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7.article - Nurse Method For Quick Interpret ECG
7.article - Nurse Method For Quick Interpret ECG
DENISE ATWOOD, JD, RN; DIANA L. WADLUND, MSN, RN, CRNFA, ACNP-BC
Disclaimer
Accreditation AORN recognizes these activities as CE for RNs. This
AORN is accredited as a provider of continuing nursing recognition does not imply that AORN or the American
education by the American Nurses Credentialing Center’s Nurses Credentialing Center approves or endorses products
Commission on Accreditation. mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.08.004
ª AORN, Inc, 2015
396 j AORN Journal www.aornjournal.org
ECG Interpretation Using the
CRISP Method: A Guide for
Nurses 2.1 www.aorn.org/CE
DENISE ATWOOD, JD, RN; DIANA L. WADLUND, MSN, RN, CRNFA, ACNP-BC
ABSTRACT
Nurses often struggle with identifying electrocardiogram (ECG) rhythms, but rapidly interpreting these
rhythms is an essential skill that every nurse should master, especially in the perioperative setting. The
CRISP (Cardiac Rhythm Identification for Simple People) method is an algorithm designed to help
nurses rapidly interpret ECGs. Key aspects of assisting patients with suspected cardiac issues include
the nursing assessment, correct three-lead ECG placement, and calculation of the heart rate. Then the
perioperative nurse can use the steps of the CRISP method to identify nursing actions related to
specific arrhythmias, including determining whether QRS complexes are present, P waves are present,
and QRS complexes are wide or narrow or whether there are more P waves than QRS complexes.
AORN J 102 (October 2015) 397-405. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.08.004
Key words: cardiac rhythms, arrhythmias, advanced cardiac life support, ECG interpretation.
E
conduction of a cardiac impulse is generated in the SA node
very nurse should be able to recognize basic located in the upper portion of the right atrium. The SA
electrocardiogram (ECG) rhythms, such as node is the natural pacemaker of the heart, and it produces
normal sinus rhythm, sinus tachycardia, atrial a heart rate between 60 and 100 beats per minute (bpm).
fibrillation, atrial flutter, heart blocks, ventricular fibrilla- The impulse spreads through the right and left atria via the
tion, and asystole. To interpret basic ECG rhythms, nurses internodal pathways.1 The impulse then travels to the AV
must understand the normal conduction pathways of the junction located in the lower portion of the right atrium.
heart, as well as the basic pathophysiology of abnormal The impulse is delayed for 0.08 to 0.12 seconds in the AV
rhythms. This article presents an algorithm that is junction, which gives the atria time to contract (ie,
designed to help health care providers rapidly interpret depolarize). The AV node is located in the AV junction. If
primary ECG rhythms. Fred Killingbeck, RN, EMT-P, the SA node fails to function, the AV node is the next in
CEN, CCRN, the creator of the algorithm, describes line in the conduction pathway, and it takes over as the
this as the CRISP (ie, cardiac rhythm identification for heart’s pacemaker. The AV node produces a heart rate
simple people) method of ECG interpretation. between 40 and 60 bpm.1
http://dx.doi.org/10.1016/j.aorn.2015.08.004
ª AORN, Inc, 2015
www.aornjournal.org AORN Journal j 397
AtwooddWadlund October 2015, Vol. 102, No. 4
ELEMENTS OF AN ECG
An ECG gives a picture of the electrical activity that causes
the different parts of the heart to beat and relax. An ECG
consists of segments or intervals (ie, P wave, PR interval,
QRS complex, ST segment, T wave, QT interval) that
help determine where an impulse was generated and assess
the length of time it takes an impulse to travel through the
heart (Figure 2).2
Atrial depolarization produces the P wave on an ECG. The Figure 1. Cardiac conduction pathways. Reprinted with
presence of P waves indicates that impulses are being permission from Atwood D. Using an algorithm to easily
generated in the SA node. The PR interval represents the interpret basic cardiac rhythms. AORN J. 2005;82(5):757-
amount of time the impulse takes to travel from the 766. Copyright ª 2005, AORN, Inc, 2170 S. Parker Road,
Suite 400, Denver, CO 80231. All rights reserved.
beginning of atrial depolarization to the beginning of ven-
tricular depolarization. The QRS complex correlates with
caused by coughing or deep inspiration is suggestive of chest
depolarization (ie, contraction) of the ventricles. The in-
wall, and not cardiac, pain.2 A patient who reports a sudden
terval from the end of ventricular depolarization to the
onset of tearing or ripping pain may be experiencing a
beginning of ventricular repolarization is represented by the dissecting aortic aneurysmda medical emergency.2
ST segment. The T wave corresponds to repolarization of
When assessing a patient for cardiac problems, it is important
the ventricles. The total time for both ventricular depolar-
for the perioperative nurse to understand that women’s cardiac
ization and repolarization is represented by the QT interval.
symptoms often differ from what men report.3 For example,
women may report vague nontypical symptoms such as
NURSE ASSESSMENT
upper back or shoulder pain,
When caring for a patient who is suspected of having a cardiac
jaw pain or pain spreading to the jaw,
problem, the perioperative nurse must rapidly assess the pa-
pressure or pain in the center of the chest,
tient, including checking the patient’s level of consciousness,
lightheadedness,
vital signs, skin color, pain, and temperature, before beginning
pain that spreads to the arm,
analysis of a suspected ECG abnormality. If the patient in-
unusual fatigue for several days,
dicates that he or she is having chest pain, the nurse must ask
sleep disturbances,
the patient to describe the chest pain. Pain that is unrelenting
shortness of breath,
and described as being sharp or radiating may indicate
indigestion, and
ischemia (ie, lack of blood and oxygen to the heart) and could
anxiety.3
be indicative of a myocardial infarct.2 Exertion-induced pain
that is relieved by rest is suggestive of angina and not a Because their symptoms may not be those that are typically
myocardial infarct.2 Chest pain that gets worse when the recognized by the lay public as being classic heart attack
patient is supine and is relieved when the patient sits up and symptoms, women are often reluctant to seek treatment or
leans forward is indicative of pericarditis, while chest pain they may delay treatment. For this reason, women’s symptoms
Figure 3. The CRISP (Cardiac Rhythm Identification for Simple People) algorithm.
Figure 10. Rhythm strip for a 16-year-old girl who Figure 11. Rhythm strip for a 36-year-old woman who
presents with normal sinus rhythm and a heart rate of presents for removal of a benign breast mass and ex-
70 beats per minute. Reprinted with permission from hibits tachycardia after an injection of lidocaine with
Atwood D. Using an algorithm to easily interpret basic epinephrine. Reprinted with permission from Atwood D.
cardiac rhythms. AORN J. 2005;82(5):757-766. Copy- Using an algorithm to easily interpret basic cardiac
right ª 2005, AORN, Inc, 2170 S. Parker Road, Suite rhythms. AORN J. 2005;82(5):757-766. Copyright ª
400, Denver, CO 80231. All rights reserved. 2005, AORN, Inc, 2170 S. Parker Road, Suite 400,
Denver, CO 80231. All rights reserved.
Second-degree AV block type IIdthe pathophysiology of a 1. Are QRS complexes present? Yes
second-degree AV heart block type II, also known as Mobitz 2. Are P waves present? Yes
type II or non-Wenckebach, is at the site of the block and 3. Are there more P waves than QRS complexes? No
most often is below the AV node (ie, infranodal). Impulse 4. What is the heart rate? 70 bpm (ie, count the number of
conduction is normal through the node; thus, no first-degree QRS complexes in a six-second strip and multiply by 10)
block and no previous PR prolongation occur on the ECG. 5. What is the rhythm? Normal sinus rhythm
As a result, the PR interval is constant with conducted beats, 6. What is appropriate treatment for this patient?
but some P waves will be present without a QRS complex. Normal sinus rhythm and a heart rate of 70 bpm is a
This rhythm is irregular.5 The nurse should think of the normal finding in a 16-year-old girl. No treatment is
type II block as having equal PR intervals, but the QRS necessary.
complexes drop (ie, the impulse is not conducted to the
ventricles, so they do not contract).
CASE STUDY TWO
II ¼ PR intervals with dropped QRS complexes: A 36-year-old woman presents to the OR for removal of a
benign breast mass. The physician injects 25 mL of lidocaine
Third-degree AV blockdthe primary pathophysiology in 1% with epinephrine 1:100,000. He then makes a 3-cm
third-degree AV heart block is AV dissociation. Injury or incision into her breast and begins to remove the mass. Five
damage to the cardiac conduction system has occurred so minutes into the surgery, the nurse reviews the patient’s ECG
that no impulses pass between the atria and ventricles (ie, strip (Figure 11). To interpret the patient’s ECG, the nurse
complete block). This rhythm is regular.5 The nurse should asks and answers the following questions:
think of a third-degree block as a dysfunction of the heart in
1. Are QRS complexes present? Yes
which the atria and ventricles do not associate with one
2. Are P waves present? Yes
another so they beat independently and do not
3. Are there more P waves than QRS complexes? No
communicate with each other.
4. What is the heart rate? 120 bpm to 124 bpm
III ¼ Do not look at or talk to each other: 5. What is the rhythm? Sinus tachycardia
6. What is appropriate treatment for this patient? The
anesthesia professional notes that the patient is
CASE STUDY ONE adequately sedated. The surgeon observes that tachy-
A 16-year-old girl arrives in the OR to undergo an appen- cardia could have resulted from the injection of
dectomy. She is healthy with no medical history. She does not the lidocaine with epinephrine. The anesthesia profes-
take any medications on a regular basis, but she received 1 mg sional administers a bolus of 1 mg/kg of esmolol over 30
of hydromorphone by IV in the emergency department less seconds. Esmolol is an IV beta-blocker medication
than an hour earlier. Her ECG strip is presented (Figure 10). effective in the treatment of sinus tachycardia. The sur-
To interpret the patient’s ECG, the nurse asks and answers the geon is able to conclude the procedure without further
following questions: incidents.
Figure 12. Rhythm strip for a 70-year-old man who Figure 13. Rhythm strip for a 23-year-old man who had
underwent repair of an abdominal aortic aneurysm and a gunshot wound and exhibits asystole. Reprinted with
exhibits idioventricular rhythm. Reprinted with permission from Atwood D. Using an algorithm to
permission from Atwood D. Using an algorithm to easily interpret basic cardiac rhythms. AORN J.
easily interpret basic cardiac rhythms. AORN J. 2005;82(5):757-766. Copyright ª 2005, AORN, Inc,
2005;82(5):757-766. Copyright ª 2005, AORN, Inc, 2170 S. Parker Road, Suite 400, Denver, CO 80231. All
2170 S. Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
rights reserved.
perioperative nurses to begin recognizing basic cardiac rhythms, American College of Cardiology. http://www.acc.org/about-acc/
but perioperative nurses should access books on this topic to press-releases/2015/03/05/16/33/women-dont-get-to-hospital-fast
understand this complex process and make it more -enough-during-heart-attack. Published March 5, 2015. Accessed
manageable for the novice ECG interpreter. Countless courses August 31, 2015.
5. Categories of arrhythmias. Texas Heart Institute. http://www
also are available that can be taken in person or online (see
.texasheart.org/HIC/Topics/Cond/arrhycat.cfm. Accessed September
Resources) to help perioperative nurses become more familiar 4, 2015.
and comfortable with the skill of ECG interpretation. 6. Understanding EKGs. Geeky Medics. http://geekymedics.com/
Perioperative managers are responsible for ensuring that 2011/03/05/understanding-an-ecg/. Accessed July 8, 2015.
nurses are competent to interpret ECGs and to respond 7. Pulseless electrical activity: etiology. Medscape. http://emedicine
appropriately to the identified arrhythmias. Providing .medscape.com/article/161080-overview#a5. Accessed July 17,
simulation exercises is an excellent way for perioperative 2015.
managers to both educate their perioperative nurses and to 8. Landrum MA. Fast Facts About EKGs for Nurses: The Rules of
Identifying EKGs in a Nutshell. New York, NY: Springer Publishing
validate competency in ECG interpretation. The most
Company, LLC; 2014.
important learning tool is constant practice. Perioperative
nurses should print ECG strips and use the CRISP algorithm
to guide them in interpreting the rhythm. Nurses also should Resources
tap into the expertise of seasoned nurses to obtain feedback Aehlert BJ. ECGs Made Easy. 5th ed. Philadelphia, PA: Elsevier Health
on any suspected arrhythmia and its treatment options. With Sciences; 2015.
Ashley EA, Niebauer J. Conquering the ECG. In: Cardiology Explained.
education and practice, basic ECG interpretation can become
London, England: Remedica; 2004.
second nature to perioperative nurses. ECG Mastery Program. MedMastery.com. http://www.medmastery
.com/course/ecg?gclid¼CMXOmPjo4MYCFchffgodsHkOVw.
Acknowledgment: The authors thank Fred Killingbeck, RN, Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical
EMT-P, CEN, CCRN, Wittmann, Arizona, for providing the Application. New York, NY: Springer Science & Business Media;
cardiac rhythm algorithm, and G. Ware, EMT, and L. Rider, EMT, 2009.
firefighters with the Glendale Fire Department’s MEDIC 155, Learn to read electrocardiograms. ECG Academy.com. http://www.ecga
Glendale, Arizona, for providing ECG strips used in this article. cademy.com/?gclid¼CJOb2-Ho4MYCFc5lfgodjbkIGA.
Continuing Education:
ECG Interpretation Using the
CRISP Method: A Guide for
Nurses 2.1 www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge specific to using the CRISP (Cardiac Rhythm Identification for
Simple People) method to interpret electrocardiograms (ECGs).
OBJECTIVES
1. Describe the electrical conduction system of the heart.
2. Identify the elements of an ECG.
3. Discuss important nursing assessments for a patient who presents with a potential cardiac problem.
4. Explain the CRISP algorithm.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.
Continuing Education:
ECG Interpretation Using the
CRISP Method: A Guide for
Nurses 2.1 www.aorn.org/CE
8A.
Will you change your practice as a result of reading this
article? (If yes, answer question #8A. If no, answer
question #8B.)
4. Explain the CRISP algorithm. 8B. If you will not change your practice as a result of
Low 1. 2. 3. 4. 5. High reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
CONTENT practice.
5. To what extent did this article increase your knowledge of 2. I do not have enough time to teach others about the
the subject matter? purpose of the needed change.
Low 1. 2. 3. 4. 5. High 3. I do not have management support to make a
change.
6. To what extent were your individual objectives met?
4. Other: __________________________________
Low 1. 2. 3. 4. 5. High
7. Will you be able to use the information from this article in 9. Our accrediting body requires that we verify the time
your work setting? you needed to complete the 2.1 continuing education
1. Yes 2. No contact hour (126-minute) program: ______________