ELECTROCARDIOGRAM (ECG)

- Electrocardiography provides a graphic recording of the heart’s electrical activity. Electrodes placed on
the skin transmit the electrical impulses to an oscilloscope or graphic recorder. With the wave forms
recorded, the electrocardiogram (ECG) can then be examined to detect dysrhythmias and alterations in
conduction indicative of myocardial damage, enlargement of the heart, or drug effects.
- Electrical changes take place as the cardiac muscle contracts and relaxes; the 12-lead ECG records the
electrical activity of the heart from 12 viewpoints or ‘leads’ through 10 cables attached to electrodes on
the patient’s chest and limbs – note that in this setting ‘leads’ refers to viewpoints rather than the cables
or wires that connect the patient to the machine. The 12 different views of cardiac electrical activity show
the three-dimensional electrical activity occurring in the heart.
- All myocardial cells are able to spontaneously generate impulses and initiate the cardiac electrical cycle
without the need for external stimulation; this is known as automaticity. Cardiac conduction normally
begins in the sinoatrial (SA) node, located in the wall of the right atrium. This is the heart’s natural
pacemaker as it normally initiates impulses at a faster rate than other myocardial cells, generating
impulses at a rate of 60–100 beats per minute. The impulse generated by the SA node spreads through
the atrial muscle fibers (depolarization), causing atrial contraction, to the atrioventricular (AV) node. The
AV node acts as a gateway into the ventricular conduction system, delaying impulses for approximately
0.1–0.2 seconds and creating a short period of electrical standstill before the depolarization spreads
through the AV node into the ventricles, allowing the atria to finish contracting before ventricular
contraction commences. From the AV node, the impulse travels rapidly through specialized conduction
tissue in the ventricles, firstly through the bundle of His, along the left and right bundle branches and then
more slowly through the mass of ventricular muscle along the Purkinje fibers, resulting in the powerful
ventricular contraction. The conduction pathway of the heart is shown below. The normal ECG waveform
depicts five deflections or waves known as P, Q, R, S and T waves. The small P wave reflects atrial
depolarization, the large QRS reflects the rapid spread of depolarization from the AV node to the Purkinje
fibers through the ventricles, and the T wave reflects ventricular repolarization – the return of the
ventricular muscle to its resting state. Atrial repolarization is not graphically represented on the ECG as it
is hidden in the QRS complex.

ELECTRODE POSITION
V1 (C1) Fourth intercostal space at the right sternal edge
V2 (C2) Fourth intercostal space at the left sternal edge
V3 (C3) Midway between V2 and V4
V4 (C4) Fifth intercostal space in the midclavicular line
V5 (C5) Left anterior axillary line at same horizontal level as V4
V6 (C6) Left midaxillary line at same horizontal level as V4 and V5
Right arm limb lead (RA, red) Right forearm, proximal to wrist
Left arm limb lead (LA, yellow) Left forearm, proximal to wrist
Left leg limb lead (LL, green) Left lower leg, proximal to ankle
Right leg limb lead (RL, black) Right lower leg, proximal to ankle
PROCEDURE:
1. Wash hands using bactericidal soap and water or bactericidal alcohol hand rub, and dry.
Rationale: To minimize the risk of infection
2 Explain the procedure to the patient and gain their consent.
Rationale: To ensure that the patient understands the procedure and is able to give their valid consent
3. Ensure that the patient is comfortably positioned in semi-recumbent position. Any variations to standard
recording techniques must be highlighted on the ECG recording (for example ‘ECG recorded whilst patient in
wheelchair’).
Rationale: To ensure optimal recording and comfort of the patient. The ECG may vary depending on the
patient’s position so it is important to note this on the ECG.
4. Clean limb and chest electrode sites. If necessary, prepare skin by cleaning with soap and water or clipping
hairs.
Rationale: To ensure good grip and therefore good contact between skin and electrode – this results in less
electrical artefact). Shaving should be avoided due to the risk of infection if the skin is grazed or bleeding if the
patient is on anticoagulation therapy.
5. Apply the limb and chest electrodes
Rationale: To obtain a three-dimensional view of the electrical activity of the heart. Following a standard
arrangement ensures consistency between recordings and prevents invalid recordings and misdiagnosis.
6. Attach the cables from the ECG machine to the electrodes, checking that the cables are connected
correctly and to the relevant electrode.
Rationale: To obtain the ECG recording. To ensure the correct polarity in the ECG recording.
7. Ensure that the cables are not pulling on the electrodes or lying over each other. Offer the patient a gown
or sheet to place over their exposed chest.
Rationale: To reduce electrical artefact and to obtain a clear ECG recording. To ensure patient dignity and
reduce shivering.
8 Ask patient to relax and refrain from movement.
Rationale: To obtain the optimal recording by the reduction of artefact from muscular movement.
9. Encourage the patient to breathe normally and not to speak while the recording is being taken.
Rationale: Speaking can alter the recording.
10. Switch the machine on and enter the patient’s details into the machine.
Rationale: To ensure that it is clear which patient the ECG was taken from.
11. Check that the machine is functioning correctly and that calibration is 10 mm/mV.
Rationale: To ensure standard recording to aid interpretation.
12. Commence the recording.
Rationale: To obtain ECG.
13. In the case of artefact or poor recording, check electrodes and connections.
Rationale: To ensure optimal recording.
14. During the procedure give reassurance to the patient.
Rationale: To ensure the patient is informed and reassured.
15. Detach the ECG print-out and ensure the recording is labelled with the patient’s name, hospital number,
date and time. Also include any diagnostic information (i.e. if the patient has chest pain during the recording)
and deviations to the standard electrode placement.
Rationale: To ensure that the ECG forms part of the correct patient’s medical record. To help with diagnosis
and interpretation.
16. If the ECG is irregular or abnormal, record a 10-second rhythm strip, usually from lead II.
Rationale: To assist with interpretation if there have been any acute rhythm disturbances.
17. Inform patient that the procedure is completed and help to remove the electrodes.
Rationale: To ensure that the patient can relax and that the electrodes are removed to prevent them drying
out and causing any skin irritation.
18. Wash hands using bactericidal soap and water or bactericidal alcohol hand rub, and dry.
Rationale: To minimize the risk of infection.
19. Inform relevant nursing and medical staff that the ECG has been completed – show the recording to the
person who will analyze the recording.
Rationale: To enable relevant nursing and medical staff to use the ECG data in their care planning and
treatment.
20. File the ECG recording in the appropriate documentation.
Rationale: To ensure appropriate record keeping and aid continuity of care.
21. Clean the ECG machine in accordance with manufacturer’s recommendations. Return it to its storage
place and plug it in to mains electricity to keep the battery fully charged.
Rationale: The ECG machine forms part of a department’s emergency equipment and should always be
available and in good working order with a charged battery for use in an emergency.
RESOURCE UNIT FOR WARD CLASS TOPIC: ELECTROCARDIOGRAM

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