Ateneo de Zamboanga University

College of Nursing
NURSING SKILL OUTPUT (NSO)
Electrocardiogram

Description
An electrocardiogram (EKG or ECG) is a test that checks for problems with the
electrical activity of your heart. An EKG shows the heart's electrical activity as line
tracings on paper. The spikes and dips in the tracings camera.gif are called waves.
The heart is a muscular pump made up of four chambers camera.gif. The two upper
chambers are called atria. The two lower chambers are called ventricles. A natural
electrical system camera.gif causes the heart muscle to contract. This pumps blood
through the heart to the lungs and the rest of the body.

Materials and Equipment Needed

WelchAllyn Schiller AT-1 3-Channel Electrocardiograph

Procedure
MACHINE PREPARATION:
Connect the power cord to wall outlet. Can be used by back up built in battery
unit if necessary. (Fully charged batteries will last 2 hours on battery use)
PATIENT PREPARATION:
Assure patient there is no danger or pain involved. Have the patient remove
clothing above the waist and don in a cloth gown opening to the front. Make the
patient comfortable lying down on the exam table. Expose the arms and legs. If
necessary shave the electrode areas before cleaning the exposed skin with alcohol
for proper electrode adhesion.
Limb Sensor Application
Place the sensors on a smooth fleshy area of the upper arms and lower legs.
Attach the limb leads.
Chest Sensor Application
Place the 6 Chest sensors on the patients chest as follows:
V1 Fourth intercostal space at right border of the sternum
V2 Fourth intercostal space at left border of the sternum
V3 Midway between position V2 and position V4
V4 At the mid-clavicular line in the fifth intercostal space
V5 At the anterior axillary line on the same horizontal level as V4
V6 At the mid-axillary line on the same horizontal level as V4 and V5
Attach the chest leads.
RECORDING THE EKG:
Follow the AT-1 user Guide instructions:

Press on to switch unit on.

Wait 10 seconds for unit to stabilize.

Press AUTO to record and print.
Press MAN PRINT to record a manual Rhythm Strip for 30 seconds, which is
equal to 6 printed squares of ECG paper. Press stop to stop the printout. Press
stop again to transport the paper to the start position.
Consult with appropriate clinical staff before disconnecting leads and allowing
patient dress.
AFTER THE RECORDING:
The person performing the ECG:

Mounts ECG recording onto the adhesive side of the mounitng sheet (kept on
cart) and place the rhythm strip on to the back side of the sheet using double
stick tape.

On the front of the mounting sheet document patient name, SID#, age, sex,
height, weight, BP, pulse, medications, date performed, ordering clinician's
name, and operator's initials.

Also place patient label or write patient name and SID# on back of sheet.

Stamps ECG for clinician to determine Keep or Send Out. All ECGs will be
logged, sent out, & tracked by Health Information Management (HIM) (see
details below).
Route to Charge Nurse or Clinician as below.

We do not routinely send out all ECGs for review by an outside specialist. It is
the clinicians discretion to have any questionable ECG mailed to a specialist
for second opinion depending on the acuity of the situation.

If a clinician ordered the ECG for diagnostic purpose, have the ordering clinician
review the ECG and decide if it is to be sent to the specialist.
1. Send to Specialist
a. Have clinician initial it and mark Send Out
b. Route to HIM to log, scan into the electronic medical record as Preliminary, and
mail to specialist.
2. Receiving back from Specialist
a. HIM receives the reviewed ECG via the mail, logs, date stamps, and routes to the
charge nurse.
b. The Charge Nurse routes to clinician for review.
c. The Clinician Initials the ECG & routes to HIM to be logged & scanned into the
EMR as Final.
3. Does NOT need to be sent to Specialist
a. The clinician signs, dates, and marks Keep on the original ECG.
b. The ECG is routed to HIM to log and scan as Final.
ECGs ordered within a Clinician visit, whether normal or abnormal, must be
reviewed by the ordering clinician.

If the ECG is done for Routine Testing as part of a physical without an ordering
clinician, prior to be being seen (i.e. Pre-SCUBA Physical):
Normal sinus rhythm:
1. The Charge Nurse signs, dates and marks the ECG as Keep.
2. Routes to HIM to log and scan as Final.
Abnormal Results: If the machine reports anything other than normal sinus
rhythmor the nurse/MA has any clinical concerns, the ECG will be reviewed by the
DOC or Medical Director prior to the patient leaving.
Abnormal ECGs (including Psychiatry patients) performed by an MA outside a
clinician visit must be reveiwed by the Charge Nurse, who will consult with the
DOC to determine patient disposition.
Abnormal ECGs performed by an MA as part of a clinician visit must be
reveiwed by the ordering clinician, who will determine patient disposition.
The clinican reviewing the abnormal ECG determines whether to "Keep" or "Send
Out" the ECG.
All ECGs ordered by CAPS are considered "Diagnostic". Normal results are
forwarded to the Medical Director for review (non-urgent). All abnormal results are
reviewed by the Medical Director or the DOC in his absence prior to the student
leaving.
Normal sinus rhythm:
1. The Charge Nurse signs, dates and marks the ECG as Keep.
2. Routes to HIM to log and scan as Final.
Abnormal Results: If the machine reports anything other than
normal sinus rhythmor the nurse/MA has any clinical concerns, the ECG will be
reviewed by the DOC or Medical Director prior to the patient leaving.
Abnormal ECGs (including Psychiatry patients) performed by an MA outside a
clinician visit must be reveiwed by the Charge Nurse, who will consult with the DOC
to determine patient disposition.
Abnormal ECGs performed by an MA as part of a clinician visit must be reveiwed by
the ordering clinician, who will determine patient disposition.
The clinican reviewing the abnormal ECG determines whether to "Keep" or "Send
Out" the ECG.
1. Send to Specialist
a. Have clinician initial it and mark Send Out
b. Route to HIM to log, scan into the electronic medical record as Preliminary, and
mail to specialist.

2. Receiving back from Specialist

a. HIM receives the reviewed ECG via the mail, logs, date stamps, and routes to the
charge nurse.
b. The Charge Nurse routes to clinician for review.
c. The Clinician initials the ECG & routes it to HIM to be logged & scanned into the
EMR as Final.
3. Does NOT need to be sent to Specialist
a. The clinician initials, dates, and marks as Keep on the original ECG.
b. The ECG is routed to HIM to log and scan as Final.

Diagram / Illustration

V. Nursing Responsibilities
References: http://www.webmd.com/heart-disease/electrocardiogram , http://shsmanual.ucsc.edu/policy/electrocardiogram-procedure