Electrocardiography
electrocardiography
doctors office or ambulatory care clinic 12-lead ECG
12 lead ECG
holter monitor
cardiac stress testing
hospital
chest pain
syncope
dizziness
altered mental status
portable ECG machines
telemedicine
types of EKG
Defibri;;attors
automated external defibrillator
AED
oppertunities
ECG / EKG tecnician
telemetry Technician
cardiovascular Tecnhologist
preparing for electrocardiography
legal and ethhcal issues
laws
what we must do
ethics
what we should do
standards of behavior based on our morals and values
professional liability
HIPPA
health insurance portabiloty and accpuntability act
oprotection for patient's healthcare information
patient determines who can and cannot see and use information
information is onlyy shared with those involved
legally responsible for his/her slactions
slander - making derogatory remarks verbally
libel - making derogatory remarks in writing
follow scope of practice
documentation
supports and provides proof of procedure
electronic
paper
consent
writtn
verbal
implied
patent education
keys to sucess
comminication
positive relationship
active listening skills
skilled interview techniques using open ended questions
communication
assiting in understanding te procedure and following instructiins
disability
culture and language
religion
developmental level
gender
Blood pressure
force at which blood is pumped against the alls of the arteries
systolic is higher number on top
diastolic number is smaller number seen on bottom
blood pressure equiptment
stethoscope
sphygmomanometer
use correct BF cuff size
placed 2/3 the distnace between the elbow and shoulder
BP cuff and stethoscope should not touch
body position
supine or sitting position with back support
feet supported and legs uncrossed
arms pplaced at the level of the hart and supported
palpatory method
1 palpate the redial pulse
2 inflate BP cuff until radial pulse is no longer felt
3 add 30 mm of hg to reading
4 total two numbers
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lesson 2 electrocardiography
standard limb leads
bipolar leads
lead 1 right and left arms
lead 11 right and left leg
lead 111 left arm and left leg
bipolar leads
measure the electrical acivity in two directions
form einthoven's triangle
right leg is not included but rather is a ground lead
Augmented leads
unipolar leads
aVR
aVL
aVF
right arm
left arm
left foot
chest leads
precordial leads
unipolar
v1 through V6
leads aand waveforms
staandard leads and waveforms
standard lead 1, 11, 111 produce positive defections on the graph
augmented leads and waveforms
augmented lead a VR produces a negative deflection
augmented leads a VL and aVF produce positive deflections
chest leads and waveforms
chest leads V1 through V6 are precordial leads , providing a view of the heart from different angles
pqrst complex
p eave occurs at the begining of atrial contraction or depolarization
PR interval represents complete atrial contraction 0.12 to 20 seconds
qrs complex represents contraction or depolarization , of the ventticles 0.01 to .12 seconds
ST segment is the time between the end of ventricular contraction and the begining of relaxation
t wave represents ventricular relaxation or repolarization
QT itnterval starts at the begining of QRS through the end of the T wave
u wave can follow t wave
types of machines and technolgy
electrocardiograph
three and six channel recorders
produce a page of 12 tracings
recordig=ng takes about 10 seconds
single channel recorders less common used one lead recorded at a time
3 basic functions
input
signal processing
output display
advancing tecnology
records diretly to a coumputer and into the
can be transmitted electronically to other locations
basic controls
speed control
gain
LCD display
heart rate limits
lead selector
regulates hoe fast or slow the paper runs through the ECG nmachiine
standard is 25 mm / second
increased to 50 mm second for a fast heart rate
decreased to 5 or 10 mm for a very slow heart rate
always document any apeed changes
regulates the heaight of the QRS complex
standard is 10 mm / mV
patient data is entered
displays error information
displays ecg results
are used to set a high and low limit for heart rate
a lead selector allows a lead to be run seperatly
analarm will sound if the patients goes ebove or below the minit
used of one of two leadss need to be reapeated and run seperatly
electrocardiograph equiptment
electrodes
placed on the patients skin in sopecific locations
conduct electrical activity to the ECG machine
self adhesive with electrolytegel
completely remove after procedure
must be sealed in package or plastic
if they dry out or expire don not use
graph paper
heat and preassure sensitive
ECG styus is hot mari=king the paper with the electrical acivity of the heart
heart rate calculations
more space between QRS complexes, the slower the heart rate
less space between the QRS complexes the faster the heart rate
the 300 method
also called the R to R method (large box)
least accurate
300 large boxes equal 1 minute strip
determine how many large boxes between two r waves and divide into 300
the 1500 method
most accurate calculation
0.-4 x 1500 = 60 seconds
1500 small boxes equal 1 minute strip
determine how many small boxes between two R waves and divide into 1500
6 second method
only method used when the patient has an irregular rhythm
6 second section of tracing is equal to 150 small squares or 30 large squares
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elecrtrocardiography
procedure preparation
room preparation
procedure performance
set up with procedure table and ECG table
keep ECG supplies stocked
ECG machine on cart
equiptment preparation
relenish if nessessary
test movement of paper through machine
patieent preparation
joint commission requires two identifiers to verify crrect patient
name
date of birth
hospital ID or medical record number
pateint consent
verbal consent
implied consent by actions
refusal is patients right
alert physician if patient declines or refuses consent
LCD display
enter into LCD display
name
hospital id or medical record number
date or birth
age and gender
medications being taken
vital signs
patient instructions
reassure the patient
provide privacy to disrobe
put on gown with opening in the front
long pants are rolled up
remove jewelry that may interfere with leads
keep patient safe and comfortable
raise patient to a 45 degree angle if breathing problems are present
use proper body mechanics if nessessary to lift or move patient
artifacts
somatic tremor
wandering baseline
altering current
interrupted baseline
caused by muscle movement
provide a few minutes for the patient to relax
ask patient put their hands under their buttocks witht he palms down
due to patient moving or loose electrode
check electode connections
remind the patient to lie still
caused by interference from other electrical devices
unplug any equipment plugged into the same outlet or near the
ecg machine
caused by interruped in connection
check for frayed or loose lead wire
electrocardiogram performance
pediatric ECG EKG
dealing with a child and parent /guardian
privide simple directions
allow the child to touch the equiptment
provide assurance that the procedure will not hurt
smaller electrodes available
v 3 can be placed on the right of the eternum if electrodes are crowded
v3 R
cardiac monitoring
only reqires placment of three leads
placement can vary depending on the system used
additional considerations
amputees - limb leads placed on upper arms/ thighs or torso
right sided ECG
STEMI
dextrocardia
posterior ECG
may be ordered by a physician for a ppatient with an inferior wall myocardial infarction MI
V 7 V8 V9 on left
V7 -R V8 -R and V9- R on right side
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handling emergencies
check the patient s status
check vital signs in nessessary
call for help
CPR is started if patient has no carotid pulse and is not breathing
ECG waves and intervals
waaves intervals and segments
segment
a portion of the atrial of ventricular contraction producing a complete waveform
complex
a portion of the atrial or ventricular contraction producing a complete waveform
waves
pr interval
QRS complex
p wave
small upward curve
contraction of the atria
includes p wave and space prior to Q wave
beginning of atrial relaxation ( repolarization
beginning of ventricular contraction (depolarization)
includes QRS waves
completrion of ventricular contraction
completion of atrial relaxation (repollarization
0.06 to .12 seconds
J point indicates end of time period
ST segment
from end of QRS complex to beginning of t wave
beginning of ventricular relaxation (repolarizationn )
T wave
small upwaard cureve
complete relaxation of ventricles (repolarization
QT interval
includes QRS complex and ST segment and T wave
entire time period pf ventricular contraction and relaxation
U wave
not always seen
small upward curve following T wave
identification and rhythm
waveforms
p waves reresent atrial depolarization (contraction of the attria
QRS complexes represent ventricular depolarization (contraction of the ventricles
p waves
calipers or boxes can be used for measurment
p to p intervals
are they equal across the 6 second tracing
qrs complexes
calipers or boxes can be used for measurment
measure from the same wave for each (from R to R waves)
hear ratte
for regular rhythm, use
300 method
1500 method is the most accurate
6 second method
p wave morphology
are the p waves clearly present ?
do they have consistant appearance
do they occur at regular intervals
does each p wave have qrs complex following it
pr interval
represents the duration of time for the sinoatrial SA node to fire spontaneously
0.04 seconds per small block
4.5 x .04 = 0.18 seconds
qrs complex
represents the amount of time it takes for the ventricles to repoloarize
2.8 x 0.04 = .11 seconds
should be less than 0.12 seconds
sinus ryhythm
depolarization and repolarization
cardiac output
amount of blood the heart pumnpes each minute
normal cardiac output
alert and oriented
no difficuty breathing
no chest pain
or pressure
stable blood pressure
patient status
check status with abnormal rhythm
check bp and pulse
inform physician or nurse to assesss the patient
symptoms include
change in mental status or dizziness
chest pain or discomfort
difficulty breathing
low blood pressure
other sinus rhythms
simus bradycardia
originates in sinus node
travels the normal electrical pathway
rate is below 60 beats per minute
sinus tachycardia
rate is above 100 beats per minute
originates in sinus node
travels the normal electrical pathway
sinus dysrhythmia
heart rate remians the same
p to p and r to r intervals are irreular
sinus arrest
SA stops fireing
causes a pause n electrical activity (asystole )
if pause is 2 seconds and regular, it will cuase low blood pressure syncope and dizziness
Atrial dysrhythmias
atrial flutter and fibrillation
atrial flutter
lmpulse occurs in the atrial tissue instead of SA node
rapid impulse causes a sawtooth or picket-fence pattern and flutter waves
atrial fibrillation
regular rythm
rate between 250-350 beats per minute
p waves are not seen
electrical impulse does not fully contract the atria
the atria will quiver, producing a chaotic wave on the tracing
ryythm and rate cannot be determined
p waves are not present
PR interval cannot be measured
atrial dysrhythmias
premature atrial contraction PAC
early electrical impulse causes pac
interrupts the regular rhythm
wandering atrial pacemaker WAP
rythm can be slightly irregular
pr intervals vary due to different P wave shapes
usually no signs or symptoms
multifocal atrial tachycardia MAT fast rate
fast rate
different p waves from beat to beat
caused by an acte condition
check vital signs and contact physician immediatly
junction and complex and rhythms
types
premature junction complex PJC
PJC occurs early, before the expected QRS complex
electrical impulse originates in the SA node
travels throught the atrial ventriclar AV node
and atrial ventriculrar bundle
impulse travels throught eh interventricular septum to the maningie finders
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p wave can be inverted
burried in the qrs complex
follow the qrs complex
the Patient will probably not show and signs of symnptoms unless there are 4-6 pjcs in a row
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additnonal arrhythmids
junctional escape rythm and accelerated junctional rhythm are simular
AV junction pacemaker
p wave may be inverted or may not be seen
effecs on patient
patneit with junctional escapse rythm and rate between 40- and 60 may dusplay low bp and altered mental status
patient with accelerated junctional rythm and rate between 60-100 may not display any symptoms
junctional tachyycardia
p wave is inverted or not seen at all
rate between 100 to 150 beats per minute
superventricular tachycardia ST
rate of 100-200 beats per minute
p wave is difficult to identifuy
p wave can be buried in T wave or can occure before , during or after the QRS complex
stable patient
unstable patient
low cardiac output
palpitations
racing feeling in chest
low bloood pressure
mental status changes
difficulty breathing
junctional abnormality identification
junctional abnormality identifcication
rake five steps for ECG analysis to determine junctinal dysrhythmias because the elctrical imulse is coming from the AV junction insteadof the SA node
1 rhythm
determination of the rhythm
2 rate
determinatrion of the rate
3 p wave
shape of the p wave
4 PR interval
measurment of the PR interval
5 QRS complex
duration and shape of the qrs complex
junctinal rhythms are simular
rhythms are regular
p wave, if seen, are often inverted
PR interval willl not be able to be determined if p wave is not seen
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First degree atrioventricular Block
types
First degree AV block
due to delay in conduction from the SA node to the AV junction
p-p interval is anylyzed first
r-r is regular
rate is within normal limits between 60-100 bpm
p wave us consistant and uorgt
qrs dyration is within normal limits
second degree AV block
pr interval is abnormal
normal pr interval is between 0.12 and .20 secinds
7 x 0.04 = . 28 pr interval duration
no patient status change
always momotor the patient
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two types due to blocked or no conduction , of electrical impulse from the SA node to the ventricles
mobits tyoe 1 (wenchebach
mobitz type 11
pp interval is regular
r-r interval is iregular
p wave is normal shape
pr intervals progressively gets longer , usually greater than .2 seconds in duration
lengthen... lengthen ... drop... equals wenckebach
p-p is regular
r-r is regular or iregular
p wave is normal is shaoe
pr interval is consnant with i=missing qrs complexes
patient status
low cardiac output with heart rate of 40 bpm or lower
patint status
high unstable
low cardiac output
critiical condition
can quickly progress to third degree block
third degree AV block
complete heart block CHP
no cardiac pattern
atria and ventricles contracting independently
p-p intervals is measured first and is regular
r-r interval is regular
atrical rate is within nrmal
ventricular rate is between 20 and 40 bpm
p wave if seen has normal shape and size
pr interval and qrs complex vary in diration
ventricular dysrhythmias part 1
premature ventricular complexes PVCs
cuased by early impulse in the ventricles
diagram on video
if thr mpulse occurs somwhere inthe pathway betwen 2 qnd 3 instead of 3 and 4 a pvc would be a result, caffine, alchollh or other cuases hormonal
p-p interval is regular
r-r interal is regular
rythm is irrreguar due to pvcs
can appear as a single complex or in a row
six second method must be used with this irregular rhythm
include the irregular waves too
idioventricular rhythms
rae skow 20-40 bpm
rate elivated is 40-100 bpm is accelerated
p-p interval cannot bw determined
r-r interval os regular
p wave is absent
qrs complex is wide and bizarre in apperance
ventricular tachycardia
continuous contraction and relaxation of ventricles
no p waves
qrs complexes are wide and unusual
can tolerate this dysryhthmia for a short time
over 50 % of patients will become unconcious immediately with V tach
tosades de pointes
twisted of points due to electrolyte deficiencies
waveforms point up and downn appear twisted
ventricular fibrillation
quivering ventricles with v fib
wave forms cannot be determined
unrespencive patient with no pulse or respirations
cpr will be initiated
code blue or ems will be activsated
other types of dysrythmias
pvcs
unifocal - single pvc
multifocal - pvcs with multiple shapes
interpolated- pvc with no interuption in the rhythm
bigeminy - a pvc every second beat
trigeminty
happens every third beat
quadgeminy
a pvc every fourthb eat
couplign pvcs occur back to back
agonal rhythm
rate lower than 20 qrs complexes are wide
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profound loss of cardiac output requires advanced cardiac support
asystle
absence of any ventricular activity
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Right Bundle branch block (RBBB)
right pathway is blocked
conduction reverses and continues only on the left
rate and rhythm can vary
qrs are widened and have a bunny ear appearance
left bundle branch block
rate and rythm can vary
qrs are widened and have a negative deflection
both arent life threatening alone
underlying condition can be life theatening
pacemakers
pacemakers
two basic parts
electrical generator
two or three lead wires
corrects dysrhythmias
implanted under the skin
pacemaker function
electrical capture
evidence on ecg tracing
mechanical capture
hearts ability to respond as a pump
confirmed by taking blood pressure and pulse measurments
confirmed by improved cardiac output
pacemaker spikes
artiral tracing
ventricular pacing
atrial ventricular spoieks
both spikes
cardiac testing
strss test
reasons
to diagnose cause of chest pin
to determine functional capacity after hear suegery oor myocardial infraction
to screen for heart disease
st segment depression
may be seen on resting ecg
can be a sign of myocardial infarction injury or ischemia
myocardial ischemica delays 1 mm or greater ST depression on ecg
stemi
ST emevation ML
current MI in orogress
non stemi n stemi
mi without ST elevation
stress test preparation
obtain consent and provide instructions
no caffine or alchol=hol prior to the test
no tabaco or beta blockers on the day of test
no food or beverages four hours prior to test
stress testing sensors
vi through v6 placed in same locaton as ecg
placed at right and left clavical areas instead of arms placed at right and left lower abdomen instead of legs
stress test monitorn=ing
report arrhythmias
monitor blood pressure continuously
pulse oximetry
monitored during stress test
oxygen level sa o2 below 90% is a sign of carida distresss
stress test
use n tredmill and monitors
transitions to increased speed and incline every 3 minutes
target heart rate
220 patients age x 0.85 = targe heart rate
protocals based on age , weight and other factors as determined by cardiologist
220 0- 65= 155
155 x 0.85 =132
stress test complications
test willll be stioed if the patient expereinces
syncope
nausea and vomiting
intense chest pain
shortness of breath extream atigue
syncope is a result of decreased oxygen to the brain and an aed may require for cardaic arrest
one pad placed on the rght ofupper sternum
one pad paced at ledt miaxillary line
other types of carida c testing
chemical stress test
invasive testing procedure
moitored as awith and stress test
iv carido active medications are given to mimic stresss placed om the heart during exercise
nuclear stress test
invac=sice stres test
iv cardiac medications are given
radioacive stracer is used eith gramma camera
echocardiogram
used sound to study the heart valves and major vessles
atress echocadriogram combines sound and a tredmill
chemical stress echocardiogram combines sound and chemical
mobile cardiac monitoring
24- 48 hour monitor
worn while going about normal daily activities
patient will keep a diary of events
digital recorders
three to five sensors
five lead is most comon
three lead is oldest method
holter monitor
provides a complete tracing of the ECG from application to removal
two v1 leads
white at the right sternal border
red at right sternal border
two v 5 leads
black at left anterior axillary line
brown at the left sternal brorder
ground lead
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green at right thoracic or abdominal area
patient diary
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record name and date and time, date of birth and startinf=g date
the patient will record the date and tune oid=f any events and symptoms
all unusua and usual daily activituties are recorded
date and time of medication taken is recorded
care
do not change rotuien
do not shower or bath w
do not remove electrodes
do not remove batterie s
do not move leads if they become loose , reattach and note time of occurance
contact physician o f any issies, ithcing or scratching
review diary
remove device
clean skin
record date and time of removal in diary
telemetry monitoring
may ue three or five leads
no diary is needed
monitored at centra location
inpatient central location monitoring
three electrode placment
white lead right sholder
black lead
left sholder
red lead abdoninal area
five electrode placmetn
same as three lead
white leade right shoulder "black lead left sholder "red lead abdominal area
two additional leads
green lead ground
right lower abdomen
brown lead to the right of the sternum
screensa re observed for abnormalities
mobile cardiac outpient rtelemetry
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