ECG CHP 5

five
Analyzing a Rhythm Strip

There are five basic steps to be followed in analyzing a rhythm strip. Each step should be
followed in sequence. Eventually, this will become a habit and will enable you to identify a
strip quickly and accurately.
Step 1: Determine Regularity (Rhythm) of R

Waves
Starting at the left side of the rhythm strip, place an index card above the first two R waves
(Figure 5.1). Using a sharp pencil, mark on the index card above the two R waves. Measure
from R wave to R wave across the rhythm strip, marking on the index card any variation in R
wave regularity. If the rhythm varies by 0.12 second (3 small squares) or more between the
shortest and longest R wave variation marked on the index card, the rhythm is irregular. If the
rhythm doesn’t vary or varies by less than 0.12 second, the rhythm is considered regular.
Copyright © 2016. Wolters Kluwer Health. All rights reserved.
Figure 5.1 Index card.
Huff, Jane. ECG Workout : Exercises in Arrhythmia Interpretation, Wolters Kluwer Health, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/conestogac/detail.action?docID=5122317.
Created from conestogac on 2024-09-08 22:18:55.
Calipers may also be used, instead of an index card, to determine regularity of the rhythm
strip. R-wave regularity is assessed in the same manner as with the index card, by placing the
two caliper points on top of two consecutive R waves and proceeding left to right across the
rhythm strip, noting any variation in the R-R regularity.
The author prefers the index card method, because each R-wave variation (however slight)
can be marked and measured to determine if a 0.12-second or greater variance exists between
the shorter and longer R-wave variations. With calipers, a variation in the R-wave regularity
may be noted, but without marking and measuring between the shortest and longest R-wave
variation, there is no way to determine how irregular the rhythm is. Examples of rhythm
measurements are shown in Figures 5.2 to 5.4.
Figure 5.2 Regular rhythm; R-R intervals do not vary.
Figure 5.3 Irregular rhythm; R-R intervals vary by 5 squares (0.20 second).
Figure 5.4 Regular rhythm; R-R intervals by 1½ squares (0.06 second).
Step 2: Calculate the Heart Rate

This measurement will always refer to the ventricular rate unless the atrial and ventricular
rates differ, in which case both will be given. The ventricular rate is usually determined by
looking at a 6-second rhythm strip. The top of the electrocardiogram paper is marked at 3-
second intervals; two intervals equal 6 seconds (Figure 5.5). Several methods can be used to
calculate heart rate. These methods differ according to the regularity or irregularity of the
rhythm.
Figure 5.5 ECG graph paper.

Regular Rhythms
Two methods can be used to calculate heart rate in regular rhythms.
Rapid rate calculation—Count the number of R waves in a 6-second strip (Figure 5.6)
and multiply by 10 (6 seconds × 10 = 60 seconds, or the heart rate per minute). The R
waves must be counted within the 6-second markers (some strips in this book are longer
than 6 seconds). This method provides an approximate heart rate in beats per minute, is
fast and simple, and can be used with both regular and irregular rhythms. If you only have
a 3-second strip, count the number of R waves in a 3-second strip and multiply by 20 (3
seconds × 20 = 60 seconds or the heart rate per minute).
Precise rate calculation—Count the number of small squares between two consecutive R
waves (Figure 5.7) and refer to the conversion table printed on the inside back cover of
the book. A removable conversion table is also provided. Although this method is
accurate, it can be used only for regular rhythms. If a conversion table isn’t available,
divide the number of small squares between the two consecutive R waves into 1,500 (the
number of small squares in a 1-minute rhythm strip). The heart rates for regular rhythms in
the answer keys were determined by the precise rate calculation method.
Figure 5.6 Regular rhythm: rapid rate calculation (six R waves in 6 second strip × 10 = 60
beats per minute heart rate).
Figure 5.7 Regular rhythm: precise rate calculation (17 small squares between two
consecutive R waves = 88 beats per minute heart rate).
Irregular Rhythms
Only rapid rate calculation is used to calculate heart rate in irregular rhythms. Count the
number of R waves in a 6-second strip and multiple by 10 (Figure 5.8), or count the number of
R waves in a 3-second strip and multiply by 20.
Figure 5.8 Irregular rhythm: rapid rate calculation (12 R waves in 6 second strip × 10 = 120
beats per minute heart rate).
Other Hints
When rhythm strips have a premature beat (Figure 5.9), the premature beat isn’t included in the
calculation of the heart rate. The premature beat is a beat from a different pacemaker site in the
heart and must be assessed separately. In this example, the basic rhythm is regular and the heart
rate is 68 beats per minute (22 small squares between R waves = 68).
Figure 5.9 Basic rhythm with premature beat.

When rhythm strips have more than one rhythm on a 6-second strip (Figure 5.10), rates
must be calculated for each rhythm. This will aid in the identification of each rhythm. In the
example, the first rhythm is irregular and the heart rate is 120 beats per minute (6 R waves in 3
seconds × 20 = 120). The second rhythm is regular and the heart rate is 250 beats per minute (6
small squares between two consecutive R waves = 250). A rhythm consists of three or more
consecutive beats, has the same appearance, and may be regular or irregular.
Figure 5.10 Rhythm strip with two different rhythms.
When a rhythm covers less than 3 seconds on a rhythm strip (Figure 5.11), rate calculation
is difficult, but not impossible. In the example, the first rhythm takes up half of a 3-second
interval. There are only two R waves. Therefore, you can’t determine if the rhythm is regular
or irregular. In this situation, multiply the two R waves by 40 (1½ second × 40 = 60 seconds or
the heart rate per minute) to obtain an approximate heart rate of 80 beats per minute. The
second rhythm is regular, with a heart rate of 167 beats per minute (9 small squares between R
waves = 167).
Figure 5.11 Calculating rate when a rhythm covers less than 3 seconds.
As you have seen, rhythm strips may have one rhythm (Figures 5.6 to 5.8) with one answer.
Rhythm strips may also have a rhythm with a beat from another pacemaker site (Figure 5.9) or
have two different rhythms (Figures 5.10 and 5.11) with more than one answer. Each beat from
a different pacemaker site and each rhythm must be analyzed separately. When interpreting a
rhythm strip, describe the basic underlying rhythm first, then add additional information such as
normal sinus rhythm with one premature ventricular contraction (PVC) (Figure 5.9).
Step 3: Identify and Examine P Waves
Analyze the P waves. One P wave should precede each QRS complex and should be identical
(or near identical) in size, shape, and position. In Figure 5.12, there is one P wave to each
QRS complex, and all P waves are the same in size, shape, and position. In Figure 5.13, there
is one P wave to each QRS complex, but the P waves vary in size, shape, and position across
the rhythm strip.
Figure 5.12 P waves have the same appearance across strip.
Figure 5.13 P waves differ in appearance across strip.

Step 4: Measure the PR Interval

Measure from the beginning of the P wave as it leaves baseline to the beginning of the QRS
complex. Count the number of small squares contained in this interval and multiply by 0.04
second. In Figure 5.14, the PR interval is 0.16 second (4 small squares × 0.04 second = 0.16
second).
Figure 5.14 PR interval 0.16 second.
Step 5: Measure the QRS Complex

Measure from the beginning of the QRS complex as it leaves baseline until the end of the QRS
complex when the ST segment begins. Count the number of small squares in this measurement
and multiply by 0.04 second. In Figure 5.15, the QRS complex takes up 3 small squares and
represents 0.12 second (3 small squares × 0.04 second = 0.12 second). In Figure 5.16, the
QRS complex takes up 2½ small squares and represents 0.10 second (2½ small squares × 0.04
second = 0.10 second).
Figure 5.15 QRS complex 0.12 second.
Figure 5.16 QRS complex 0.10 second.
If rhythm strips are analyzed using a systematic step-by-step approach (Box 5.1), accurate
interpretation will be achieved most of the time.
Box 5.1 Rhythm Strip Analysis

1. Determine regularity (rhythm).
2. Calculate rate.
3. Examine P waves.
4. Measure PR interval.
5. Measure QRS complex.
MEASUREMENT PRACTICE:
MEASURING PR INTERVALS AND QRS
COMPLEXES
Instructions: The intervals and complexes have been marked to help you learn where to begin
and where to end. Count the number of small squares marked and multiply by 0.04 second.
Check your measurement answers with the answer key in the appendix.
PR Intervals
Strip 5.1
Strip 5.2
Strip 5.3
QRS Complexes
Strip 5.4
Strip 5.5
Strip 5.6
Strip 5.7
Strip 5.8
Strip 5.9
RHYTHM STRIP PRACTICE:

ANALYZING RHYTHM STRIPS
Instructions: Analyze the following rhythm strips using the five-step process discussed in this
chapter. Check your answers with the answer key in the appendix.
Strip 5.10
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.11
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.12
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.13
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.14
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.15
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.16
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.17
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.18
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.19
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________
Strip 5.20
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex
Strip 5.21
Rhythm:_________________
Rate:_________________
P wave:_________________
PR interval:_________________
QRS complex:_________________

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five

Analyzing a Rhythm Strip

Step 1: Determine Regularity (Rhythm) of R

Figure 5.1 Index card.

Figure 5.2 Regular rhythm; R-R intervals do not vary.

Step 2: Calculate the Heart Rate

Figure 5.5 ECG graph paper.

Figure 5.9 Basic rhythm with premature beat.

Figure 5.12 P waves have the same appearance across strip.

Figure 5.13 P waves differ in appearance across strip.

Step 4: Measure the PR Interval

Step 5: Measure the QRS Complex

Box 5.1 Rhythm Strip Analysis

RHYTHM STRIP PRACTICE:

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