment depression
o May reflect myocardial ischemia or
hypokalemia

7. Determine the Q-T interval

o Beginning of the QRS complex to the
end of the T-wave
o # of small squares x 0.04 sex
o Normal: 0.36-.044 sec
8. Describe the T waves
The T wave
- Slightly asymmetric
- Usually 5 mm or less in height in any limb
lead

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Degree of hyperkalemia
- Severe: >6.5 mEq/L
- P waves disappear, QRS widens, tall ST
segment may be elevated
e.g. normal ECG
normal sinus rhythm
with heart rate of approx. __ bpm
isoelectric ST segment
upright T waves

Simplified steps in 12-lead analysis

1. Identify the rate and underlying rhythm
2. Analyze waveforms
3. Examine for evidence of infarction
4. Ascertain in STEMI imposters are present that
may account for ECG changes

ACUTE CORONARY SYNDROME

Myocardial ischemia
- Delays repolarization
- ECG changes include temporary changes in
the ST-segment and T wave
Myocardial injury
- Injured cells die until blood flow is quickly
restored
- Viewed on the ECG as ST-segment elevations
Myocardial Infarction
- Recognition on the ECV relies on the
detection of changes in the shape of the QRS
complex, the T wave, and the ST segment
o STEMI or NSTEMI, (+) cardiac markers
STEMI
o ECG changes often occur in a
predicatble pattern
Hyperacute may occur within
the first few minutes of
infarction; tall T waves
Early acute tall T waves, ST
segment elevation
Later acute elevated ST
segment, inverted T wave
Fully evolved elevated ST
segment, pathologic Q wave,
inverted T wave
Healed Q wave (scar in
myocardial tissue), not as
deep as fully evolved, slight
ST elevation
NSTEMI
o S/Sx, Hx, cardiac markers

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