ECG

Measuring Electrical Impulses in the Heart

  • Purpose of Measurement:

    • Assess electrical impulses in the heart for various conditions.

    • Indications include:

    • Suspected coronary artery issues.

    • Checking defibrillators and pacemakers functionality.

    • Patients experiencing syncope (loss of consciousness).

    • Identifying metabolic problems, including electrolyte imbalances.

    • Monitoring patient symptoms such as bradycardia.

    • Post-medication monitoring.

Types of Telemetry Monitoring

  • Telemetry Equipment:

    • Options include 3 lead, 5 lead, and 12 lead monitoring.

    • 5 Lead Monitoring: Common configuration for continuous monitoring of heart rhythm.

    • 12 Lead Monitoring: One-time snapshot often used for initial screenings.

Role of the Nurse

  • Pre-Placement Considerations:

    • Assess the eight reasons for telemetry: essential to know electrolyte levels and cardiac assessments prior to monitoring.

    • Verify the order for telemetry monitoring is present.

  • Patient Assessment Before Telemetry:

    • Code Status: Determine if patient has a DNR (Do Not Resuscitate) order since telemetry data may indicate the need for CPR (Cardiopulmonary Resuscitation) or other interventions.

    • Allergies: Important to check for potential allergic reactions to adhesive.

    • Historical Data: Gather data on previous lab results, medications, and any other relevant patient history.

Placement of Telemetry Leads

  • Lead Placement Process:

    • Mnemonic: "Snow over grass, smoke over fire, and brown goes in the middle" for correct lead placement when facing the patient’s left side.

    • 1st Lead: Snow (white) on the right shoulder.

    • 2nd Lead: Grass (green) on the right lower ribcage.

    • 3rd Lead: Smoke (black) on the left shoulder.

    • 4th Lead: Fire (red) on the left lower ribcage.

    • Brown lead placed in the center to ensure grounding.

  • Skin Preparation:

    • Ensure skin is clean and dry; potential need for skin preparation in diuretic patients.

    • Take precautions with hair and, if necessary, shave the area for better lead adhesion.

Analyzing Heart Rhythms

  • Assessment of Rhythm:

    • Identify the rate, regularity, P wave, QRS complex, ST segment, and T wave.

    • Determine if the rhythm is regular or irregular by analyzing R-R intervals.

    • Distinguish between different types of rhythm:

    • Regularly Irregular: Patterned abnormalities in rhythm.

    • Irregularly Irregular: No discernible pattern.

  • Rate Calculation:

    • For ventricular rate, count R waves in a 6-second strip delineated by black lines.

    • If assessing P waves, count them for atrial rates when necessary.

Normal Sinus Rhythm and Variations

  • Normal Sinus Rhythm:

    • Rate of 60-100 beats per minute with all components (P wave, QRS complex, T wave) identifiable.

  • Sinus Bradycardia:

    • Rate is less than 60 bpm, characterized by the presence of all components but slower due to potential causes such as medications (e.g., beta blockers), athletes’ heart, or underlying cardiac conditions.

    • Symptoms may include dizziness, syncope, and hypotension; treatment options include oxygenation and atropine administration.

  • Sinus Tachycardia:

    • Rate exceeds 100 bpm but all components are present, often caused by stress, hypotension, or hypovolemia.

    • Symptoms may include palpitations and anxiety; respond with bear down techniques or medications (beta/ calcium channel blockers).

Atrial Rhythms

  • Premature Atrial Contractions (PACs):

    • Characterized by early P waves, often triggered by stimulants like caffeine, and symptoms are usually benign.

  • Atrial Fibrillation (A-fib):

    • Irregularly irregular rhythm, lack of clear P waves, can lead to thromboembolism; treatment includes anticoagulants and potential cardioversion.

  • Atrial Flutter:

    • Defined by sawtooth P waves, often regular but can lead to poor ventricular filling and similar treatment protocols as A-fib.

Ventricular Rhythms

  • Premature Ventricular Contractions (PVCs):

    • Identified by wide, bizarre-looking QRS complexes, can indicate underlying issues and potential for malignant rhythms if frequent.

  • Supraventricular Tachycardia (SVT):

    • Rapid rhythm usually over 160, characterized by narrow QRS complexes where P waves may be obscured; treatment may require emergency intervention to avoid progression to ventricular tachycardia.

Conclusion

  • Summary of Cardiac Monitoring:

    • Continuous assessment of heart rhythms and effective monitoring are critical in managing both acute and chronic cardiac conditions.

    • Understanding the various rhythms is essential for appropriate interpretation and response.

    • Vital to ensure all equipment functions properly and to adhere to guidelines in placing leads and interpreting strips effectively.