12 Lead Echocardiogram

Republic of the Philippines
PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
Intramuros, Manila
COLLEGE OF NURSING
(Kolehiyo ng Pagkalinga)
Intensive Care Nursing Skills Laboratory
INTENSIVE CARE NURSING – SKILLS

CHECKLIST
12 LEAD ELECTROCARDIOGRAM
Name: Score: Block: 4-9

Prof.: _
Indication:
The ECG is a useful tool in the diagnosis of those conditions that may cause aberrations in the
electrical activity of the heart. Examples of this conditions are as follows:
1. Myocardial Infarction and other type of coronary artery diseases.
2. Cardiac dysrhythmias
3. Cardiac enlargement
4. Electrolyte disturbances, especially calcium and potassium levels.
5. Inflammatory diseases of the heart.
6. Effects on the heart by drugs such as digoxin and tricyclic antidepressants.
Basic Principles:
1. Electrical Activity is generated by the cells of the heart as ions are exchanged
across cell membranes.
2. Electrodes that are capable of conducting electrical activity from the heart to the ECG
machine are placed at strategic positions on the extremities and chest precordium.
3. The electrical energy sensed is then converted to graphic display by the ECG
machine. This display is referred to as electrocardiogram.
4. A heart contraction is represented by wave forms on the ECG graph paper, which are
designated P, Q, R, S, and T waves.
5. Wave forms are referred to as deflections relative to an isoelectric line ( a line that
express no energy). The isoelectric line can be determined by looking at the T-P
interval.
a. The P wave is the first positive deflection and represents atrial depolarization.
b. The Q wave is the first negative deflection after the P wave;
c. The R wave is the first positive deflection after the P wave.
d. The S wave is the negative deflection after the R wave.
e. The QRS wave form is generally regarded as a unit and represents ventricular
depolarization.
f. The T wave follows the S wave and is joined to the QRS complex by the S-T
segment. The T wave represents the return of ions to the appropriate side of the cell
membranee. This signifies relaxation of the muscle fibers and is referred to as
repolarization of the ventricles.
g. The Q-T interval is the time between the Q wave and the T wave.
Intramuros, Manila
COLLEGE OF NURSING
ECG leads and normal wave form interpretation.
1. The standard ECG consists of 12 leads (I, II, III, AVR, AVL, AVF, V1, V2, V3,
V4, V5, V6).anatomic position.
a. Each leads records the heart’s electrical activity from a different anatomic position.
b. Identification of specific myocardial changes on certain leads assists in defining
pathologic conditions.
2. The normal amplitude of the P wave is 3mm or less; the normal duration of the p wave is
0.04 to
0.11 second. P waves that exceed these measurements are considered to be a
deviation from normal.
3. The P-R interval is measured from the upstroke of the P wave to the Q-R junction and is
normally between 0.12 and 0.20 second.
a. The P-R interval represents the time of impulse transmission from the sinoatrial (SA)
node to the atrioventricular (AV) node.
b. There is a built-in delay in time at the AV node to allow for adequate verntricular
filling to maintain normal stroke volume (the amount of blood ejected with each
contraction).
4. The QRS complex contains separate waves and segments, which should be evaluated
separately. Normal QRS complex should be between 0.06 and 0.l0 second.
a. The Q wave, or first downward stroke after the P wave, is usually less than 3mm in
Intramuros, Manila
COLLEGE OF NURSING
depth. A Q wave of significant deflection is not normally present in the healthy

heart. A pathologic Q wave usually indicates a completed Myocardial Infarction.
b. The R wave is the first positive deflection after the P wave, normally 5 to 10 mm in
height. Increases and decreases in amplitude become significant in certain disease
states. Ventricular hypertrophy produces very high R waves because the
hypertrophied muscle requires a stronger electrical current to depolarize.
5. The S-T segment begins at the end of S wave, the first negative deflection after the R
wave, and terminates after the upstroke of the T wave.
Intramuros, Manila
COLLEGE OF NURSING
6. The T wave represents the repolarization of myocardial fibers or provides the resting
state of myocardial work; the T wave should always be present.
a. Normally, the T wave should not exceed a 5-mm amplitude in all leads except the
precordial (V1 to V6), where it may be as high as 10mm.
Electrodes Positioning
Intramuros, Manila
COLLEGE OF NURSING
Nursing and Patient care considerations.
STEPS/PROCEDURE RATIONALE
1. Confirm the right patient for ECG procedure, Confirming the order helps avoid
then possible mistakes. Verifying
introduce yourself. identification ensures client safety
by ensuring the right procedure for
the right client.
2. Explain the procedure to the patient. Providing details about the

procedure safeguards the client's
rights and promotes their active
involvement in their care.
a. Provide privacy and ask the patient to Arrange drapes to expose the area
undress, exposing chest, wrists, and being assessed while covering other
ankles. Assist with draping as body areas. Client exposure can
appropriate. often be embarrassing, so
maintaining privacy is important.
b. Place lead on chest and extremities as labeled, Correct positioning of electrodes

using self-adhesive electrodes or water enables accurate recording of the
soluble gel or other conductive material. heart's electrical activity on ECG
Eventhough it is named 12-lead ECG, it uses paper.
only 10 electrodes.
A. Limb Leads
1. Lead I, AVR – placed at right arm
2. Lead II, AVL– placed at left arm
3. Lead III, AVF– placed at left leg
4. Neutralizer – placed at right leg
B. Chest Leads
5. V1–4th Intercoastal Space, Right,
Sternal Border
6. V2–4th Intercoastal Space, Left,
Sternal Border
7. V3–midway between V2 and V4
Midclavicular Line
Anterior Axillary Line
Intramuros, Manila
COLLEGE OF NURSING
10.V6–5th Intercoastal Space, MidAxillary

Line
c. Instruct patient to lie still, avoiding This posture enhances client
movement, coughing, or talking while ECG is comfort. Keeping arms and legs
recording to avoid artifact. relaxed minimizes shaking and
produces a more accurate tracing.
Encouraging the client to relax and

stay still will result in a more
accurate tracing.
Reference:
https://
downloads.lww.com/
wolterskluwer_vitalstream_
com/sample-content/
9780781788786_craven/
samples/mod10/topic1d/
text.html
d. Make sure ECG machine is plugged and Facilitates accurate display of chest
grounded, leads on the graph.
and operate according to manufacturer’s directions.
Ensures optimal functioning
through proper setup
e. If continuous monitoring is being done, To reduce muscle tremor and

advise patient on the parameters of mobility patient movement, attempt to warm
as movement may trigger alarms and false a shivering patient or make them
reading. more comfortable in a reclined
position.
Reposition leads as needed.

Activate machine to obtain
simultaneous tracing of all
12 leads. If patient
experiences chest pain,
document occurrence on
ECG printout
3. Interpret ECG. Develop a systematic approach to This review identifies the normal
assist in accurate interpretation of conduction sequence and
Intramuros, Manila
COLLEGE OF NURSING
dysrhythmia, myocardial damage, or abnormalities that may require

other changes. further evaluation or treatment. A
clear pattern is required to make
accurate judgments about the
patient's status and treatment.
Having a systematic
approach in
interpreting an ECG
improves the speed
and reliability of the
assessment,
especially if a dysrhythmia
is present.
a. Determine the rate. Is it fast, slow, or normal? A normal heart rate is usually stated
as 60 to 100 beats per minute.
Slower than 60 is bradycardia;
faster than 100 is tachycardia.
b. Determine the rhythm. Is it regular, irregular, It is important to assess the

regularly irregular, or irregularly irregular? distances across the whole strip to
Use calipers or count blocks between QRS account for any potential
complexes to abnormality.
determine regularity.
c. Examine each wave and segment for Certain changes may require
abnormality. prompt treatment. Muscle
movements may cause “fuzzy”
waveforms
Intramuros, Manila
COLLEGE OF NURSING
d. If satisfactory ECG tracing was obtained, Promotes comfort and hygiene

(check for grounded tracings and artifacts) and minimize skin irritation.
remove the leads from the patient’s body.
e. Clean/wipe the area of the body with gel. Electrode resistance changes as the
gel dries, so changing all electrodes
at once prevents differences in
resistance among electrodes.
Provides comfort and hygiene.
f. Perform hand hygiene. Handwashing reduces transfer of
microorganisms.
g. Refer to the attending physician the ECG tracing. In line with best practice, the
Nursing and Midwifery Council
(NMC) advises that all care should
be accurately and promptly
documented (NMC 2015). The
medical practitioner should be
informed that the ECG is complete
and of the patient’s current status.
For proper interpretation and

intervention
Provides for review of ECG by

cardiologist. This allows
comparison with previous readings
that helps to detect possible
abnormalities.
SCORE:
Link References:
https://elsevier.health/en-US/preview/cardiac-monitor-set-up-and-lead-placement
https://www.studocu.com/ph/document/catanduanes-state-university/nursing/ecg-
procedural-cheklist-with-rationale/67439447
https://wtcs.pressbooks.pub/nursingadvancedskills/chapter/7-3-a-systematic-approach-to-
interpreting-an-ecg/
https://www.health.harvard.edu/heart-health/hows-your-heart-rate-and-why-it-matters
https://wtcs.pressbooks.pub/nursingadvancedskills/chapter/7-3-a-systematic-approach-to-
Intramuros, Manila
COLLEGE OF NURSING
interpreting-an-ecg/
https://elsevier.health/en-US/preview/cardiac-monitor-set-up-and-lead-placement
https://www.studocu.com/ph/document/mariano-marcos-state-university/bacherlor-of-
science-in-nursing/12-lead-ecg-placement/37509633
https://downloads.lww.com/wolterskluwer_vitalstream_com/sample-content/
9780781788786_craven/samples/mod10/topic1d/text.html
https://www.pearson.com/content/dam/one-dot-com/one-dot-com/us/en/higher-ed/en/
products-services/course-products/berman-10e-info/pdf/CH30.pdf
GRADING:
2 POINTS Correct/Complete
Rationale 1 POINT Incomplete
Rationale
0 POINT Incorrect Rationale
Prepared By: Prof. Jennifer T.
Lagundino
Student’s Name:
Signature
Date: _
Clinical Instructor:
Name and signature

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Republic of the Philippines

PAMANTASAN NG LUNGSOD NG MAYNILA

Intensive Care Nursing Skills Laboratory

INTENSIVE CARE NURSING – SKILLS

Name: Score: Block: 4-9

Intensive Care Nursing Skills Laboratory

ECG leads and normal wave form interpretation.

Intensive Care Nursing Skills Laboratory

depth. A Q wave of significant deflection is not normally present in the healthy

Intensive Care Nursing Skills Laboratory

Intensive Care Nursing Skills Laboratory

Nursing and Patient care considerations.

2. Explain the procedure to the patient. Providing details about the

b. Place lead on chest and extremities as labeled, Correct positioning of electrodes

Intensive Care Nursing Skills Laboratory

10.V6–5th Intercoastal Space, MidAxillary

Encouraging the client to relax and

e. If continuous monitoring is being done, To reduce muscle tremor and

Reposition leads as needed.

Intensive Care Nursing Skills Laboratory

dysrhythmia, myocardial damage, or abnormalities that may require

b. Determine the rhythm. Is it regular, irregular, It is important to assess the

Intensive Care Nursing Skills Laboratory

d. If satisfactory ECG tracing was obtained, Promotes comfort and hygiene

For proper interpretation and

Provides for review of ECG by

Intensive Care Nursing Skills Laboratory

Prepared By: Prof. Jennifer T.

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