LEARNING MODULE FOR ELECTROCARDIOGRAM (ECG) 12 LEAD

Transcription

1 LEARNING MODULE FOR ELECTROCARDIOGRAM (ECG) 12 LEAD Lead application and recording of a 12 lead ECG is a Post-Entry Level Competency for: Licensed Practical Nurses Medical Lab Technologist (MLT) and Medical Lab Assistant (MLA) at Eastern Shore Memorial Hospital Lead application, recording of 12 lead ECGs, extra leads and assessment of 12 Lead ECG is a Post-Entry Level Competency for Registered Nurses Developed by: Revised by: Mary Stevens, Clinical Educator Joy Durand, Clinical Educator Jan Schwartz-Marriott, Clinical Educator Lindsay Pottinger, Clinical Educator Revision Date: July 2014

2 12 Lead Electrocardiogram (ECG) Page 2 of 10 TABLE OF CONTENTS Page Introduction 3 Prerequisites 3 Learning Objectives 3 Directions 4 Suggested Readings / References 5 Self-Test 6 Answers to Self-Test 7 Proficiency Standard Skills Checklists 8

3 12 Lead Electrocardiogram (ECG) Page 3 of 10 Introduction: This is a tool to assist LPN s, MLT s, MLA s and RN s to develop proficiency in 12 Lead Electrocardiogram: Lead Placement Recording of Assessment of (RN s in applicable units/areas only) Prerequisites: Proficiency in the Post-Entry Level Competency, Cardiac Monitoring: Cardiac Rhythm Assessment and Telemetry Monitoring CC is a pre-requisite for RN s who: Derive 12 lead ECGs from continuous cardiac monitoring systems. Assess 12 lead ECG tracings in comparison to normal or previous 12 lead ECGs. Learning Objectives: LPNs, MLTs, MLAs Following completion of this and reference material, the LPN, MLT, MLA will be able to: RNs 1. Demonstrate accurate lead placement for 12 lead ECG. 2. Set up and operate ECG equipment according to Operator s Manual / Manufacturer s instructions. 3. Record a legible 12 Lead ECG that has minimal artifact. Following completion of this and reference material the RN will be able to: 1. Demonstrate accurate lead placement for: 12 lead ECGs Left posterior leads ( applicable units/areas only) Right precordial leads (applicable units/areas only) 2. Set-up and operate 12 Lead ECG equipment according to Operator s Manual / Manufacturer s Instructions. 3. Record a legible 12 Lead ECG that has minimal artifact. 4. Use a systematic approach to assess a 12 Lead ECG (applicable units/areas).

4 12 Lead Electrocardiogram (ECG) Page 4 of Describe why right precordial leads and left posterior leads are appropriate (applicable units/areas). Directions / Method: LPN s, MLT s, MLA s RN s Review the policy & procedure. Review relevant operational / equipment manual for operation and troubleshooting guidelines for unit or site-specific cardiac equipment. Observe an RN or preceptor delegate prepare skin, apply leads and record a 12 Lead ECG. Be observed by an RN or preceptor delegate successfully completing all skills outlined in the Proficiency Skills Checklist: Lead Application and Recording of a 12 lead Electrocardiogram. Review the policy & procedure. Review relevant operational / equipment manual for operation and troubleshooting guidelines for unit or site-specific cardiac equipment. Observe an RN or preceptor delegate prepare skin, apply leads and record a 12 Lead ECG. Be observed by a RN or preceptor delegate successfully completing all skills outlined in the Proficiency Skills Checklist: Lead Application and Recording of a 12 lead Electrocardiogram. For Assessment component: Review policy and complete learning module for the Post-Entry Level Competency, Cardiac Monitoring: Cardiac Rhythm Assessment and Telemetry Monitoring CC Review Theory on 12 Lead ECG Assessment using one of the references outlined in this module, or using available unit or site specific literature, textbooks, or reference material on 12 Lead ECG. Complete the attached Self-Test. Be observed by a delegate / preceptor successfully completing all skills outlined in the Proficiency Skills Checklist: Systematic Approach to 12 Lead Assessment.

5 12 Lead Electrocardiogram (ECG) Page 5 of 10 Suggested Readings/ Resource Material for Assessing 12 Lead Electrocardiograms At least one of the following textbooks: Allen, D., Bekken, N., Crisfulla, K., Espinoza, M., Hill, K., Kabeli, C., Knight-Frank, K., Mikalaitis, M., Rader, C., Trujillo, L., Unruh, R. Wilson, O. (Eds.) (2011) ECG Interpretation Made Incredibly Easy. (5 th ed.) Lippincott, Williams & Wilkins Davis, D. (2001), 12-lead ECG Interpretation (3 rd ed.). Philadelphia: J.B. Lippincott Davis, D. (2004). Quick and Accurate 12-Lead ECG Interpretation (4 th ed.) Philadelphia: J.B. Lippincott Jackson, K., Mayer, B., Kuksta, C., Eggengerger, T., Follin, S.A., Robinson, K. (Eds.) (2002) ECG Interpretation Made Incredibly Easy. (2 nd ed.) Pennsylvania: Springhouse Note: Any recent textbook, CD or other resource material that includes a thorough overview of key concepts of 12-lead ECG may also be acceptable. Additional resources for self-directed learning, on-line are available such as: The Alan E. Lindsay ECG Learning Center in Cyberspace References Davis, D. (2001). 12-lead ECG Interpretation (3 rd ed.). Philadelphia: J.B. Lippincott Jackson, K., Mayer, B., Kuksta, C., Eggengerger, T., Follin, S.A., Robinson, K. (Eds.) (2002) ECG Interpretation Made Incredibly Easy. (2 nd ed.) Pennsylvania: Springhouse Lynn-McHale Wiegand, D. (Ed.) (2011) AACN Procedure Manual for Critical Care. (6 th ed.)philadelphia: Saunders, an imprint of Elsevier Inc.

6 12 Lead Electrocardiogram (ECG) Page 6 of 10 SELF-TEST* *APPLICABLE FOR SYSTEMATIC ASSESSMENT OF 12 LEAD COMPONENT ONLY. 1. A 12 Lead ECG can provide information about all of the following except: Hyperkalemia Heart block Myocardial ischemia Congestive heart failure 2. Application of right precordial leads is useful in diagnosis and management of some MI patients. Why? Right ventricular MI occurs concurrently with lateral wall MI approximately 33% of the time. Right ventricular MI occurs concurrently with inferior wall MI approximately 33 % of the time. Right ventricular MI is usually considered insignificant. Right ventricular MI can result in heart block. 3. The term R wave progression refers to: Normally the R wave gets smaller from lead V 1 to V 5 and slightly bigger in V 6 A special button on the ECG machine for recording R waves. The R wave normally gets taller in leads V 1 to V 5 and slightly smaller in lead V 6 Elevation of R waves in leads II and III. 4. Where do you measure for ST elevation and ST depression? Start at the j point and measure 2 spaces beyond Between the T wave and the P wave at the isoelectric baseline. Between the P wave and the S wave. 5. What does ST elevation in lead V 4R indicate? 6. What does ST elevation in lead V 8 and V 9 indicate? 7. Why is it important to determine if your patient has a right or left bundle branch block? 8. ST elevation in leads II, III and AVF indicate infarction of which myocardial wall and involves which coronary artery?

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8 12 Lead Electrocardiogram (ECG) Page 8 of Congestive Heart Failure. ANSWERS TO SELF-TEST: 2. Right ventricular MI occurs concurrently with inferior wall MI approximately 33% of the time. 3. The R wave normally gets taller in leads V 1 to V 5 and slightly smaller in lead V Start at the J point and measure two spaces beyond 5 Acute right ventricular wall infarct 6. Posterior wall infarct 7. If left BBB is present, the ECG will be of little value in determining presence of MI due to the abnormal ST segments, widened QRS complexes and T wave distortion associated with LBBB. 8. Inferior wall MI, right coronary artery

9 12 Lead Electrocardiogram (ECG) Page 9 of 10 PROFICIENCY STANDARDS SKILLS CHECKLIST TITLE: Lead Application and Recording of a 12 lead Electrocardiogram Note: The Proficiency Standard Skills Checklists are tools to assess technical competence. For complete information on the concepts discussed in the checklist, the reference material must be utilized. Name: Evaluator: Unit: Date: YES NO 1. Verifies patient with 2 identifiers and explains procedure. 2. Sets up & operates equipment according to manufacturer s instructions. Refer to equipment specific Operator s Manual for operational instructions. 3. Prepares skin as recommended (clip hair if necessary). 4. Places limb leads over soft tissue on appropriate extremity. 5. a.) Applies chest leads accurately using anatomical landmarks. b.) Applies right precordial leads accurately using anatomical landmarks (RNs in applicable units only) c.) Applies left posterior leads accurately using anatomical landmarks (RNs in applicable units only) 6. Fastens lead wires to electrodes. 7. Enters patient name and hospital unit number in portable ECG machine or monitor 8. Ensures extra leads are accurately identified on tracing. 9. Assesses tracing for quality. 10. Utilizes trouble-shooting methods to obtain tracing with minimal artifact. 11. Ensures ECG is either transmitted to appropriate location or printed (or both) 12. Follows unit/area protocol for assessment of tracing, notification of physician & documentation.

10 12 Lead Electrocardiogram (ECG) Page 10 of 10 Proficiency Standards Skills Checklist Title: Systematic Approach to 12 Lead Assessment Note: The Proficiency Standard Skills Checklists are tools to assess technical competence. For complete information on the concepts discussed in the checklist, the reference material must be utilized. Name: Evaluator: Unit: Date: Verify that standardization is 1.0 mm and the paper speed on machine is 25 mm/sec. Lead AVR should be negative. Verify ECG tracing is free from electrical interference and drift. Follow systematic approach for ECG assessment, comparing with patient s previous ECG to identify changes. If no previous ECG, compare with normal 12 lead: Assess heart rate, rhythm and regularity Assess P wave and PR interval Assess for NSR or arrhythmias / rhythm changes Assess QRS duration in V 1 Assess for BBB In applicable units / areas: Examine R wave in precordial leads for R wave progression Assess axis Assess for ST segment depression or elevation in groups of leads Assess for abnormal T waves and Q waves Assess for ventricular hypertrophy Correlate ECG findings with patient condition Notify physician according to unit / area protocol. Document according to unit / area protocol. Yes No