BACHELOR OF SCIENCE IN NURSING:

NCMB418: CARE OF THE CLIENTS WITH LIFE-

THREATENING CONDITIONS, ACUTELY-ILL / MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY
SITUATION (ACUTE AND CHRONIC)
COURSE MODULE COURSE LAB WEEK
2 1 7
Basic ECG

✓ Comprehend the course and laboratory unit objectives.

✓ Peruse through the study guide prior to class attendance.
✓ Analyze the required learning resources; refer to course unit
terminologies for jargons.
✓ Proactively participate in classroom discussions.
✓ Participate in weekly discussion board (Canvas).
✓ Answer and submit course unit tasks on time.

At the end of this unit, the students are expected to:

1. Discuss the pathophysiologic responses of clients with life- threatening conditions, acutely ill,
high acuity and emergency situation related to the cardiovascular system.
2. Analyze a client’s health status/competence with the use of electrocardiography.
3. Institute appropriate corrective actions to prevent or minimize harm arising from adverse
effects.
4. Apply safe and quality interventions to address the client’s identified dysrhythmias.
5. Offer client health education as appropriate for the ECG tracing observed.

Computer device or smartphone with internet access (at least 54 kbps)

ECG (Electrocardiography)
- A graphical recording of the heart’s electrical activities
- 1st diagnostic test done when cardiovascular disorder is suspected

12-LEAD ELECTROCARDIOGRAM
- Printed in a standard four-column format
- ECG machine reads three leads simultaneously for 2.5 to 3 seconds until all 12 leads are
obtained and then prints out the 12-lead ECG
- ECG electrodes are color-coded; each is identified by a specific code that refers to its
intended placement. There are two coding systems currently in use:
✓ American Heart Association (AHA) system
✓ International Electrotechnical Commission (IEC) system.

Table 1: ECG Coding Systems

Code & Color
Placement / Location
AHA IEC
V1 Brown/red C1 White/red Fourth intercostal space at the right sternal border
V2 Brown/yellow C2 White/yellow Fourth intercostal space at the left sternal border
V3 Brown/green C3 White/green Halfway between leads V2 and V4
V4 Brown/blue C4 White/brown Fifth intercostal space in the midclavicular line
V5 Brown/orange C5 White/black Left anterior axillary line on the same horizontal plane as V4
V6 Brown/purple C6 White/purple Left midaxillary line on the same horizontal plane as V4 and V5
RA White R Red Right arm (inner wrist)
LA Black L Yellow Left arm (inner wrist)
RL Green N Black Right leg (inner ankle)
LL Red F Green Left leg (inner ankle)
(Adapted from Crawford and Doherty 2010; Jevon 2010; Cables and Sensors 2016)

Reading the electrocardiogram:

(Open a sample using this link: https://www.ndsu.edu/pubweb/~grier/1to12-lead-ECG-EKG.html)
1. Beginning on the left-most column, the printout contains the standard limb leads I, II, and III.
The 12-lead ECG machine then uses the limb leads and, with the creation of Wilson’s central
terminal, creates the augmented leads, aVR, aVL, and aVF.
2. Moving from the limb leads to the precordial leads, the machine reads and records the
precordial leads, starting with V1, V2, and V3, then reads and records V4, V5, and V6

Anatomy of the ECG

➢ P wave – atrial depolarization
➢ PR-Segment – 0.04 sec delay by AV Node for completion of ventricular filling
➢ QRS Complex- ventricular depolarization
➢ ST segment – early ventricular repolarization
➢ T wave – ventricular repolarization
➢ U wave – repolarization of the mid-myocardial cell
➢ PR-Interval – transition of impulse from SA node to Purkinje fibers
➢ QT-interval – duration time from ventricular depolarization to ventricular repolarization
Figure 2: The Electrocardiogram

Example

*** small box = 0.04 sec; large box = 0.2 sec

Determining the Heart Rate (6-second strip)

1. Regular rhythm
a. HR = 1500 ÷ # small boxes between RR-interval
b. HR = 300 ÷ # large boxes R-R)
2. Irregular rhythm
a. HR = # of Rs x 10

Regular Rhythm
SMALL BOXES: 21 – HR = 1500 / 21 = 71bpm
LARGE BOXES: 3 – HR 300 / 4 =75 bpm

Irregular rhythm
HR = 8 R-waves x 10 = 80bpm

Common Pathologic Waves in an Electrocardiogram

1. T-wave inversion – may be due to ischemia
- cause: myocardial repolarization is altered and delayed
2. ST-segment changes – injured myocardial cells depolarize normally but repolarize more
rapidly than normal, causing ST-segment to rise at least 1mm above the isoelectric line
- elevation in the ST-segment in two continuous leads is a KEY DIAGNOSTIC indicator of
MI
3. Abnormal/Pathologic Q-wave – develops within 1-3 days (there is no depolarization current
conducted from necrotic tissue)
- May occur without ST or T-wave changes (indicates a previous MI)

SKILLS PROCEDURE

IMPORTANT! Ensure all your equipment and materials are at hand before going to the client.
Materials needed: ECG machine, clean gloves (1 pair), soap & water or alcohol-based wipes / cotton
balls with alcohol, hair clipper, if needed

Placement of Leads
❖ FIRST: Introduce self and identify the client by asking for at least 2 identifiers (e.g. name,
birthday, age, etc.). Wash hands and don PPE, if appropriate
❖ Briefly explain what the procedure will involve using the appropriate language.
❖ Gain consent to proceed with the ECG recording
Assessment:
1. Verify the doctor’s order for obtaining an ECG for the client.
2. Review client’s chart for medical history and/or contraindications.
3. Assess client’s vital signs and mobility.
4. Assess client’s skin around the areas where leads are to be placed, the client’s
temperature and pain sensitivity.
5. Assess client’s skin hair near the wrist and ankle areas and the chest.
6. Check and ensure the room is at a comfortably warm temperature (This will
prevent muscular tension or movements from producing unnecessary tracings
on the ECG recording).
7. Assess client and family’s awareness, understanding of the procedure, and
related safety factors.

Planning:
1. Identify expected outcomes
2. Assemble and prepare the equipment and supplies needed.

Implementation (Note: AHA coding system is used in this procedure.)

✓ Ensure to provide privacy at all times.
A. Placement of chest electrodes:
1. Explain the procedure and purpose to the client, sensations the client would feel and
precautions to prevent client discomfort.
2. Skin preparation. If the patient’s skin is dirty, clean with soap and water, and then dry. If
the skin is oily or the patient applied any creams or lotions, use an alcohol wipe to clean
each electrode placement site.

Some ECG machines may also provide a ‘rough patch’ either separately or on the
electrodes, which can be used to rub on the skin to increase electrode adherence. Care
should be taken not to cause abrasions.

3. Ask the patient to lay on the clinical examination couch with the head of the couch at a
45° angle
4. Adequately expose the client’s chest for the procedure (offer a blanket to allow exposure
only when required). Exposure of the patient’s lower legs and wrists is also necessary to
apply the limb leads.
5. Apply V1 at the 4th intercostal space at the right sternal edge
6. Apply V2 at the 4th intercostal space at the left sternal edge
7. Apply V3 midway between the V2 and V4 electrodes
8. Apply V4 at the 5th intercostal space in the midclavicular line
9. Apply V5 at the left anterior axillary line at the same horizontal level
as V4
10. Apply V6 at the left mid-axillary line at the same horizontal level as
V4 and V5.

B. Limb electrode and lead placement

1. Apply the red lead on the ulnar styloid process of the right arm
2. Apply the yellow lead on the ulnar styloid process of the left arm
3. Apply the green lead on the medial or lateral malleolus of the left
leg Placement of ECG Leads
 4. Apply the red lead on the ulnar styloid process of the right arm
5. Apply the black lead on the medial or lateral malleolus of the right leg

C. Recording the trace

1. Turn on the ECG machine and ensure ECG paper has been loaded.
2. Double-check all the electrodes are attached in the appropriate locations.
3. Politely ask the client to remain still and not talk during the recording as muscle activity
can cause an artefact which obscures the ECG trace of myocardial activity
4. Press the appropriate button on the ECG machine to record the ECG trace. If the ECG
trace is poor, double-check the connections to ensure there is good skin contact.
5. Once an ECG trace has been obtained, switch off the ECG machine.
6. Detach the ECG leads from the electrodes and then remove the electrodes carefully,
warning the patient this may feel uncomfortable.
7. Explain to the client that the procedure is now finished.
8. Thank the client for their time.
9. Dispose of PPE appropriately and wash your hands.
10. Label the ECG with the patient's details, i.e., client’s name, age, gender, date & time the
tracing was obtained.

Evaluation
1. Inspect the body part or wound condition and sensitivity.
2. Ask client to describe level of comfort and burning sensation following the treatment.
3. Identify any unexpected outcome.

Recording and Reporting: Record, document, and report all pertinent information of the
procedure performed.

1. The use of search engines (e.g. Google, Yahoo), text/e-books, NANDA are allowed.
2. Students must submit this accomplished worksheet through email or Canvas upload.
3. Copy and paste all the illustrations in a separate document for your submission. Use a Letter-
sized paper, use the Times New Roman font of 12, and a 1.5 spacing format. Submit your
answers by uploading it in the Canvas Assignment tab provided.

Activity: The Interpreter

1. Look at the graphic recording of cardiac electrical activity below. (1 point each)

For each action below, write the appropriate letter or letters seen from the illustration on the line
provided.
a. _____ventricular muscle repolarization
 b. _____time required for an impulse to travel through the atria and the conduction system to
the Purkinje fibers
c. _____atrial muscle depolarization
d. _____Ventricular muscle depolarization
e. _____early ventricular repolarization of the ventricles

2. Look at the graphic recording of cardiac electrical activity. What is the approximate heart
rate? (5 points)

3. Consider the graphic recording below. Identify and encircle the 3 alterations that are
consistent with myocardial ischemia and infarction hours to days after the attack. (3points)

4. Analyze the graphic recording below and answer the questions that follow.

Give the answer and explain how each is obtained

a. What is the approximate heart rate?
b. What is the PR interval in seconds?
c. What is the physiological QRS in seconds?
d. Identify the repolarization abnormality/abnormalities and give the possible causes(s).
e. From the identified possible causes(s), develop a nursing care plan with an actual problem
diagnosis.

Date Completed:
Date Submitted:
Burns, S. (2018) AACN Essentials of Critical Care Nursing. Mc Graw Hill
Education.

Crawford, J. & Doherty, L. (2010). Ten steps to recording a standard 12-lead

ECG. Practice Nursing, vol. 21, no. 12, pp. 622-29,
https://www.magonlinelibrary.com/doi/abs/10.12968/pnur.2010.21.12.622.

Cables and Sensors. (2016). 12-Lead ECG Placement Guide with Illustrations, Cables and Sensors.
https://www.cablesandsensors.com/pages/12-lead-ecg-placement-guide-with-illustrations

Hinckle, J (2018) Brunner and Suddarth’s Textbook of Medical and Surgical Nursing, Lippincott,
Williams and Wilkins

Jevon, P. (2010). Procedure for Recording a standard 12-lead electrocardiogram. British Journal of
Nursing, 19(10), pp. 649-51, https://www.ncbi.nlm.nih.gov/pubmed/20622761

Schumacher L. (2012) Saunder’s Nursing survival guide: Critical Care and Emergency Nursing.
Elsevier