PROCEDURE FOR Twelve-Lead Electrocardiogram (ECG or EKG)

PURPOSE:     To provide instructions of how to obtain a twelve-lead electrocardiogram.

EQUIPMENT:

1.        12 – lead ECG machine and recorder

2.        Electrodes

3.        Gauze pads or terry cloth washcloth

4.        Cleansing tissue or non-emollient soap and water in basin

5.        Patient cable and lead wires

6.        Alcohol pads

NURSING ACTION:

PROCEDURE STEPS:

1.        Wash Hands.

2.        Check cables and lead wires for fraying, broken wires, or discoloration.

3.        Plug the ECG machine into a grounded alternating current (AC) wall outlet or ensure functioning if battery operated.

4.        Turn the ECG machine on and input the information required.

5.        Ensure that the patient is in the supine position, not touching the bedrails or footboard.

6.        Expose only the necessary parts of the patient’s legs, arms, or chest.

7.        Identify lead sites:

a.        Limb leads

b.       Chest leads – Identify the angle of Louis or the sternal notch:

·         Palpate the upper sternum to identify where the clavicle joins the sternum (suprasternal notch).  Slide fingers down the center of the sternum to the obvious bony prominence.  This is the sternal notch, which identifies the second rib and provides a landmark for noting the fourth ICS.

·         When the fourth ICS is located, place the V leads: (see figure 1)

·        V₁ at the fourth ICS right sternal border

·        V₂ at the fourth ICS left sternal border

·        V₃ equidistant between V₂ and V₄

·        V₄ at the fifth ICS midclavicular line

·        V₅ horizontal level to V₄ at the anterior axillary line

·        V₆ horizontal level to V₄ at the midaxillary line

(figure 1)

8.        Cleanse the area for the application of electrodes with cleansing pads or soap and water, and dry thoroughly.

9.        Clean the intended sites with alcohol pads.  Consider using skin preparation solutions.

10.     For pregelled electrodes, remove backing and test for moistness. 

11.     Apply the electrodes securely.

12.     Fasten the lead wires to the limb electrodes, avoid bending or strain on the wires, and use the correct lead-to-electrode connection.

13.     Identify the multiple-channel machine recording setting.

14.     Check the settings on the ECG machine: paper speed (25 mm/sec), sensitivity (1 or 10 mm/sec), baseline at center.

15.     Obtain a 12-lead ECG recording.  Most systems record each lead for 3 – 6 seconds and automatically mark the correct lead. 

16.     Examine the 12-lead ECG tracing to see if it is clear, and repeat the ECG if it is not.

17.     Interpret the recording for rhythm, rate, presence and configuration of P waves, length or P-R intervals, length of QRS complexes, configuration and deviation of the ST segments, presence and configuration of T waves, length of Q-T intervals, presence of extra waves, and identification of dysrhythmias.

18.     Evaluate the 12-lead ECG for any signs of ischemia, injury, or infarct and other significant myocardial alterations.

19.     Disconnect the equipment, and clean the gel off the patient and prepare the equipment for future use.

20.     Discard used equipment, and wash hands.

21.     Transmit the ECG.

a.        Connect the phone cord to the modem on the back of the ECG cart.

b.       Use the Main Menu to select the File Manager function.  Then, the File Manager menu and a directory of files stored to the disk will appear.

c.        Select Location.  Use the arrow pad to select one of the phone numbers.

d.       Select All.

e.        Select Transmit.

REFERENCES:

AACN Procedure Manual for Critical Care; Wiegand, Debra J., Carlson, Karen, K: Elsevier Saunders, 5th edition,

     2005, St. Louis, MO.

RESOURCE PERSON(S):   Celeste Bryson, RN, MSN, CCRN, CCNS, MBA; Kelly Urban, BSN, RN; Tina Farmer, RRT