ELECTROCARDIOGRAM (ECG)

ELECTROCARDIOGRAM (ECG) Electrocardiogram or electrocardiograph is a diagnostic tool used in assessing the cardiovascular system. It is a graphic recording of the electrical activity of the heart.

TYPES OF ECG

1. 12 Lead ECG (12LECG)

Commonly used to diagnose myocardial ischemia or infarction, high or low calcium and potassium levels and effects of some medications.

2. 15 Lead ECG

Three (3) additional chest leads across the precordium and is a valuable tool for the early diagnosis of the Right ventricular and posterior left ventricular infarction.

3. 18 Lead ECG

early detection of myocardial ischemia and injury

WAYS TO OBTAIN AN ECG

1. Standard 12 Lead ECG

V1 > 4th intercostals space, right sternal border (Red)

V2 > 4th intercostals space, Left sternal border (yellow)

V3 > diagonally between V2 and V4 (green)

V4 > 5th intercostal space left mid-clavicular line (brown)

V5 > same level as V4 anterior axillary line (black)

V6 > same level as V4 and V5 mid-axillary line (violet)

2. Hardwire Monitoring

3-5 electrodes ( cardiac monitor) 3. Telemetry

Small box that the patient carries and continuously transmits ECG information by radio waves to a central monitor elsewhere ( wireless)

4. Holter Monitor

10-24 hours

small, lightweight tape recorder like machine, continuously records the ECG on a tape which is later viewed and analyzed with a scanner

5. Trans-telephonic Monitoring

The patient attaches a specific lead system for transmitting the signal and places a telephone mouth piece over the transmitter box: The ECG is recorded and evaluated at another location. ELECTROCARDIOGRAM LEAD PLACEMENT

A. Limb electrode placement

B. Standard 12 Lead ECG Placement

C. 15 Lead ECG Placement

D. 18 LEAD ECG PLACEMENT

ECG PAPER

(Indicate the Name, age and the initial BP of the patient in the lower part of the ECG paper)

CARDIAC MONITOR

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 12leads 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.

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.

LA Left Arm

RARight Arm

RLRight leg

LLLeft Leg

LA Yellow

RA Red

RL Black

LL Green