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Cabibi | Cerenio | Cobillas | Dedace
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OBJECTIVES
After 5 hours of lecture-discussion, the level 4 nursing students will be able to:

1. define the following terms:

a. Electrocardiogram
b. Electrocardiography
c. ECG complex
d. Rhythm strip
e. Electrodes
f. Lead
g. Plane
h. Depolarization
i. Repolarization
OBJECTIVES
2. discuss the anatomy and physiology of the heart
3. identify the transmission of electrical impulses
4. differentiate the depolarization and repolarization cycle
5. explain the phases of the cardiac cycle
6. name the indications and contraindication of ECG interpretation
7. recognize the types of ECG reading
8. illustrate the component of the ECG complex
9. cite down the guidelines in ECG interpretation
10. enumerate the nursing responsibilities before, during and after the ECG interpretation
 Electrocardiogram

- An elect rocardi ogram ( ECG) i s one of the s i mpl e s t and f as te s t t e st s u se d t o

evaluat e t he he art. The el ectri cal acti vi ty of the he art i s the n m e a su r e d,
i nt erpre t e d, and pri nted ou t. No e l e ctri ci ty i s s e nt i nto the body .

- A graphi cal re p res entati on of t he e l e ctri cal cu rre nt of the he a r t .

(source: hopkinsmedicine.org)
Electrocardiography
- T h e p r o c e s s o f a c q u i r i n g a n E CG
-T h e E CG i s o b t a i n e d b y p l a c i n g d i s p o s a b l e
electrodes in standard positions on the
s k i n o f t h e c h e s t wa l l s a n d e x t r e mi t i e s .

(source: Brunner and Suddarth's textbook of Medical Surgical Nursing)

TYPES OF ECG/EKG TEST:

HOLTER TEST
-A small and wearable device that uses
electrodes and a recording device to
track the heart’s rhythm for 24 to 72
hours

STRESS TEST
-To determine the amount of stress that
your heart can take before
$4,999 it develops an
ONWARDS
abnormal rhythm or decreased blood
flow to the heart muscle.
ECG
COMPLEX

-Reflects the function of the heart’s

conduction system in relation to the specific
lead.

-When reviewing an ECG, each complex should

be explained and compared with others.

(source: Brunner and Suddarth's textbook of Medical Surgical Nursing)

RHYTHM STRIP
-A rhythm strip is at least a 6-
second tracing printed out on
graph paper which shows activity
from one or two leads.

-They are printed on a graph paper

that is divided by vertical and
horizontal lines in standard interval

(source: Brunner and Suddarth's textbook of Medical Surgical Nursing)

ELECTRODES
-An ECG is obtained by placing
electrodes on the body at specific
areas

-Electrodes come in various shapes

and sizes, but all have two components:
(1) an adhesive substance that
attaches to the skin to secure
the electrode in place.
(2) a substance that reduces the
skin’s electrical impedance
 LEAD

-A graphical representation of the electrical activity of

the heart, and is created by analyzing several electrodes.

-Leads are “views” of the heart. There are 12 leads that

are traditionally obtained with a 12-lead
(source: ecgwaves.com & healthandwillness.org)
PLANE
-The direction in which the impulses flow in the
heart

-There are two planes, horizontal and vertical

planes.

(source: ecg.utah.edu)
DEPOLARIZATION
-Process by which cardiac muscle cells
change from a more negatively charged to a
more positively charged intracellular state.

-Indicates myocardial contraction.

REPOLARIZATION
-Process by which cardiac muscle cells
return to a more negatively charged
intracellular condition

$4,999 ONWARDS
-Indicates myocardial resting state

(source: Brunner and Suddarth's textbook of Medical Surgical Nursing)

 A N D P H Y
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A N A

(Source: Seeley’s anatomy and Physiology textbook)

1. STRUCTURES

a. Heart has 4 chambers – RA, RV, LA, LV

i. RA & LA are reservoirs for blood
being sent to the RV & LV
ii. RV & LV are the main pumping
chambers of the heart

b. Heart contains 4 valves

i. Atrioventricular Valves

1. Tricuspid valve is between the

Right atrium & Right Ventricle
2. Bicuspid or Mitral valve is between
the Left Atrium & Left Ventricle
ii. 2 Semilunar Valves

a. Pulmonic valve is between the Right

Ventricle & pulmonary artery
b. Aortic valve is between the Left
Ventricle & aorta

-V a l v e s o p e n a n d c l o s e i n r e s p o n s e t o
pressure changes in the heart
=V a l v e s a c t a s o n e w a y d o o r s t o k e e p b l o o d
moving forward
c. Heart Walls consist 3 layers

1.Endocardium - is the thin membrane

that lines the interior of the heart.

2. Myocardium - is the middle layer of

the heart. It is the heart muscle and is
the thickest layer of the heart.

3. Epicardium - is a thin layer of the

heart on the surface of the heart in
which the coronary arteries lie.
2. WHAT AFFECTS THE HEART

a. Sympathetic nervous system (or Adrenergic)

accelerates the heart
two chemicals are influenced by the
sympathetic system – epinephrine &
norepinephrine
these chemicals increase heart rate,
contractibility, automaticity, and AV
conduction

b. Parasympathetic nervous system (or

Cholinergic)
slows the heart
the vagus nerve is one of this system's
nerves, when stimulated slows heart rate
and AV conduction
3. ELECTROPHYSIOLOGY
A. Cardiac cells – two types: electrical and
myocardial (``working")

a. Electrical cells
- make up the conduction system of the
heart
- are distributed in an orderly fashion
through the heart
- possess specific properties:

1. automaticity – the ability to

spontaneously generate and discharge an
electrical impulse
2. excitability – the ability of the cell to
respond to an electrical impulse
3. conductivity – the ability to transmit an
electrical impulse from one cell to the next
B. Myocardial cells
-make up the muscular walls of the atrium
and ventricles of the heart
-possess specific properties:

1.contractility – the ability of the cell to

shorten and lengthen its fibers

2.extensibility – the ability of the cell to

stretch
 S MISS
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OF ELECTRICAL IMPULSES
(Source: Seeley’s anatomy and Physiology textbook)
Inherent firing rate is the rate at which the
SA node or another pacemaker site
normally generates electrical impulses.

A. SA Node - Sinoatrial node

Dominant or primary pacemaker of the
heart.

Inherent rate 60 – 100 beats per minute.

Located in the wall of the right atrium,

near the inlet of the superior vena cava.

Once an impulse is initiated, it usually

follows a specific path through the
heart, and usually does not flow
backward.
B. Interatrial tracts - Bachmann's bundle

As the electrical impulse leaves the SA

node, it is conducted through the left
atria by way of the Bachmann's bundles,
through the right atria, via the atrial
tracts.
C. AVJunction - Made up of the AV node and
the bundle of His

i. AV node
Is responsible for delaying the impulses
that reach it.

Located in the lower right atrium near

the interatrial septum.
Waits for the completion of atrial
emptying and ventricular filling, to allow
the cardiac muscle to stretch to its
fullest for peak cardiac output.

Th e n o d a l t i s su e i t s e l f h a s n o p a c e m a k e r
c e l l s , t h e t i s s ue s u r r o u nd i n g i t ( c a l le d
t h e j u n c t i o n a l t i s s ue ) c o nt a i n s
pacemaker cells that can fire at an
inherent rate of 40 – 60 beats per
minute.
ii. Bundle of His

Resumes rapid conduction of the

impulses through the ventricles

Makes up the distal part of the AV

junction then extends into the
ventricles next to the interventricular
septum

Divides into the Right and Left bundle

branches
iii. Purkinje Fibers

Conduct impulses rapidly through the

muscle to assist in depolarization and
contraction

Can also serve as a pacemaker,

discharges at an inherent rate of 20 –
40 beats per minute or even more
slowlyAre not usually activated as a
pacemaker unless conduction
through the bundle of His becomes
blocked or a higher pacemaker such
as the SA node or AV junction do not
generate an impulse
Extends from the bundle branches
into the endocardium and deep into
the myocardial tissue
 P ARIS
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OF DEPOLARIZATION & REPOLARIZATION CYCLE

(Source: Seeley’s anatomy and Physiology textbook)

 DEPOLARIZATION
Initiated as electrical cell generates
an electrical impulse, this electrical
impulse causes the ions to cross the
cell membrane and causes the
action potential.
The movement of ions across the
cell membrane through sodium,
potassium and calcium channels, is
the drive that causes contraction of
the cardiac cells/muscle.
REPOLARIZATION
The end of depolarization as the
electrical impulse stops stimulating
the myocardium.
The closing of sodium ion channels
and the opening of potassium ion
channels.
 DEPOLARIZATION REPOLARIZATION

The contraction of myocardial Repolarization is the return of the

muscle moves as a wave through the ions to their previous resting state,
heart which corresponds with relaxation
of the myocardial muscle

The closing of sodium ion channels

and the opening of potassium ion
channels.
 H A S ES
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OF THE CARDIAC CYCLE

(Source: Seeley’s anatomy and Physiology textbook)
 Atrial Systole
- The atria contract, forcing
additional blood to flow into the
ventricles to complete their filling.
The semilunar valves remain closed.

Ventricular Systole
-At the beginning of the ventricular
systole, contraction of the
ventricles push blood toward the
atria, causing the AV valves to close
as the pressure begins to increase.
As the ventricular systole
continues, the increasing
pressure in the ventricles
exceeds the pressure in the
pulmonary trunk and aorta, the
semilunar valves are forced
open, and blood is ejected into
the pulmonary trunk and aorta.
 Ventricular Diastole
-At the beginning of ventricular
diastole, the pressure in the
ventricles decreases below the
pressure in the aorta and pulmonary
trunk The semilunar valves close and
prevent blood from flowing back
into the ventricles
As diastole continues, the pressure
continues to decline in the ventricles
until atrial pressure is greater than
ventricular pressure. Then the AV
valves open, and blood flows directly
from the atria into the relaxed
ventricles. During the previous
ventricular systole, the atria were
relaxed and blood collected in them.
When the ventricles relax and the AV
valves open, blood flows into the
ventricles and they begin to fill again.
 C O NTRA
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OF ECG INTERPRETATION
 INDICATIONS

To look for the cause of chest pain.

To evaluate problems which may be heart-related, such as severe tiredness,

shortness of breath, dizziness, or fainting.

To identify irregular heartbeats.

To help determine the overall health of the heart before procedures such as
surgery; or after treatment for conditions such as a heart attack (myocardial
infarction, or MI), endocarditis (inflammation or infection of one or more of
the heart valves); or after heart surgery or cardiac catheterization.
 INDICATIONS

To see how an implanted pacemaker is working.

To determine how well certain heart medicines are working.

To get a baseline tracing of the heart's function during a physical exam; this
may be used as a comparison with future ECGs, to determine if there have
been any changes.
 CONTRAINDICATIONS

No absolute contraindications to performing an ECG exist,

other than patient refusal. Some patients may have allergies
or, more commonly, sensitivities to the adhesive used to
affix the leads; in these cases, hypoallergenic alternatives
are available from various manufacturers
 SINUS BRADYCHARDIA

Heart rhythm that’s slower than expected (fewer than 60 beats per minute in
an adult). SA node creates an impulse at a slower-than-normal rate.
Management: 0.5 mg of atropine & catecholamines.
 SINUS TACHYCARDIA
CONTRAINDICATIONS

Sinus tachycardia occurs when the sinus

node creates an impulse at a faster-
than-normal rate.

Management: Synchronized
cardioversion vagal maneuvers &
adenosine.
 SINUS ARRHYTHMIA
CONTRAINDICATIONS

Sinus arrhythmia occurs when the sinus node creates an impulse at an

irregular rhythm; the rate usually increases with inspiration and
decreases with expiration.
Management: Does not cause any significant hemodynamic effect.
PREMATURE ATRIAL COMPLEXES
CONTRAINDICATIONS

Single ECG complex that occurs

when an electrical impulse starts
in the atrium before the next
normal impulse of the sinus node.

Management: infrequent, no
treatment is necessary
reduction of caffeine intake,
correction of hypokalemia.
 ATRIAL FIBRILLATION
CONTRAINDICATIONS

Electrophysiologic changes in the atrial

myocardium. abnormal impulse
formation that occurs when structural or
electrophysiological abnormalities alter
the atrial tissue.

Management: antithrombotic drugs &

antiarrhythmic agents.
 ATRIAL FLUTTER
CONTRAINDICATIONS

Occurs because of a conduction

defect in the atrium and causes a
rapid, regular atrial impulse at a
rate between 250 and 400 bpm.

Management: vagal maneuvers &

adenosine
 PREMATURE JUNCTIONAL
CONTRAINDICATIONS
COMPLEXES

An impulse that starts in the

AV nodal area before the next
normal sinus impulse reaches
the AV node.

Management: infrequent, no
treatment is necessary
reduction of caffeine intake,
correction of hypokalemia
JUNCTIONAL RHYTHM
CONTRAINDICATIONS

Junctional or idionodal rhythm occurs

when the AV node, instead of the
sinus node, becomes the pacemaker
of the heart.

Management: Emergency pacing may

be needed, 0.5 mg of atropine
catecholamines.
 NONPAROXYSMAL
CONTRAINDICATIONS
JUNCTIONAL TACHYCARDIA

Is caused by enhanced automaticity in the junctional area, resulting in a

rhythm similar to junctional rhythm, except at a rate of 70 to 120 bpm.
 AV NODAL REENTRY TACHYCARDIA

Impulse is conducted to an area in the AV node that causes the impulse to be

rerouted back into the same area over and over again at a very fast rate.
Management: vagal maneuvers & calcium channel blocker.
PREMATURE VENTRICULAR COMPLEXES

Impulse that starts in a

ventricle and is conducted
through the ventricles before
the next normal sinus impulse.

Management: Amiodarone or
sotalol
 VENTRICULAR TACHYCARDIA

Defined as three or more PVCs

in a row, occurring at a rate
exceeding 100 bpm.

Management: antiarrhythmic
medications, antitachycardia
pacing & direct cardioversion
VENTRICULAR FIBRILLATION

Which is a rapid, disorganized

ventricular rhythm that causes
ineffective quivering of the
ventricles.

Management: Early defibrillation,

immediate bystander
cardiopulmonary resuscitation &
amiodarone and epinephrine
 IDIOVENTRICULAR RHYTHMS

Also called ventricular escape rhythm,

occurs when the impulse starts in the
conduction system below the AV node.

Management: Administering IV
epinephrine, vasopressor medications &
initiating emergency transcutaneous
pacing.
VENTRICULAR ASYSTOLE

Characterized by absent QRS

complexes confirmed in two different
leads, although P waves may be
apparent for a short duration.

Management: high-quality CPR,

intubation and establishment of IV
access.
 FIRST DEGREE
ATRIOVENTRICULAR BLOCK

Occurs when all the atrial impulses

are conducted through the AV
node into the ventricles at a rate
slower than normal.
SECOND-DEGREE ATRIOVENTRICULAR
BLOCK, TYPE I (WENCKEBACH)

Occurs when there is a repeating pattern

in which all but one of a series of atrial
impulses are conducted through the AV
node into the ventricles.
 SECOND DEGREE ATRIOVENTRICULAR
BLOCK, TYPE II

Occurs when only some of the atrial

impulses are conducted through the AV
node into the ventricles.
THIRD-DEGREE ATRIOVENTRICULAR BLOCK

Occurs when no atrial impulse is

conducted through the AV node
into the ventricles.

Management: pacemaker
implantation & IV bolus of atropine
 N M E D I CA
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ADMINISTERED DURING A CODE
GENERIC NAME CLASSIFICATION PURPOSE

- Ventricular Dysrhythmia
Lidocaine Antidysrhythmics (Class I) Sodium Channel Blocker

- Ventricular Tachycardia
- Slows the nerve impulses in the heart
Procainamide Antidysrhythmics (Class I)
Reduces sensitivity of heart tissues

- Ventricular Tachycardia
- Slows the nerve impulses in the heart
- Reduces sensitivity of heart tissues
- Paroxysmal supraventricular tachycardia, Wolff-
Adenosine Antidysrhythmics (Class III)
Parkinson White Syndrome
- Slows cardiac conduction through the AV node
- Prolongs repolarization

GENERIC
CLASSIFICATION PURPOSE
NAME

- Ventricular Tachycardia, Ventricular Fibrillation

- Slows cardiac conduction
Amiodarone Antidysrhythmics (Class III)
-Prolongs repolarization

- Heart Failure, cardiogenic shock

- Increase heart rate increase cardiac output
Dobutamine Antidysrhythmics (Class III) - Strengthen cardiac
- Decrease total systemic vascular pressure

 GENERIC
CLASSIFICATION PURPOSE
NAME

- Cardiac arrest, Cardiac resuscitation

- Increase heart rate
Epinephrine Adrenergic Agonist - Increase cardiac output
-Strengthen cardiac contraction

- Hypotension, cardiogenic and septic shock

- Increase heart rate
Norepinephrine Adrenergic Agonist - Increase cardiac output
Strengthen heart contraction

 GENERIC
CLASSIFICATION PURPOSE
NAME

- Bradycardia
- Increases heart rate
Atropine Anticholinergic
Improves atrioventricular conduction

- Increases contraction, coronary blood flow, and

oxygen consumption
Calcium Chloride Electrolytes -Stabilizes contractions after metabolic changes
causes have caused arrhythmias

GENERIC
CLASSIFICATION PURPOSE
NAME

-Manage hypocalcemia, cardiac arrest, and

Calcium cardiotoxicity due to hyperkalemia or
Electrolytes
Gluconate hypermagnesemia

-Polymorphic ventricular tachycardia (torsades de

Magnesium
Electrolytes pointes)
Sulfate

 GENERIC
CLASSIFICATION PURPOSE
NAME

Reverses respiratory depression due to opioids

Naloxone Opioid Antagonist

Glucose (D50W) Carbohydrate -Prevent or reverse hypoglycemia

- Cardiac arrest causes metabolic acidosis

Sodium
Alkalizing Agents -Balance Ph levels
Bicarbonate

 L U S T R AT
I L E

THE COMPONENT OF THE ECG COMPLEX

 P wave
-Results from depolarization of the atrial myocardium.

QRS complex
-Results from depolarization if the ventricles.
= 0.11 seconds or less in duration.

T wave
-Represents repolarization of the ventricles.

PR interval
-Time it takes for sinus node stimulation, atrial depolarization,
and conduction through the AV node to occur before
ventricular depolarizations happens.
= 0.12-20 seconds in duration.

QT interval
-Total time for ventricular depolarization and repolarization.
 ST segment
-Early ventricular repolarization

TP interval
-Isoelectric line

PP interval
-Determines atrial rate and rhythm

RR interval
-Determines ventricular rate and rhythm

Big box
= .20 seconds

Small box
= 0.04 seconds
 I D E L INE
G U S

IN ECG INTERPRETATION
 GUIDELINES
Determine the ventricular rate

Determine the ventricular rhythm

Determine the QRS duration

Determine whether QRS duration is consistent throughout thestrip,

if not, identify other duration.

Identify the QRS shape; if not consistent, then identify other shapes.

Identify P wave; is there a P wave in front of every QRS?

 GUIDELINES

Identify the P wave shape, identify whether it is consistent or not.

Determine the atrial rate.

Determine atrial rhythm.

Determine each PR interval.

Determine if the [R interval is consistent, irregular but with a

pattern to the irregularity, or just irregular.

Determine how many P wave for each QRS (P:QRS ratio).

 E S P O N S
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BEFORE, DURING & AFTER ECG
 BEFORE

Explain the procedure to the patient. Inform the patient that

echocardiography is used to evaluate the size, shape, and motion of
various cardiac structures. Tell who will perform the test, where it
will take place, and that it’s safe, painless, and is noninvasive.

No special preparation is needed. Advise the patient that he doesn’t

need to restrict food and fluids for the test.

Ensure to empty the bladder. Instruct the patient to void prior and
to change into a gown.
 BEFORE
Encourage the patient to cooperate. Advise the patient to remain
still during the test because movement may distort results. He may
also be asked to breathe in or out or to briefly hold his breath
during the exam.

Explain the need to darken the examination field. The room may be
darkened slightly to aid visualization on the monitor screen, and
that other procedure (ECG and phonocardiography) may be
performed simultaneously to time events in the cardiac cycles.

Explain that a vasodilator (amyl nitrate) may be given. The patient

may be asked to inhale a gas with a slightly sweet odor while changes
in heart functions are recorded.
 DURING

Inform that a conductive gel is applied to the chest area. A

conductive gel will be applied to his chest and a quarter-sized
transducer will be placed over it. Warn him that he may feel
minor discomfort because pressure is exerted to keep the
transducer in contact with the skin.

Position the patient on his left side. Explain that the transducer
is angled to observe different areas of the heart and that he
may be repositioned on his left side during the procedure.
 AFTER

Remove the conductive gel from the patient’s skin. When the
procedure is completed, remove the gel from the patient’s
chest wall.

Inform the patient that the study will be interpreted by the

physician. An official report will be sent to the requesting
physician, who will discuss the findings with the patient.

Instruct the patient to resume regular diet and activities. There

is no special type of care given following the test.
 AFTER

Remove the conductive gel from the patient’s skin. When the
procedure is completed, remove the gel from the patient’s
chest wall.

Inform the patient that the study will be interpreted by the

physician. An official report will be sent to the requesting
physician, who will discuss the findings with the patient.

Instruct the patient to resume regular diet and activities. There

is no special type of care given following the test.
 T S
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OF AN ECG MACHINE
thank you for listening!