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Jared Larmore

on 5 March 2013

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Transcript of MA III EKG

Cardiac Diagnostic Testing The Medical Assistant’s Role
Instruct patient to carry on with all routine daily activities
Advise patient to take sponge baths and avoid getting equipment wet
Avoid electric blankest or being around metal detectors, magnets, high voltage areas We are interpreting:
Duration of the electrical waves
Segments/Intervals What Is This All For? Action Potentials Path of Blood Anatomical Review Mitral Valve Prolapse
Miocardial Infarction: Heart attack
Artherosclerosis: Hardening of the arteries
Angina Pectoris
Dysrhythmia: Abnormal rhythm of the heart
Premature Contractions
Heart Failure: COMMON
HEART CONDITIONS AND DISEASES Precordial Leads: Labeled V1, V2, V3, V4, V5, and V6.

V1: 4th intercostal space at the right margin of sternum

V2: 4th intercostal space at the left margin of sternum Augmented Leads: (aVR, aVL, aVF)

Record frontal plane activity, giving three additional views Augmented Leads- Labeled aVR, aVL, aVF.

Augmented means “to become larger.” Clips
Lead Wires
Lead Electrodes
ECG paper Parts of an Electrocardiograph A machine used to obtain an EKG / ECG

Captures electrical current from the heart and converts it into tracings

Results should always be place in patients Medical record Electrogardiograph Electrocardiogram (ECG): is a procedure frequently used for the diagnosis of heart disease and cardiac dysfunction
The test is painless, safe and typically a quick procedure
Also can be referred to as an EKG ECG or EKG Defibrillator Provides counter shock to convert cardiac arrhythmias into regular sinus rhythm
Make sure equipment is working properly and to have everything ready for a cardiac emergency
Should be CPR certified Done on patients that had a normal ECG, but still are experiencing irregular chest pain or discomfort
24 hour hook up period that will record cardiac events
Electrodes attached to chest wall and portable recorder is attached to a belt attached to patient
Patient will keep a diary of all activities and any discomfort experienced
Patient will return machine after 24 hour period Holter Monitor The Medical Assistants Role: Sinus criteria
Rhythm: regular
Rate: < 60
Causes: MI, ischemia, sinus node disease, vagal maneuvers, drugs Sinus Bradycardia V3: Midway between the position of V2 and V4

V4: 5th intercostal space of the left midclavicular line

V5: At horizontal level of position V4 at left anterior axillary line

V6: At horizontal level of position V4 at left midaxillary line Augmented Leads- Labeled aVR, aVL, aVF.
Augmented means “to become larger.” Bipolar/Standard Leads- Labeled I, II, III. Placed on the fleshy part of limbs.
Right Leg Electrode called the “Ground Electrode”
The three limb leads form a triangle called “Einthoven’s Triangle” Lead Placement In as little as 0.2 seconds an electrical impulse will make its way through the entire electrical system
In as little as 0.3 seconds the heart will have reset and be ready to fire again Depolarization & Repolarization Echocardiography (ECHO) Noninvasive diagnostic procedure that records sound waves reflected through the heart

Measurements are calculated to determine abnormalities within the heart P wave
Atrial Depolarization
QRS Complex
Ventricle Depolarization
T wave
Ventricle Repolarization EKG complexes Presented by: Jared Larmore RN, BSN K - Potasium
Ca - Calcium
Na - Sodium 1 LARGE box
5mm = 0.20 sec 1 small box
1mm = 0.04 sec 5 LARGE boxs
25mm = 1 sec EKG Complexes Previous MI (Myocardial Infarction)
Cardiac muscle enlargement
Rhythm disturbances
Normal sinus rhythm
Atrial Fibrillation
Ventricular Tachycardia
Ventricular Fibrillation
Paroxysmal Atrial Tachycardia WHAT ARE WE TESTING FOR? Sinus criteria
Rate: 60-100
Rhythm: Regular Normal Sinus Rhythm (NSR) Sinus Tachycardia Sinus criteria
Rhythm: regular
Rate > 100
Causes: Hypoxemia, hypovolemia, pain, anxiety, infection, etc.. Sinus Arrhythmia Sinus criteria
Rate: 60-100
Rhythm: P-P and R-R irregularity
Rate usually increases with inspiration and decreases with expiration.
The non respiratory form is present in diseased hearts and sometimes confused with sinus arrest.
Treatment is not usually required unless symptomatic bradycardia is present. Rate: Atrial not measurable; usually 350-600;
Ventricular rate may be fast (>150) when acute
Ventricular rate may be slow when chronic
Rhythm: Irregular (hallmark is irregular irregularity of the ventricular rhythm
P wave: Replaced by fibrillatory (f) waves
QRS: Narrow unless there’s IVCD
Conduction; variable AV conduction; if untreated, rate usually fast (AFIB OR A-FIB) 11 beats of PAT at rate of ~ 200 Sinus rhythm returns Rate:160-250/min.
Rhythm: Regular
P wave: P on T phenomenon
QRS: normal (unless associated with aberrant ventricular conduction).
Starts/stops suddenly, interrupting underlying rhythm. Paroxysmal Atrial Tachycardia (PAT) Ventricular Tachycardia
(V-Tach) Originates in ventricles
No associated P waves.
Check patient immed; call code if sustained (> 30 sec) and/or patient is unstable or pulseless.
Patient may be
1) stable with pulse (drugs)
2) unstable with pulse (cardioversion); or
3) pulseless (defibrillation). Ventricular Fibrillation Chaotic electrical discharge in both ventricles
No organized P waves or QRS complexes
No ventricular pumping resulting in no cardiac output
Patient will be pulseless Results are interpreted by the ordering physician, or will be sent to a cardiologist for interpretation.

Newer machines can perform their own interpretation EKG Results Allows Physician to judge deviations
2mm wide 10mm high
Adjustments can be made depending on size of tracing with the sensitivity dial
Stylus should be centered on middle of paper
Tracing paper speed is 25mm/sec. If cycle runs to close together, the speed can be adjusted to 50mm/sec 25mm/sec Pt complaints/symptoms
Past medical history of cardiac problems
Ages between 35-40 to establish a baseline reading
Routine annual physical exams
Every 5-10 years after baseline
Frequency may increase with patient health history
Smoking history
Hyperlipidemia When Are ECG’s Ordered? FEMALE PATIENTS Depending on breast size it may be necessary to elevate breast tissue to place V3, V4, V5 leads correctly
Elevate breast tissue using the back of the hand instead of touching the breast with your fingers
Always do your best to provide privacy and to keep patient from being exposed
Use a gown or drape for patient coverage Print a copy of the report
Document patients name, DOB, age, current date, and your initials Turn on Machine
Adjust stylus to center of page
25mm/sec position
Make standardization mark: 2mm wide and 10mm high
Press “Auto” and run 12 lead ECG PREPPING THE PATIENT Patient must disrobe from waist up and clothing around lower legs
Provide patient PRIVACY
Assist patient onto table
Pull out LEG RESTS and adjust pillow
Make sure patient is COMFORTABLE and RELAXED
Explain procedure to patient Performing an EKG Prep Machine
Plug in machine
Keep machine clear
Assemble electrodes
Connect wires
WASH HANDS Lead placement is similar to ECG EXCEPT:
Right arm and left arm are placebeneath right and left clavicle

Right leg and left leg are placed at the edge of the rib cage in line with the right arm lead and the left arm and V4 leads (trunk) Stress Test Hookup To detect unknown cause of cardiac problem
Under physician supervision
Done on patients with elevated risks of developing heart disease
Patient that have continued chest pain after ECG
Patient walks on treadmill until the ideal heart rate or METS are reached. Or develops active symptoms
METS=metabolic equivalents also know as artifact Any kind of movement that can interfere with tracing and produce artifact
Shivering from nerves or chills
Somatic tremor: Additional activity
AC Interference: Caused by electrical activity When ECG Is Completed
Remove lead wires and electrodes
Clean electrode sites with a warm, wet paper towel. Then dry
Assist patient to a sitting position and off the table if appropriate
Change table paper and pillow case
WASH HANDS Performing an EKG Interference EKG Testing Electrocardiograms or ECG Performing an EKG Performing an EKG Performing an EKG Performing an EKG Standardization Stress Test Purpose Performing an EKG Monitor BP while patient is exercising on treadmill Additional Testing Blood Flow http://www.skillstat.com/tools/ecg-simulator#/-prep This is an example of a six (6) second strip.

The sheet on the right contains 4 sets of strip. The shaded in area lead into the next line buy one second.

These strip are commonly used when printing reports or saved rhythms off the computer This is a six (6) second strip EKG grid Determining Heart Rate by distance Rate = 33 Rate = 37 Rate = 42/43 Rate = 50 Rate = 60 Rate = 75 Rate = 100 Rate =150 Rate = 300 EKG grid When the rhythm is regular ( 3 small boxes difference between waves), the rate is 300 divided by the number of large squares between the R waves For example, if there are 4 large squares between regular QRS complexes, the heart rate is 60 (300/5=60).  Step 1 & 2: Rate & Regularity If less than a full large box between R waves, use small boxes divided into 1500. Ex.16 small boxes between R waves: 1500/16 = 94 Step 1 & 2: Rate & Regularity When the rhythms is irregular, use the 6-second method.
May be used to estimate HR in regular rhythms also.
The number of waves (P or R) in six seconds multiplied by 10. 6-Second method of Calculating HR 0.12 to 0.20 Duration: 0.12 to 0.20 seconds.

Location: From the beginning of the P wave to the beginning of the QRS complex.

Represents the time it takes an impulse to travel from the atria through the AV node, bundle of His, and bundle  branches to the Purkinje fibers. Step 4: P-R Interval (PRI) Are they all the same size and shape?

What is the duration?

Are they all the same distance from the T waves that follow them?

Do they all point in the same direction? Step 5 - QRS Complex
Questions to ask Are they all the same size and shape?

What is the duration?

Are they all the same distance from the T waves that follow them?

Do they all point in the same direction? Step 5 - QRS Complex
Questions to ask ST segment: the end of the ventricular depolarization and the beginning of ventricular repolarization. Must be on baseline to be normal.

If depressed, indicates ischemia

If elevated, indicates injury ST Segment ST elevation
Acute MI
STEMI protocol
Prepare for cath lab

ST depression
Ischemia to heart muscle
Give O2 and possible NTG
Could lead to ST elevation Treatment of ST elevation and
ST depression ST elevation
Acute MI
STEMI protocol
Prepare for cath lab

ST depression
Ischemia to heart muscle
Give O2 and possible NTG
Could lead to ST elevation Treatment of ST elevation and
ST depression P wave: normal if sinus rhythm
Aberrant conduction through ventricles; ventricles depolarize separately rather than at the same time.
Wide QRS (>0.12 sec)
Right or left Bundle Branch Block Clinical significance

By itself is not significant and requires no treatment.
The underlying heart disease that causes the BBB usually determines the prognosis.
An MI can cause a BBB which can cause pump failure or life threatening dysrhythmias and increases mortality rates.

A transcutaneous pacemaker is indicated if:
BBB results from a MI
BBB is complicated by 1st or 2nd degree AV blocks with MI.
BBB progresses to complete heart block with AMI. Causes
May be present in normal hearts
Usually a sign of heart disease:
Ischemic heart disease affecting IV septum.
Degenerative disease of the conduction system
Cardiomyopathy: primary myocardial disease
Severe left ventricular hypertrophy due to HTN
Acute MI
Miscellaneous Causes
Acute CHF, acute pulmonary embolism or infarction, acute
pericarditis or myocarditis, rheumatic and congenital heart disease
Trauma – including cardiac cath and cardiac surgery
Potassium overdose Bundle Branch Blocks Leads used for diagnosis
A 12 lead ECG is needed to identify a BBB

Look predominantly at leads V1 and V6. Bundle Branch Blocks
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