ecg work book

7/30/2019 ECG Work Book

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Obtaining anAccurate

ECG


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Welcome to the ECG workbook for health care providers. If you are going tobe regularly carrying out ECGs in your clinical setting then you need to haveread this information.If you have been trained to perform patient ECG previously then this sessionwill 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 toas a refresher.Once you have completed the theory you will need to watch a demonstrationof ECG technique in your unit setting with an experienced peer.You are then required to perform at least two ECGs one on a male patientone on a female patient for assessment with your Clinical Resource Nurse oryour Charge Nurse, or a designated senior nurse. The assessment formaccompanies this document.

For your competency to remain current you are currently required to performone 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 6monthly on two patients.

Ideally nurses will complete the initial theory package as part of theirorientation to the clinical setting where electrocardiographs are regular toolsof practice and then as often as they feel necessary as a refresher or to clarifypoints of interest. A quiz follows this theory package which you will need tocomplete and return to the Clinical Resource Nurse for marking and feedback.

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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?

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Workbook Objectives


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What is an ECG?

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

It is important to remember that all an ECG does is report on the electrical activity ofa persons heart. The ECG does not replace full nursing assessment of the clientand is only useful as a tool when used in conjunction with an understanding of thepatients 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.

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Introduction

Example of a normal ECG


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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.

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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, electrodestickers, some machines use armbands for the limb lead electrodes.(do not mix electrode brands)

Conductive cream where using armband or sucker bulbs(do not useanything other than specified conductive cream.)

ECG Paper in the paper feed.

Disposable razor,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 topreventing 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 mainsduring a procedure you need to earth the machine with the cableprovided. Dont forget to plug the machine back into the mains whennot in use.

Preventing Cross Infection:Wash hands before and after each procedure. Use disposableelectrodes on isolated patients and thoroughly wipe down the machineafter use.

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Equipment and Maintenance

For skin prep


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Wash reusable electrodes in warm soapy water. Dry well.

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 theirclothing from the waist up. That they will need to lie flat and thatyou may need to shave some hair off where the electrodes are tobe attached. Stress the importance of relaxing and lying still andnot speak while the ECG is recording.

How do I position the patient and prepare their skin for theprocedure?

Approach the Patient from their left side.Have the patient remove their, clothing from the waist up and any socksstockings if using leg bands. Remove watches or metal jewelry that maycontact the electrodes. Disconnect any electrical machinery around thebed. 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 theircondition 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 alcoholswab or deodorant if skin is sweaty, oily or dirty.

The machine: disconnect the machine from the mains or earth. Makesure the ECG is on the appropriate settings ie Paper speed = 25 msecVoltage +10 mV and the filter is off.

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Preparing a Patient for an ECG?


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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 downpalpating 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 leadon top of breast then document.Dressings/wounds If this requires you to leave of chest leads thendocument which ones and why.Babies/Small children remove V3.

Filter: Avoid using the filter as it can remove important variations in theECG that are significant in diagnosing such as ST elevation. However ifunable to remove artifact after troubleshooting (see next page), youmay filter the ECG but must document that the ECG is filtered andpresent 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


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

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

Somatic Artifact (Noise) Can be caused by poor electrode placement, patientmovement, muscle tremor

Wandering Baseline: Can be caused by a loose contact, dirty/greasy/sweaty skin,poor contact or respiratory swing.

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What is Artifact?

Trouble Shooting:Turn of electrical equipment,remove bed end, move bed awayfrom the wallReplace electrodes, Check skinprep, check connectors and leadsfor signs of damage.

Trouble Shooting:Encourage Patient to relax, keepwarm, and ensure adequate painrelief.Move the limb electrodes further upthe limb.

Trouble Shooting. Encourage Patientto relax, have them hold their breathfor 3-6 secounds and not talk. Checkelectrodes.


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Ensure that the ECG is dated and timed. (Dont trust the date and time on themachine)

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 unusualposition.

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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Documentation


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Barker,G 2000, ECG Workshop for Health Professionals, South Auckland HealthPublication

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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References


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Obtaining an Accurate ECGObtaining 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?________________________________________________________________________________________________________________________________________________________________________________________________

5. 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 MrCollins 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) Normal paper speed for ECG tracings is 25msec

d) It is never acceptable to filter an ECG

e) The normal voltage setting for an ECG tracing is 10 mV

f) 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: WARD/DEPT:

Completed ECG education and quiz Date 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 ofelectrical 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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