ELECTROCARDIOGRAM (ECG or EKG)

DANILYN R. CENITA PAULA M. PAULO

BSN III

ELECTROCARDIOGRAM
- Is a recording of electrical activity of heart conducted thru ions in body to surface

2 Components of ELECTRODES
Adhesive substance

Substance

*The number and placement of the electrodes depend on the type of ECG needed

Types of ECG Recordings

Bipolar leads record voltage between electrodes placed on wrists & legs (right leg is ground) Lead I records between right arm & left arm Lead II: right arm & left leg Lead III: left arm & left leg

 POSITIONING CHEST ELECTRODES To ensure accurate test results, position chest electrodes as

follows:

V1 : Fourth intercostal space at right border of sternum

V2 : Fourth intercostal space at left border of sternum

V3 : Halfway between V2 and V4

V4 : Fifth intercostal space at midclavicular line

V5 : Fifth intercostal space at anterior axillary line (halfway between V4 and V6 )

V6 : Fifth intercostal space at midaxillary line, level with V4

Obtaining an ECG

An ECG machine A cardiac monitor A small box A small, lightweight tape-

recorder machine

Interpreting the ECG

ECG waveforms are printed on graph paper that is

divided by light and dark vertical and horizontal lines at standard intervals. TIME and RATE: measured on the horizontal axis of the graph AMPLITUDE or VOLTAGE: vertical axis POSITIVE deflection NEGATIVE deflection

WAVES. COMPLEXES, & INTERVALS

3 DISTINCT WAVES ARE PRODUCED DURING CARDIAC CYCLE

P wave caused by atrial

depolarization QRS complex caused by ventricular depolarization T wave results from ventricular repolarization

P wave
- starting in the SA node and spreading thru the atria; ATRIAL DEPOLARIZATION = 2.5 mm or less in ht. and 0.11s or less in duration

P wave
- starting in the SA node and spreading thru the atria; ATRIAL DEPOLARIZATION = 2.5 mm or less in ht. and 0.11s or less in duration

P wave
- starting in the SA node and spreading thru the atria; ATRIAL DEPOLARIZATION = 2.5 mm or less in ht. and 0.11s or less in duration

P wave
- starting in the SA node and spreading thru the atria; ATRIAL DEPOLARIZATION = 2.5 mm or less in ht. and 0.11s or less in duration

QRS Complex
- VENTRICULAR DEPOLARIZATION

= less than 0.12s in duration

PR interval - beginning of P wave to the beginning of QRS complex = 0.12 to 0.20s in duration

T wave - VENTRICULAR REPOLARIZATION

 ST segment:

Connects the QRS complex and T wave

QT Interval

Measured from beginning of QRS to the end of the T wave = 0.32 to 0.40s in duration (if 85 to 95 BPM) QT interval varies based on heart rate, gender, and age

 PP interval

- beginning of one P wave to the beginning of the next

RR interval - from one QRS complex to the next QRS complex - determine ventricular rate and rhythm U wave - repolarization of the Purkinje fibers

PROCEDURES
1. Verify the order for the ECG in the client's chart. 2. Confirm the client's ID by checking two client identifiers according to your facility's policy. 3. Provide privacy and explain the procedure to the client. Explain that the test records the heart's electrical activity and that it may be repeated at certain intervals. Emphasize that no electrical current will enter the body. Tell the client that the test typically takes about 5 minutes.

4. Wash your hands. 5. Place the ECG machine close to the client's bed and plug the cord into the wall outlet or, battery-operated, ensure that it is functioning. Turn on the machine and input required client information. If the client is already connected to a cardiac monitor, move the electrodes to accommodate the precordial leads. 6. Have the client lie supine in the center of the bed with arms at his sides. You may raise the head of the bed to promote comfort. Expose the arms and legs and cover the client appropriately. The arms and legs should be relaxed to minimize muscle trembling, which can cause electrical interference.

7. If the bed is too narrow, place the client's hands under his buttocks.

8. Select flat, fleshy areas to place the limb lead electrodes. Avoid muscular and bony areas. If the client has an amputated limb, choose a site on the stump.

9. If an area is excessively hairy, clip it. Clean excess oil or other substances from the skin with soap and water to enhance electrode contact.

10. Apply disposable electrodes to the client's wrists and to the medial aspects of the ankles. Apply the pre-gelled electrode directly to the prepared site, as recommended by the manufacturer's instructions. To guarantee the best connection to the lead wire, position disposable electrodes on the legs with the lead connection pointing superiorly.

 11. Expose the client's chest. Put a pre-gelled

electrode at each electrode position. If your client is a woman, be sure to place the chest electrodes below the breast tissue. In a large-breasted woman, you may need to displace the breast tissue laterally.

12. Connect the lead wires to the electrodes. The tip of each lead wire is lettered and color-coded for easy identification. The white or RA lead wire goes to the right arm; the green or RL lead wire, to the right leg; the red or LL lead wire, to the left leg; the black or LA lead wire, to the left arm; and the brown or V1 to V6 lead wires, to the chest electrodes. 13. Check to see that the paper speed selector is set to the standard 25 mm/second and that the machine is set to full voltage. The machine will record a normal standardization marka square that is the height of two large squares or 10 small squares on the recording paper.

 14. Ask the client to relax and breathe normally.

Tell the client to lie still and not to talk when you record the ECG. 15. Press the AUTO button. Observe the tracing quality. The machine will record all 12 leads automatically, recording three consecutive leads simultaneously. Some machines have a display screen so that you can preview waveforms before the machine records them on paper. If any part of the waveform height extends beyond the paper when you record the ECG, adjust the normal standardization to half standardization. Note this adjustment on the ECG strip because this change will need to be considered in interpreting the results.

 16. When the machine finishes recording the 12-

lead ECG, remove the electrodes and clean the client's skin. After disconnecting the lead wires from the electrodes, dispose of the electrodes.
17. Assist the client to a comfortable position.

Ensure the bed is in a low position.

18. Remove any remaining equipment and wash

your hands.

19. Document in your notes the test's date and time and significant responses by the client. Verify the date, time, client's name, and assigned ID number on the ECG itself. Note any appropriate clinical information on the ECG.

 LIFESPAN CONSIDERATIONS
Infant/Child When obtaining a pediatric ECG enlist the help of

the parents, if possible, try distracting the child to keep them still during the tracing. If artifact from either the arm or leg is a problem try moving the lead to a more proximal position on the extremity. Older Adult In older adults remove the electrodes carefully to prevent tearing of the skin, as adults grow older the skin becomes thinner and tears easily.

Special Considerations Small areas of hair on the client's chest or extremities may be clipped; clipping usually is not necessary.
If the client's skin is exceptionally oily, scaly, or

diaphoretic, rub the electrode site with a dry 4" 4" gauze pad or washcloth before applying the electrode to help reduce interference in the tracing. During the procedure, ask the client to breathe normally. If the respirations distort the recording, ask the client to hold his breath briefly to reduce baseline wander in the tracing.

 If the client has a pacemaker, you can

perform an ECG with or without a magnet, according to the physician's orders. Be sure to note the presence of a pacemaker and the use of a magnet on the strip.

Arrhythmias Detected on ECG

Arrhythmias are abnormal heart

rhythms TYPES: - Sinus - Atrial - Junctional - ventricular

SINUS BRADYCARDIA HR: less than 60 BPM RHYTHM: regular QRS SHAPE AND DURATION: normal P WAVE: normal and consistent shape PR INTERVAL; between 0.12 to 0.20s P: QRS RATIO: 1:1
SINUS TACHYCARDIA HR: greater than 100 BPM RHYTHM: regular QRS SHAPE AND DURATION: normal P WAVE: normal and consistent shape PR INTERVAL; between 0.12 to 0.20s P: QRS RATIO: 1:1

SINUS ARRHYTHMIA
HR: less than 60 BPM RHYTHM: regular QRS SHAPE AND DURATION: normal P WAVE: normal and consistent shape PR INTERVAL; between 0.12 to 0.20s P: QRS RATIO: 1:1

PREMATURE ATRIAL COMPLEX HR: depends on the underlying rhythm RHYTHM: irregular d/t P waves QRS SHAPE AND DURATION: normal or may be abnormal P WAVE: early and different P wave PR INTERVAL; between 0.12 to 0.20s P: QRS RATIO: 1:1 ATRIAL FLUTTER HR:AR: 250-400 BPM;VR: 75150bpm RHYTHM: regular QRS SHAPE AND DURATION: normal or abnormal or absent P WAVE: saw-toothed shape; F waves PR INTERVAL; multiple F waves

ATRIAL FIBRILLATION
HR: AR: 300-600Bbpm; VR: 120-200 bpm RHYTHM: highly irregular QRS SHAPE AND DURATION: normal or abnormal P WAVE: no discernable P waves PR INTERVAL; cannot be measured P: QRS RATIO: many:1

JUNCTIONAL RHYTHM
HR: VR: 40 to 60; AR: 40 to 60 RHYTHM: regular QRS SHAPE AND DURATION: normal or abnormal P WAVE: may be absent or inverted PR INTERVAL: less than 0.12s P: QRS RATIO: 1:1 or 0:1

PREMATURE VENTRICULAR COMPLEX HR: depends on the underlying rhythm RHYTHM: irregular d/t early QRS QRS SHAPE AND DURATION: 0.12s or longer, shape is bizarre & abnormal P WAVE: depends on the timing of PVC PR INTERVAL; less than 0.12s P: QRS RATIO: 1:1, 0:1 VENTRICULAR TACHYCARDIA

HR:AR: depends on the u.r. ;VR: 100-200bpm RHYTHM: regular QRS SHAPE AND DURATION:

VENTRICULAR FIBRILLATION HR: greater than 300bpm RHYTHM: extremely irregular QRS SHAPE AND DURATION: irregular IDIOVENTRICULAR RHYTHM HR:AR: 20-40 BPM RHYTHM: regular QRS SHAPE AND DURATION: bizarre, abnormal shape, 0.12s or more VENTRICULAR ASYSTOLE HR:AR: none RHYTHM: none QRS SHAPE AND DURATION: absent

1ST DEGREE AV BLOCK HR: depends on the underlying rhythm RHYTHM: depends on the underlying rhythm QRS SHAPE AND DURATION: normal or abnormal P WAVE: regular shape PR INTERVAL; greater than 0.20s, constant P: QRS RATIO: 1:1 2ND DEGREE AV BLOCK TYPE 1 HR:AR: depends on the underlying rhythm RHYTHM: regular (PP interval) QRS SHAPE AND DURATION: normal or abnormal P WAVE: depends on the underlying rhythm P: QRS RATIO: 3:2, 4:3, 5:4

2ND DEGREE AV BLOCK TYPE II HR: depends on the underlying rhythm RHYTHM: depends on the underlying rhythm QRS SHAPE AND DURATION: normal or abnormal P WAVE: depends on the underlying rhythm PR INTERVAL; constant just before QRS P: QRS RATIO: 2:1, 3:1, 4:1 3RD DEGREE AV BLOCK HR:AR: depends on the underlying rhythm RHYTHM: regular (PP & RR interval) QRS SHAPE AND DURATION: depends on the underlying rhythm P WAVE: depends on the underlying rhythm P: QRS RATIO: more P waves than QRS complexes