Recording

ElectroCardiogram
(ECG)

Alfrina Hany, S.Kp, M.Ng (Acute Care)

Keperawatan Medikal Bedah I kelas Reguler 2/10/2019
Outline of lecture;

• Definition of ECG
• Reasons for Performing ECG
• Types of Leads ( 12, 15, 18 Leads)
• Types of ECG (Stress ECG, Continuous ECG
• Important Clinical Consideration
• Preparation
• Placement of electrodes
• References
 Electrocardiography (ECG or EKG*)

• the process of recording the

electrical activity of the heart
over a period of time using
electrodes placed on a patient's
body.
 Electrocardiography (ECG or EKG*)

• These electrodes detect the

tiny electrical changes on the
skin that arise from the heart
muscle depolarizing during
each heartbeat.
ECG, EKG
It is the procedure of recording the electrical activity of the heart. The
electrode combination records the difference of potential difference at two
sites on the body. The potential differences are produced due to the electrical
activity of the heart.

Electrocardiograph is the machine

Electrocardiogram is the record

The characteristic shape and timing of the ECG waves are due to the spread
of wave of depolarization and repolarization associated with each heart beat.
• The ECG is not only the
oldest but, in fact, over
100 years after its
introduction, continues
as the most commonly
used cardiovascular
laboratory procedure.
What does the ECG look like?
Electrocardiography (ECG or EKG*)

• In a conventional 12 lead ECG, ten electrodes are placed on the patient's

limbs and on the surface of the chest recorded over a period of time
(usually 10 seconds).

• A typical ECG tracing is a repeating cycle of three electrical entities:

a. a P wave (atrial depolarization)
b. a QRS complex (ventricular depolarization)
c. a T wave (ventricular repolarization).
Types of Leads used in Obtaining
ECG
1. Standard 12 Lead
Most commonly used tool to diagnose:
• Dysrhythmias
• Conduction abnormalities
• Enlarged heart chambers
• Myocardial ischemia or infarction
• High / low calcium and Potassium level
• Effects of some medications
Types of Leads used in Obtaining
ECG
2. 15 Lead ECG

• 3 chest leads are added across the right precordium

• A valuable tool for early diagnosis of Right ventricular
and posterior left ventricular infarction
Types of Leads used in Obtaining
ECG
3. 18 Lead ECG

• 3 chest leads are added from the 15 lead ECG

• Early detection of Myocardial Ischemia and injury
ECG measures the following:

• rate and rhythm of heartbeats

• the size and position of the heart chambers
• the presence of any damage to the heart's muscle
cells or conduction system
• the effects of cardiac drugs
• the function of implanted pacemakers.
Reasons for performing electrocardiography
include:
1. Suspected heart attack
2. Suspected pulmonary embolism
3. A third heart sound, fourth heart sound, a cardiac
murmur or other findings to suggest structural
heart disease
4. Perceived cardiac dysrhythmias
Reasons for performing electrocardiography
include:
5. Fainting or collapse
6. Seizures
7. Monitoring the effects of a heart medication
8. Assessing severity of electrolyte abnormalities, such
as hyperkalemia
 Types of ECG

1. Stress Electrocardiography

• Uses ECG to assess the client’s

response to an increased cardiac
workload during exercise using
treadmill or stationary bicycle
 Stress Electrocardiography

• Goal of this test: to increase the

heart rate to the target rate

• Client with Coronary artery disease

may develop chest pain and
characteristic ECG changes during
exercise
 When to Terminate Stress Test

1. When Target heart rate is achieved

2. When patient experiences symptoms /
complications:
• Chest pain
• Extreme fatigue
• Decrease in BP/ PR
• Serious dysrhythmia or ST segment
changes in ECG
 Nursing Responsibility for
Stress Electrocardiography
Monitor :
• Two or more ECG leads for HR, rhythm
and ischemic changes
• BP
• Skin temperature
• Physical appearance
• Perceived exertion
• Symptoms ( chest pain, dyspnea,
dizziness, leg cramping, fatigue)
 2. Continuous Electrocardiographic
Monitoring

• Standard for patients who are at risk

for dysrhythmias

• Patients should be informed that this

monitoring will not detect symptoms
such as dyspnea or chest pain,
therefore, patients need to be
advised to report symptoms to the
nurse whenever they occur
 Important clinical considerations

• Correct lead-placement and good skin contact are essential.

• Avoid electrical interference (machine to be earthed).
• Compare serial tracings, if available.
• Relate any changes to age, gender, clinical history, etc.
• Consider co-morbidities and intercurrent illnesses that may have
an effect on the ECG.
• Obtain a photocopy for future reference.
• Interpret the ECG systematically to avoid errors.
 Obtaining 12-lead ECG

Recording the 12-Leads ECG

Explanation
• Tell the patient that the doctor has ordered an ECG and explain the
procedure
• Emphasize that the test takes about a few minutes and that it’s a safe
and painless way to evaluate cardiac function
• Answer the patient’s question, and offer reassurance. Preparing him well
helps alleviate and promote co-operation
 Obtaining 12-lead ECG

Prepping the Patient

• Ask the patient to lie supine in the center of the bed with his arms at his
sides
• If he can’t tolerate lying flat, raise the head of the bed to semi-Fowler’s
position
• Ensure privacy, and expose the patient’s arms, legs, and chest

Selection of the Electrode Sites

• Choose spots that are flat and fleshy, not muscular or bony
• Clean excess oil or ather substances from the skin to enhance electrode
contact. Remember – the better the electrode contact, the better the
recording
 Preparation

1. Ensure that the client did not receive any medication

2. Ask your pt to remove all jewelry and to wear a hospital

gown

3. Usually ECG is taken while the patient is resting so ask your

pt to lie down

4. Areas such as the chest where the adhesive electrodes will

be placed may need to be shaved first, then skin is cleaned
 Preparation
5. Avoid oily or greasy skin creams and lotions the day of
the test. They interfere with the electrode-skin contact

6. Avoid full-length hosiery, as electrodes need to be placed

directly on the legs.

7. Wear a shirt that can be easily removed to place the leads

on the chest.
 Obtaining 12-lead ECG

Steps in recording the ECG

• Know your machine

• Set the ECG paper speed selector to 25mm/second. If
necessary, enter the patient’s identification data. Then
calibrate or standardize the machine according to the
manufacturer’s instructions.
• Plug the cord of the ECG machine into a grounded outlet. If the
machine operates on a charged battery, it may not need to be
plugged in.
• Place one or all of the electrodes on the patient’s chest, based
on the type of machine you’re using.
• Make sure all the leads are securely attached, and then turn on
the machine.
Placement of electrodes

• Ten electrodes are used for a 12-lead ECG.

• The electrodes usually consist of a conducting gel, embedded in the
middle of a self-adhesive pad onto which cables clip. Sometimes the gel
also forms the adhesive. They are labeled and placed on the patient's
body
• Proper placement of the limb electrodes, color-coded
• The limb electrodes can be far down on the limbs or close to the
hips/shoulders, but they must be even (left vs right)
Electrode
Electrode placement
label
RA On the right arm, avoiding thick muscle.
LA In the same location where RA was placed, but on the left arm.
RL On the right leg, lateral calf muscle.
LL In the same location where RL was placed, but on the left leg.
 Chapter 27 Management of Patients

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Figure 27-2 ECG electrode placement. The standard left pre-
cordial leads are V1—fourth intercostal space, right sternal bor- Waves,
der; V2—fourth intercostal space, left sternal border; V3—diago-
nally between V2 and V 4; V 4 —fifth intercostal space, left The EC
midclavicular line; V5—same level as V4, anterior axillary line; V6 the QR
(not illustrated)—same level as V4 and V5, midaxillary line. The of segm
right precordial leads, placed across the right side of the chest,
• Instruct patient to be calm and no movement, Then print the
result
• The test is completely painless and takes less than a minute
to perform once the leads are in position.
• After the test, the electrodes are removed & clean the skin
 Obtaining 12-lead ECG

nInstruct the patient to relax, lie still, and breathe normally. Ask him not to talk
during the recording to prevent distortion of the ECG tracing.
nPress the AUTO button and record the ECG. If you’re performing a right chest lead
ECG, select the approriate button for recording.
nObserve the quality of the tracing. When the machine finishes the recording, turn
it off.
nRemove the electrodes and clean the patient’s skin.
Obtaining 12-lead ECG

Documentation
• Date
• Time
• Doctor’s name
• Nurse’s name
• Special circumstances : vital sign, client’s condition
 Obtaining 12-lead ECG

Troubleshooting
Problem Cause Solution
Power line AC Poor electrode contact. Abrade skin. Use new electrodes.
interference Dry or dirty electrodes Reapply electrodes.

Power line AC Lead wires may be picking Route lead wires along limbs and away
interference up interference from from other equipment. Fix or move poorly
poorly grounded grounded equipment
equipment near the patient

Power line AC Patient cable is too Move cardiograph away from the
interference close to the cardiograph patient. Unplug the cardiograph and
or other power cords operate on battery only. Move other
equipment away from the patient
 Problem Cause Solution
Wandering Electrode Be sure that the lead
baseline movement. Poor wires are not pulling on
electrode contact the electrodes. Reapply
and skin electrodes. Press the
preparation “filter”key

Patient movement Reassure and relax the

patient

Respiratory Move lead wires away

interference from areas with the
greatest respiratory
motion
Obtaining 12-lead ECG
Obtaining 12-lead ECG

Problem Cause Solution

Tremor or muscle Poor electrode Clean the electrode
artifact placement. Poor site. Be sure the
electrode contact. limb electrodes are
Patient is cold placed on flat, non-
muscular areas.
Warm the patient
Tense, Reassure and relax
uncomfortable the patient. Press
patient the “filter”key
Tremors Attach the limb
electrodes near the
trunk. Pressthe
“filter”key
Obtaining 12-lead ECG

Problem Cause Solution

Intermittent or Poor electrode Clean the electrode
jittery waveform contact. Dry site. Reapply
electrodes electrodes
Faulty lead wires Replace faulty
patient cable
Poor print quality Dirty printhead or Clean printhead or
ink has finished change the ECG
stylus

Emergency Nurses Chapter, 2001

References
• Brunner & Suddarth’s Medical Surgical Nursing.
10th ed
• Kozier & Erbs’ Fundamentals of Nursing . Eighth
ed. 2008