PROCEDURE

57 Twelve-Lead Electrocardiogram
Shu-Fen Wung
PURPOSE: A 12-lead electrocardiogram (ECG) provides information about the
electrical activity of the heart from 12 different views or leads. The ECG is the most
commonly performed cardiovascular diagnostic procedure.1 Common uses of a
12-lead ECG include diagnosis of acute coronary syndromes, identification of
arrhythmias, and determination of the effects of medications, electrolytes, or
structural abnormalities on the electrical system of the heart.

PREREQUISITE NURSING
KNOWLEDGE
• Understanding of the anatomy and physiology of the car-
diovascular system, principles of electrophysiology, ECG
lead placement, basic rhythm interpretation, and electrical
safety is necessary.
• Advanced cardiac life support (ACLS) knowledge and
skills are needed.
• A 12-lead ECG provides different views or leads of the
electrical activity of the heart. The 12 standard leads
include six limb leads (I, II, III, augmented vector right
[aVR], augmented vector foot [aVF], and augmented
vector left [aVL]), and six chest leads (V1 to V6).
• The limb leads view the heart from the frontal or vertical
plane (Fig. 57-1), and the chest leads view the heart from
the horizontal plane (Fig. 57-2).
• The basic ECG waveforms are labeled with P, Q, R, S,
and T waves, which represent electrical activity within the
heart.
• Accuracy in identification of anatomical landmarks for
location of electrode sites and knowledge of the impor-
tance of accurate electrode placement are needed. Accu-
rate ECG interpretation is possible only when the recording
electrodes are placed in the proper positions. Slight altera-
tions of the electrode positions may distort significantly
the appearance of the ECG waveforms and can lead to
misdiagnosis.2 Reliable comparison of serial (more than
two ECGs recorded at different times) ECG recordings
relies on accurate and consistent electrode placement. An
indelible marker is recommended for clear identification
of the electrode locations to ensure that the same electrode
locations are selected when serial ECGs are recorded.
• Nurses should be aware of body-positional changes that
can alter ECG recordings. Serial ECGs should be recorded
with the patient in a supine position to ensure that all
recordings are done in a consistent manner. Side-lying
positions and elevation of the torso may change the posi-
tion of the heart within the chest and can change the
waveforms on the ECG recording.3,4 If a position other
than supine is clinically necessary, notation of the altered
position should be made on the tracing.
• Nurses should be able to operate the 12-lead ECG machine.
Calibration of 1 mV equals 10 mm and paper speed of
25 mm/sec are standards used in clinical practice. For
ST-segment analysis, filter settings of 0.05 to 100 Hz are
recommended by the American Heart Association.5 Any
variation used for particular clinical purposes should be
noted on the tracing. Specific information regarding con-
figuring the ECG machine, troubleshooting, and safety
features is available from the manufacturer and should be
read before use of the equipment.
• Nurses should be able to interpret recorded ECGs for the
presence or absence of myocardial ischemia/infarction and
arrhythmias so that patients can be treated appropriately.
• Advances in technology have allowed for online or wire-
less transmission, networking capabilities, and computer-
ized interpretation of the 12-lead ECG (Fig. 57-3). The
12-lead ECG cable is attached to a processing device that
digitizes the 12-lead ECG recording and transfers the
information to the wireless device, which transmits the
information to the medical record. This increases access
to the 12-lead ECG for review and can assist with rapid
interpretation and treatment of the patient.
EQUIPMENT
• 12-lead ECG machine with patient cable and lead wires
• ECG electrodes
Additional equipment, to have available as needed, includes
the following:
• Gauze pads or terrycloth washcloth
• Cleansing pads or nonemollient soap and water
• Skin preparation solution (e.g., skin barrier wipe or tinc-
ture of benzoin)
• Indelible marker
• Clippers or scissors to clip hair from the patient’s chest if
needed
PATIENT AND FAMILY EDUCATION
• Describe the procedure and reasons for obtaining the
12-lead electrocardiogram. Reassure the patient that the
procedure is painless. Rationale: This communication

494

Figure 57-1 Vertical plane leads: I, II, III, aVR, aVL, aVF.
Figure 57-2 Horizontal plane leads: V1 to V6.
clarifies information, reduces anxiety, and gains coopera-
tion from the patient.
• Explain the patient’s role in assisting with the ECG record-
ing and emphasize actions that improve the quality of the
ECG tracing, such as relaxing, avoiding conversation and
body movement, and breathing normally. Rationale: This
explanation ensures the patient’s cooperation to improve
the quality of the tracing and avoids unnecessary repeating
of the ECG because of muscle artifact.
PATIENT ASSESSMENT AND
PREPARATION
Patient Assessment
• Interpret previously recorded ECGs. Rationale: Each
patient has an individual baseline ECG. Previous ECG
57 Twelve-Lead Electrocardiogram 495
Figure 57-3 Example of a wireless electrocardiograph (ECG)
device. The 12-lead cable is attached to a processing device that can
then be transmitted to the medical record.
recordings can help clinicians determine whether a change
is acute or chronic.
• Assess for the presence of anginal symptoms, such as
chest pain, pressure, tightness, heaviness, fullness, or
squeezing sensation; radiated pain; or shortness of breath,
nausea, and extreme fatigue. Rationale: This evaluation
correlates ECG changes with patient symptoms.
• Assess the patient’s history of cardiac conditions and
review medication history. Rationale: Knowledge about
the patient’s cardiac history and medications can help in
interpretation of ECG recordings.
Patient Preparation
• Verify that the patient is the correct patient using two
identifiers. Rationale: Before performing a procedure, the
nurse should ensure the correct identification of the patient
for the intended intervention.
• Ensure that the patient and family understand prepro-
cedural teaching. Answer questions as they arise, and
reinforce information as needed. Rationale: This com-
munication evaluates and reinforces the understanding of
previously taught information.
• Assist the patient to the supine position and expose the
patient’s torso while maintaining the patient’s modesty.
Rationale: This position enables the recording of a
standard 12-lead ECG and allows comparison of serial
ECGs and comparison with standard waveforms. Body-
positional changes, such as elevation and rotation, can
change recorded amplitudes and axes.
496 Unit II Cardiovascular System
Procedure for 12-Lead Electrocardiogram
Steps
1. HH
2. Check cables and lead wires for
fraying or broken wires.
3. Check the lead wires for accurate
labels.
4. Plug the ECG machine into a
grounded alternating current (AC)
wall outlet or ensure functioning if
battery operated.
5. Turn the ECG machine on and
program the ECG machine: paper
speed, 25 mm/sec; calibration,
10 mm/mV; filter settings, 0.05–
100 Hz. (Level E*)
6. PE
7. Place the patient in a supine
position. (Level B*)
8. Expose only the necessary body
parts of the patient (legs, arms, and
chest) for electrode placement.
9. Identify skin electrode locations.
A. Limb leads (Fig. 57-4).
Figure 57-4
*Level B: Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.
*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional orga­nizational standards without clinical studies to
support recommendations.
Rationale
Detects faulty equipment.
Obtains accurate ECG recordings
and proper placement of leads.
Maintains electrical safety.
Equipment may require self-test
and warm-up time. Verify
equipment settings in
accordance with clinical practice
and recommendations by the
American Heart Association
(AHA).5 Multichannel machines
may require input of information
(e.g., data about the patient) to
store the ECG appropriately.
Provides adequate support for
limbs so that muscle activity is
minimal. Body-position changes
can cause ST-segment deviation
and QRS waveform
alteration.3,4,6
Provides privacy and warmth,
which reduces shivering.
Ensures the accuracy of the lead
placement.
Limb lead placement in 12-lead ECG.
Special Considerations
If the equipment is damaged, obtain
alternative equipment and notify
a biomedical engineer for repair.
Follow manufacturer’s
recommendations and institutional
protocol on electrical safety per
the biomedical department.
Manufacturers provide a calibration
check in the machine to identify
the sensitivity setting. Most
machines have automatic settings.
ECGs should be recorded in the
same body position to ensure
ECG changes are not caused by a
change in body position. If
another position is clinically
necessary, note the altered
position on the ECG recording.
Ensuring privacy may reduce
anxiety.
Shivering may interfere with the
quality of recording.
 57 Twelve-Lead Electrocardiogram 497

Procedure for 12-Lead Electrocardiogram—Continued

Steps Rationale Special Considerations
• Right arm (RA): inside right Accurate electrode placement is Limb leads should be placed in
forearm essential for obtaining valid and fleshy areas; bony prominences
• Left arm (LA): inside left reliable data for ECG should be avoided. The limb
forearm recordings. The RL electrode is leads need to be placed
• Right leg (RL): anywhere on a ground electrode that does not equidistant from the heart and
the body; by convention, contribute to the ECG tracings. should be positioned in
usually on the right ankle or approximately the same place on
inner aspect of the calf each limb.
• Left leg (LL): left ankle or
inner aspect of the calf
B. Precordial Leads (Fig. 57-5)
• Identify the sternal notch. The angle of Louis assists with Variations in precordial lead
Slide fingers down the center identifying the second rib for placement of as little as 2 cm can
of the sternum to the obvious correct placement of precordial result in important diagnostic
bony prominence, angle of leads in the appropriate ICS. errors, particularly in anteroseptal
Louis, which identifies the Slight alterations in the position of infarction and ventricular
second rib and provides a any of the precordial leads may hypertrophy.6
landmark for noting the second alter the ECG significantly and If precordial leads cannot be
intercostal space (ICS). can affect diagnosis and accurately placed because of
❖ V1: fourth ICS at right treatment.2,7,8 chest wounds, placement of
sternal border defibrillator pads, or other
❖ V2: fourth ICS at left sternal reasons, the alternative site
border should be clearly documented on
❖ V4: fifth ICS at the ECG.9
midclavicular line It is recommended that electrodes
❖ V3: halfway between V2 and be placed under the breast in
V4 women until additional studies
❖ V5: horizontal level to V4 at are available.5
the anterior axillary line
❖ V6: horizontal level to V4 at
the midaxillary line

Figure 57-5 Precordial or chest lead placement.

10. Clean and slightly abrade the skin Removes dead skin cells, Failure to properly prepare the skin
where the electrodes will be applied. promoting impulse may cause artifacts and interfere
A. Wash the skin with soap and transmission.10-12 Moist skin is with interpretation.
water, if needed. not conducive to electrode
B. Abrade the skin with a gauze adherence.
pad or abrader.
C. Ensure that the skin is dry before
skin electrodes are applied.
D. Clipping of chest hair may be
necessary to ensure that adequate
skin contact with the skin
electrodes is made. (Level C*)

*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results.
Procedure continues on following page
498 Unit II Cardiovascular System

Procedure for 12-Lead Electrocardiogram—Continued

Steps
11. Identify the electrode sites and mark
them with an indelible marker.
12. For pregelled electrodes, remove the
backing and test for moistness. For
adhesive electrodes, remove the
backing and check each adhesive
pad, as each should be sticky or
moist.
13. Apply the electrodes securely and
place the electrodes on the marked
locations.
14. Fasten the lead wires to the limb
electrodes, avoiding bending or
strain on the wires, and use the
correct lead-to-electrode connection.
15. Identify the multiple-channel
machine recording setting
(Fig. 57-6).
Rationale
Minimizes ECG changes caused
by altered electrode placement.2,6
Allows for appropriate conduction
of impulses.
Electrodes must be secure to
prevent external influences from
affecting the ECG. Secure the
electrodes to obtain quality ECG
recordings.
Provides for correct lead-to-limb
connection.
Multiple-channel machines run
several leads simultaneously and
can be set to run leads in
different configurations.
Special Considerations
After accurate identification of the
locations, an indelible marker
should be used to mark the
electrode sites if serial ECGs are
anticipated.
Gel must be moist. If pregelled
electrodes are not moist or
adhesive electrodes are not sticky,
replace the electrodes.
If limb plate electrodes are used, do
not overtighten to minimize
discomfort.

Figure 57-6 Multiple-channel ECG machine. (Courtesy Philips

Medical Systems, Andover, MA.)
 57 Twelve-Lead Electrocardiogram 499

Procedure for 12-Lead Electrocardiogram—Continued

Steps
16. Obtain a 12-lead ECG recording.
Most systems record each lead for
3–6 seconds and automatically mark
the correct lead.
17. Examine the quality of the 12-lead
ECG tracing.
18. Disconnect the equipment; clean the
gel off the patient (if necessary),
remove PE , discard used supplies,
and prepare the equipment for
future use.
19. HH
Rationale
Three to six seconds are all that is
needed for a permanent record;
a longer strip may be obtained if
a rhythm strip is needed.
While the patient is still connected
to the machine, the nurse should
examine the ECG to see whether
any leads need to be repeated.
Increases patient comfort.
Reduces the transmission of
microorganisms; Standard
Precautions.
Special Considerations
A multiple-channel machine runs
the limb and chest leads
simultaneously.
Reviews the normal conduction
sequence and identifies
abnormalities that may necessitate
further evaluation or treatment.
Some pregelled electrodes can be
left in place for repeat ECGs.
Follow the manufacturer’s
directions and hospital policy for
electrode use and removal in
these cases.

Expected Outcomes Unexpected Outcomes

• A clear and accurate 12-lead ECG recording that
allows clinicians to diagnose dysrhythmias and
ischemia (Fig. 57-7)
• Prompt identification of abnormalities
• Altered skin integrity
• Inaccurate lead placement or connection (Fig. 57-8)
• AC interference, also called 60-cycle interference
(see Fig. 54-9)
• Wandering baseline (see Fig. 54-10)
• Artifact or waveform interference (see Fig. 54-11)
Procedure continues on following page

Figure 57-7 Clear 12-lead ECG recording.

500 Unit II Cardiovascular System

B
Figure 57-8 Limb lead reversal on 12-lead electrocardiograph (ECG) in lead I. A, Correct place-
ment. B, Incorrect placement.

Patient Monitoring and Care

Steps Rationale Reportable Conditions
These conditions should be reported
if they persist despite nursing
interventions.
1. Obtain a 12-lead ECG as Provides determination of • Angina
prescribed and as needed (e.g., for myocardial ischemia, injury, • Arrhythmias
angina or arrhythmias). and infarction. Aids in • Abnormal 12-lead ECG
diagnosis of arrhythmias.
2. Compare the 12-lead ECG with the Determines normal and • Any abnormal changes in the
previous 12-lead ECGs. abnormal findings. 12-lead ECG
3. Follow institutional standards for Promotes comfort. • Continued pain despite pain
assessing pain. Administer interventions
analgesia and nitrates as prescribed.

Documentation
Documentation should include the following:
• Patient and family education • Pain assessment, interventions, and patient response
• The fact that a 12-lead ECG was obtained to interventions
• The reason for the 12-lead ECG • Follow-up to the 12-lead ECG as indicated
• Any altered lead placement and reason • Unexpected outcomes
• Symptoms that the patient experienced (e.g., chest • Additional interventions
pain, syncope, dizziness, or palpitations)

References and Additional Readings

For a complete list of references and additional readings for
this procedure, scan this QR code with any freely available
smartphone code reader app, or visit
http://booksite.elsevier.com/9780323376624.

References
1. Kligfield P: The centennial of the Einthoven
electrocardiogram. J Electrocardiol 35(Suppl):123–129,
2002.
2. Drew BJ: Pseudo myocardial injury patterns because of
nonstandard electrocardiogram electrode placement.
J Electrocardiol 41(3):202–204, 2008.
3. Adams MG, Drew BJ: Body position effects on the ECG:
Implication for ischemia monitoring. J Electrocardiol
30(4):285–291, 1997.
4. Nelwan SP, et al: Correction of ECG variations caused by
body position changes and electrode placement during
ST-T monitoring. J Electrocardiol 34(Suppl):213–216,
2001.
5. Kligfield P, et al: Recommendations for the
standardization and interpretation of the
electrocardiogram: Part I: the electrocardiogram and its
technology: A scientific statement from the American
Heart Association Electrocardiography and Arrhythmias
Committee, Council on Clinical Cardiology; the American
College of Cardiology Foundation; and the Heart Rhythm
Society: endorsed by the International Society for
Computerized Electrocardiology. Circulation
115(10):1306–1324, 2007.
6. Baevsky RH, et al: Supine vs semirecumbent and upright
12-lead electrocardiogram: Does change in body position
alter the electrocardiographic interpretation for ischemia?
Am J Emerg Med 25(7):753–756, 2007.
7. Drew BJ: Pitfalls and artifacts in electrocardiography.
Cardiol Clin 24(3):309–315, 2006.
8. Wung SF: Computer-assisted continuous ST-segment
analysis for clinical research: Methodological issues.
Biol Res Nurs 3(2):65–77, 2001.
9. Drew BJ, et al: Practice standards for
electrocardiographic monitoring in hospital settings:
An American Heart Association scientific statement
from the Councils on Cardiovascular Nursing, Clinical
Cardiology, and Cardiovascular Disease in the Young:
endorsed by the International Society of Computerized
Electrocardiology and the American Association of
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2004.
10. Clochesy JM, Cifani L, Howe K: Electrode site
preparation techniques: A follow-up study. Heart Lung
20(1):27–30, 1991.
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Additional Readings
Burns S: AACN essentials of critical care nursing, New York,
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electrocardiogram: Part V: Electrocardiogram changes
associated with cardiac chamber hypertrophy: A scientific
statement from the American Heart Association
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on Clinical Cardiology; the American College of
Cardiology Foundation; and the Heart Rhythm Society.
Endorsed by the International Society for Computerized
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2009.
Macfarlane PW: Age, sex, and the ST amplitude in health and
disease. J Electrocardiol 34(Suppl):235–241, 2001.
Mason JW, et al: Recommendations for the standardization
and interpretation of the electrocardiogram: Part II:
Electrocardiography diagnostic statement list a scientific
statement from the American Heart Association
Electrocardiography and Arrhythmias Committee, Council
on Clinical Cardiology; the American College of
Cardiology Foundation; and the Heart Rhythm Society
Endorsed by the International Society for Computerized
Electrocardiology. J Am Coll Cardiol 49(10):1128–1135,
2007.
Rautaharju PM, et al: AHA/ACCF/HRS recommendations for
the standardization and interpretation of the
electrocardiogram: Part IV: The ST segment, T and U
waves, and the QT interval: A scientific statement from the
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Arrhythmias Committee, Council on Clinical Cardiology;
the American College of Cardiology Foundation; and the
Heart Rhythm Society. Endorsed by the International
Society for Computerized Electrocardiology. J Am Coll
Cardiol 53(11):982–991, 2009.
Sole M, Klein D, Moseley M: Introduction to critical care
nursing, ed 6, St. Louis, 2013, Elsevier Saunders.
Surawicz B, et al: AHA/ACCF/HRS recommendations for the
standardization and interpretation of the electrocardiogram:
Part III: Intraventricular conduction disturbances: A
scientific statement from the American Heart Association
Electrocardiography and Arrhythmias Committee, Council
on Clinical Cardiology; the American College of
Cardiology Foundation; and the Heart Rhythm Society.
Endorsed by the International Society for Computerized
Electrocardiology. J Am Coll Cardiol 53(11):976–981,
2009.
Wagner GS, et al: AHA/ACCF/HRS recommendations for the
standardization and interpretation of the electrocardiogram:
Part VI: Acute ischemia/infarction: A scientific statement
from the American Heart Association Electrocardiography
and Arrhythmias Committee, Council on Clinical
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Foundation; and the Heart Rhythm Society: endorsed by
the International Society for Computerized
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