Oxygenation: Cardiovascular : Cardiac Assessment

Performing Electrocardiography

Purpose

1. To perform electrocardiography according to the standard of care.

Assessment

• Assess the client's medical record for information regarding the needs for an ECG.
• Assess the client's heart rate, heart sounds, and blood pressure.
• Assess the client's chest for areas of irritation, skin breakdown, or excessive hair growth that may interfere with the electrode placement.

Equipment

• ECG machine
• Recording paper
• Disposable pre-gelled electrodes
• 4" × 4" gauze pads or washcloth
• Optional: clippers, marking pen

Procedure

1. Verify the order for the ECG in the client's chart.
   Rationale: Verification of order prevents potential errors.
2. Confirm the client's ID by checking two client identifiers according to your facility's policy.
   Rationale: Checking identification ensures client safety through concept of correct procedure for correct client.
3. Provide privacy and explain the procedure to the client. Explain that the test records the heart's electrical activity and that it may be repeated at certain intervals. Emphasize that no electrical current will enter the body. Tell the client that the test typically takes about 5 minutes.
   Rationale: Explanation of procedure protects client's rights and encourages participation in care.
4. Wash your hands.
   Rationale: Handwashing reduces transfer of microorganisms
5. Place the ECG machine close to the client's bed and plug the cord into the wall outlet or, battery-operated, ensure that it is functioning. Turn on the machine and input required client information. If the client is already connected to a cardiac monitor, move the electrodes to accommodate the precordial leads.
   Rationale: Moving electrodes and keeping client away from electrical fixtures and power cords will minimize electrical interference on ECG tracing.
6. Have the client lie supine in the center of the bed with arms at his sides. You may raise the head of the bed to promote comfort. Expose the arms and legs and cover the client appropriately. The arms and legs should be relaxed to minimize muscle trembling, which can cause electrical interference.
   Rationale: This position increases client comfort. Relaxing arms and legs reduces trembling and creates a better tracing.
7. If the bed is too narrow, place the client's hands under his buttocks to prevent muscle tension. Also use this technique if the client is shivering or trembling. Make sure the feet are not touching the bed board.
8. Select flat, fleshy areas to place the limb lead electrodes. Avoid muscular and bony areas. If the client has an amputated limb, choose a site on the stump.
   Rationale: Tissue conducts current more effectively than bone, which produces a better tracing.
9. If an area is excessively hairy, clip it. Clean excess oil or other substances from the skin with soap and water to enhance electrode contact.
   Rationale: Do not shave hair; shaving causes microabrasion on skin.
10. Apply disposable electrodes to the client's wrists and to the medial aspects of the ankles. (See Positioning Chest Electrodes.) Apply the pre-gelled electrode directly to the prepared site, as recommended by the manufacturer's instructions. To guarantee the best connection to the lead wire, position disposable electrodes on the legs with the lead connection pointing superiorly.
    Rationale: Positioning lead connections superiorly guarantees best connection to lead wire
11. Expose the client's chest. Put a pre-gelled electrode at each electrode position. If your client is a woman, be sure to place the chest electrodes below the breast tissue. In a large-breasted woman, you may need to displace the breast tissue laterally.
    Rationale: Proper lead placement ensures accurate test results.
12. Connect the lead wires to the electrodes. The tip of each lead wire is lettered and color-coded for easy identification. The white or RA lead wire goes to the right arm; the green or RL lead wire, to the right leg; the red or LL lead wire, to the left leg; the black or LA lead wire, to the left arm; and the brown or V1 to V6 lead wires, to the chest electrodes.
    Rationale: Proper setup ensures proper functioning.
13. Check to see that the paper speed selector is set to the standard 25 mm/second and that the machine is set to full voltage. The machine will record a normal standardization mark—a square that is the height of two large squares or 10 small squares on the recording paper.
14. Ask the client to relax and breathe normally. Tell the client to lie still and not to talk when you record the ECG.
    Rationale: Having client relax and remain still will produce a better tracing.
15. Press the AUTO button. Observe the tracing quality. The machine will record all 12 leads automatically, recording three consecutive leads simultaneously. Some machines have a display screen so that you can preview waveforms before the machine records them on paper. If any part of the waveform height extends beyond the paper when you record the ECG, adjust the normal standardization to half standardization. Note this adjustment on the ECG strip because this change will need to be considered in interpreting the results.
    Rationale: Note any adjustments made during tracing to ensure accurate interpretation of results.
16. When the machine finishes recording the 12-lead ECG, remove the electrodes and clean the client's skin.
17. After disconnecting the lead wires from the electrodes, dispose of the electrodes.
    Rationale: Proper disposal reduces spread of microorganisms.
18. Assist the client to a comfortable position. Ensure the bed is in a low position.
    Rationale: Repositioning of bed promotes client safety.
19. Remove any remaining equipment and wash your hands.
    Rationale: Handwashing reduces transfer of microorganisms
20. Document in your notes the test's date and time and significant responses by the client. Verify the date, time, client's name, and assigned ID number on the ECG itself. Note any appropriate clinical information on the ECG.

Sample Documentation
10/10/10	1700	Client complained of substernal chest pain 9/10. Sublingual NTG administered as ordered. EKG obtained. Vital signs as per flow sheet. Dr. Smith at the bedside to assess client and review ECG. At 1705, client rated chest pain 0/10. Natalie Conway,RN

POSITIONING CHEST ELECTRODES

To ensure accurate test results, position chest electrodes as follows: V1 : Fourth intercostal space at right border of sternum V2 : Fourth intercostal space at left border of sternum V3 : Halfway between V2 and V4 V4 : Fifth intercostal space at midclavicular line V5 : Fifth intercostal space at anterior axillary line (halfway between V4 and V6 ) V6 : Fifth intercostal space at midaxillary line, level with V4

Lifespan Considerations

Infant/Child

• When obtaining a pediatric ECG enlist the help of the parents, if possible, try distracting the child to keep them still during the tracing. If artifact from either the arm or leg is a problem try moving the lead to a more proximal position on the extremity.

Older Adult

• In older adults remove the electrodes carefully to prevent tearing of the skin, as adults grow older the skin becomes thinner and tears easily.

Special Considerations

• Small areas of hair on the client's chest or extremities may be clipped; clipping usually is not necessary.
• If the client's skin is exceptionally oily, scaly, or diaphoretic, rub the electrode site with a dry 4" × 4" gauze pad or washcloth before applying the electrode to help reduce interference in the tracing. During the procedure, ask the client to breathe normally. If the respirations distort the recording, ask the client to hold his breath briefly to reduce baseline wander in the tracing.
• If the client has a pacemaker, you can perform an ECG with or without a magnet, according to the physician's orders. Be sure to note the presence of a pacemaker and the use of a magnet on the strip.