ELECTROCARDIOG
RAM
ELECTROCARDIOGRAM
An ECG is a recording of waveforms that reflects the electrical
activity of the heart.
An Electrocardiogram is a graphic record of the electrical
impulses that are generated by depolarization & repolarization
of the myocardium.
INDICATIONS
Palpitation, cyanosis, chest pain, syncope, seizure, poisoning
Signs tachycardia, bradycardia, hypothermia, murmur, Shock
Evaluation of rheumatic heart disease, congenital heart diseases
Evaluation of suspected electrolyte imbalance
During cardiopulmonary resuscitation (CPR)
Evaluation of patients with implanted defibrillators and pacemakers
To detect myocardial injury, ischemia, and the presence of prior infarction
as well.
CONTRAINDICATIONS
No absolute contraindications patient refusal, exist.
patients allergies to adhesive used to affix the leads
LEAD SYSTEM
12-lead ECG
10 electrodes required to produce 12-lead
ECG
4 Electrodes on all 4 limbs (RA, LL, LA, RL)
6 Electrodes on precordium (V1–6)
LEAD SYSTEM
CHEST LEADS-6
V1,V2,V3,V4,V5 & V6
V1-Electrode positioned in the 4th intercostal
space in the right sternal border
V2-4th ICS in the left sternal border
V3- Midway between V2&V4
V4-5th ICS in the left midclavicular line
V5- Same level as V4, anterior axillary line
V6-Same level as V4 & V5, midaxillary line
4 Electrodes on all 4 limbs (RA, LL, LA, RL)
1. Right Arm
2. Right Leg
3. Left Arm
4. Left Leg
LEAD SYSTEM
12- lead ECG: Provides multiple electrical views of
the heart along a vertical & horizontal plane.
6 limb leads
6 chest leads
LIMB LEADS-6
3 Bipolar limb leads ( Standard limb leads )- I, II,&
III
3 Unipolar Augmented leads (aVR, aVL & aVF)
LEAD SYSTEM
LEAD I
The electrical events between the negative right arm
(RA) and positive left arm (LA) electrodes
LEAD II
The signal between the negative RA and positive left leg
(LL) electrodes
LEAD III
The signal between the negative LA and positive LL
electrodes
These leads provide information about the electrical
activity of the heart in the vertical plane, specifically
between the upper and lower extremities.
LEAD SYSTEM
•aVR: Augmented vector right, with the positive electrode on
the right arm
•aVL: Augmented vector left, with the positive electrode on
the left arm
•aVF: Augmented vector foot, with the positive electrode on
the left leg
They are unipolar leads, ie the negative pole is a
combination of signals from other electrodes
LEAD SYSTEM
Monitors 12 leads (V1–V6), (I, II, III) and (aVR,
aVF, aVL)
Allows interpretation of specific areas of the
heart
Inferior (II, III, aVF)
Lateral (I, aVL, V5, V6)
Anterior (V1–4)aVR
ECG PATTERN
ISO-ELECTRIC LINE : It occurs when there is
no current flow.
POSITIVE DEFLECTION: If the current flows
toward the lead, i.e. above the baseline
NEGATIVE DEFLECTION: If the current flows
away from the lead. ie, below the baseline.
Left ventricle has more influence on the
ECG, because of its increased muscle mass.
NORMAL ECG
Letters P, Q, R, S, T.
P wave represents atrial contraction,
duration of 0.04 to 0.11 sec
P wave duration is less than 0.12
seconds
QRS complex represents ventricular
depolarization and is composed of 3
waves, the Q, R & S.
Q wave is the first negative deflection.
R wave is the first positive deflection
after the p wave.
S wave is the negative deflection
following r wave.
NORMAL ECG
PR interval Measured from the beginning
of P wave to the beginning of QRS
complex.
The normal PR interval is 0.12 - 0.2 sec,
represented by 3-5 small squares.
The time it takes for the impulse to
spread from atria to ventricles.
ST segment An isoelectric line
representing early ventricular
repolarisation.
NORMAL ECG
T wave Represents ventricular
repolarisation.
Usually positive, rounded
U wave Results from slow repolarisation
of ventricular Purkinje fibers.
More common in lead V3. Hypokalemia.
QT interval Represents total time
required for ventricular depolarization &
repolarisation.
From the beginning of QRS complex to
the end of T wave.
Normal QT interval is 0.36 to 0.45 sec.
A prolonged QT interval may lead to
ventricular tachycardia.
ECG PAPER
The paper is divided into a grid of small and large
squares
The horizontal axis measures time in seconds
The vertical axis measures the amplitude of the wave or
deflection in volts
The paper speed is usually 25 mm/sec
Each small square is 1 mm and represents 0.04 seconds
Each large square is 5 mm and represents 0.2 seconds
ECG INTERPRETATION
Heart rate:
•As per speed of the paper, one minute is equal to
1500 small squares or 300 big squares.
Rhythm
•Whether the waves are repeated at regular interval
in consecutive beats.
Normal Sinus Rhythm
•P wave One ‘p’ Infront of every QRS, 3mm in height
ECG INTERPRETATION
•PR interval gradually lengthens in (2nd degree heart block)
•ST segment ST depression in ischemia
•ST elevation in acute myocardial infarction
•T wave Positive except in aVR.
•Inverted T wave is found in ischemia, RVH, LVH, severe
hypokalemia.
•Tall ‘T’wave in moderate hyperkalemia.
NURSING IMPLICATIONS
No preparation of the client is necessary
Explain the procedure & reassure him that the procedure is absolutely safe & he will not
be electrocuted.
In coronary care units, the nurses must be familiar with ECG monitoring & must be able to
detect the development of abnormalities.
Abnormal changes should be reported immediately
Ensure good contact between the client’s skin & the electrodes by applying electrode jelly
to the skin where the electrode is attached.
NURSING IMPLICATIONS
The client should lie flat & as relaxed as possible, because any movements
or muscular twitching recorded by the machine may alter the tracings.
The bystanders should be kept away from the client to prevent them
touching during ECG procedure. The client should not wear ornaments
during ECG.
If it is unavoidable, care should be taken that the leads should not come in
contact with the ornaments.
NURSING IMPLICATIONS
The machine should be properly grounded to prevent interference with
the recording.
The nurses should ensure the correct placement of leads while taking ECG.
The improper placement of chest leads can greatly distort the tracing and
alter the diagnosis.
No other electric equipment should work in the monitoring area.
SHORTCOMINGS OF ECG
50% percent of all patients with AMI have no ECG
changes.
A patient may have a normal ECG, present pain free
& still have significant risk for myocardial ischemia
Several disease processes can mimic that of an AMI,
including Left bundle-branch blocks, Ventricular paced
rhythms, and Left Ventricular Hypertrophy.
