Dysrhythmia Recognition — Fillable Student Coursebook

Thompson Health · Nursing Education

Dysrhythmia
Recognition & Response

Student Follow-Along Coursebook

Class Edition · 2026

F.F. Thompson Hospital · Canandaigua, NY
For educational use during class presentation
Fill in blanks as your instructor covers each topic

Name:

Unit / Department:

Class Date:

This workbook follows the live class presentation. Fill in blanks during lecture. Use the notes spaces to capture what your instructor emphasizes.

Modules
1 · Introduction & Conduction System	3
2 · AV Blocks (Heart Blocks)	4–5
3 · Pacemakers	6
4 · ECG Basics & The 5-Step Method	7–9
5 · Sinus Rhythms	10
6 · Atrial Rhythms (PAC / Flutter / AFib / SVT)	11
7 · Junctional Rhythms	12
8 · Ventricular Rhythms & Arrest	13
Reference Tools
Rhythm Identification Flowchart	13
Practice
Practice Strips (20 strips — unlabeled)	15–24
Final Assessment — Capstone Strips	25

How to use this booklet: Your instructor will present each module using the course slides. As they teach, fill in the blanks in each section. The blanks are clues — they mark the most important facts to remember. Each module includes a practice strip — apply what you just learned before moving on.

Why AV Blocks & Pacemakers Come First: Understanding why conduction can fail — and how we compensate — makes every subsequent rhythm click into place. Learn the blocks, then the 5-step method will feel like second nature.

The Clinical Mantra Recognize → Assess → Act. Every rhythm you learn leads to a clinical decision. Rate and rhythm on paper only matter in the context of how your patient looks.

2

The Clinical Approach

The three-step mantra: → →
Always treat the , not the monitor
Signs of instability: hypotension, chest pain, , altered level of consciousness

The Electrical Pathway

Fill in the conduction pathway in order:

SA Node

→

Pacemaker Hierarchy

Pacemaker Site	Intrinsic Rate	Resulting Rhythm If Primary
SA Node	– bpm	Normal Sinus Rhythm
AV Junction	– bpm	rhythm
Ventricles	– bpm	Idioventricular rhythm

Key Point Higher pacemakers suppress lower ones. If the SA node fails, the AV junction takes over — but at a slower rate. Each backup pacemaker is a safety net, not a normal state.

Notes

3

All AV blocks share one feature: between atria and ventricles.

Block Type	PR Interval	Dropped Beats?	QRS	Risk Level
1st Degree	> sec, constant	None	Narrow
2nd Degree Type I (Wenckebach)	Progressively	Yes — ically	Usually narrow
2nd Degree Type II (Mobitz II)	(fixed)	Yes — ly	Often wide	— can progress to 3rd degree
3rd Degree (Complete)	(no relationship)	Complete dissociation	Wide (ventricular) or narrow (junctional)	— emergent pacing

♥ Heart Block Decision Tree

START: Look at the PR intervals — are they consistent?

↓

BRANCH A — PR is FIXED (same before every beat)

Are ALL beats conducted? (No dropped QRS?)

YES ↓

PR > 0.20 sec?

YES ↓

✔ First-Degree AV Block
PR prolonged but constant; all beats conduct

NO ↓

Normal conduction
Not a block — PR is normal & all beats present

NO — beats are dropped ↓

QRS drops suddenly with no warning? (PR fixed right up to the drop)

YES ↓

⚠ Second-Degree Type II — Mobitz II
Fixed PR → sudden QRS disappears. HIGH RISK — can deteriorate to 3rd degree. Prepare to pace.

BRANCH B — PR is VARIABLE (changes beat to beat)

Does the PR progressively lengthen, then a beat drops — then cycle repeats?

YES ↓

↗ Second-Degree Type I — Wenckebach
PR gradually ↑ → dropped QRS → reset → repeat. Usually benign, but monitor.

Are P waves and QRS complexes completely independent? (Different rates, no relationship, no pattern)

↓

🚨 Third-Degree (Complete) Heart Block
AV dissociation. Atria and ventricles march independently. EMERGENT PACING REQUIRED.

⚠ Remember: 3rd degree HAS visible P waves — they just march independently and bear no relationship to the QRS. Do not mistake P waves for "normal conduction."

4

Wenckebach (Type I) Clues

PR gets then drops a beat
Cycle then
The RR intervals get progressively
Location: usually at node
Generally (benign / dangerous)

▶ Strip: Identify — Wenckebach or other?

Rate

Rhythm

Interpretation

Action

▶ Strip: Is the PR interval prolonged?

Rate

Rhythm

Interpretation

Action

Mobitz II Clues

PR interval is until a beat drops
No warning — the QRS just
Location: below the
Can deteriorate to
Action: prepare for

▶ Strip: Fixed PR or lengthening?

Rate

Rhythm

Interpretation

Action

▶ Strip: Are P waves and QRS related?

Rate

Rhythm

Interpretation

Action

Key Point — 3rd Degree Block Complete AV dissociation: P waves and QRS complexes march on independently. The atrial rate is faster than the ventricular rate. This is a medical emergency — the ventricles are running on their own escape rhythm.

Notes

5

Recognizing Paced Rhythms

A pacemaker appears as a sharp vertical mark
Atrial pacing: spike before wave
Ventricular pacing: spike before (wide QRS)
Dual-chamber: spikes per beat
A paced QRS is (narrow / wide)

Types of Pacemakers

Transcutaneous: (temporary, external)
Transvenous: temporary,
Permanent: implanted,
VVI mode: paces , senses , inhibits on demand

▶ Strip: Find the pacer spikes

Rate

Rhythm

Interpretation

Action

Pacemaker Malfunctions

Failure to Capture:
Spike present but no follows
Causes: lead displacement, , threshold change
Action: increase output /

Failure to Sense:
Pacemaker fires a native beat (can't "see" it)
Appears as: spikes in places
Risk:

Failure to Pace:
No spike when one is expected
Causes: battery depletion,
Action:

▶ Strip: Capture present?

Rate

Rhythm

Interpretation

Action

▶ Strip: Any sensing issues?

Rate

Rhythm

Interpretation

Action

Key Point Capture = spike followed by a P wave or QRS complex. If you see a pacemaker spike without a following deflection → failure to capture. Always assess the patient — is the underlying rate adequate without pacemaker support?

Notes

6

Interpret each strip using your clinical observation skills. Tip: We'll introduce a systematic 5-step approach in Module 4 — you'll use it for all future strips.

Strip 1

Rate

Rhythm

P Waves

PR Interval

QRS Width

Interpretation

Clinical Action

Strip 2

Rate

Rhythm

P Waves

PR Interval

QRS Width

Interpretation

Clinical Action

Strip 3

Rate

Rhythm

P Waves

PR Interval

QRS Width

Interpretation

Clinical Action

B1-1

Strip 4

Rate

Rhythm

P Waves

PR Interval

QRS Width

Interpretation

Clinical Action

Strip 5

Rate

Rhythm

P Waves

PR Interval

QRS Width

Interpretation

Clinical Action

Strip 6

Rate

Rhythm

P Waves

PR Interval

QRS Width

Interpretation

Clinical Action

B1-2

Clinical Scenario

72-year-old male admitted for syncope. History: dual-chamber pacemaker implanted 2 years ago for complete heart block. Current vitals: HR 32, BP 88/52, SpO₂ 94% RA, confused and diaphoretic.

Failure to capture — pacing spikes without QRS

What rhythm is shown? _______________________________________________
What is the rate? ___________________________________________________
Is this patient stable or unstable based on HR 32, BP 88/52, and confusion? _________________________________________
What is your FIRST nursing action? _________________________________________

B1-3

ECG Paper — Horizontal (Time)

1 small box = seconds
1 large box = seconds
5 large boxes = second(s)
Standard paper speed = mm/sec

ECG Paper — Vertical (Amplitude)

1 small box = mV
1 large box = mV
Standard: 10 mm = mV

Normal Intervals

Interval	Normal Range
P wave	< sec
PR interval	– sec
QRS complex	< sec
QT interval	< sec (HR dependent)

PR in small boxes: to boxes
QRS in small boxes: < boxes

Waveform Meanings

Waveform / Interval	Electrical Event	What it means clinically
P wave		Atria contract
QRS complex		Ventricles contract
T wave		Ventricles reset
PR interval	Atrial depolarization +	AV node conduction time

Key Point Normal PR = 0.12–0.20 sec (3–5 small boxes). Normal QRS < 0.12 sec (< 3 small boxes). Wide QRS means the signal traveled an abnormal path through the ventricles. Now that you've seen what blocks look like — a prolonged PR takes on new meaning!

Notes

7

Apply these steps in order for every rhythm strip. Write the step name in each blank.

1 Step 1:

Is the rhythm regular or irregular?
Method:

2 Step 2:

Count QRS complexes in -second strip ×
Or: 300 ÷

3 Step 3:

Are they present?
Upright? One per QRS?

4 Step 4:

Normal range: – sec
Consistent or changing?

5 Step 5:

Normal QRS is (narrow / wide) Wide QRS suggests:

Rate Calculation — 6-Second Method

Count the number of complexes in a 6-second strip
Multiply by to get beats per minute
6 seconds = large boxes on standard ECG paper
This method works best for rhythms

Key Point Use the same 5 steps on every strip, every time. Consistency prevents errors. After every interpretation: "Is this patient stable?"

Quick reminder: Rhythm → Rate → P Waves → PR Interval → QRS Width → Interpret → Act

Notes

8

Practice: Reading Measurements

Use the ECG intervals diagram below. Find each feature and record your measurements.

1. P wave — small boxes: boxes = sec
2. PR interval (P start → QRS start): boxes = sec
3. QRS width: boxes = sec
4. PR interval normal? (3–5 boxes = 0.12–0.20 sec):

Quick Reference P wave: < 0.12 sec (< 3 small boxes)
PR interval: 0.12–0.20 sec (3–5 boxes)
QRS: < 0.12 sec (< 3 boxes)
QT: < 0.44 sec (varies with HR)

Practice — Apply the 5 Steps

Use this strip. Walk through all 5 steps out loud before writing your interpretation.

▶ Apply the 5-Step Method — identify this rhythm

Step 1 — Rhythm (regular or irregular?)

Step 2 — Rate (6-sec method)

Step 3 — P Waves (present? upright? 1 per QRS?)

Step 4 — PR Interval (normal / long / variable?)

Step 5 — QRS Width (narrow or wide?)

Interpretation:

Notes

9

Rhythm	Rate	P Waves	PR / QRS	Common Cause / Action
Normal Sinus Rhythm	– bpm	Upright, per QRS	Normal	No action needed
Sinus Bradycardia	< bpm	Normal	Normal	Treat if
Sinus Tachycardia	> bpm	Normal	Normal	Treat the
Sinus Arrhythmia	60–100 bpm	Normal	Normal	Rate varies with

Key Teaching Points

All sinus rhythms originate in the node
Sinus bradycardia causes: , medications, athletes
Sinus tachycardia causes: — always find the cause
Sinus tachycardia with hemodynamic instability: consider
A wandering pacemaker has ≥ different P-wave morphologies

Key Point — Sinus Brady A rate below 60 bpm is only an emergency if the patient is symptomatic. Athletes and sleeping patients may have heart rates in the 40s — this is normal for them.

Key Point — Sinus Tachy Sinus tachycardia is always a response to something (pain, fever, fear, hypovolemia). Treat the cause, not the number on the monitor.

▶ Practice: Sinus rhythm — fast, slow, or normal?

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves / PR

Step 5 — QRS / Interpretation

Clinical Scenario — Practice

Patient: HR 48 · BP 108/68 · SpO₂ 97% · Alert & oriented · No complaints

This rhythm strip shows sinus bradycardia. What is the most appropriate action?

Is this patient hemodynamically stable?
Does the rate alone require treatment?
What is your action?

Notes

10

PAC (Premature Atrial Contraction)

Origin: ectopic focus in
P wave: present but
Appears than expected
QRS: usually (narrow / wide)
Clinical: usually

Atrial Flutter

Atrial rate: approximately bpm
Classic pattern: waves (sawtooth)
Conduction ratio: often :1 or :1
Ventricular rate with 4:1 block ≈ bpm
Risk: can convert to

Atrial Fibrillation

Atrial rate: – bpm (chaotic)
Ventricular rhythm: irregularly
P waves: absent, replaced by
Major risk: (stroke)
Anticoagulation decision: use score

SVT (Supraventricular Tachycardia)

Rate: – bpm
Onset: sudden / gradual (circle one)
P waves: or retrograde
First intervention:
Drug of choice:

Key Point — AFib The hallmark of AFib is an irregularly irregular ventricular rhythm with no identifiable P waves. The big danger isn't the rate — it's the thrombus that forms in the non-contracting atrium.

▶ Practice: Identify the atrial rhythm — P waves present?

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves / PR

Step 5 — QRS / Interpretation

Notes

11

When the AV Junction Takes Over

Junctional rhythms occur when the fails or is suppressed
Junctional escape rate: – bpm
Accelerated junctional rate: – bpm
Junctional tachycardia rate: > bpm

P Wave Clues in Junctional Rhythm

P waves may be: (1) (before QRS, inverted) or
(2) (buried in QRS, not visible) or
(3) (after QRS)
When P wave precedes QRS, PR interval is than normal (< 0.12 sec)
QRS width: usually (narrow / wide)

Clinical Significance

Type	Rate	Priority	Common Cause
Junctional Escape	40–60 bpm		SA node failure, vagal tone
Accelerated Junctional	60–100 bpm	Monitor
Junctional Tachycardia	> 100 bpm		Dig toxicity, ischemia

Key Point Junctional rhythms are escape rhythms — the junction fires because a higher pacemaker failed. The key question: why did the SA node fail? Look for medications, ischemia, or high vagal tone.

Inverted P wave rule: If P waves are inverted in leads II, III, and aVF → the impulse is going up the atria instead of down → junctional or ventricular origin.

▶ Practice: Where are the P waves?

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves / PR

Step 5 — QRS / Interpretation

Notes

12

Apply the 5-Step Rhythm Method to every strip: Rate → Rhythm → P Waves → PR Interval → QRS Width → Interpretation. Complete independently before the group review.

Strip 1

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 2

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 3

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

B2-1

Strip 4

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 5

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 6

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

B2-2

Clinical Scenario

68-year-old female with known chronic AFib on anticoagulation therapy. Current vitals: HR 148, BP 106/72, SpO₂ 96% RA, alert and oriented. Complains of palpitations and mild fatigue.

Atrial fibrillation with rapid ventricular response

What rhythm is shown? _______________________________________________
What is the rate? ___________________________________________________
Is this patient stable or unstable based on HR 148, BP 106/72, and mental status? _________________________________________
What is your FIRST nursing action? _________________________________________

B2-3

Rhythm	QRS Width	Rate	Key Feature	Immediate Action
PVC	> sec	Varies	, no P wave before	Monitor; treat if >/min or runs
V-Tach (sustained)	Wide	> bpm	≥ consecutive PVCs	If stable: ; if unstable:
Ventricular Fib	No QRS	No pulse	Chaotic,	Immediate + CPR
Idioventricular	Wide	– bpm	Escape rhythm	Do NOT suppress; find cause
Asystole	None	0	(flat line)	CPR, epinephrine, find cause

PVC Patterns — Know These

Unifocal PVCs: all (same shape)
Multifocal PVCs: different — more concerning
Bigeminy: every beat is a PVC
Trigeminy: every beat is a PVC

Couplet: PVCs in a row
Triplet: PVCs in a row
R-on-T phenomenon: PVC falls on the wave → can trigger

▶ Practice: Wide QRS — count the rate, check for P waves

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves / PR

Step 5 — QRS / Interpretation

⚡ Defibrillation is the only definitive treatment for VFib and pulseless V-Tach. Begin CPR immediately while the defibrillator charges. Every second counts.

Notes

13

Apply the 5-Step Rhythm Method to every strip: Rate → Rhythm → P Waves → PR Interval → QRS Width → Interpretation. Complete independently before the group review.

Strip 1

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 2

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 3

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

B3-1

Strip 4

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 5

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 6

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

B3-2

Clinical Scenario

Post-operative day 1 patient found unresponsive in bed. Monitor shows wide complex tachycardia at rate 180 bpm. No palpable pulse. Code team has been activated.

Wide complex tachycardia — ventricular tachycardia

What rhythm is shown? _______________________________________________
What is the rate? ___________________________________________________
What did the nurse find when checking for a pulse? _________________________________________
What is the appropriate treatment pathway for this rhythm without a pulse? _________________________________________

B3-3

You see a rhythm on the monitor

↓

STEP 1: Screen for Heart Block FIRST (Check PR interval)

Is the PR interval present and CONSISTENT?

PR progressively
LENGTHENS → dropped QRS?

Cycle repeats (group patterns)

↳ Wenckebach (Type I)

PR FIXED → sudden
dropped QRS?

No progressive change

↳ Mobitz II (Type II) ⚠

P waves & QRS completely
UNRELATED (diff. rates)?

AV dissociation

↳ 3rd-Degree Block 🚨

PR > 0.20 sec but
ALL beats conduct?

No dropped beats

↳ 1st-Degree Block ✔

↓ If no block pattern identified — continue to 5-Step Method below ↓

STEP 2: Apply the 5-Step Method

1 What is the RATE?

▸ < 60 → Bradycardia branch Sinus Brady / Junctional Escape / Idioventricular

▸ 60–100 → Normal rate NSR / 1° Block / PAC / PVC

▸ > 100 → Tachycardia branch Sinus Tachy / SVT / AFib / VTach

2 Is rhythm REGULAR or IRREGULAR?

▸ Irreg. irreg. → Think AFib first

▸ Regularly irreg. → Group patterns suggest Wenckebach or PACs

3 Are P WAVES present?

▸ None → Junctional or Ventricular origin

▸ Inverted → Junctional (retrograde)

▸ Sawtooth → Atrial Flutter

▸ Fibrillatory → Atrial Fibrillation

▸ Upright × 1 → Sinus origin likely

4 PR INTERVAL

▸ 0.12–0.20s Normal — Sinus origin likely

> 0.20s 1st Degree AV Block

▸ < 0.12s → Junctional or WPW

▸ Absent / var. → Block or Junctional/Ventricular

5 QRS WIDTH

▸ < 0.12s Narrow → Supraventricular origin

▸ ≥ 0.12s Wide → Ventricular or aberrant SVT

▸ Paced wide Look for pacer spikes

Common Terminal Diagnoses

NSR Sinus Brady Sinus Tach 1° Block SVT / PSVT AFib AFlutter Wenckebach Junctional PVCs Mobitz II ⚠ V-Tach V-Fib 🚨 3° Block 🚨 Idioventricular

Green = Benign / Monitor

Orange = Monitor / Assess patient

Red = Urgent / Act

Dark Red = Emergency / Immediate intervention

Always: After identifying the rhythm — assess the patient. Rate and rhythm only matter in context. Ask: "Is my patient hemodynamically stable?"

14

Apply the 5-Step Rhythm Method to every strip: Rate → Rhythm → P Waves → PR Interval → QRS Width → Interpretation. Complete all fields independently before asking your instructor.

Strip 1

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 2

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

15

Strip 3

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 4

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

16

Strip 5

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 6

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

17

Strip 7

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 8

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

18

Strip 9

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 10

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

19

Strip 11

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 12

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

20

Strip 13

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 14

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

21

Strip 15

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 16

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

22

Strip 17

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 18

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

23

Strip 19

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Strip 20

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Clinical Action

Well done! You've worked through 20 strips using the 5-step method. Rhythm interpretation is a skill built with repetition. Keep practicing, and always connect the rhythm to your patient's clinical picture.
Remember: Recognize → Assess → Act.

← Back to Course (Online Version)

24

Instructions — For each strip below, complete all three steps:

Name the rhythm using your 5-step method (Rate → Rhythm → P Waves → PR Interval → QRS)
State the stability criteria you would assess at the bedside (mental status, BP, SpO₂, symptoms)
Describe your first action — what would you do if this patient is stable? If unstable?

Strip A

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Stability criteria I would assess

If stable: If unstable:

Strip B

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Stability criteria I would assess

If stable: If unstable:

Strip C

Step 1 — Rate

Step 2 — Rhythm

Step 3 — P Waves

Step 4 — PR Interval

Step 5 — QRS Width

Interpretation

Stability criteria I would assess

If stable: If unstable:

25

Table of Contents

Module 1 · Introduction & Conduction System

The Clinical Approach

The Electrical Pathway

Pacemaker Hierarchy

Module 2 · AV Blocks (Heart Blocks)

Module 2 (cont.) · AV Blocks — Clinical Details & Practice

Wenckebach (Type I) Clues

Mobitz II Clues

Module 3 · Pacemakers

Recognizing Paced Rhythms

Types of Pacemakers

Pacemaker Malfunctions

Independent Practice — Break 1

Independent Practice — Break 1 (cont.)

Independent Practice — Break 1 · Clinical Scenario

Module 4 · ECG Basics & Paper Reading

ECG Paper — Horizontal (Time)

ECG Paper — Vertical (Amplitude)

Normal Intervals

Waveform Meanings

Module 4 (cont.) · The 5-Step Rhythm Method

Rate Calculation — 6-Second Method

Module 4 (cont.) · Practice: Measurements & The 5-Step Method

Practice: Reading Measurements

Practice — Apply the 5 Steps

Module 5 · Sinus Rhythms

Key Teaching Points

Module 6 · Atrial Rhythms

PAC (Premature Atrial Contraction)

Atrial Flutter

Atrial Fibrillation

SVT (Supraventricular Tachycardia)

Module 7 · Junctional Rhythms

When the AV Junction Takes Over

P Wave Clues in Junctional Rhythm

Clinical Significance

Independent Practice — Break 2

Independent Practice — Break 2 (cont.)

Independent Practice — Break 2 · Clinical Scenario

Module 8 · Ventricular Rhythms & Arrest

PVC Patterns — Know These

Independent Practice — Break 3

Independent Practice — Break 3 (cont.)

Independent Practice — Break 3 · Clinical Scenario

Rhythm Identification Flowchart

Practice Strips

Practice Strips (cont.)

Practice Strips (cont.)

Practice Strips (cont.)

Practice Strips (cont.)

Practice Strips (cont.)

Practice Strips (cont.)

Practice Strips (cont.)

Practice Strips (cont.)

Practice Strips (cont.)

Final Assessment · Practice Strips — Capstone