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INTRODUCTION

Cardiovascular disease is not just a disease of the elederly, 45% of all heart attacks occur in
people under the age group of 65 years. Because of the high incidence of heart disease and
the seriousness of its complications the nurse must know how to assess the cardiovascular
system. Assessment of the cardiovascular system incorporates data obtained from history
taking, physical examination and diagnostic studies including ECG.
As the body fluids and tissues are good conductors of electricity. The electrical changes
which occur by the contraction of myocardium can be detected by attaching electrodes to the
surface of the body. The pattern of electrical activity may be displayed on tread on paper.
The apparatus used in called as an electrocardiograph and the tracing is called as an ECG.
The ECG was invented and introduced by Willem Einthoven in the year 1893. Among the
health care professional nurse are the persons who provide care for the client in all times. So
that nurses must have the knowledge regarding ECG and able to interpret ECG. It helps in
physicians to save the patients life in time with standing orders.
CONDUCTION SYSTEM THE HEART:
The hear has an intrinsic system where by the cardiac muscle is automatically stimulated to
contract without the need for external stimulation.
Sino Artial Node(S A Node)
Sinoartial node(S A node) is the one of the important nodal tissue which is intitaated
impulses from right atrium and spreads lefte atrium. It is also called primary pace maker.
Impulses finally teavels towards SA node to AV Node to take 0.1 sec.
Atrio Ventricular Node (A V NODE):
Atrio ventricular node (A V NODE): is present in between atrium and ventricules. It
receives the impulses from sino artial node. It is also act as secondary pacemaker.
Purkinje Fibers:
The excitation then moves through the Bundle OF His and along the intraventricular
septum by way of the left and right bundle branches. The left bundle branch has two
fascicles, an anterior and a posterior. From there the wave diffuses widely trough the walls of
both ventricles by means purkinje fibers.
DEFINITION:
ECG is a graphical recording of electrical activity of the heart as detected by
electrodes attached to the surface of the skin.

TYPES OF ECG
Signal average ECG
Is used to record and process low level signals that are not detected by an ECG.
Halter monitor or continuous monitor
The client wears a portable halter monitor an ECG training is recorded continuously
over a period of time a day or longer. it is used to identify dysrhythmias
Exercise ECG:
It is done to detect coronary heart diseases here a controlled and carefully supervised
exercise done to evaluate the myocardial oxygen demand and to evaluate the coronary
arteries abilities to meet the demands. The two major modes of exercise used for stress testing
are:
1. Bicycle ergonometric
2. Tread mill testing
PURPOSE:

To assess the cardiac functions


To identify rhythm of the heart
To diagnosis cardiac diseases
To find out electrolyte imbalances
To detect the presence of heart injury
To detect size and position of the heart
To used for those who cant exercise for an ECG stress test.

INDICATIONS

Causes of chest pain


Myocardial ischemia &infarction
Cardiac arrhythmia
Heart muscle diseases
Heart rate determination
Effects of medications (especially cardiac drugs)
Palpitations
Pericarditis
Electrolyte imbalances especially potassium
Effect of systemic diseases an heart (i.e. renal and pulmonary diseases)

12 LEAD ECG
1. LEADS
The standard ECG has 12 lead system offering 12 points of reference for recording the
electrical activity of the heart. It measure the difference in electrical potential between two
points. The standard ECG has 12 leads
1. Standard leads
2. Chest leads or precordial leads
Standard Leads: The standard leads obtain a graph of the electrical forces as recorded
between limbs. The standard leads divided into two
1. Standard limb leads (Bipolar) 3
2. Augmented limb leads (Unipolar)- 3
Standard limb leads (Bipolar):
The standard limb leads obtain a electrical forces as recorded between two limbs at a
time. It also called as bipolar leads. There are three standard limb leads namely
Leads- I measures the difference in the electrical potential between the left arm and
right arm
Leads- II - measures the difference in the electrical potential between left leg and
right arm
Leads- III - measures the difference in the electrical potential between the left leg and
left arm.
Augmented limb leads
Augmented limb leads obtain a graph of the electrical forces as recorded from one
limb at a time. Therefore the Augmented limb leads are also called unipolar leads.
aVR - measures electrical potential between the center of the heart and right arm
aVL - measures electrical potential between the center of the heart and left arm
aVF - measures electrical potential between the center of the heart and left leg
Chest leads or precordial leads
V1- In the fourth intercostal space just to the right of the sternum (breastbone).
V2 - In the fourth intercostal space just to the left of the sternum
V3 - Between leads V2 and V4.
V4 - In the fifth intercostal space in the mid-clavicular line

V5 - left anterior axillary line at the same level of V4


V6 - midaxillary line at the same level of V4 and V5
SUMMARY OF THE LEADS
Standard leads

Limb leads

Bipolar leads

I,II,III

Unipolar leads

aVR, aVL,aVF

Precordial leads

V1-V2

Lead orientation
We have thus seen that the 12 lead ECG consists of the following 12 leads recorded in
successions. I, II, II, aVR, aVL, aVF, V1,V2,V3,V4,V5,V6.
2. WAVES
P wave- represents the depolarisation of atrium. It will take time of less than 0.11 sec
QRS represents the depolarisation of ventricles. It will take time of 0.04 to 0.11
T - Represents the repolarization of the ventricles.
U wave - represents the repolarization of the interventricular septum.
J wave represents the junctions where the QRS complex and ST segment beginning
PR interval - The PR interval is measured from the beginning of the P wave to the
beginning of the QRS complex. The PR interval reflects the time the electrical impulse
takes to travel from the sinus node through the AV node and entering the ventricles. It
will take time 0.02 to 0.2 sec
ST segment - the ST segment connects the QRS complex and the T wave. The ST
segment represents the period when the ventricles are depolarized.it will take time of 0.04
to 0.03 sec
QT interval - The QT interval is measured from the beginning of the QRS complex to
the end of the T wave. it will take time of interval of 0.43 sec in women 0.42 sec in men.
3. Graph paper
The ECG paper is marked like a graph consisting of horizontal and vertical lines. There
are five lines marked 1 mm apart every fifth line is marked boldly. The bold lines are
placed 5 mm apart.
Time is marked along the horizontal axis in and voltage is marked along the vertical axis
in millivolts. During ECG recording the usual paper speed is 25 mm per second. This

means that 25 small square are covered in one second. Each small square signifies 0.04
seconds and each large square 0.2 seconds.
ECG PROCEDURE AND NURSES RESPONSIBILITY
Preparation

Explain the purpose procedure

Avoid heavy meals before procedure

Avoid smoking and alcohol before procedure

Wear a loose cotton comfortable dress

No hot water bath 1-2 hours before procedure

Continue all drugs unless restricted by physician

Before procedure do through physical examination done

During procedure BP and ECG are closely monitored

Observe the client for any symptoms like chest pain, dyspnea, drop BP

Emergency trolley with equipment and drugs should be kept ready

Articles

ECG machine

Electrodes for ECG lead

Jelly of electro conductive

Front open gown or shirt

Tissue paper

Procedure
1. Explain the purpose of ECG and procedure to the patient reassure patient that
procedure is painless and safe
2. Advice the patient to remove all metallic jewels because at alter conduction and
impulses
3. Ask female patients to remove all tight clothes and wear the loose gown or shirt
4. Ensure proper standardization of machine

Set at 25 mm/sec

Provide standard 1 mV signal to ECG machine so that the spike made


will be 10 mm or 2 large square in height.

5. Ask the patient to lie in supine position and be as relaxed as possible


6. Provide privacy by pulling the curtains around the patient

7. Expose chest completely. Apply electro conductive jelly on lead placement sites
and position all electrodes appropriately

Check the colour codes of limb leads

Place suction electrodes at appropriate sites

Ensure proper contact between the lead and skin

8. Instruct the patient that you are going to start the recording and should be lie still
in the bed without moving and talking till the recording is complete, which may
tale 5-10 min
9. To record the limb leads, chest leads and automatic recording.
10. Check the ECG record for all leads
11. Inform patient that ECG recording is complete.

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