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# ECG or EKG

## I. Graphic recording of electrical activity of heart muscle (i.e. rhythm strip)

Can you have a normal EKG and have heart disease?
Yes
Can you have an abnormal EKG but no heart disease?
Yes
II. Made on grid that allows measurement of (See igure !"#! p\$%&)
'. Intensity of electrical events i.e. voltage
Each vertical s(uare ) *.% m+
,. -ime
Each hori.ontal s(uare ) *.*/ sec
Each large or thic0 1loc0 (& small 1loc0s) ) *.2* sec
5 large blocks = ____1____ sec?
3 large blocks = ___!______ sec?
"ertical lines on to# margin o\$ gra#h #a#er are usually 15 large blocks
a #art = ___3___ sec?
III. 3ead provides % view of heart4s electrical activity
3ead system made up of a positive (5) pole and negative (#) pole
Imaginary line 7oining 2 poles
,. Cardiac a6is
8irection of electrical current flow in heart
C. 9elationship 1etween lead a6is and cardiac a6is is responsi1le for deflection on EKG
(See igure !"#2 p\$%!)
,aseline is isoelectric line
i. :ccurs when there is no current flow in heart
%hen &ould this occur in relationshi# to de#olari'ation and re#olari'ation?
(\$ter com#lete de#olari'ation and also a\$ter com#lete re#olari'ation
If direction of electrical current flow in heart is toward the (5) pole; a positive deflection is
seen
)s this above or belo& the baseline?
above
If direction of electrical current flow in heart is moving away from (5) pole toward (#) pole; a
negative deflection is seen
)s this above or belo& the baseline?
belo&
If cardiac a6is is moving neither toward nor away from (5) pole; a 1iphasic comple6 (1oth
a1ove and 1elow 1aseline) is seen
%
I+. %2 lead EKG consists of %2 leads (or views) of heart4s electrical activity (See -a1le !"#%
p\$%/)
'. Electrodes placed on chest (chest or precordial leads) in " positions and on / e6tremities
(lim1 leads # 9'; 3'; 33; 93)< 9' always (#)< 33 always (5); 3' (5) or (#); 93 always
ground
,. Consists of
Standard 1ipolar lim1 leads = Each measures electrical activity 1etween 2 points and a /
th
(right leg) that acts as a ground electrode
ii. 3ead I> 9ight 'rm (#) 3eft 'rm (5)
iii. 3ead II> 9ight 'rm (#) 3eft 3eg (5)
iv. 3ead III> 3eft 'rm (#) 3eft 3eg (5)
'ugmented unipolar lim1 leads = consist of a positive electrode only (other end of the lead is
the center of the electrical field; at the center of the heart)
v. Meaning of letters
a = augmented; amplitude increased 1y &*?
+ = unipolar< electrical potential only recorded 1y (5) electrode
9 9ight 'rm (5)
3 3eft 'rm (5)
3eft 3eg (5)
a+9
a+3
a+
Chest (precordial) unipolar leads = determined 1y placement of the chest electrode
vii. +
%
+
"
viii. 9egisters electrical activity in hori.ontal plane
@ositioning of electrodes must 1e accurate and identical for comparison purposes
+. Components of normal EKG = See igure !"#&; p \$%"
'. @ wave
9epresents spread of impulse thru atria i.e. atrial depolari.ation
)s this the same as atrial contraction?
*o
Ahen electrical impulse is consistently generated from S' node; @ waves have a consistent
Ahen an impulse is generated from a different (ectopic) focus the shape of the @ wave
changes in the lead indicating an ectopic focus has fired
%hat does ecto#ic mean?
+i\$\$erent
2
,. @9 segment
Isoelectric line from end of @ wave to 1eginning of B9S
9epresents time re(uired for electrical impulse to travel thru
6. '+ node where it is delayed
6i. ,undle of Cis
6ii. ,undle 1ranches
6iii. @ur0in7e fi1ers
Dust 1efore ventricular depolari.ation
%hat #art o\$ the rhythm stri# sho&s atrial re#olari'ation?
%e don,t see the (tria re#olari'e because it is hidden under the -./ &ave0
C. @9 interval
Measured from 1eginning of @ wave to end of @9 segment
9epresents time for atrial depolari.ation as well as impulse delay in '+ node and travel time
to @ur0in7e fi1ers
Eormal> *.%2 = *.2* sec
1o& many small blocks is this?
5
8. B9S comple6
9epresents ventricular depolari.ation
6iv. B wave is the first negative deflection< It is small and represents ventricular
septal depolari.ation
6v. 9 wave is a positive deflection< It may 1e large; small or a1sent depending on
6vi. S wave is a negative deflection following the 9 wave and is not present in all
Measured from 1eginning of B (or 9) wave to end of S wave
%hy does it sometimes begin &ith an . &ave rather than a - &ave?
2he - &ave is the \$irst negative de\$lection and is not #resent in all leads0
%hat does it mean i\$ a - &ave is abnormally #resent in a lead?
%hen the - &ave is abnormally #resent in a lead3 it re#resents myocardial necrosis
4cell death5
E. B9S duration
9epresents time re(uired for depolari.ation of 1oth ventricles
Measured from 1eginning of B9S to D point
%here is the 6 #oint?
the 7unction &here the -./ com#le8 ends and the /2 segment begins
Eormal> *.*/ = *.%* sec
1o& many small blocks is this?
u# to three small blocks
. S- segment
Eormally isoelectric line
9epresents early ventricular repolari.ation
Measured from D point to 1eginning of - wave
Eormally not elevated F % mm or depressed F *.& mm from isoelectric line
S- elevation and depression can 1e caused 1y
!
6vii. Myocardial in7ury; ischemia or infarction
6viii. Conduction a1normalities
6i6. 'dministration of meds
G. - wave
ollows S- segment
9epresents ventricular repolari.ation
Gsually (5); rounded and slightly asymmetric
If an ectopic stimulus e6cites the ventricles during this time you can get the 9 on -
phenomenon
%hat is the . on 2 #henomenon
)\$ an ecto#ic stimulus e8cites the ventricles during this time3 it may cause ventricular
irritability3 lethal dysrhythmias3 and #ossible cardiac arrest in the vulnerable heart0
66. Can cause ventricular irrita1ility; lethal dysrhythmia; possi1le cardiac arrest in
vulnera1le heart
- waves may 1e tall; pea0ed; inverted (#) or flat due to
66i. Myocardial ischemia
66ii. K5 or Ca55 im1alances
66iii. Medications
66iv. 'ES effects
C. G wave
Eot normally seen in all leads
ollows - wave when present
May result from slow repolari.ation of ventricular @ur0in7e fi1ers
Cas same polarity as - wave although it is usually smaller
%hat does an abnormal 9 &ave suggest?
an electrolyte abnormality 4#articularly hy#okalemia5 or other disturbance
)\$ you are not sure &hether the de\$lection is a 9 &ave or a : &ave &hat should you
do?
noti\$y the health care #rovider and re;uest that a #otassium level be obtained0
I. B- interval
9epresents total time re(uired for ventricular depolari.ation and repolari.ation
Goes from 1eginning of B9S to end of - wave
May 1e prolonged 1y certain meds; electrolyte distur1ances; @rin.metal4s angina; or
su1arachnoid hemorrhage
D. 'rtifact
Interference seen on monitor or rhythm strip
May loo0 li0e a wandering or fu..y 1aseline
Can 1e caused 1y
66v. Client movement
66vi. 3oose or defective electrodes
66vii. Improper grounding
66viii. aulty EKG e(uipment
%hy is it so im#ortant to identi\$y arti\$act?
can mimic lethal dysrhythmias like ventricular tachycardia 4&ith tooth
brushing5 or ventricular \$ibrillation 4&ith ta##ing on the electrode5
/
i. 8etermination of Ceart 9ate
K. ! methods
" sec strip method (See igure !"#/ p\$%&)
66i6. 8etermine the num1er of B9Ss within " seconds and multiply 1y %*
666. Gse when rhythm is irregular
666i. 3east accurate method
,ig 1loc0 method
666ii. 8etermine num1er of large s(uares 1etween consecutive B9Ss (usually 9 to 9)
1o& many large blocks re#resent ! seconds?
3
666iii. 8ivide !** 1y that num1er
%hat does 3 re#resent?
the number o\$ large blocks in 1 minute
If little 1loc0s are left over when counting 1ig 1loc0s; count each little 1loc0 as *.2 and add to
num1er of 1ig 1loc0s
666iv. More accurate
666v. Gsed only when heart rhythm is regular (B9S comple6es are evenly spaced)
Memory method
666vi. ind B9S that falls on dar0 line and count dar0 lines 1ac0wards to ne6t B9S
Each dar0 line is a memori.ed num1er i.e. !**; %&*; %**; \$&; "*; &*; /!; !\$; !!; and !*
Gsed with regular rhythms
Most widely used in hospitals
Calculate the heart rate \$or the EKG stri# in <igure 3!=> #?15 using the !
second method0
30> big blocks@3A30>=BB0C3
%hy is the ! second method the a##ro#riate method in this situation?
2he heart rhythm is regular
3. Current monitoring systems display a continuous C9
%hat is the nurse,s res#onsibility i\$ using a continuous 1. monitoring system?
\$or accurate ECG rhythm inter#retation3 as &ell as \$or #atient assessment and
management0
M. EKG rhythm analysis (See igure !"#\$ p\$%H)
E. 8etermine Ceart 9ate
If atrial and ventricular rhythms are regular can use any method
Eormal> "* = %**
:. 8etermine heart rhythm
9egular or irregular (regularly irregular; occasionally irregular or irregularly irregular)
%hat is the di\$\$erence bet&een regularly irregular and irregularly irregular?
%hen the irregularity ha##ens at a constant it is regular3 &hen it ha##ens
inconsistently it is an irregular irregular rhythm??
&
Chec0 atrial and ventricular rhythm
666vii. 'trial
Chec0 regularity of @#@ interval
@ waves of a different shape create an irregularity
' slight irregularity of no F ! small 1loc0s is considered regular if all @ waves have same shape<
due to changes in intrathoracic pressure during respirations
666viii. +entricular
Chec0 regularity of 9#9 interval
B9S comple6es of a different shape create an irregularity
Same as a1ove for slight irregularity
@. 'naly.e @ waves
Chec0 for consistent shape indicating that impulse is originating from % focus usually S'
node
%hat &ould : &aves o\$ di\$\$erent sha#es indicate?
( dysrhythmia e8ists
Chec0 for one @ wave 1efore each B9S indicating that an impulse from % focus is responsi1le
for 1oth atrial and ventricular depolari.ation
B. Measure @9 interval
Eormally *.%2 = *.2 sec
Chec0 duration
Chec0 consistency i.e. are the @9 intervals constant across EKG strips
9. Measure B9S duration
Eormally *.*/ = *.%* sec
Measure from 1eginning of B9S to D point
Chec0 that measurement is constant throughout entire strip
If narrow (I *.*/ sec) ) impulse was not formed in ventricles i.e. supraventricular
%hat does su#raventricular mean?
(bove the ventricles
If wide (F *.%* sec) ) impulse is either of
666i6. +entricular origin
6l. Supraventricular origin
%hat does aberrant conduction mean?
deviating \$rom the normal course or #attern
Chec0 that B9S comple6es are similar in appearance
%hat does it mean i\$ -./ com#le8es have di\$\$erent sha#es?
dysrhtythmia
S. Interpret rhythm
"
Aith a1errant conduction
-. Eormal rhythms
G. ES9
%hat does */. mean?
*ormal sinus rhythm 4*/.5 is the rhythm originating \$rom the sinoatrial 4/(5 node
4dominant #acemaker5 that meets these ECG criteria
9hythm originating from S' node that meets following criteria>
9ate
6li. atrial and ventricular rates of "* = %** 1eatsJmin
@ waves .
6lii. @resent; consistent configuration; one @ wave 1efore each B9S
9hythm>
6liii. atrial and ventricular rhythms regular
@9 interval
6liv. *.%2 = *.2* sec and constant
B9S duration
6lv. *.*/ = *.%* sec and constant
+. Sinus arrhythmia
1o& is this rhythm di\$\$erent \$rom */.?
/inus arrhythmia has all the characteristics o\$ */. e8ce#t \$or its irregularity0 2he :: and
.. intervals vary3 &ith the di\$\$erence bet&een the shortest and the longest intervals being
greater than 01C second 4three small blocks5
+ariant of ES9
Ceart rate increases slightly during inspiration
Ceart rate decreases slightly during e6halation
Irregular rhythm fre(uently o1served in healthy children and adults
Cas all the characteristics of ES9 e6cept atrial and ventricular rhythms are irregular
6lvi. @#@ and 9#9 intervals vary with difference 1etween shortest @#@ or 9#9 interval
and longest @#@ or 9#9 interval 1eing F *.%2 sec
i. Eursing care
A. E6plain purpose and procedure so patient rela6ed and cooperative
K. Emphasi.e that machine records electrical energy produced 1y heart
L. Ensure ade(uate grounding of machine
M. Encourage to lie still
''. May as0 client with large 1reasts to displace 1reasts
,,. Ensure electrode placement is identical for each EKG
CC. Aash s0in 1efore placement of electrodes to decrease s0in oils and improve electrode
contact
88. @lace electrodes on flat surfaces a1ove wrists and an0les
EE. Eotify M8 of any suspected a1normality
\$
8ue to changes in intrathoracic
pressure during 1reathing or
. Continuous EKG monitoring
GG. Continual assessment of heart4s electrical activity in persons 0nown or suspected to have
dysrhythmia
CC. EKG ca1les can 1e attached
8irectly to a wall mounted monitor if patient restricted to ,9 or sitting in chair as in ICG
-o a 1attery operated transmitter held in pouch worn 1y client if patient am1ulatory as on
telemetry unit< EKG is transmitted via antennae located in strategic places to a remote
monitor
II. @lacement of electrodes
'll on trun0 to decrease artifacts
If & electrodes used
6lvii. 9' 7ust 1elow right clavicle
6lviii. 3' 7ust 1elow left clavicle
6li6. 93 on lowest palpa1le ri1 on right MC3
l. 33 on lowest palpa1le ri1 on left MC3
li. &
th
placed to o1tain % of " chest leads
lii. Aith this placement can monitor lead I; II; III; a+r; a+3; a+; or % chest lead
If ! electrodes used
liii. @lace 9'; 3'; and 33 as a1ove
liv. Aith this placement can monitor 3ead I; II; and III
Clarity of recordings affected 1y s0in preparation and electrode (uality
lv. Clean s0in and shave area prn
lvi. 8ry s0in
lvii. Ma0e sure gel on electrode is moist and fresh
lviii. Ma0e sure s0in free of lotion; tincture and other su1stances
li6. Chec0 tight seal 1etween; electrode and s0in
l6. Chec0 secure connections
l6i. 8on4t use irritated s0in or site with scar
Can unlicensed assistive #ersonnel 49(:5 a##ly the electrodes? %hat is the
nurse,s res#onsibility?
2he a##lication o\$ electrodes may be done by unlicensed assistive #ersonnel
49(:53 but the nurse must determine &hich lead to select and check \$or correct
electrode #lacement
)\$ acute care \$acility has monitor technicians to &atch a bank o\$ monitors on a
unit and inter#ret rhythms &hat is the nurse res#onsible \$or?
2he nurse remains ultimately res#onsible \$or accurate ECG rhythm inter#retation3
as &ell as \$or #atient assessment and management0
9outine strips; as well as any changes in rhythm are printed and documented in the patient4s
record
%ho is res#onsible \$or determining &hen monitoring can be sus#ended?
1ealth care #rovider
N