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Obtaining an Accurate ECG

Welcome to the ECG workbook for health care providers. If you are going to be regularly carrying out ECGs in your clinical setting then you need to have read this information. If you have been trained to perform patient ECG previously then this session will act as a refresher to your previous training and experience. You are required to complete this theory component before you begin taking ECGs and may then repeat the programme when ever you feel you need to as a refresher. Once you have completed the theory you will need to watch a demonstration of ECG technique in your unit setting with an experienced peer. You are then required to perform at least two ECGs one on a male patient one on a female patient for assessment with your Clinical Resource Nurse or your Charge Nurse, or a designated senior nurse. The assessment form accompanies this document. For your competency to remain current you are currently required to perform one ECG a year for assessment with a clinical assessor, or if you have not performed an ECG in 6 months then you need to be clinically assessed 6 monthly on two patients. Ideally nurses will complete the initial theory package as part of their orientation to the clinical setting where electrocardiographs are regular tools of practice and then as often as they feel necessary as a refresher or to clarify points of interest. A quiz follows this theory package which you will need to complete and return to the Clinical Resource Nurse for marking and feedback.

Workbook Objectives

After reading this workbook you should be able to answer these questions.

What is an ECG? Why is an ECG useful? When might I need to record an ECG? What equipment do I require to record an ECG? Are there any Safety issues I need to consider when recording an ECG? How do I prepare a Patient for an ECG? - What do I say to them? - How do I position them? - What skin preparation is necessary? - Where do I place the electrodes? - What if..? What is Artifact? What can I do to eliminate it? What should I document where?

Introduction

What is an ECG?
An Electrocardiogram, ECG, reflects the electrical activity of the heart. Ten electrodes (or leads) are attached to a patients arms, legs, and chest. The electrodes detect the electrical impulses generated by the heart, and transmit them to the ECG machine. The ECG machine produces a graph (the ECG tracing) of those cardiac electrical impulses. (Even though there are only ten electrodes the ECG machine is able to calculate twelve different perspectives.)

Example of a normal ECG It is important to remember that all an ECG does is report on the electrical activity of a persons heart. The ECG does not replace full nursing assessment of the client and is only useful as a tool when used in conjunction with an understanding of the patients history and condition.

Why is an ECG useful?

An ECG is a tool that can assist medical staff to recognise and measure Heart Rate Heart Rhythm Heart Blocks Atrial and Ventricular abnormalities Ischemia or Injury.

When might I need to record an ECG?

As a baseline recording - In the assessment of : Chest pain Sudden alteration in heart rate New irregular pulse Palpitations, dizziness, altered level of consciousness, syncope. To record the serial progression of a Myocardial infarction To monitor effects of some medications.

Equipment and Maintenance

What equipment do I require to record an ECG?

12 lead ECG machine 10 cables connected to machine. 10 electrode connecting clips for dots and stickers. 10 electrodes either sucker bulbs, red or blue dots, electrode stickers, some machines use armbands for the limb lead electrodes. (do not mix electrode brands) Conductive cream where using armband or sucker bulbs(do not use anything other than specified conductive cream.) ECG Paper in the paper feed. Disposable razor, For skin prep Deodorant or alcohol swabs

Are there any Safety issues I need to consider when recording an ECG?
As with all electrical equipment good maintenance is a key to preventing electrical faults. The Machinery: Dont run over the cables Drape the cables over the machine untangled when not in use. Keep the battery charged by plugging into mains when not in use. Clean equipment with a damp cloth, avoid excessive water.

NB: ECG machines are best run on battery. If you have to plug into mains during a procedure you need to earth the machine with the cable provided. Dont forget to plug the machine back into the mains when not in use. Preventing Cross Infection: Wash hands before and after each procedure. Use disposable electrodes on isolated patients and thoroughly wipe down the machine after use.
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Wash reusable electrodes in warm soapy water. Dry well.

Preparing a Patient for an ECG?

What do I say to the Patient?

Introduce yourself. Check the patients identification. Explain the procedure to the patient. Reassure them that it is a painless procedure that only takes about five minutes. Explain that they will need to remove their clothing from the waist up. That they will need to lie flat and that you may need to shave some hair off where the electrodes are to be attached. Stress the importance of relaxing and lying still and not speak while the ECG is recording.

How do I position the patient and prepare their skin for the procedure?
Approach the Patient from their left side. Have the patient remove their, clothing from the waist up and any socks stockings if using leg bands. Remove watches or metal jewelry that may contact the electrodes. Disconnect any electrical machinery around the bed. Ensure that the patient is not touching the metal bed ends. Lie the patient flat or at no more than a 30-degree angle if their condition doesnt allow them to lie flat. (leave one pillow) Shave the area where you are going to place electrodes if hairy. Wipe the skin where you are going to place the electrodes with alcohol swab or deodorant if skin is sweaty, oily or dirty. The machine: disconnect the machine from the mains or earth. Make sure the ECG is on the appropriate settings ie Paper speed = 25 msec Voltage +10 mV and the filter is off.

Where do I place the electrodes?

Place the arm leads on the inside wrist (marked RA & LA) Place the leg leads on the inner lower leg (RL & LL) V1: Fourth intercostal Space and right Sternal Boarder. (Find the jugular notch (see diagram) Move down and palpate the solid Manubrium until you come to the angle of Lois. Directly to the right of the angle of Lois is the second right rib. Below the second right rib is the second intercostal space. Move your fingers down palpating the next two ribs. Below the fourth rib and to the right of the Sternal Boarder is the fourth intercostal space.) V2: fourth intercostal space on the left Sternal Boarder. V4: left side, fifth intercostal space, Mid Clavicular line. (in line with the middle of shoulder blade) V3: Half way between V2 and V4 V5: Same level as V4 at anterior axillary line V6: Same level as V4 at midaxillary (middle of armpit) line.

What if.?
Amputees: Place Electrodes on stump in line on other leg/arm. Large Breasts: Place V3 on breast and V4-6 underneath. If placed lead on top of breast then document. Dressings/wounds If this requires you to leave of chest leads then document which ones and why. Babies/Small children remove V3. Filter: Avoid using the filter as it can remove important variations in the ECG that are significant in diagnosing such as ST elevation. However if unable to remove artifact after troubleshooting (see next page), you may filter the ECG but must document that the ECG is filtered and present both the filtered and unfiltered ECG to the Dr.
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Lead Placement

Diagram from: Grauer,Ken. 1998, A Practical Guide to ECG Interpretation . Second Edition. Mosby. USA

What is Artifact?

What is Artifact? What can I do to eliminate it?

60-Cycle interference: Can be caused by faulty electrodes or leads, dry or dirty electrodes, poor contact, coupling between patient and equipment or between ECG and other equipment.

Trouble Shooting: Turn of electrical equipment, remove bed end, move bed away from the wall Replace electrodes, Check skin prep, check connectors and leads for signs of damage.

Somatic Artifact (Noise) Can be caused by poor electrode placement, patient movement, muscle tremor Trouble Shooting: Encourage Patient to relax, keep warm, and ensure adequate pain relief. Move the limb electrodes further up the limb.

Wandering Baseline: Can be caused by a loose contact, dirty/greasy/sweaty skin, poor contact or respiratory swing. Trouble Shooting. Encourage Patient to relax, have them hold their breath for 3-6 secounds and not talk. Check electrodes.

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Documentation

Ensure that the ECG is dated and timed. (Dont trust the date and time on the machine) Attach Patient label. Note if patient had chest pain at time of ECG. Note if ECG was filtered, leads were left off or patient was in an unusual position. Ensure that the Dr that requested the ECG is notified that it is ready for review. Document in the notes that the ECG was taken and the Dr notified.

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References

Barker,G 2000, ECG Workshop for Health Professionals, South Auckland Health Publication Crawford,M Spense,M 1995 Commonsense Approach to Coronary Care, sixth Ed. Mosby USA Grauer,K 1998, A Practical Guide to ECG Interpretation. Secound Ed. Mosby USA Mee,C Possanza,C 1997 How to Record an Accurate 12-Lead ECG. Nursing, March. South Auckland Health Nursing Privileging/ Credentialling Committee, 1998,.

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Obtaining an Accurate ECG

1. List five situations where an ECG may be indicated as a diagnostic tool. ________________________ ________________________ ________________________ ________________________ ________________________ 2. List five things an ECG can be used to detect. ________________________ ________________________ ________________________ ________________________ ________________________ 3. How many electrodes are used in a 12 lead ECG? 4. How can you prevent cross infection when obtaining an ECG? __________________________________________________________________ __________________________________________________________________ ____________________________________________________________ Mr Collins is a fit 65-year-old man being admitted for an Inguinal Hernia Repair. The Doctor has requested a routine ECG. Write a paragraph explaining to Mr Collins the reason for the ECG, and what it will involve. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
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6. Answer each question true or false a) The ECG machine is best positioned on the Right side of the patient.

b) Water is an acceptable conductive medium when using reusable electrodes. c) d) e) f) Normal paper speed for ECG tracings is 25msec It is never acceptable to filter an ECG The normal voltage setting for an ECG tracing is 10 mV It is acceptable to leave lead v3 off a baby or child.

7. List seven things you need to document on an ECG. ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ 8. If a doctor is not available to review an ECG what can you do? 9. List 5 things you can do to avoid or correct tracings that look like these.

________________________ ________________________ ________________________ ________________________ ________________________ ________________________

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10. Indicate where you would place the chest leads on the diagram below.

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ECG SKILLS TRAINING RECORD

NAME:
Completed ECG education and quiz Date

WARD/DEPT:
Signature

GUIDELINES FOR PRACTICAL ASSESSMENT OF ECGs

Demonstrated Competency taking an ECG record on two selected patients
COMPETENCIES

COMMENT

THE PATIENT
Identifys patient as per Hospital policy Explains to the patient the procedure Appropriately requests patients to prepare chest Ensures patient is supine and relaxed Recognises and removes where possible potential sources of electrical interface THE EQUIPMENT Machine is used on battery wherever possible. If must be mains powered, earth lead is connected appropriately Unnecessary electrical connections to the patient are identified and turned off THE PROCESS Appropriate amount of electrolyte used Accurate chest lead positions Appropriate limb lead positions Patient relaxed Artefact-free recording produced - if artefact initially present, identification and elimination performed Recording scanned for serious arrhythmias Trace labelled appropriately Electrodes removed and skin wiped COMPLETION Trace is labelled appropriately Electrodes are cleaned OUTCOMES Accurate chest lead placement Artefact recognised and eliminated No artificial filtering of signal Trace labelled correctly

Completed two practical ECGs

Date

SIGNATURE:

When you have completed the above practical assessments please forward your Training Record to Clinical Resource Nurse Al Rahba Hospital.
(This will be returned to you with your certificate).

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