ECG

Electrocardiogram is a graphical representation that describes about the heart

activities.
Each event has a distinctive waveform, the study of which can lead to greater
insight into a patient’s cardiac pathophysiology.
Normal Impulse Conduction
Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

BASIC PRINCIPLES OF ECG

 An ECG is a permanent record of the electrical impulses generated in the heart by
the depolarization and repolarization (contraction & relaxation) of the myocardium.
 These impulses are transmitted to the surface of the body where they are detected
and picked up by the electrodes and measured by a galvanometer
(electrocardiograph).
PURPOSE OF ECG MONITORING
 To assess the heart rate, rhythm, and ST segment.
 To check for ectopy (abnormal heart beat) or dysrhythmia.
Note:
The system which is used for quick monitoring of ECG is 3 lead system.
CLINICAL USES OF ECG
 To assess the cardiac functions. Eg:- rhythm and conduction.
 To diagnose cardiac rhythm disorders. Eg:-heart block.
 To diagnose cardiac diseases. Eg:-myocardial infaraction.
 To detect electrolyte imbalance. Eg:-hyperkalemia.

1
  To evaluate effects of treatments. Eg:-administration of cardiac drugs.
ECG PAPER
• Light lines small squares- 1 X 1 mm
• Bold lines large squares 5 X 5 mm
• Horizontal axis=time
1. Distance across small square=0.04 sec.
2. Distance across large square=0.2 sec.
• Vertical axis=voltage
1. Distance across small square=0.1 mV
2. Distance across large square=0.5 mV

 ECG paper speed = 25mm/sec

 Voltage calibration 1 mV = 1cm
 Timings
 1 small square = 0.04sec
 1 large square = 0.2sec
 25 small squares = 1sec
 5 large squares = 1sec

COMPONENTS OF ELECTROCARDIOGRAM
ECG consists of waves, complexes, segments and intervals.
1. Wave or complex : it is a deflection that can be positive, negative or both.
Eg:-waves – P,Q, R, S, T, U.
Complexes – QRS.
2. Segment : A segment is the period of time between a wave or complex and another
wave or complex; normally, it is a straight line. Eg:- P-Q, S-T, T-P.
3. Interval : An interval is the period of time between two points on the ECG that includes
a wave, a complex or both. . Eg:-P-R, Q-T, R-R.
 P wave is the first positive deflection (appearing above the base line) seen on the ECG.
 It is smoothly rounded.
 It appears just before the QRS complex.

2
 Presence of P wave indicates that the stimulus began in the S.A. node (pacemaker) and
subsequently spreads through both atria causing atrial contraction.
 It represents the time taken by the atria to empty the blood into the ventricles through
the open A.V. valves.
 Normal, P wave has a duration of less than 0.11 second and a height of less than 2.5 mV.
( 3 small squares width and 3 small squares height)
SUMMARY OF ECG AND THEIR SIGNIFICANCE
WAVE SIGNIFICANCE TIME ABNORMALITIES
PERIOD
P wave Depolari zation of Less than Abnormal or absence of P wave indicates
atria 0.12 that an area other than S.A. node is acting
second as pacemaker.
P-R Time of the impulse Less than Prolonged P-R interval indicates
Interval to reach the 0.20 conduction block(first degree heart
ventricles. second block)
QRS Depolarization of Less than Prolonged (wide) QRS complex indicates
complex ventricles 0.12 abnormal sequence of conduction
second through the ventricles (bundle branch
block)
S-T Completion of Less than Elevation or depression of S-T segment
segment depolarization of 0.20 represents ischemia or infarction of the
ventricles. second cardiac muscle.
T wave Complete electrical Less than Flat T ischemia; inverted T wave
recovery of the 0.20 indicates myocardial infarction. Tall and
ventricles. second spiky T wave indicates elevated serum
potassium.
LEADS FOR ECG MONITORING
Electrocardiogram consists of 12 leads. These are:
 3 standard bipolar leads (I, II, III)
 3 unipolar limb leads ( aVR, aVL,aVF )

3
  6 unipolar chest leads (V1 – V6 )
Lead I - records the difference of electrical potential between the left arm (LA) and
right arm (RA).
Lead II - records the difference of electrical potential between the left leg (LL) and the
right arm (RA).
Lead III - records the difference of electrical potential between the left leg (LL) and left
arm (LA).
aVR (augmented voltage right ) - records the difference of electrical potential between
the right limb and the central terminal. The later is also called the indifferent electrode and
is constructed within the ECG machine by connecting all three extremities. It has practically
zero potential.
aVL (augmented voltage left ) - records the difference of electrical potential between left
arm and the central terminal.
aVF (augmented voltage foot) - records the difference of electrical potential between the
left leg and the central terminal.
V Leads (chest leads) - - records the difference of electrical potential between the centre
of the heart and the following six chest positions:
V1 – 4th intercostal space to the right of the sternum.
V2 – 4th intercostal space to the left of the sternum.
V3 – half way between V2 and V4.
V4 – 5th intercostal space in the midclavicular line.
V5 – 5th intercostal space in the anterior axillary line.
V6 – 5th intercostals space in the midaxillary line.
Leads V1 and aVR : Represent the right side of the heart.
Leads V2, V3 and V4 : represent transition between the right and left side of the heart.
Leads V5, V6 , I and aVL : represent the left sides of the heart.
Leads II, III and aVF : represent the inferior part of the heart.

EINTHOVEN’S TRIANGLE
The standard limb leads are placed in such a way that they are relatively
equistant from the heart. ( the heart begin at the centre of an equilateral triangle, whose
4
apices are at the right arm, left leg and the left arm). The triangle, thus formed is called
Einthoven’s triangle.
ECG Interpretation
Analyzing a Rhythm
Component Characteristic
Rate The bpm is commonly the ventricular rate.
If atrial and ventricular rates differ, as in a 3rd-degree block, measure
both rates.
Normal: 60–100 bpm
Slow (bradycardia): _60 bpm
Fast (tachycardia): _100 bpm
Regularity Measure R-R intervals and P-P intervals.
Regular: Intervals consistent
Regularly irregular: Repeating pattern
Irregular: No pattern
P Waves If present: Same in size, shape, position
Does each QRS have a P wave?
Normal: Upright (positive) and uniform
Inverted: Negative
Notched: P′
None: Rhythm is junctional or ventricular.
PR Interval Constant: Intervals are the same.
Variable: Intervals differ.
Normal: 0.12–0.20 sec and constant
QRS Interval Normal: 0.06–0.10 sec
Wide: _0.10 sec
None: Absent
QT Interval Beginning of R wave to end of T wave
Varies with HR.
Normal: Less than half the R-R interval

5
Dropped beats Occur in AV blocks.
Occur in sinus arrest.

NURSING IMPLICATIONS FOR ECG RECORDING

 No special preparation of the patient is necessary to take an ECG. However, if the
patient is ignorant of the procedure, explain the procedure and reassure him that it is
absolutely safe.
 The female patient should put on a gown with its opening in front.
 If the patient needs to be transported to the ECG department, transport him on a
trolley; never allow him to walk till diagnosis is confirmed.
 Ask the patient to lie flat and as relaxed as possible.
 Keep the bystanders away from the patient to prevent unnecessary disturbance.
 See that the ECG machine is in functioning order.
 There should be proper standardization; while testing for standardization, the spike
made should be 10 mm or 2 large squares in height.
 The machine should be properly grounded.
 Make sure that the electrodes are placed in the proper place and manner.
 There should be good contact between the patient’s skin and the electrodes. This is
achieved by applying electrode jelly to skin where the electrodes are applied. The jelly
lowers the skin resistance, so that the electrodes can pick up the electric signals better.
 Select the correct limb leads
R.A – to the right arm.
L.A – to the left arm.
R.L – to the right leg.
L.L – to the left leg.
V leads – to the chest.
 While selecting a site, select a flat and fleshy site instead of bony surfaces and muscular
areas to avoid artifacts (artifacts mean alterations in the ECG tracing causing by the
patient’s movements or improper contact between the electrode and the skin surface).

6
 After each use. The electrode plates should be thoroughly cleansed with soap and water
and dried to prevent conductive compound from encrusting on the electrode and
forming a layer of insulation that can cause distortion of the ECG signal.
CAUSES OF POOR ECG SIGNAL
 Oily, dirty and scaly skin.
 Dirty or encrusted electrodes.
 Improper application of electrodes.
 Loose or dislodged electrodes.
 Patient’s movement.
 Muscle tremor.
 Broken cable wire.
 Faulty grounding.
 Faulty equipment.