Echocardiogram

UPDATED ON JANUARY 21, 2019

BY PAUL MARTIN, BSN, R.N.

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Echocardiogram, also known as echocardiography, or heart ultrasound is a

noninvasive, painless test that uses high-frequency sound waves to visualize the
shape, size, and movement of the structures of the heart. It is useful to evaluate
patients with chest pain, enlarged cardiac silhouettes on X-rays,
electrocardiogram (ECG) changes unrelated to CAD, and abnormal heart sounds
on auscultation.
 In this test, a transducer directs ultrahigh-frequency sound waves toward cardiac
structure, which reflect these waves. The echoes are converted to images that are
displayed on a monitor and recorded on a strip chart or videotape. Results are
correlated with clinical history, physical examination, and findings from the
additional test.

The techniques most commonly used in echocardiography are M-mode (motion

mode), for recording the motion and dimensions of intracardiac structures, and
two-dimensional  (cross-sectional), for recording lateral motion and providing the
correct spatial relationship between structures.

The responsibilities of a nurse during echocardiography includes explanation of

the procedure to the patient, monitoring during tranesophageal and stress
examinations, and establishing intravenous access for sonicated saline,
microsphere contrast, and medication administration.

 Types
 Indication
 Procedure
 Interfering factors
 Nursing Responsibilities
o Before the procedure
o During the procedure
o After the procedure
 Normal results
 Abnormal results:
 Gallery
 References

Types

The different types of echocardiogram are:

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  Transthoracic Echocardiogram (TTE). It is the most common type of
echocardiogram and is noninvasive. A device called transducer is placed on
the patient’s chest and transmits ultrasound waves into the thorax. These
waves bounce off the structures of the heart, creating images and sounds
that are shown in a monitor.
 Transesophageal Echocardiogram (TOE). It is a special type of
echocardiography that uses an endoscope to assist the transducer down to
the esophagus where it produces a more detailed image of the heart than
a transthoracic echocardiogram.
 Stress Echocardiogram. An echocardiogram that is performed while the
patient is using a treadmill or stationary bicycle. This type can be used to
measure the function of the heart both at rest and while exercising.
 Dobutamine Stress Echocardiogram. For patients who are unable to
exercise on a treadmill, a drug called dobutamine is given instead through
a vein that stimulates the heart in a similar manner as exercise. This type of
echocardiogram is used to evaluate coronary artery disease and measures
the effectiveness of cardiac therapeutic regimen.
 Doppler echocardiogram. Measures and assess the blood flow through
the heart and blood vessels.
Indication

Echocardiogram is indicated for several reasons, which includes:

 Detect and evaluate valvular abnormalities

 Detect atrial tumors
 Measure the size of the heart chambers
 Evaluate chambers and valves in congenital heart disorders
 Diagnose hypertrophic and related cardiomyopathies
 Evaluate cardiac function or wall motion after myocardial infarctions
 Detect pericardial effusion and mural thrombi
Procedure
The following are the steps and processes on how an echocardiography or
echocardiogram is performed:

1. Place patient in a supine position.

Patient is placed in a supine position and a conductive gel is applied to the
third or fourth intercostal space to the left of the sternum. The transducer
is placed directly over it.

2. Transducer is placed
The transducer directs ultra-high-frequency sound waves towards cardiac
structures, which reflect these waves; the transducer picks up the echoes,
converts them to electrical impulses, and relays them to an
echocardiography machine for display.

3. Motion mode is used

In motion mode (M-mode), a single, pencil-like ultrasound beam strikes
the heart and produces a vertical view, which is useful for recording the
motion and dimensions of intracardiac structures.

4. Change in position
In two-dimensional echocardiography, a cross-sectional view of the cardiac
structures is used for recording the lateral motion and spatial relationship
between structures. For a left lateral view, the patient is placed on his left
side.

5. Transducer is angled.
The transducer is systematically angled to direct ultrasonic waves at
specific parts of the patient’s heart.

6. Record findings.
During the test, the screen is observed; significant findings are recorded on
a strip chart recorder or a video tape recorder.

7. Doppler echocardiography.
 Doppler echocardiography also may be used where color flow stimulates
red blood cell flow through the heart valves. The sound of blood flow also
may be used to assess heart sounds and murmurs as they relate to cardiac
hemodynamics.

Interfering factors

These are factors that may affect the outcome of echocardiography:

 Patient doing unnecessary movement during the procedure.

 Incorrect placement of the transducer over the desired test area.
 Metallic objects within the examination field, which may hinder organ
visualization and cause unclear images
 Patients who are dehydrated, resulting in failure to demonstrate the
boundaries between organs and tissue structures.
 Patients who have a severe chronic obstructive pulmonary disease have a
significant amount of air and space between the heart and the chest cavity.
Airspace does not conduct ultrasound waves well.
 In obese patients, the space between the heart and the transducers is
greatly enlarged; therefore, the accuracy of the test is decreased.
Nursing Responsibilities

The following are the nursing interventions and nursing care considerations for a
patient undergoing a normal echocardiogram:

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Before the procedure

The following interventions are done prior and during the study:
  Explain the procedure to the patient. Inform the patient that
echocardiography is used to evaluate the size, shape, and motion of
various cardiac structures. Tell who will perform the test, where it will take
place, and that it’s safe, painless, and is noninvasive.
 No special preparation is needed. Advise the patient that he doesn’t
need to restrict food and fluids for the test.
 Ensure to empty the bladder. Instruct patient to void prior and to change
into a gown.
 Encourage the patient to cooperate. Advise the patient to remain still
during the test because movement may distort results. He may also be
asked to breathe in or out or to briefly hold his breath during the exam.
 Explain the need to darkened the examination field. The room may be
darkened slightly to aid visualization on the monitor screen, and that other
procedure (ECG and phonocardiography) may be performed
simultaneously to time events in the cardiac cycles.
 Explain that a vasodilator (amyl nitrate) may be given. The patient may
be asked to inhale a gas with a slightly sweet odor while changes in heart
functions are recorded.
During the procedure
The following are the nursing considerations during echocardiogram:

 Inform that a conductive gel is applied to the chest area. A conductive

gel will be applied to his chest and that a quarter-sized transducer will be
placed over it. Warn him that he may feel minor discomfort because
pressure is exerted to keep the transducer in contact with the skin.
 Position the patient on his left side. Explain that transducer is angled to
observe different areas of the heart and that he may be repositioned on his
left side during the procedure.
After the procedure
The nurse should be aware of these post-procedure nursing interventions after
an echocardiogram, they are as follows:

 Remove the conductive gel from the patient’s skin. When the

procedure is completed, remove the gel from the patient’s chest wall.
  Inform the patient that the study will be interpreted by the
physician. An official report will be sent to the requesting physician, who
will discuss the findings with the patient.
 Instruct patient to resume regular diet and activities. There is no special
type of care given following the test.
Normal results

Normal findings of echocardiogram will reveal the following:

 For mitral valve: Anterior and posterior mitral valve leaflets separating in

early diastole and attaining maximum excursion rapidly, then moving
toward each other during ventricular diastole; after atrial contraction, mitral
valve leaflets coming together and remaining together during ventricular
systole.
 For aortic valve: Aortic valve cusps moving anteriorly during systole and
posteriorly during diastole.
 For tricuspid valve: The motion of the valve resembling that of the mitral
valve.
 For pulmonic valve: Movement occurring posterior during atrial systole
and ventricular ejection, cusp moving anteriorly, attaining its most anterior
position during diastole.
 For ventricular cavities: Left ventricular cavity normally an echo-free
space between the interventricular septum and the posterior left
ventricular wall.
 Right ventricular cavity: Normally an echo-free space between the
anterior chest wall and the interventricular septum.
Abnormal results:

Abnormal echocardiogram findings will show the following:

  In mitral stenosis: Valve narrowing abnormally because of the leaflets’
thickening and disordered motion; during diastole, both mitral valve
leaflets moving anteriorly instead of posteriorly.
 In mitral valve prolapse: One or both leaflets ballooning into the left
atrium during systole.
 In aortic insufficiency: Aortic valve leaflet fluttering during diastole.
 In stenosis: Aortic valve thickening and generating more echoes.
 In bacterial endocarditis: Disrupted valve motion and fuzzy echoes
usually on or near the valve.
 Large chamber size: May indicate cardiomyopathy, valvular disorders,
or heart failure: small chamber size: may indicate restrictive pericarditis.
 Hypertrophic cardiomyopathy: Identified by a systolic anterior motion of
the mitral valve and asymmetrical septal hypertrophy.
 Myocardial ischemia or infarction: May cause absent or paradoxical
motion in ventricular walls.
 Pericardial effusion: Fluid accumulates in the pericardial space, causing an
abnormal echo-free space.
 In large effusions: Pressure exerted by excess fluid restricting pericardial
motion.
Gallery

Images related to echocardiogram:

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Virtual Tranesophageal Cardiogram
Ventricular septal defect shown in echocardiogram.
Echocardiogram showing pulmonary stenosis.
Machine used for an echocardiogram.
References

Additional resources and references for this study guide for echocardiography:

 Suzanne C. Smeltzer. Brunner & Suddarth’s Handbook of Laboratory and

Diagnostic Tests: Lippincott Williams & Wilkins
 Henry, W. L., DeMaria, A., Gramiak, R., King, D. L., Kisslo, J. A., Popp, R. L., …
& Weyman, A. E. (1980). Report of the American Society of
Echocardiography Committee on nomenclature and standards in two-
dimensional echocardiography. Circulation, 62(2), 212-217.
 Gottdiener, J. S., Bednarz, J., Devereux, R., Gardin, J., Klein, A., Manning, W.
J., … & Schiller, N. B. (2004). American Society of Echocardiography
recommendations for use of echocardiography in clinical trials: A report
from the american society of echocardiography’s guidelines and standards
committee and the task force on echocardiography in clinical trials. Journal
of the American Society of Echocardiography, 17(10), 1086-1119.
 Erbel, R., Daniel, W., Visser, C., Engberding, R., Roelandt, J., Rennollet, H., &
For, T. E. C. S. G. (1989). Echocardiography in diagnosis of aortic
dissection. The Lancet, 333(8636), 457-461.
 Oxygenation: Cardiovascular : Cardiac Assessment
Performing Electrocardiography
» Choose Procedure
Purpose

1. To perform electrocardiography according to the standard of care.

Assessment

 Assess the client's medical record for information regarding the needs for an ECG.
 Assess the client's heart rate, heart sounds, and blood pressure.
 Assess the client's chest for areas of irritation, skin breakdown, or excessive hair growth that
may interfere with the electrode placement.
Equipment

 ECG machine
 Recording paper
 Disposable pre-gelled electrodes
 4" × 4" gauze pads or washcloth
 Optional: clippers, marking pen
Procedure

1. Verify the order for the ECG in the client's chart.

Rationale: Verification of order prevents potential errors.

2. Confirm the client's ID by checking two client identifiers according to your facility's policy.

Rationale: Checking identification ensures client safety through concept of correct

procedure for correct client.

3. Provide privacy and explain the procedure to the client. Explain that the test records the
heart's electrical activity and that it may be repeated at certain intervals. Emphasize that no
electrical current will enter the body. Tell the client that the test typically takes about 5
minutes.

Rationale: Explanation of procedure protects client's rights and encourages

participation in care.

4. Wash your hands.

Rationale: Handwashing reduces transfer of microorganisms

5. Place the ECG machine close to the client's bed and plug the cord into the wall outlet or,
battery-operated, ensure that it is functioning. Turn on the machine and input required client
information. If the client is already connected to a cardiac monitor, move the electrodes to
accommodate the precordial leads.
 Rationale: Moving electrodes and keeping client away from electrical fixtures and
power cords will minimize electrical interference on ECG tracing.

6. Have the client lie supine in the center of the bed with arms at his sides. You may raise the
head of the bed to promote comfort. Expose the arms and legs and cover the client
appropriately. The arms and legs should be relaxed to minimize muscle trembling, which can
cause electrical interference.

Rationale: This position increases client comfort. Relaxing arms and legs reduces
trembling and creates a better tracing.

7. If the bed is too narrow, place the client's hands under his buttocks to prevent muscle tension.
Also use this technique if the client is shivering or trembling. Make sure the feet are not
touching the bed board.

8. Select flat, fleshy areas to place the limb lead electrodes. Avoid muscular and bony areas. If
the client has an amputated limb, choose a site on the stump.

Rationale: Tissue conducts current more effectively than bone, which produces a

better tracing.

9. If an area is excessively hairy, clip it. Clean excess oil or other substances from the skin with
soap and water to enhance electrode contact.

Rationale: Do not shave hair; shaving causes microabrasion on skin.

10. Apply disposable electrodes to the client's wrists and to the medial aspects of the ankles.
(See Positioning Chest Electrodes.) Apply the pre-gelled electrode directly to the prepared
site, as recommended by the manufacturer's instructions. To guarantee the best connection to
the lead wire, position disposable electrodes on the legs with the lead connection pointing
superiorly.

Rationale: Positioning lead connections superiorly guarantees best connection to

lead wire

11. Expose the client's chest. Put a pre-gelled electrode at each electrode position. If your client is
a woman, be sure to place the chest electrodes below the breast tissue. In a large-breasted
woman, you may need to displace the breast tissue laterally.

Rationale: Proper lead placement ensures accurate test results.

12. Connect the lead wires to the electrodes. The tip of each lead wire is lettered and color-coded
for easy identification. The white or RA lead wire goes to the right arm; the green or RL lead
wire, to the right leg; the red or LL lead wire, to the left leg; the black or LA lead wire, to the
left arm; and the brown or V1 to V6 lead wires, to the chest electrodes.

Rationale: Proper setup ensures proper functioning.

13. Check to see that the paper speed selector is set to the standard 25 mm/second and that the
machine is set to full voltage. The machine will record a normal standardization mark—a
square that is the height of two large squares or 10 small squares on the recording paper.

14. Ask the client to relax and breathe normally. Tell the client to lie still and not to talk when you
record the ECG.

Rationale: Having client relax and remain still will produce a better tracing.

15. Press the AUTO button. Observe the tracing quality. The machine will record all 12 leads
automatically, recording three consecutive leads simultaneously. Some machines have a
display screen so that you can preview waveforms before the machine records them on paper.
If any part of the waveform height extends beyond the paper when you record the ECG,
adjust the normal standardization to half standardization. Note this adjustment on the ECG
strip because this change will need to be considered in interpreting the results.

Rationale: Note any adjustments made during tracing to ensure accurate

interpretation of results.

16. When the machine finishes recording the 12-lead ECG, remove the electrodes and clean the
client's skin.

17. After disconnecting the lead wires from the electrodes, dispose of the electrodes.

Rationale: Proper disposal reduces spread of microorganisms.

18. Assist the client to a comfortable position. Ensure the bed is in a low position.

Rationale: Repositioning of bed promotes client safety.

19. Remove any remaining equipment and wash your hands.

Rationale: Handwashing reduces transfer of microorganisms

20. Document in your notes the test's date and time and significant responses by the client. Verify
the date, time, client's name, and assigned ID number on the ECG itself. Note any appropriate
clinical information on the ECG.

Sample Documentation
10/10/1 1700 Client complained of substernal chest pain 9/10. Sublingual NTG administered
0 as ordered. EKG obtained. Vital signs as per flow sheet. Dr. Smith at the
bedside to assess client and review ECG. At 1705, client rated chest pain 0/10.

Natalie Conway,RN
 POSITIONING CHEST ELECTRODES
To ensure accurate test results, position chest electrodes as follows:

V1 : Fourth intercostal space at right border of sternum

V2 : Fourth intercostal space at left border of sternum

V3 : Halfway between V2 and V4

V4 : Fifth intercostal space at midclavicular line

V5 : Fifth intercostal space at anterior axillary line (halfway between V4 and V6 )

V6 : Fifth intercostal space at midaxillary line, level with V4

Lifespan Considerations
Infant/Child

 When obtaining a pediatric ECG enlist the help of the parents, if possible, try distracting the
child to keep them still during the tracing. If artifact from either the arm or leg is a problem
try moving the lead to a more proximal position on the extremity.
Older Adult

 In older adults remove the electrodes carefully to prevent tearing of the skin, as adults grow
older the skin becomes thinner and tears easily.
Special Considerations

 Small areas of hair on the client's chest or extremities may be clipped; clipping usually is not
necessary.
 If the client's skin is exceptionally oily, scaly, or diaphoretic, rub the electrode site with a dry
4" × 4" gauze pad or washcloth before applying the electrode to help reduce interference in
the tracing. During the procedure, ask the client to breathe normally. If the respirations distort
the recording, ask the client to hold his breath briefly to reduce baseline wander in the tracing.
 If the client has a pacemaker, you can perform an ECG with or without a magnet, according to
the physician's orders. Be sure to note the presence of a pacemaker and the use of a magnet
on the strip.