Electrocardiography for Healthcare Professionals, 6e (Oct 13, 2023)_(1266092013)_(McGraw Hill) 9781266092015, 1266092013

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This linternational Student Edition is for use outside of the UJSk



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ELECTROCARDIOGRAPHY FOR HEALTHCARE PROFESSIONALS Sixth Edition

Kathryn A. Booth, RN-BSN, RMA (AMT), RPT (AMT), EFR, CPhT, MS Total Care Programming, Inc. Palm Coast, Florida

Thomas E. O’Brien, AAS, CCT, CRAT, RMA, CCMA, CPT Remington College Medical Assisting Program, Capstone Instructor



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ELECTROCARDIOGRAPHY FOR HEALTHCARE PROFESSIONALS Published by McGraw Hill LLC, 1325 Avenue of the Americas, New York, NY 10019. Copyright ©2024 by McGraw Hill LLC. All rights reserved. Printed in the United States of America. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of McGraw Hill LLC, including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning. Some ancillaries, including electronic and print components, may not be available to customers outside the United States. This book is printed on acid-free paper. 1 2 3 4 5 6 7 8 9 LMN 28 27 26 25 24 23 ISBN 978-1-266-09201-5 MHID 1-266-09201-3 Cover Image: Enot-poloskun/E+/Getty Images All credits appearing on page or at the end of the book are considered to be an extension of the copyright page. The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate an endorsement by the authors or McGraw Hill LLC, and McGraw Hill LLC does not guarantee the accuracy of the information presented at these sites. mheducation.com/highered



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Dedication To the individuals using the information in this book, you have chosen a much needed, worthwhile, and rewarding profession. Thank you; your skills and services are truly needed. To my children and grandchildren who keep me young. To my students and patients, may your futures be even better than expected.

Kathryn Booth I want to thank my beautiful wife, Michele, and our wonderful children, Thomas, Robert, and Kathryn. Without their love and support, I would have nothing. They inspire me every day to make a difference in people’s lives. Today’s students are the difference makers of tomorrow!

Thomas O’Brien



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About the Authors Kathryn A. Booth, RN-BSN, RMA (AMT), EFR, RPT, CPhT, MS, is a registered nurse (RN) with CPR and ACLS training as well as a master’s degree in education. She serves on the Cardiovascular Credentialing International Certified Rhythm Analysis Technician Item Writer and Reviewer’s committee and the American Medical Technologists registered Phlebotomy Technician Examinations, Qualifications, and Standards committee. She has over 40 years in healthcare and education including nursing, electrocardiography, phlebotomy, and medical assisting. Her experience spans five states. As an educator, Kathy has been awarded the teacher of the year in three states where she taught various health educational courses including healthcare science, nursing, and medical assisting. She is a past and current member of two educational advisory boards. Her larger goal is to develop up-to-date, dynamic healthcare educational materials to assist other educators as well as to promote the healthcare profession. This is why she became the owner, author, educator, and consultant for Total Care Programming, Inc. Kathy enjoys developing and presenting innovative new learning solutions for the changing healthcare and educational landscape to her fellow professionals nationwide. Thomas E. Davidson-O’Brien, AAS, CCT, CRAT, RMA, CCMA, CPT, is the capstone instructor for the Medical Assisting program at Remington College, Fort Worth, Texas. Tom also works as an author and editor of Practical Clinical Skills (www.practicalclinicalskills.com) and EKG Academy. He is a former member of the Board of Trustees and Exam Chair for the Certified Cardiographic Technician (CCT) and Certified Rhythm Analysis Technician (CRAT) Registry Examinations working with Cardiovascular Credentialing International (CCI). Tom continues to volunteer his efforts as an active contributor to both credential exams as a member of the Item Writing team. His background includes over 40 years in healthcare including the U.S. Air Force and U.S. Army Medical Corps. Tom’s medical career as an Air Force Independent Duty Medical Technician (IDMT) has taken him all over the United States and the world. He has several years of experience working in the Emergency Services and Critical Care arena (Cardiothoracic Surgery and Cardiac Cath Lab). He was awarded Master Instructor status by the U.S. Air Force in 1994 upon completion of his teaching practicum. He now has over 20 years of teaching experience; subjects include Emergency Medicine, Cardiovascular Nursing, Fundamentals of Nursing, Dysrhythmias, and 12-Lead ECG Interpretation. His current position provides challenges to meet the ever-changing needs of the medical community and to provide a first-rate education to a diverse adult education population.



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Brief Contents Preface

xii

Acknowledgments

xx 1

CHAPTER

 1

Electrocardiography

CHAPTER

 2

The Cardiovascular System

CHAPTER

 3

The Electrocardiograph

CHAPTER

 4

Performing an ECG

CHAPTER

 5

Rhythm Strip Interpretation

CHAPTER

 6

Sinus Rhythms

CHAPTER

 7

Atrial Dysrhythmias

CHAPTER

 8

Junctional Dysrhythmias

CHAPTER

 9

Heart Block Dysrhythmias

CHAPTER

10

Ventricular Dysrhythmias

CHAPTER

11

Pacemaker Rhythms

CHAPTER

12

Cardiac Stress Testing

275

CHAPTER

13

Ambulatory Monitoring

304

36

57

87 126

143 165 184 204 224

253

CHAPTER

14

CHAPTER

15

Clinical Presentation and Management of the Cardiac Patient

Basic 12-Lead ECG Interpretation

331

363



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APPENDIX

A

Cardiovascular Medications

APPENDIX

B

Standard and Isolation Precautions

APPENDIX

C

Medical Abbreviations, Acronyms, and Symbols

APPENDIX

D

Anatomical Terms

APPENDIX

E

Identifying Components of ECG Strips

APPENDIX

F

Competency Checklists Available through the Instructor Resources on C Glossary Index

I-1

G-1

A-1 B-1 C-1

D-1 E-1



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Contents Preface xii Acknowledgments xx

CHAPTER

1

Electrocardiography

1

1.1 The ECG and Its History 2 1.2 Uses of an ECG 3 1.3 Preparing for an ECG 11 1.4 Infection Control 16 1.5 Vital Signs 20 Competency Checklists 1-1 Measuring Pulse and Respirations 1-2 Measuring Adult Blood Pressure

CHAPTER

2

The Cardiovascular System

32 34

36

2.1 Circulation and the ECG 37 2.2 Anatomy of the Heart 37 2.3 Principles of Circulation 42 2.4 The Cardiac Cycle 44 2.5 Conduction System of the Heart 46 CHAPTER

3

The Electrocardiograph

57

3.1 Producing the ECG Waveform 57

3.2 ECG Machines 63 3.3 ECG Controls 67 3.4 Electrodes 71 3.5 ECG Graph Paper 72 3.6 Calculating Heart Rate 75

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CHAPTER

4

Performing an ECG

87

4.1 Preparation for the ECG Procedure 88 4.2 Communicating with the Patient 89 4.3 Safety 91 4.4 Applying the Electrodes and Leads 93 4.5 Operating the ECG Machine 99 4.6 Checking the ECG Tracing 99 4.7 Reporting ECG Results 104 4.8 Equipment Maintenance 105 4.9 Pediatric ECG 107 4.10 Cardiac Monitoring 108 4.11 Special Patient Considerations 109 4.12 Handling Emergencies 113 Competency Checklists 4-1 Recording an Electrocardiogram 4-1 Continuous Cardiac Monitoring

CHAPTER

5

Rhythm Strip Interpretation

122 124

126

5.1 Electrical Stimulation and the ECG Waveform 126

5.2 Rhythm Interpretation 130 5.3 Identifying the Components of the Rhythm 132 CHAPTER

6

Sinus Rhythms

143

6.1 Rhythms Originating from the Sinus Node 143 6.2 Sinus Bradycardia 146 6.3 Sinus Tachycardia 148 6.4 Sinus Dysrhythmia 150 6.5 Sinus Arrest 152 6.6 Sinus Exit Block 154 CHAPTER

7

Atrial Dysrhythmias

165

7.1 Introduction to Atrial Dysrhythmias 165 7.2 Premature Atrial Complexes 166 7.3 Wandering Atrial Pacemaker 168 7.4 Multifocal Atrial Tachycardia 170

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7.5 Atrial Flutter 171 7.6 Atrial Fibrillation 174 CHAPTER

8

Junctional Dysrhythmias

184

8.1 Introduction to Junctional Dysrhythmias 184 8.2 Premature Junctional Complex (PJC) 186 8.3 Junctional Escape Rhythm 187 8.4 Accelerated Junctional Rhythm 189

8.5 Junctional Tachycardia 191 8.6 Supraventricular Tachycardia (SVT) 193 CHAPTER

9

Heart Block Dysrhythmias

204

9.1 Introduction to Heart Block Dysrhythmias 204 9.2 First-Degree Atrioventricular (AV) Block 204 9.3 Second-Degree Atrioventricular (AV) Block, Type I (Mobitz I or Wenckebach) 206 9.4 Second-Degree Atrioventricular (AV) Block, Type II (Mobitz II) 209 9.5 Third-Degree Atrioventricular (AV) Block (Complete) 212 CHAPTER

10

Ventricular Dysrhythmias

224

10.1 Introduction to Ventricular Dysrhythmias 224 10.2 Premature Ventricular Complexes (PVCs) 225 10.3 Agonal Rhythm 229 10.4 Idioventricular Rhythm 231 10.5 Accelerated Idioventricular Rhythm 232 10.6 Ventricular Tachycardia 234 10.7 Ventricular Fibrillation 236 10.8 Asystole 239 CHAPTER

11

Pacemaker Rhythms

253

11.1 Introduction to Pacemakers 253 11.2 Evaluating Pacemaker Function 257

11.3 Pacemaker Complications Relative to the ECG Tracing 262 Competency Checklists 11-1 Pacemaker Evaluation

273



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CHAPTER

12

Cardiac Stress Testing

275

12.1 Cardiac Stress Testing 275 12.2 Why Is Exercise Electrocardiography Used? 277 12.3 Other Types of Cardiac Stress Testing 278 12.4 Preparing the Patient for Exercise Electrocardiography 281 12.5 Providing Safety 284 12.6 Performing Exercise Electrocardiography 287 12.7 Common Protocols 289 12.8 After Exercise Electrocardiography 292 Competency Checklists 12-1 Assisting with Exercise Electrocardiography (Stress Testing) 300

CHAPTER

13

Ambulatory Monitoring

304

13.1 Ambulatory Monitoring 304 13.2 How Is Ambulatory Monitoring Used? 306 13.3 Types of Ambulatory Monitoring 307 13.4 Educating the Patient 313 13.5 Preparing the Patient 316

13.6 Applying an Ambulatory Monitor 316 13.7 Removing an Ambulatory Monitor and Reporting Results 320 Competency Checklists 13-1 Applying and Removing an Ambulatory (Holter) Monitor 327

CHAPTER

14

Clinical Presentation and Management of the Ca 14.1 Coronary Arteries 332 14.2 Cardiac Symptoms 334 14.3 Atypical Patient Presentation 336 14.4 Acute Coronary Syndrome 338 14.5 Heart Failure 341 14.6 Cardiac Patient Assessment and Immediate Treatment 344 14.7 Treatment Modalities for the Cardiac Patient 349 Competency Checklists 14-1 Immediate Care for a Cardiac Patient

361



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CHAPTER

15

Basic 12-Lead ECG Interpretation

363

15.1 The Views of a Standard 12-Lead ECG and Major Vessels 363 15.2 Ischemia, Injury, and Infarction 368 15.3 Introduction to Bundle Branch Block 372 15.4 LBBB vs. RBBB 376 15.5 Electrical Axis 378

15.6 Left Ventricular Hypertrophy 381 Appendix A Cardiovascular Medications

A-1

Appendix B Standard and Isolation Precautions

B-1

Appendix C Medical Abbreviations, Acronyms, and Symbols 1 Appendix D Anatomical Terms

D-1

Appendix E Identifying Components of ECG Strips

E-1

Appendix F Competency Checklists Available through the Instructor Resources on Connect and www.mcgrawhillcreate.com F-1 Glossary Index

G-1 I-1

C-



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Preface Healthcare is an ever-changing and growing field that needs well-trained individuals who can adapt to change. Flexibility is key to obtaining, maintaining, and improving a career in electrocardiography. Obtaining ECG training and certification, whether it be in addition to your current career or as your career, will make you employable or a more-valued employee. This sixth edition of Electrocardiography for Healthcare Professionals will prepare users for a national ECG certification examination, but most importantly, it provides comprehensive training and practice for individuals in the field of electrocardiography. The fact that you are currently reading this book means that you are willing to acquire new skills or improve the skills you already possess. This willingness translates into your enhanced value, job security, marketability, and mobility. Once you complete this program, taking a certification examination is a great next step for advancing your career. This sixth edition of Electrocardiography for Healthcare Professionals can be used in a classroom as well as for online learning. Checkpoint Questions and Connect exercises correlated to the Learning Outcomes make the learning process interactive and promote increased comprehension. The variety of materials included with the program provides for multiple learning styles and ensures individual success.

Text Organization The text is divided into 15 chapters: Chapter 1 Electrocardiography includes introductory information about the field as well as legal, ethical, communication, and patient education information. In addition, basic vital signs and troubleshooting are addressed. Competency Checklists are included to practice checking vital signs. Chapter 2 The Cardiovascular System provides a complete introduction and review of the heart and its electrical system. The information focuses on what you need to know to understand and perform an ECG. Specific topics include anatomy of the heart, principles of circulation, cardiac cycle, and the cardiac conduction system. Chapter 3 The Electrocardiograph creates a basic understanding of the ECG, including producing the ECG waveform, the ECG machine, electrodes, and ECG graph paper. Chapter 4 Performing an ECG describes the procedure for performing an ECG in a simple step-bystep fashion. Each part of the procedure is explained in detail, taking into consideration the latest guidelines. The chapter is divided into the following topics: preparation, communication, page xiii safety, anatomical landmarks, applying the electrodes and leads, operating the ECG machine, checking the tracing, reporting results, and equipment maintenance. Extra sections are included regarding pediatric ECG, cardiac monitoring, special patient circumstances, and emergencies.

Competency Checklists are included to practice performing both an ECG and continuous monitoring. Chapter 5 Rhythm Strip Interpretation includes details about the electrical stimulation of the heart and how the waveform is developed. It then introduces the five-step criteria for the classification approach to rhythm interpretation that will be utilized throughout Chapters 6 through 11. Chapter 6 Sinus Rhythms has updated, realistic rhythm strip figures and explanations to learn to interpret the sinus rhythms, including criteria for classification, how the patient may be affected, basic patient care, and treatment. Chapter 7 Atrial Dysrhythmias provides an introduction to and interpretation of the atrial dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment. Chapter 8 Junctional Dysrhythmias provides an introduction to and interpretation of the junctional dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment. Chapter 9 Heart Block Dysrhythmias provides an introduction to and interpretation of the heart block dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment. Chapter 10 Ventricular Dysrhythmias provides an introduction to and interpretation of the ventricular dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, and treatment. Chapter 11 Pacemaker Rhythms provides an introduction to pacemaker rhythms, evaluation of pacemaker function, and complications related to the ECG tracing. Chapter 12 Cardiac Stress Testing provides the information necessary to assist with the exercise electrocardiography procedure. The Competency Checklist provides the step-by-step procedure for practice and developing proficiency at the skill. Chapter 13 Ambulatory Monitoring includes the latest information about various types of ambulatory monitors and includes what you need to know to apply and remove a monitor. A Procedures Checklist is provided for this skill. Chapter 14 Clinical Presentation and Management of the Cardiac Patient expands on the anatomy of the coronary arteries and relates them to typical and atypical cardiac symptoms. STEMI, nonSTEMI, and heart failure are introduced. The chapter includes a section about sudden cardiac death as compared to myocardial infarction and finishes with assessment, immediate care, and page xiv continued treatment of the cardiac patient. Chapter 15 Basic 12-Lead ECG Interpretation provides an introduction to 12-lead ECG interpretation. It includes anatomical views of the coronary arteries and correlates the arteries with the leads and views obtained on a 12-lead ECG. It also identifies the morphologic changes in the tracing that occur as a result of ischemia, injury, and infarction. An introduction to bundle branch block dysrhythmias, including criteria for classification, how the patient may be affected, basic patient care, treatment, and how to differentiate between left and right bundle branch block is included. Axis deviation and left ventricular hypertrophy round out the chapter concepts. An extra Putting It All Together section after the chapter review is provided to help users practice the chapter concepts together for 12-lead interpretation. These chapters can be utilized in various careers and training programs. Following are some

suggested examples: Telemetry technicians (Chapters 1–12, depending on requirements) EKG/ECG technicians (the entire book, depending on requirements) Medical assistants (the entire book, depending on where they work) Cardiovascular technicians working in any number of specialty clinics, such as cardiology or internal medicine (the entire book) Remote monitoring facilities personnel (Chapters 1–10, 13–15) Emergency medical technicians (Chapters 2, 5–10, 15, possibly more depending on where they work) Paramedics (Chapters 2–15) Nursing, especially for cross-training or specialty training (Chapters 2–15) Patient care tech or nursing assistant (Chapters 2–4, 13, perhaps more depending on job requirements) Polysomnography technologist (Chapters 2–10) Echocardiography technologist (Chapters 2, 5–12) Cardiac cath lab technologist (Chapters 2–11, 15)

New to the Sixth Edition We split the 5th edition Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms into two chapters, which are now Chapter 5 Rhythm Strip Interpretation and Chapter 6 Sinus Rhythms. Moved the content “Electrical Stimulation and the ECG Waveform” into the new Chapter 5 Rhythm Strip Interpretation for seamless learning. Chapter 15 Basic 12-Lead ECG Interpretation now includes the information from the 5th edition Chapter 10 Bundle Branch Block. Improved many of the ECG tracings to make them more realistic. Added and updated content about the following topics: ECG career opportunities, cardiac conduction system, vital sign ranges by age (new Table 1-5), ECG for adolescents, low cardiac output (new Table 6-1), various rhythms Interpret-Tips and How the Patient Is Affected sections, ACLS page xv guidelines, cardiac stress test timing, anticoagulation medications, and axis deviation to name a few. Added or updated over 20 images throughout the new content.

Features of the Text Key Terms and Glossary: Key terms are identified at the beginning of each chapter. These terms are in bold, color type within the chapter and are defined both in the chapter and in the glossary at the end of the book. Checkpoint Questions: At the end of each main heading in the chapter are short-answer Checkpoint Questions. Answer these questions to make sure you have learned the basic concepts presented. Think It Through: The Think It Through feature identifies problems and situations that may arise

when you are caring for patients or performing a procedure. At the end of this feature, you are asked a question to answer in your own words. Safety & Infection Control: You are responsible for providing safe care and preventing the spread of infection. This feature presents tips and techniques to help you practice these important skills relative to electrocardiography. Communicate and Connect: Patient interaction and education and intrateam communication are integral parts of healthcare. As part of your daily duties, you must communicate effectively, both orally and in writing, and you must provide patient education. Use this feature to learn ways to perform these tasks. Law & Ethics: When working in healthcare, you must be conscious of the regulations of HIPAA (Health Insurance Portability and Accountability Act) and understand your legal responsibilities and the implications of your actions. You must perform duties within established ethical practices. This feature helps you gain insight into how HIPAA, law, and ethics relate to the performance of your duties. Real ECG Tracings: Actual ECG tracings, or rhythm strips, have been provided for easy viewing and to make the task of learning the various dysrhythmias easier and more realistic. Use of these ECG rhythm strips for activities and exercises throughout the program improves comprehension and accommodates visual learners. Competency Checklists: Checklists at the end of some chapters (as appropriate) help you practice your skills in performing key procedures. Chapter Summary: Once you have completed each chapter, take time to read and review the summary table. It has been correlated to key concepts and learning outcomes within each chapter and includes handy page number references. Chapter Review: Complete the chapter review questions, which are presented in a variety of formats. These questions help you understand the content presented in each chapter. Chapters page xvi 4, 11, and 12 also include Procedures Checklists for you to use to practice and apply your knowledge.

Features of Connect Here is what you can expect to find in Connect for Electrocardiography for Healthcare Professionals: A variety of question types, including Strip Exercises and Practice Exam Questions, that can be used for homework, quizzes, or tests Smartbook: An adaptive reading experience that personalizes learning Health Professions Virtual Labs: Simulated labs that help students learn practical and conceptual lab skills Application-Based Activities: Simulated real-life scenarios and animation activities that allow students to apply knowledge and problem solve

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Resources Additional Instructor Resources Instructor’s Manual with course overview, lesson plans, answers to Checkpoint and End-of-Chapter Review questions, competency correlations, sample syllabi, and more. PowerPoint Presentations for each chapter, containing teaching notes correlated to learning outcomes. Each presentation seeks to reinforce key concepts and provide an additional visual aid for students. Transition Guide with a chapter-by-chapter breakdown of how the content has been revised between editions. The guide is helpful if you are currently using Electrocardiography for Healthcare Professionals and moving to the new edition. Instructor Asset Map to help you find the teaching material you need. These online chapter tables are organized by Learning Outcomes and allow you to find instructor notes, PowerPoint slides, and even test bank suggestions with ease! The Asset Map is a completely integrated tool designed to help you plan and instruct your courses efficiently and comprehensively. It labels and organizes course material for use in a multitude of learning applications. Competency Correlations provide a correlation structure that enhances the product’s usefulness to both students and instructors. We have been careful to ensure that the text and digital products provide coverage of topics crucial to all of the following: Commission on Accreditation of Allied Health Programs (CAAHEP) Accrediting Buraus of Health Education Schools (ABHES) Cardiography Credentialing International (CCI): Certified Cardiographic Technician (CCT) and Certified Rhythm Analysis Technician (CRAT) National Center for Competency Testing: ECG Technician (NCET) National Healthcareer Association: Certified EKG Technician (CET) Appendix F provides all of the Competency Checklists from the textbook in one handy document. All of these helpful materials can be found within your Connect course within the Library, under the Instructor Resources.



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Instructors The Power of Connections A complete course platform Connect enables you to build deeper connections with your students through cohesive digital content and tools, creating engaging learning experiences. We are committed to providing you with the right resources and tools to support all your students along their personal learning journeys.

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Affordable solutions, added value Make technology work for you with LMS integration for single sign-on access, mobile access to the digital textbook, and reports to quickly show you how each of your students is doing. And with our Inclusive Access program, you can provide all these tools at the lowest available market price to your students. Ask your McGraw Hill representative for more information.

Solutions for your challenges A product isn’t a solution. Real solutions are affordable, reliable, and come with training and ongoing support when you need it and how you want it. Visit supportateverystep.com for videos and resources both you and your students can use throughout the term.



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Students Get Learning that Fits You Effective tools for efficient studying Connect is designed to help you be more productive with simple, flexible, intuitive tools that maximize your study time and meet your individual learning needs. Get learning that works for you with Connect.

Study anytime, anywhere Download the free ReadAnywhere® app and access your online eBook, SmartBook® 2.0, or Adaptive Learning Assignments when it’s convenient, even if you’re offline. And since the app automatically syncs with your Connect account, all of your work is available every time you open it. Find out more at mheducation.com/readanywhere

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Acknowledgments Authors Kathryn Booth: Thanks to all the reviewers who spent time helping to make sure this sixth edition is upto-date. In addition, I would like to acknowledge everyone at McGraw-Hill who helped with this edition: Michelle Vogler, Portfolio Director; Marah Bellegarde, Portfolio Manager; Krystal Faust, Senior Product Developer; Jeni McAtee and Brent dela Cruz, Content Project Managers; Gina Oberbroeckling, Content Licensing Specialist; and Tamara Hodge, Marketing Manager. Special thanks to Beth Baugh, Freelance Product Developer, for getting us through the initial step with patience. Additionally, I would like to acknowledge Patricia Dei Tos and the members of the Inova Health system, who help to create and support the original development of this textbook. For the sixth edition, I also want to thank Kathy Hellums and Lisha Smith for their knowledge and excellent reviews. Last but not least I would also like to thank my co-author, Thomas O’Brien, for his continued dedication and timely support for the project. Thomas E. Davidson-O’Brien: I would like to acknowledge Mr. David Rubin, president & CEO of Aerotel Medical Systems (1998) Ltd., 5 Hazoref St., Holon 58856, Israel. I would like to express my sincere appreciation to a pair of former students and Central Florida Institute graduates: Rebecca Walton, CCT, for her contribution of Interpret-Tips and Jamie Merritt, CCT, for “bunny branch block.” I would also like to extend a special thank you to a Remington College graduate, Tayshaun Gary for offering to be my model for the 12-Lead ECG image in this edition. I would also like to give a special thank you to the staff members of the Non-Invasive Cardiology Departments at the Pepin Heart Hospital, Morton Plant Hospital, All Children’s Hospital, and Palms of Pasadena Hospital for their inputs and generous donation of their time and expertise. Additionally, I would like to thank my co-workers and the leadership at Remington College, especially my Program Directors Dr. Jessalyn Ludley and Dr. Rose Van Alstine for their continued support in enhancing the training for our students and esteemed colleague Mr. Davy Hobson. A special thank you to Mr. John Michael Maloney, RCIS (RIP), and Mrs. Kathy Hellums, RCS, for their contributions of support and expertise without reservation. Finally, a very special thank you to my son Rob for his hours devoted to scanning many of the cardiac rhythms and my daughter Kat for proofing my authored works in this text.

Sixth Edition Reviewers

Celeste Dator, RMA, ADN

Las Vegas College

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Danny Opperman, AAS (AHS), AAS (PS), AAS (EMS), BS

Rowan College at Burlington County

Barbara Pape, CMA, CET, CPT

Tidewater Medical Training

Krista Rodgers, MS, BS, BLS, ECG, RMA (AMT)

ECPI University

Greg Russell, AAS

Front Range Community College

Maria Sgambati, MD

Hillsborough Community College

Carlos Vargas, MS

Monroe College

Suzanne Wambold, RN, PhD

The University of Toledo

Barb Westrick, CMA (AAMA), CPC, CET, CPT, CPCT, CHUC, PTTC, MCBC, AAS

St. Clair County Community College

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page 1

1 Electrocardiography

Learning Outcomes 1.1

Describe the history and the importance of the ECG.

1.2

Identify the uses of an ECG and career opportunities for an electrocardiographer.

1.3

Troubleshoot legal, ethical, patient education, and communication issues related to the ECG.

1.4

Perform infection control measures required for the ECG.

1.5

Compare basic vital sign measurements related to the ECG.

Key Terms auscultated blood pressure automatic external defibrillator (AED) cardiac output cardiopulmonary resuscitation (CPR) cardiovascular disease (CVD) cardiovascular technologist Code Blue coronary artery disease (CAD) defibrillator diastolic blood pressure dysrhythmia ECG monitor technician electrocardiogram (ECG) electrocardiograph electrocardiograph (ECG) technician

ethics event monitor filtering facepiece respirator healthcare providers hypertension hypotension isolation precautions law libel medical professional liability myocardial infarction (MI) (heart attack) personal protective equipment (PPE) slander standard precautions stat sphygmomanometer systolic blood pressure telemedicine tilt table test vital signs



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1.1 The ECG and Its History According to the Centers for Disease Control and Prevention (CDC), the leading cause of death in the United States every year since 1921 is cardiovascular disease (CVD), or a disease of the heart and blood vessels. Approximately 659,000 Americans die every year because of coronary artery disease (CAD), which is narrowing of the arteries of the heart, causing a reduction of blood flow. Unbelievably, one out of every three American adults has some form of CAD. You may know someone who has a heart condition. Maybe someone you know has had a myocardial infarction (MI) or heart attack. cardiovascular disease (CVD) Disease related to the heart and blood vessels (veins and arteries). coronary artery disease (CAD) Narrowing of the arteries of the heart, causing a reduction of blood flow. myocardial infarction (MI) (heart attack) Occlusion (blockage) of one or more of the

coronary arteries causing lack of oxygen to the heart and death of the muscle tissue. An electrocardiograph is an instrument that allows the heart’s electrical activity to be recorded and studied. It is used to produce an electrical (electro) tracing (graph) of the heart (cardio). This representative tracing of the electricity as it moves through the heart is known as an electrocardiogram (ECG). electrocardiograph An instrument used to record the electrical activity of the heart. electrocardiogram (ECG) A tracing of the heart’s electrical activity recorded by an electrocardiograph. Willem Einthoven (1860–1927) invented the first electrocardiograph, sometimes referred to as EKG (electro), Kardio (Greek for heart) gram (recording). There is no difference between an ECG and an EKG. ECG stands for electrocardiogram, and EKG is the German spelling for elektrokardiographie, which is the word electrocardiogram translated into the German language. An ECG (EKG) is a test that measures the electrical activity of the heart. An ECG may also be called a 12-lead ECG or a 12-lead EKG. Advancements in this technology have brought about today’s modern ECG machines (see Figure 1-1). Technology continues to improve the availability and speed of computer interpretation and quickly page 3 communicates this information to a healthcare professional. Digital communication allows healthcare professionals to monitor patients from locations hundreds or even thousands of miles away. Figure 1-1 Today’s 12-lead ECG machine is attached to the patient’s chest, arms, and legs using electrodes and lead wires. It records a tracing of the electrical activity of the heart. Jim Varney/Science Source

Performing the actual ECG procedure is not difficult; however, it must be performed competently. The tracing of the electrical current of the heart must be accurate because it is used to make decisions about a patient’s care. An inaccurate tracing could result in a wrong decision about the patient’s medication or treatment. These decisions could result in a negative outcome for the patient.

Checkpoint Questions (LO 1.1) 1. What is the leading cause of death in the United States? 2. Who invented the first electrocardiograph?

1.2 Uses of an ECG Healthcare providers study the ECG tracing to determine many things about the patient’s heart. They look for abnormalities in the recording and changes from earlier recordings when available. The American

Heart Association (AHA) recommends that individuals over the age of 40 have an ECG done annually as part of a complete physical. This baseline tracing assists the physician in diagnosing abnormalities of the heart. A sample of a normal tracing is shown in Figure 1-2. healthcare provider The scope of practice of each healthcare provider will determine the extent of the interpretation and treatment of each of the cardiac dysrhythmias or conditions. Each specific scope is determined by the licensure of each state. For example: Prescribing a medication is the responsibility of the physician. But some state practices allow nurse practitioners and physician assistants to prescribe medication under the guidance of the physician. Figure 1-2 A normal ECG tracing is a horizontal line with upward and downward waves or deflections that indicate electrical activity within the heart.



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Electrocardiography can be performed in a number of healthcare settings. The type of ECG tracing produced depends on the setting and the type of ECG machine used.

In the Hospital (Acute Care) The 12-lead ECG is one of the most commonly used tools to assess the heart in the hospital setting. A 12lead ECG provides a tracing of the electrical activity in the patient’s heart. In the hospital, routine ECGs are frequently done before surgery. A 12-lead ECG is usually performed during a Code Blue medical emergency such as a cardiac or respiratory arrest. An emergency ECG may also be required stat, or immediately. These are done for many reasons including when a patient experiences chest pain, shortness of breath, dizziness, syncope, altered mental status, or has a change in cardiac rhythm. Code Blue A code blue indicates a medical emergency such as cardiac or respiratory arrest and notifies healthcare providers that assistance is needed immediately. stat Immediately.

Think It Through Remain Calm It is essential that you remain calm when recording a stat ECG. Remaining calm is necessary to avoid stress to the patient and to reduce confusion during the emergency. What would be an appropriate way to tell a patient you are doing a stat ECG?

Another use of the ECG tracing in the hospital is during continuous cardiac monitoring. The purpose of continuous monitoring is to observe the pattern of the electrical activity of the patient’s heart over time. During continuous monitoring, sensors, also known as electrodes, are attached to the patient’s chest. Wires are connected to the sensors and a small transmitter-like box or connected directly to a monitor displaying the patient’s heart rhythm. Patients on continuous monitoring are usually in an intensive care unit (ICU), coronary care unit or cardiac care unit (CCU), surgical intensive care unit (SICU), inpatient telemetry unit, or emergency department (ED). Continuous monitoring is also done routinely during surgery (see Figure 1-3). Figure 1-3

Continuous monitoring in an acute care facility will include the ECG tracing as well as the patient vital signs.

Losevsky Pavel/Alamy Stock Photo

Continuous monitoring done in a hospital with a small transmitter box connected to the patient using electrodes and lead wires is known as telemetry monitoring. The monitor is usually housed in a case and

attached to the patient so they can move about. The ECG tracing is transmitted to a central location for evaluation. When several patients are on a telemetry unit, the tracings of all the patients are recorded on multiple monitors at the nursing or patient care station.

Doctors’ Offices and Ambulatory Care Clinics A 12-lead ECG is a routine diagnostic test performed in almost any doctor’s office or ambulatory care facility. It may be performed as part of a general, routine, or pre-operative examination. This routine ECG provides a baseline tracing to be used for comparison if problems arise with a patient. The page 5 physician or trained expert looks for changes in a tracing that may indicate different types of health problems. Table 1-1 provides a list of conditions that may be diagnosed by an ECG.

TABLE 1-1 Conditions Evaluated by the ECG Disorders in heart rate or rhythm and the conduction system. Presence of electrolyte imbalance. Condition of the heart prior to defibrillation. Damage assessment during and after a myocardial infarction (heart attack). Symptoms related to cardiovascular disorders, including weakness, chest pain, or shortness of breath. Diagnosis of certain drug toxicities. Diagnosis of metabolic disorders such as hyper- or hypokalemia, hyper- or hypocalcemia, hyper- or hypothyroidism, acidosis, and alkalosis. Heart condition prior to surgery for individuals at risk for undiagnosed or asymptomatic heart disease. Damage assessment following blunt or penetrating chest trauma or changes after trauma or injury to the brain or spinal cord. Assessment of the effects of cardiotoxic or antiarrhythmic therapy. Suspicion of congenital heart disease. Evaluation of pacemaker function.

Another type of ECG that may be performed in an outpatient setting is treadmill stress testing (Figure 1-4). The treadmill stress test, also known as exercise electrocardiography, is done to determine whether the heart receives adequate blood flow during stress or exercise. The stress test is discussed in more detail in the chapter Cardiac Stress Testing.

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Figure 1-4 This patient is performing a treadmill stress test, also known as exercise electrocardiography. During the exercise, the patient’s heart and blood pressure are monitored carefully. andresr/E+/Getty Images

A Holter monitor is one type of ambulatory monitor. It is a small box that is strapped to a patient’s waist, neck, or shoulder to continuously monitor the heart for 24 to 48 hours while the patient is at home (Figure 1-5). Other types of ambulatory monitors, such as event monitors, may be worn up to 30 days as page 7 the patient performs normal daily activities. An event monitor is a battery-powered portable device that the patient controls to record the heart’s electrical activity (ECG) when symptoms occur. After the monitoring period, the ECG tracing is analyzed and interpreted by the physician. Various types of ambulatory monitors are discussed in detail in the chapter Ambulatory Monitoring. event monitor An event monitor is a battery-powered portable device that the patient controls to record the heart’s electrical (ECG) when symptoms occur. Figure 1-5 The Holter, a type of ambulatory monitor, allows the patient to participate in routine daily activities while the electrical activity of the heart is being recorded. Rob Walls/Alamy Stock Photo

Outside of a Healthcare Facility Outside of a healthcare facility, the ECG is used during cardiac emergencies such as a myocardial infarction. Emergency medical technicians and paramedics are equipped with portable ECG machines that can produce an ECG tracing at the site of the emergency. Whether the patient is at home, in a car, or in a crowded football stadium, emergency personnel can trace and monitor the electrical activity of the heart. Figure 1-6 shows one example of a portable ECG machine. In an emergency setting, the tracing can be evaluated for an abnormal ECG pattern. It is either transmitted back to the physician for evaluation or assessed by the emergency medical personnel at the scene. An abnormal pattern may require immediate treatment. Figure 1-6 A portable ECG monitor is transported to the scene during a cardiac emergency and is attached to the patient. The ECG tracing is recorded and viewed by the emergency personnel. In addition, the tracing can be transmitted to the hospital, where a physician can evaluate and determine the necessary drugs and treatment for the patient based upon the heart rhythm viewed and the report from the emergency personnel. Vladislav Gajic/Alamy Stock Photo

Defibrillators Treatment for abnormal rhythms may include the use of a defibrillator and/or administration of cardiac medications. A defibrillator produces an electrical shock to the heart that is intended to correct the heart’s electrical pattern. A defibrillator is commonly used in emergencies such as a Code Blue in the hospital or other care facilities or at the site of the emergency by specially trained personnel. In situations when defibrillation is the appropriate treatment (pulseless ventricular tachycardia and ventricular fibrillation), the heart must be defibrillated quickly in an effort to restore a regular heart rhythm. The survival page 8 rate of the victim decreases by 7% to 10% for every minute a normal heartbeat is not restored. defibrillator A machine that produces and sends an electrical shock to the heart in an attempt to correct the electrical pattern of the heart.

Automatic External Defibrillators Automatic external defibrillators (AEDs) have enabled lay rescuers to help patients with sudden cardiac arrest and serious dysrhythmias (Figure 1-7). AEDs are available in public and private places where large numbers of people gather or live. They may also be kept in homes by people who are at high risk for heart attacks. An AED is a lightweight, portable device that recognizes an abnormal rhythm and determines if the rhythm is considered a “shockable rhythm.” Note: The equipment is placed only on patients who are unresponsive to stimulation (who cannot be aroused) and have no evidence of breathing or a pulse. AEDs shock abnormal heart rhythms such as pulseless ventricular tachycardia and ventricular fibrillation. Learning about normal and abnormal rhythms is part of rhythm strip interpretation, which is discussed in later chapters. When the machine recognizes other rhythms that cause the patient to be unresponsive, the AED recommends beginning cardiopulmonary resuscitation (CPR). Individuals using an AED should consider safety for themselves and the patient. A healthcare-provider-level CPR course is best for learning this technique. The patient should be checked for medication patches, pacemakers, and metal objects that could cause burns. In addition, do not use an AED when the patient is in water. automatic external defibrillator (AED) A lightweight, portable device that recognizes

abnormal rhythm and determines if the rhythm is considered a “shockable rhythm.” dysrhythmia Abnormal heartbeat. cardiopulmonary resuscitation (CPR) The provision of ventilations (breaths) and chest compressions (blood circulation) for a person who shows no signs of breathing or having a heartbeat. Figure 1-7 Automatic external defibrillators (AEDs) can deliver an electrical impulse that may correct an abnormal heart rhythm and increase the survival rate of myocardial infarction victims. AEDs can be found in public places and require minimal training to operate. Chris Pancewicz/Alamy Stock Photo



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Once the equipment is placed on the patient’s bare chest, it analyzes the rhythm to determine if it is likely to respond to an electric shock. Once the machine has positively identified the abnormal rhythm, it may indicate that a “SHOCK IS ADVISED.” Everyone near the patient must move back and not touch the patient. One person will then announce, “clear,” “everyone clear,” and press the shock button. After the shock has been provided, the rescuers continue administering CPR until the patient wakes up, the machine indicates to defibrillate again, or specially trained healthcare professionals take over. AEDs make it possible for laypeople to perform defibrillation safely. The AED is now viewed as a necessary piece of equipment—similar to a fire extinguisher.

Telemedicine

Another use of the ECG tracing outside of a healthcare facility is telemedicine. Remote monitoring of patients is frequently used and ECG tracings are just one type of data that is communicated via the Internet or in some cases cellular service. For example, transtelephonic monitoring means transmitted (trans) over the telephone (telephonic). Digital monitoring allows ECG data to be recorded with an electronic device and then transmitted over the Internet to the healthcare facility. telemedicine A monitoring system in which ECG tracings are communicated from a patient outside a medical facility to the physician via a telephone or digital system. Remote monitoring helps physicians evaluate, diagnose, and then monitor ECG tracings of a patient over time. The ECG tracing can be sent through various devices from external devices with leads and wires to implantable monitors. They are all useful for patients with symptoms of heart disease that did not occur while they were in the healthcare facility. The information from these devices may be transmitted to a healthcare facility continuously or on specific days throughout the monitoring period (Figure 1-8). Individuals with external or implanted devices must understand the purpose of the device, what to report, and when and how to record and send a transmission. Figure 1-8 This small device known as a LINQ II Insertable Cardiac Monitor (ICM) is implanted in a patient with infrequent cardiac symptoms that requires long-term monitoring and management. Bob Collier/AP Images



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Career Opportunities in ECG Many healthcare professionals work with electrocardiography as a part of their profession. Some examples include medical assistants, nurses, emergency medical technicians, and paramedics. There are a few careers in which people work exclusively with the ECG. These include the ECG technician, the ECG monitoring (telemetry) technician, and the cardiovascular technologist. Other careers include stress and

Holter monitor technicians, cardiovascular technologists, electrophysiology technologists, and echocardiography technologists. An electrocardiograph (ECG) technician is an individual who records the ECG and prepares the report for the physician. ECG technicians should be able to determine if a tracing is accurate and recognize abnormalities caused by interference during the recording procedure. Most ECG technicians are employed in hospitals, but they may also work in medical offices, cardiac centers, cardiac rehabilitation centers, and other healthcare facilities. In some large hospitals, ECG technicians work in the home healthcare branch. They take the ECG machine to the patient’s home; record the ECG; and give or transmit the report to the physician for interpretation. With the development of multiple tests and devices to evaluate the heart, the ECG technician who obtains continuing education can expect a rewarding and expanding career. For example, you may chose to be a cardiac device specialist and service the devices used for electrocardiography. electrocardiograph (ECG) technician An individual who has the technical skills and knowledge to record an ECG and prepare it for the physician. ECG monitor (telemetry) technicians view, analyze, and report the electrical activity of multiple patients’ hearts on a monitor (Figure 1-9). ECG monitor technicians are employed at hospitals or other page 11 inpatient facilities where patients are attached to continuous or telemetry monitors. The main responsibility of an ECG monitor technician is to view the ECG tracings and, if an abnormal heart rhythm occurs, alert the healthcare professional who can treat the abnormality. ECG monitor technicians must be able to evaluate the ECG tracing. They must understand the various heart rhythms and recognize abnormal ones. They may also be asked to perform other duties, such as maintaining patient records and recording ECGs. ECG monitor (telemetry) technician An individual who has the technical knowledge and skills to view and evaluate the electrical tracings of patients’ hearts on an oscilloscope and, when necessary, alert the appropriate healthcare professional to treat abnormalities. Figure 1-9 Multiple patients can be monitored on a single monitor screen. The patients being monitored may be in a hospital or at home depending upon the type of monitoring device they are using. Paul Burns/Corbis

If you enjoy the field of electrocardiology and want to advance your skills or education, you may choose to be a cardiovascular technologist. Technologists require more extensive training than technicians. They may assist physicians with invasive cardiovascular diagnostic tests and procedures such as cardiac catheterization. Cardiac electrophysiology technologists assist physicians with diagnosing and treating slow and fast heart rhythms by implanting internal cardiac devices and performing radio frequency ablation. Another specialization for cardiovascular technologists is performing ultrasounds on the heart and/or blood vessels. Ultrasound equipment transmits sound waves and then collects the echoes to form an image on a screen. As part of their duties, cardiovascular technologists may also perform ECGs. cardiovascular technologist An individual who has advanced skills and can assist physicians with invasive cardiovascular diagnostic tests and procedures, such as angioplasty or cardiac device implants.

Checkpoint Questions (LO 1.2) 1. An automatic external defibrillator (AED) is used to treat what conditions? 2. Briefly describe the role of an ECG technician.

1.3 Preparing for an ECG Preparing for an ECG involves more than just making sure the equipment is in order. You must be aware of legal and ethical issues, and you must also communicate appropriately with the patient to make sure the patient understands the procedure.

Legal and Ethical Issues Laws are rules of conduct that are enforced by a controlling authority such as the government. An unlawful act can result in loss of your job, a fine, or other penalty such as time in jail. Ethics are standards of behavior and concepts of right and wrong. They are based on moral values that are formed through the influence of the family, culture, and society. Unethical acts may result in poor job evaluations or even job loss. When comparing law and ethics, you should understand that illegal acts are always unethical, but unethical acts are not always illegal. law Rules of conduct enforced by a controlling authority such as the government. ethics Standards of behavior and concepts of right and wrong.

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Protecting Patient Information: HIPAA The Health Insurance Portability and Accountability Act (HIPAA) established a national standard for electronic healthcare transactions and also for providers, health plans, and employers. HIPAA is meant to ensure that widespread use of electronic data is limited and secure. The patient can specify who can see information and what information is protected. A patient’s information cannot be shared among healthcare professionals unless it is necessary for the patient’s treatment.

Law & Ethics Keep Information Private The patient’s healthcare data should not be left open in an area where other patients or visitors may be able to view it. This is a breach of confidentiality and HIPAA.

Practicing Ethics Many professions have a code of ethics. These are standards of behavior or conduct as defined by the professional group. As a healthcare professional, you must follow the standards of behavior or code of ethics set forth by your profession and place of employment. ECG professions also have a scope of practice. The scope of practice is the procedures and processes permitted for a specific practice. Practice outside your scope of practice is both unethical and can be illegal. The following are some basic ethics you should practice.

Confidentiality is an essential part of patient care. You may collect information about a patient for use during their care and treatment; however, this information should not be made public. Confidentiality is a basic right of every patient. You should not speak about your patient or allow information about your patient to be heard or seen by anyone other than those caring for them. A breach in confidentiality is both unethical and illegal. Treat all patients with respect and dignity. You should respect the privacy of patients at all times. Avoid exposing your patient’s body when performing any procedure by closing the door, pulling the curtain, and/or draping the patient. In some cases, it may be necessary for a male healthcare professional to have a third person present when performing an ECG on a female. Check the policies at the facility where you are employed. Practicing ethics also includes acting professionally and cooperating with coworkers, supervisors, and other healthcare professionals. Maintain your professionalism by continuing your education and training to provide the highest level of care for your patients.

Professional Liability Medical professional liability means that a healthcare professional is legally responsible for their performance. Healthcare professionals can be held accountable for performing unlawful acts (malfeasance), performing legal acts improperly (misfeasance), or simply failing to perform an act (nonfeasance) when they should. For example, if you find a patient’s wallet after they leave and you decide to keep it, this is an illegal act. While you are assisting with a treadmill stress test, if you report the blood pressure results incorrectly, resulting in the patient having a severe heart attack, this is page 13 performing a legal act improperly. If you decide to take a break when you are supposed to be monitoring a patient’s heart rhythm and during the time you are gone the patient experiences an abnormal heart rhythm resulting in death from lack of prompt treatment, you have failed to perform your duties as required. Always work within your scope of practice and the standards set by your profession. medical professional liability Legal responsibility of healthcare professionals for their performance.

Slander and Libel You will be speaking and writing about patients as part of your job as an electrocardiographer; you should never speak defamatory words about patients even when they upset you. Making derogatory remarks about a patient—or anyone else—that jeopardizes their reputation or means of livelihood is called slander. Slander is an illegal and unethical act that could cause you to lose your job. If you write defamatory words, this is known as libel, which is also illegal and unethical. slander Making derogatory remarks about someone that jeopardizes his or her reputation or means of livelihood; slander is both illegal and unethical. libel Writing defamatory words about someone; this is both illegal and unethical.

Documentation Medical care and treatment must be documented as part of the medical record. The medical record is for communication about a patient but can be used in court as evidence in a medical professional liability case. To protect yourself legally and to provide continuity of patient care, be sure to include complete information in the medical record. Each entry must be clear, accurate, legible, dated, and signed. Table 1-

2 contains a list of the information that needs to be documented in the medical record.

TABLE 1-2 Required Entries for Medical Records Patient identification, including full name, medical record number or Social Security number, birth date, full address and telephone number, marital status, and place of employment, if applicable. Patient’s medical history. Dates and times of all appointments, admissions, discharges, and diagnostic tests (such as an ECG). Diagnostic test results. Information regarding symptoms and reasons for appointment, diagnostic tests, and admissions. Physician examinations and records of results, including patient instructions. Medications and prescriptions given, including refills. Documentation of informed consent when required. Name of legal guardian or representative, if patient is unable to give informed consent.

Medical records may be paper or electronic. Electronic records are digitally signed. Electronic records improve communication and the quality and efficiency of healthcare. For example, an ECG recorded electronically can be transferred through a wireless connection immediately to a healthcare provider on the other side of the country.

Consent Before you can perform an ECG on any patient, the patient must agree, or consent, to having the procedure done. Consent is often implied between the patient and healthcare professional. For example, when a patient comes to the physician’s office, they are agreeing to be treated by the physician. This is page 14 implied consent. When a patient agrees to the ECG procedure, this is also implied consent.

Think It Through Obtaining Consent When a patient who cannot read is required to sign a consent form, you will need to explain the procedure to both the patient and a family member or the patient’s legal guardian or representative. The patient then signs the consent form. If the patient cannot write, explain the procedure to the patient with a witness present. Ask the patient to place an X on the form in the witness’s presence, and then have the witness sign. Who should sign the consent form if a patient cannot read or write?

Medical procedures such as surgery and certain diagnostic tests, including a treadmill stress test, require informed consent. The patient must understand the procedure, benefits, alternative procedures, associated risks, and potential risk if there is a refusal of treatment. Informed consent requires the patient to sign a consent form.

Education, Communication, and Critical Thinking Professional communication is necessary for successful recording of an ECG. You must develop a positive relationship and atmosphere to reduce apprehension and anxiety during the procedure. Maintain a friendly, confident manner while interacting with your patient. Helping the patient understand the procedure and follow instructions is essential. When explaining the procedure, use simple terms and speak slowly and distinctly. Encourage the patient to ask questions and repeat the instructions. This process will help ensure patient understanding. Your patient will be more cooperative if they trust that you are competent to perform your job.

Communicate & Connect Improving Communication When speaking to a patient who is hard of hearing, look directly at the patient and speak slowly and distinctly. The patient may be able to read your lips. If the patient speaks another language, a certified medical interpreter is required to interpret or assist you with communication, thus reducing apprehension and anxiety.

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Think It Through Critical Thinking and Problem Solving Being able to troubleshoot situations that arise during the ECG procedure is essential. Troubleshooting requires critical thinking. Critical thinking is the process of thinking through the situation or problem and making a decision to solve it. The problem-solving process includes the following steps: 1. Identify and define the problem. 2. Identify possible solutions. 3. Select the best solution.

4. Implement the selected solution. 5. Evaluate the results. 6. If, in step 5, you determine that the problem has not been solved, repeat steps 2 through 5 until an acceptable solution is reached. While performing an ECG, you may need to troubleshoot actual or potential complications using the steps of the problem-solving process. These problems may arise from the patient’s condition, lack of patient communication, equipment failure, or other complications. For example, suppose that you are about to perform an ECG, and the patient refuses to let you attach the lead wires. As part of troubleshooting, you ask the patient why they are refusing. The patient states, “I do not want that electricity going through me!” In a calm manner, you explain that the machine does not produce or generate electricity, and it is not harmful. After your explanation, the patient agrees to have the ECG. You have performed successful troubleshooting. The previous example describes a problem with communication. However, you may also need to troubleshoot problems that occur with the equipment or tracing produced. Throughout this text, the Think It Through boxes will provide a variety of problems or situations you may encounter and then ask for your solution. Use your critical thinking and problem-solving skills to answer each question. In each chapter, review the “What Should You Do?” questions to check your ability to think critically and troubleshoot.

Checkpoint Question (LO 1.3) 1. Explain how you would employ the steps of the problem-solving process if a patient refuses to have an ECG.

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1.4 Infection Control Healthcare-associated infections (HAIs) are infections that occur while patients are receiving any type of healthcare. HAIs are a threat to patient safety. Preventing the spread of infection is an essential part of providing healthcare and performing an ECG. The CDC has implemented two levels of precautions to prevent infections—standard precautions and isolation precautions.

Standard Precautions

Standard precautions include a combination of performing hand hygiene and wearing gloves when there is a possibility of exposure to blood and body fluids, nonintact skin, or mucous membranes (Figure 1-10). Standard precautions apply to blood and all body fluids, secretions, and excretions (except sweat), regardless of whether they contain visible blood, and are practiced in all employment situations in which exposure to blood or body fluids is likely. Standard precautions reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. In addition to performing hand hygiene and wearing gloves, practices may include using personal protective equipment (PPE) such as a gown, mask, and eye protection (Figure 1-11). A faceshield is worn over the mask and glasses or goggles when splashes and splatters are likely. Specialized PPE masks such as a filtering facepiece respirators (FFR) may be required when caring for patients with respiratory illnesses or contagious diseases. (Figure 1-12) standard precautions Procedures, used with all patients, which are designed to prevent the spread of infection, such as performing hand hygiene and wearing gloves. personal protective equipment (PPE) Devices such as gloves, gowns, face masks or shields, and eye protection designed to protect a healthcare worker from sources of infection. filtering facepiece respiratory (FFR) Specialized PPE mask to be worn when caring for patients with or with the potential for respiratory illnesses or contagious diseases. Figure 1-10 Hand Hygiene A. Handwashing especially when your hands are visibly soiled is essential to prevent the spread of infection. B. The use of an alcohol-based rub on hands is accepted when the hands do not have visible soilage. Jill Braaten/McGraw Hill Lillian Mundt

Figure 1-11 Wearing appropriate personal protective equipment (PPE) reduces the risk of transmission of infection. PPE includes items such as gloves, mask, gown, and eye protection. Total Care Programming, Inc.

Figure 1-12

Filtering facepiece respirators (FFR): A. N95, B. KN95.

new york rat/Alamy Stock Photo

In addition, the CDC advises healthcare workers not to wear artificial nails because they are more

likely to harbor Gram-negative pathogens than natural nails, both before and after handwashing. Natural nails should be no more than 1/4-inch long.

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Table 1-3 provides a list of standard precautions that you should practice when recording an ECG. See the appendix Standard and Isolation Precautions for additional information about these precautions.

TABLE 1-3 Standard Precautions Related to Electrocardiography Hand Hygiene Wash your hands after touching blood, body fluids, secretions, excretions, and contaminated items. Wash your hands before putting on gloves and after removing gloves. Wash your hands between patient contacts. Wash your hands between tasks and procedures on the same person. Use alcohol-based hand rub if you have no visible soilage. Gloves Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Wear gloves when touching mucous membranes and nonintact skin. Change gloves between procedures and patients. Change gloves after contacting materials that are highly contaminated. Remove gloves promptly after use. Remove gloves before touching uncontaminated surfaces or items. Wash your hands immediately after glove removal. Masks, Eye Protection, and Face Shields Wear mask, eye protection, and face shield during procedures and tasks that are likely to cause splashes or sprays of blood, body fluids, secretions, and excretions. Wear specialized masks as required when care for respiratory illness or contagious disease. Gowns Wear a gown during procedures and activities that are likely to cause splashes or sprays of blood, body fluids, secretions, or excretions. Remove a soiled gown promptly. Wash your hands immediately after gown removal. Equipment Handle used equipment carefully. It may be soiled with blood, body fluids, secretions, and excretions. Prevent skin and mucous membrane exposure and clothing contamination. Clean, disinfect, or sterilize reusable equipment before it is used on another person. Discard single-use equipment promptly. Environmental Control Follow facility procedures for the routine care, cleaning, and disinfection of surfaces. This includes environmental surfaces, nonmovable equipment, and other frequently touched surfaces. Occupational Health and Bloodborne Pathogens Use resuscitation devices for mouth-to-barrier resuscitation.

Safety & Infection Control Hand Hygiene Performing proper hand hygiene is the single most important thing you can do to prevent the spread of infection. Wash your hands or use an alcohol-based rub (if no visible soilage is present) between patients and procedures and before and after you use gloves. Note: Certain types of infections, such as Clostridium difficile, require handwashing because the use of alcohol-based hand rubs is not sufficient to kill all the infectious organisms. Always use the method of hand hygiene that is most appropriate for the patient’s condition.

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Isolation Precautions Isolation precautions make up the second level of protection. These precautions are based on how the infectious agent is transmitted. Isolation precautions include the following: Airborne precautions—require special air handling, ventilation, and additional respiratory protection (N-95 or other filtering facepiece respirators). Droplet precautions—require mucous membrane protection (goggles and masks). Contact precautions—require gloves and gowns for direct skin-to-skin contact or for contact with contaminated linen, equipment, and so on. isolation precautions The second level of steps taken to prevent the spread of infection; some examples include separating the infected patient from others and using personal protective equipment. Isolation precautions are used less often than standard precautions and only with patients who have specific infections. When isolation precautions are in place for a patient during an ECG, you will be required to follow the specific guidelines for the type of precautions implemented. Follow the facility’s policy and the guidelines provided in Table 1-4.

TABLE 1-4 Isolation Precautions for Isolation of Hospitalized Patients In addition to standard precautions, follow these guidelines and the policy of your place of employment to prevent the spread of infections. Airborne Precautions For patients known or suspected to be infected with microorganisms transmitted by minute airborne droplets: Use a private room that has monitored negative air. Keep the room door closed and the patient in the room. Wear special FFR, EFR, or PAPR masks for respiratory protection when entering the room of a patient with known or suspected infectious respiratory disease.

Do not enter the room of a patient known or suspected to have rubeola or varicella if you are susceptible; if you must enter the room, wear respiratory protection. Limit the movement and transport of patients from the room to essential purposes only. Place a mask on the patient if transport or movement is necessary. Droplet Precautions For patients known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures. Place patient in a private room (special air handling and ventilation are not necessary and the door may remain open). Wear a mask when working within 3 feet of the patient. Limit the movement and transport of the patient from the room to essential purposes only. Use a mask on the patient if transport or movement is necessary. Contact Precautions Contact precautions are used for patients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct or indirect contact. Direct contact includes hand or skin-to-skin contact that occurs when performing patient care that requires touching the patient’s dry skin; indirect contact includes touching environmental surfaces or patientcare items in the patient’s environment. For these patients: Place patients in a private room. Wear gloves according to standard precautions. Wear gloves when entering the room and while providing patient care. Change gloves after having contact with infective material that may contain high concentrations of microorganisms, such as feces and wound drainage. Remove gloves before leaving the patient’s room. Wash hands immediately. Do not touch potentially contaminated environmental surfaces or items in the patient’s room after glove removal. All equipment must be disinfected after leaving the patient’s room. The 12-lead ECG machine must be wiped down immediately.



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Disinfecting Equipment and Surfaces Equipment and surfaces can act as a sources of infection if not kept clean. The CDC recommends “cleaning high-touch surfaces at least once a day or as often as determined is necessary.” In the medical setting, a list of such surfaces includes, but is not limited to, counter tops, writing instruments, ECG machines and carts, computer keyboards, phones, and other ECG equipment. Disinfectants may include 10% bleach, 3% hydrogen peroxide, 70% isopropyl alcohol, or specialized chemical disinfectant wipes. The surface is either wiped or sprayed with the disinfectant and left to remain on the surface for a period of time (contact time as indicated on the label). Some equipment requires special cleaning procedures. Follow the cleaning procedure established at your facility.

Checkpoint Questions (LO 1.4) 1. What measures would you use to prevent the spread of infection to you and your patients?

2. Name three types of isolation precautions and describe the PPE required for each.

1.5 Vital Signs A patient’s vital signs—pulse, respiration, blood pressure, temperature, pulse oximetry, weight, and pain assessment—are among the most important assessments for determining a patient’s current health status. Changes in the vital signs can indicate an abnormality, or they can be a normal response to exertion, heat, stress, or other environmental factors. This section focuses on adult pulse, respirations, and blood pressure since these vital signs may be checked or monitored by ECG professionals. The normal ranges for these are found in Table 1-5. vital signs Temperature, pulse, respirations, blood pressure, and pain assessment.

TABLE 1-5 Vital Sign Ranges by Age

Source: Adapted from PALS Algorithms 2021.



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Pulse and Respiration Pulse and respiration are related because the circulatory and respiratory systems work together. Pulse is measured as the number of times the heart beats in 1 minute. Respiration is the number of times a patient breathes in 1 minute. One breath, or respiration, equals one inhalation and one exhalation. Usually, if either the pulse or respiration rate is high or low, the other is also.

Pulse A pulse rate gives information about the patient’s cardiovascular system. It is an indirect measurement of the patient’s cardiac output, or the amount of blood the heart is able to pump in 1 minute. If the pulse is weak, irregular, or abnormally fast or slow, the patient may show signs of low cardiac output.

cardiac output The volume of blood the heart pumps each minute. Measure the pulse of adults at the radial artery, where it can be felt in the groove on the thumb side of the inner wrist (Figure 1-13). Press lightly on this pulse point with the pads of your fingers. Do not use your thumb because your thumb has a pulse, which you may feel instead of the patient’s pulse. Count the number of beats you feel in 1 minute and note the rhythm and volume. The rhythm can be regular or irregular. The volume can be weak or thready, strong, or bounding. A bounding pulse feels like it is leaping out and then quickly disappearing with each pulse beat. Figure 1-13

Place your fingers in the groove on the thumb side of the inner wrist to check a patient’s pulse.

In some instances, you will not be able to feel a pulse at the wrist, especially if the patient is very weak or has unstable vital signs. In these cases, you can check for a pulse at the carotid artery. This artery is located on the side of the neck next to the airway (Figure 1-14). This is the same pulse location that is used for adults during basic life support. Figure 1-14



To check the carotid pulse, place your fingers on the side of the neck next to the airway.

page 22

If you are still unable to palpate a pulse when checking the carotid artery, you may need to obtain an apical pulse (Figure 1-15). This is done with a stethoscope placed over the left side of the chest at the fifth intercostal space about 3 inches to the left of the sternum (breast bone) at approximately the midclavicular line. The pulse is counted for 60 seconds. This technique is commonly used on infant/small children and patients who are gravely ill.

Figure 1-15 A stethoscope is used over the apex of the heart to listen for the heart sounds and measure the heart rate in patients in whom pulse is not otherwise detectable.

Respiration A patient’s respiration rate indicates how well the patient’s body is providing oxygen to tissues. The best way to check respiration is by watching, listening, or feeling the movement at the patient’s chest, stomach, back, or shoulders. If you cannot see the chest movement, then place your hand over the patient’s chest, shoulder, or abdomen and listen and feel for the movement of air. Respirations also may be counted with a stethoscope. Place the stethoscope on one side of the spine in the middle of the back to count respirations. Count the respirations subtly because once the patient is aware that respiration is being measured, they may unintentionally alter their breathing. If you are using a stethoscope, tell the patient that you want to listen to their lungs. If you are not using a stethoscope, count the respirations while you have your hand on the pulse site. Respirations are counted for one full minute to determine the rate, rhythm, and effort (quality). Counting for less than a minute may cause you to miss certain breathing abnormalities. The rhythm should be regular. The quality or effort may be normal, shallow, or deep. Irregularities such as hyperventilation (excessive rate and depth of breathing), dyspnea (difficult or painful breathing), tachypnea (rapid breathing), or hyperpnea (abnormally rapid, deep, or labored breathing) are indications of possible disease and should be noted. When using a stethoscope, rales, rhonchi, and gurgling are types of noisy breathing that can indicate an abnormality. Rales—crackling sounds—may indicate fluid in the lungs and can be heard in patients with page 23 pneumonia, congestive heart failure, and other conditions. Rhonchi are wheezing or snorelike sounds that occur when the airways are narrowed or obstructed.

Blood Pressure Blood pressure (also known as arterial blood pressure) is the force at which blood is pumped against the walls of the arteries. The standard unit for measuring blood pressure is millimeters of mercury (mm Hg). The pressure measured when the left ventricle of the heart contracts is known as the systolic blood pressure. The pressure measured when the heart relaxes is known as the diastolic blood pressure. The diastolic pressure indicates the minimum amount of pressure exerted against the vessel walls at all times. systolic blood pressure The blood pressure measured when the left ventricle of the heart

contracts; the number corresponding with the first Korotkoff sound heard when performing an auscultated blood pressure. diastolic blood pressure The blood pressure measured when the heart relaxes, representing the minimum amount of pressure exerted against the vessel walls at all times; the number corresponding to the last Korotkoff sound heard when performing an auscultated blood pressure. Expected adult systolic readings are less than 120 mm Hg and adult diastolic readings are less than 80 mm Hg. These values may increase with advancing age. When monitoring blood pressure it is necessary to be aware of normal and abnormal measurements. Table 1-6 outlines blood pressure categories as established by the American Heart Association.

TABLE 1-6 Blood Pressure Classifications Classification

Systolic (mmHg)

Diastolic (mmHg)

Normal

and
0.20 Second Degree Type II: Atrial rate normal; Ventricular rate slower due to blocked QRS Varied PRI

page E-3

Second Degree Type I (Wenckebach): A rate normal; V rate slower with prolonging PRI until QRS drops then cycle begins again (recurrent prolonging pattern). Third Degree (Complete Heart Block or CHB): P–P and R–R intervals are constant but firing at a different rate (A rate 60–100, V rate 20–40 or 40–60 depending upon the level of heart block and pacemaker site initiating ventricular activity).

VENTRICULAR RHYTHMS (Typically wide [measures 0.12 second or greater] and bizarre QRS and no P wave.) Premature Ventricular Complexes (PVC): An early QRS complex with no P wave. Agonal Rhythm: V rate < 20 Idioventricular Rhythm: Ventricular rate 20–40 Accelerated Idioventricular Rhythm: Ventricular rate 40–100 Ventricular Tachycardia (V Tach): “Sharkteeth” appearance, V rate > 100 Torsades De Pointes (Multifocal V Tach) (“twisting of the points”): QRS morphology varies in width and shape and voltage V rate is greater than 100. Ventricular Fibrillation (V Fib): Chaotic in appearance Asystole: No noticeable deflection in waveform (flatline). Pulseless Electrical Activity (PEA): Absence of a palpable pulse with organized electrical activity.

BUNDLE BRANCH BLOCKS QRS will be ≥ 0.12 with P wave. Bundle branch block may occur as part of any supraventricular rhythm. Left BBB: Will have a QS waveform (negative deflection). From the V1 location on a 12-lead ECG locate the J point and go one small box back into the QRS. Determine the direction of the terminal portion of the ventricular depolarization. Note: For 12-lead interpretation only. Right BBB: From the V1 location on a 12-lead ECG locate the J point and the terminal portion of the QRS will be positively deflected. RSR pattern is common. Note: For 12-lead interpretation only.



page F-1

Online Appendix F Competency Checklists Use these Competency Checklists in your classroom, laboratory, or clinical setting. During classroom training, you can review the procedures presented in the book in a step-by-step format. For learning the handson procedures of phlebotomy, the checklist format provides a place to mark your practice and proficiency. In addition, there are areas for the instructor or clinical supervisor to document that you have mastered the competency. Completed Competency Checklists can be placed in your educational or employment portfolio. Please note that specific procedures may vary according to facility requirements.

Table of Contents Competency Checklist

Page #

Measuring Pulse and Respirations (1)

F-2

Measuring Adult Blood Pressure (1)

F-4

Recording an Electrocardiogram (4)

F-6

Continuous Cardiac Monitoring (4)

F-8

Pacemaker Evaluation (11)

F-10

Assisting with Exercise Electrocardiography (Stress Testing) (12)

F-12

Applying and Removing an Ambulatory (Holter) Monitor (13)

F-16

Immediate Care for a Cardiac Patient (14)

F-20



page F-2

Name:

Date:

COMPETENCY CHECKLIST: MEASURING PULSE AND RESPIRATIONS Procedure Steps (Rationale)

Practice Practice

Test

Mastered

Preprocedure

Yes

No

Yes

No

Yes No Date

Initials

1. Gather the equipment.

















2. Wash your hands.

















3. Introduce yourself and identify the patient using two forms of identification.

















4. Explain to the patient that you are going to check vital signs. Do not say that you will be counting respirations. (This prevents the patient from unconsciously changing their breathing rate while you are counting.)

















1. Ask the patient to sit comfortably and rest the arm on the table, palm down.

















2. Place yourself so that you can see (or feel) the patient’s chest wall movements.

















3. Locate the patient’s pulse by first locating the radial bone on the thumb side of the wrist, then slide your fingers into the groove on the inside of the wrist. Place two or three fingers on the pulse site. Note: If you are having trouble seeing the patient’s respirations, you may place the patient’s arm across the chest to feel the respirations while you are checking the pulse.

















4. If the pulse is regular, count it for 30 seconds, noting both the rhythm and the volume. If the pulse is irregular, count for a full 60 seconds. (Counting for a full minute allows a more accurate measurement of an irregular pulse.)

















5. Without releasing the wrist, observe or feel the respirations for a full 60 seconds, observing the rhythm, volume, and effort of the respirations.

















1. After you have counted both the pulse and the respirations, release the patient’s wrist.

















2. Record both numbers in the patient’s chart. If you counted the pulse for less than a full minute, remember to calculate and record the beats per minute. If you counted for 15 seconds, multiply by 4. If you counted for 30 seconds, multiply by 2.

















3. Document the results with the date and time, and report any abnormal findings, or findings that are significantly different from previous readings on this patient.

















4. Wash your hands.

















Procedure

Postprocedure

Comments:

page F-3

Signed Evaluator: Student:



page F-4

Name:

Date:

COMPETENCY CHECKLIST: MEASURING ADULT BLOOD PRESSURE Procedure Steps (Rationale)

Practice Practice

Test

Mastered

Preprocedure

Yes

No

Yes

No

Yes No Date

Initials

1. Gather the equipment. Check the sphygmomanometer to be sure it is calibrated and in working order. (Accurate results can be obtained only when the sphygmomanometer is correctly calibrated.)

















2. Introduce yourself and identify the patient using two forms of identification.

















3. Wash your hands and explain the procedure to the patient.

















4. Select the appropriate size cuff for the patient. The bladder in the cuff should encircle at least 80% of the arm. If you are not sure which size cuff to use, use a larger cuff. (Using the proper cuff size increases the accuracy of the reading.)

















1. Wrap the cuff snugly around the patient’s bare upper arm so that the midline of the bladder is over the brachial artery. The cuff should be 1 inch above the antecubital space. If the patient is wearing long sleeves, ask them to roll up the sleeve loosely. If the sleeve is too tight to be rolled up, ask them to change into a gown. (Checking the blood pressure through the clothing decreases the accuracy of the reading.)















2. Position the manometer so that the gauge is at eye level and easy to see. Make sure the tubing from the blood pressure cuff is not obstructed.

















3. Close the valve on the bulb so that it is finger-tight, but do not overtighten it.

















4. Determine the palpatory pressure if required. To do so, squeeze the bulb to inflate the cuff rapidly to 70 mm Hg. Then increase the pressure in 10 mm Hg increments while using your other hand to palpate the radial pulse in the patient’s wrist. Note the pressure at which the radial pulse disappears. This is the palpatory pressure. Open the valve and deflate the

















Procedure

cuff completely. Then wait 30 seconds or remove and replace the cuff before proceeding with the auscultated blood pressure measurement. (Failure to deflate the cuff completely may cause blood to pool in the artery, which can result in an inaccurate reading.) 5. Place the stethoscope’s earpieces in your ears so that they point up or toward your nose. Rotate the head of the stethoscope in the diaphragm position and test it by tapping gently.

















6. Place the diaphragm of the stethoscope over the patient’s brachial artery and hold it firmly using your index and middle fingers. Make sure the entire surface of the diaphragm is in contact with the patient’s skin and that it does not touch the blood pressure cuff. (Do not use your thumb to hold the stethoscope in place because your thumb has a pulse that can interfere with the reading.)















page F-5

7. Inflate the bladder rapidly to a pressure that is 20 to 30 mm Hg higher than the palpatory pressure (if obtained) or at least 30 mm Hg higher than the highest recorded systolic blood pressure for the patient. If neither are known, inflate cuff to 180 to 200 mg Hg.















8. Partially open the screw on the valve to deflate the bladder at about 2 mm per second. Listen for the Korotkoff sounds. Note the pressure at which you first hear the repetitive sounds. This is the systolic pressure.

















9. Continue to deflate the cuff at the same rate, noting the pressure at which the sound becomes muffled, and then the pressure at which the sound disappears. The pressure at which the sound disappears is the diastolic pressure.

















10. Continue to deflate the cuff and listen for another 10 mm Hg. Listen to be sure the repetitive sounds do not resume. (This ensures that you are measuring the diastolic pressure, not an auscultatory gap.)

















11. Rapidly deflate the cuff the rest of the way and remove it from the patient’s arm.

















1. Record the systolic and diastolic numbers in the patient’s chart, separated by a slash. Record the date and time, the arm in which you measured the pressure, and the patient’s position (sitting or lying). If you used a nonstandard cuff size, record the cuff size as well.

















2. Use an alcohol moistened gauze to disinfect the diaphragm and earpieces of the stethoscope.

















3. Dispose of the used gauze appropriately and wash your hands.

















Postprocedure

Comments:

Signed Evaluator: Student:



page F-6

Name:

Date:

COMPETENCY CHECKLIST: RECORDING AN ELECTROCARDIOGRAM Practice Practice Procedure Steps (Rationale)

Yes

No

Yes

No

Test

Mastered

Yes No Date

Initials

Preprocedure 1. Receive and validate the order.

















2. Check the machine for proper functioning, including electrical cord, lead wires, and paper.

















3. Read the specific information from the manufacturer’s instructions.

















4. Obtain the necessary supplies.

















5. Ensure that adequate paper is available.

















6. Change or add paper if necessary.

















7. Enter the data into the ECG machine if available.

















1. Identify the patient using two forms of identification.

















2. Explain the procedure.

















3. Wash hands.

















4. Position and prepare the patient. Ask the patient to turn off and remove electronics. (Prevents artifact)

















5. Provide for privacy and prevent exposure. (Provides comfort, alleviates stress)

















6. Ensure that the bed or exam table is not touching the wall. (Prevents artifact)

















Procedure

7. Move the bed or exam table away from electrical equipment. (Prevents artifact)

















8. Ensure that the patient is not touching the headboard, footboard, or side rails. (Prevents artifact)

















9. Cleanse and prepare the skin as necessary.

















10. Apply electrodes to the limbs and chest.

















11. Attach the lead wires, ensuring that no tension is on the wires. Make a stress loop. (Prevents discomfort to the patient and helps prevent artifact)

















12. Enter the additional patient data in the LCD panel if necessary.

















13. Press the Run button.

















14. Check the tracing for quality. Observe for artifact.

















15. Run the additional ECG if necessary.

















16. Observe the LCD display for errors.

















17. Turn off the machine and unplug it when completed.

















18. Remove the electrodes and clean the skin, if necessary.

















19. Assist the patient to a safe and comfortable position.

















1. Write on ECG tracing any variations in lead placement, reason for poor-quality tracing, or change in tracing speed. (Ensures accurate evaluation)

















2. Provide the results to the licensed practitioner.

















3. Place the completed ECG tracing in the appropriate area.

















4. Clean the leads.

















5. Drape the lead wires of the machine in an orderly fashion.

















6. Return the machine to the designated storage location.

















7. Perform hand hygiene.

















page F-7

Postprocedure

Comments: Signed Evaluator: Student:



page F-8

Name:

Date:

COMPETENCY CHECKLIST: CONTINUOUS CARDIAC MONITORING Practice Practice Test Procedure Steps (Rationale)

Mastered

Yes

No

Yes

No

Yes No Date

Initials

















1. Identify the patient.

















2. Introduce yourself.

















3. Explain what you are going to do to the patient, and ask if the patient has any questions.

















4. Ask the patient to undress from the waist up (assist as necessary). Provide the patient with a gown or drape to use for privacy.

















5. Wash your hands and don medical exam gloves.

















6. Expose only the areas necessary to perform the procedure (maintain patient privacy).

















7. Select appropriate locations and prep the skin. (Brisk circular rub with dry gauze, rasp, or alcohol; let alcohol dry.) Note: Avoid bony prominences. Right arm—just under the clavicle and medial to the right shoulder Left arm—just under the clavicle and medial to the left shoulder Left leg—upper abdomen at the margin where the abdomen and lowest rib meet

















8. Shave or clip hair if necessary (follow facility policy).

















9. Attach the electrodes to the ends of the cables.

































Preprocedure Gather the supplies and equipment: Cardiac monitor (check monitor before applying to the patient) Cable and lead wires Electrodes Skin prep supplies (i.e., alcohol, gauze pads, razor as necessary) Gloves Procedure

10. Place the white cable with electrode (labeled RA) on the right arm location.

page F-9

11. Place the black cable with electrode (labeled LA) on the left arm location.

















12. Place the red cable with electrode (labeled F or LL) on the left leg location.

















Note: Remember to press around the outer edge of the electrode to ensure good adhesive contact with the skin. Note: Remember to press around the center of the electrode to ensure good gel-to-skin contact with conductive media (reduces artifact). Note: It may be necessary to make stress loops and tape them directly to the patient.

















13. Attach the cable clip to the sheet or patient gown to reduce tugging on electrodes (reduces artifact).

















14. Turn the cardiac monitor on and select lead II.

















15. Select the heart rate limits according to local policy.

















16. Observe the heart rate and rhythm—troubleshoot if artifact is noted.

















17. Print a rhythm strip for further analysis and reporting to licensed healthcare practitioner.

















1. Remove gloves and wash hands.

















2. Document the procedure.

















Postprocedure

Comments: Signed Evaluator: Student:

Name:

page F-10

Date:

COMPETENCY CHECKLIST: PACEMAKER EVALUATION

Practice Practice Practice Procedure Steps (Rationale)

Yes

No

Yes

No

Yes

No

Mastered Date

Initials

Preprocedure















1. Assess rhythm regularity. Rhythm is typically regular when the pacemaker is functioning appropriately. However, when the pacemaker is under- or oversensing or there are battery or programming issues, the rhythm may be irregular.

















2. Determine the heart rate using the most accurate technique based on the regularity of the rhythm.

















3. Assess the P wave. Atrial, atrioventricular, and atriobiventricular pacemaker rhythms each present with a telltale spike prior to the P wave. They all share in common the placement of an atrial lead wire in the right atrium. P waves should be described as always with the additional comment of “with spike” if one is present.

















4. Assess the PR interval from the beginning of atrial depolarization to the beginning of ventricular depolarization. The presence of pacing spikes actually makes this easier. If it is an atrial pacemaker, measure from the atrial spike to the beginning of the QRS. If it is a ventricular pacemaker, measure from the beginning of the P wave to the ventricular spike. If it is an atrioventricular pacemaker, measure from the atrial spike to the ventricular spike.

















5. Assess the QRS complex. Measure from the spike to the end of the QRS complex. Ventricular, atrioventricular, biventricular, and atriobiventricular pacemaker rhythms each present with a telltale spike or spikes prior to the QRS complex. They share in common the placement of a ventricular lead wire in the right ventricle. Describe QRS complexes as always (narrow, uniform, wide, bizarre) with the additional comment of “with spike(s)” when present.

















6. Interpretation: Atrial pacemaker rhythm: Spike prior to P wave only. Ventricular pacemaker rhythm: Spike prior to the QRS complex only. Atrioventricular pacemaker rhythm: Spike prior to the P wave and prior to the QRS complex. Biventricular pacemaker rhythm: Two closely timed spikes prior to the QRS complex. Atriobiventricular pacemaker rhythm: Spike prior to the P wave and two closely timed spikes prior to the QRS complex.

































1. Gather supplies and equipment – Calipers – Calculator – Pen Procedure

page F-11

Postprocedure 1. Report and document the rhythm. Comments:

Signed Evaluator: Student:



page F-12

Name:

Date:

COMPETENCY CHECKLIST: ASSISTING WITH EXERCISE ELECTROCARDIOGRAPHY (STRESS TESTING) Practice Practice Performed Procedure Steps (Rationale)

Yes

No

Yes

No

Yes

No

Mastered Date

Initials

Preprocedure 1. Verify that the medical history is complete (to ensure safety and accurate testing).

















2. Explain the procedure, including the reason for the test, possible complications, and all safety measures that will be followed during the procedure.

















3. Explain “informed consent,” and ask the patient to sign the consent form.

















4. Inform the patient that on the day of the test he or she should wear comfortable clothing (shorts or gym suit, tennis shoes). The patient should refrain from use of tobacco, caffeine, or alcohol according to facility guidelines. (The effects of tobacco, caffeine, or alcohol could affect the results of the test.) Ensure that the patient knows the guidelines for eating and drinking on the day of the test.

















5. Check the physician’s order against the patient’s medication list to provide information as to what medications the patient should not take on the day of the test. (Certain medications can affect the results of the test.)

















6. Go over all instructions and information with the patient. Encourage questions, and ask the patient to repeat important information back to you (to make sure the patient fully understands the procedure).

















7. Provide a copy of the detailed list of instructions, making sure the facility telephone number and your name appear on the list. Encourage the patient to call if they have any questions prior to test day.

















1. Verify that the equipment is in working order and supplies are on hand, including plenty of tracing paper. Be certain to inspect the cables; make sure the treadmill and computer are working and the correct protocol is determined (to prevent problems during the procedure when the patient and physician are present).

















2. Gather all supplies, including electrodes, skin prep solution, gauze sponges, clippers if needed, adhesive tape, and blood pressure cuff.

















3. Check that the crash cart is ready and fully supplied and that the defibrillator is working.

















4. Verify the physician’s order, that the medical history is complete, and that the informed consent is signed.

















5. Bring the patient into the room.

















6. Formally identify the patient and verify they have completed with all instructions.

















7. Provide the patient with privacy to change into the gown with the opening in the front. Assist if necessary. (The opening needs to be in the front in order to place leads.)

















8. Assist the patient onto the examination table (provides for patient safety).

















9. Prepare the skin, and apply electrodes as indicated by the protocol of the facility or equipment manual.

















10. Connect the cables, apply the blood pressure cuff, and check the ECG tracing for artifact (ensures proper results during the examination).

















11. Obtain the patient’s blood pressure and ECG and record.

















12. Demonstrate the treadmill, including the proper posture and holding the hand grip (prevents falls).

















13. Explain the test protocol, making sure the patient understands that the speed and incline will increase every 3 minutes during the test phase.

















14. Be sure the patient understands that they are to report any pain, shortness of breath, faintness, tingling sensations, numbness, or extreme fatigue immediately (provides for patient safety).

















15. Watch the patient closely during the test, looking for visual signs of any pain, shortness of breath, faintness, tingling sensations, numbness, or extreme fatigue

















Procedure: Day of Appointment

page F-13

page F-14

(provides for patient safety). 16. Ask the patient repeatedly during the procedure how they feel (provides for patient safety).

















17. Explain to the patient again that the test will be completed when the target heart rate (THR) is reached: THR = [(220 − age) × 0.60] to THR = [(220 − age) × 0.85] or when the patient cannot continue due to fatigue or other symptoms.

















18. Inform the practitioner who will be in the room that the patient is ready to begin the test. (The physician must be present during the procedure.)

















19. When the physician is in the room, assist the patient to the treadmill, making sure the patient’s feet are not on the belt.

















20. Start the belt; tell the patient to get used to the speed and then to step onto the belt. Ask the patient if they are ready to begin, explaining again that the belt speed and incline will increase. Begin the test phase.

















21. At the end of the first minute (beginning of the second minute) of each stage, take the blood pressure, and enter the data into the computer. Remind the patient before every transition to a new phase, and be ready to assist the patient as needed (provides for patient safety).

















22. When the treadmill phase of the test is complete either because the THR has been reached or because the patient cannot continue, assist the patient to the waiting chair (provides for patient safety).

































2. After the 10- to 15-minute cool-down period, remove the cables and electrodes and wipe off any remaining gel or adhesive.































Postprocedure 1. Continue to monitor and observe the patient’s condition closely, taking the blood pressure, entering the data, and then taking an ECG tracing every 3 to 5 minutes for 10 to 15 minutes (verifies the patient’s condition and tolerance of the testing procedure).

3. Allow the patient to dress (assist if needed).

page F-15 4. Explain to the patient that they should avoid tobacco, caffeine, and alcohol for at least 3 hours. The patient should avoid extreme temperature changes, including a shower or bath, for 2 hours. The patient should rest and recuperate after the test (provides for patient safety).

















5. Explain when the results will be available based on the facility’s protocol. Thank the patient for their participation.

















6. File the results and report per the protocol of the facility.

















7. Make sure all information from the patient chart is returned to its proper place (maintains HIPAA).

















Comments: Signed Evaluator: Student:



page F-16

Name:

Date:

PROCEDURES CHECKLIST: APPLYING AND REMOVING AN AMBULATORY (HOLTER) MONITOR Practice Practice Performed Procedure Steps (Rationale)

Yes

No

Yes

No

Yes

No

Mastered Date

Initials

Preprocedure















Prep razor

















Alcohol

















Electrodes

















Gauze pads

















Skin rasp

















Tape

















Holter unit with strap and case

















Fresh or newly charged batteries

















Digital disk (SD card)

















Pen and patient diary

















1. Gather supplies and equipment.

















Documentation (diary), activities of daily living (ADLs), when symptoms occur.















Medications.

















Physical restrictions such as new activities (should maintain normal routine), bathing, showers, and swimming while wearing the device.

















How to operate the event marker.

















How to reapply an electrode if one comes loose or falls off.

















Must return with the Holter and diary to complete the test.

















Must wear loose-fitting garments on the upper body to reduce artifact.















Provide facility phone number, copy of instructions, and “point of contact” if the patient has questions, problems, or concerns.

















Provide picture of electrode locations, extra electrodes, and adhesive tape per clinic policy.

















1. Identify the patient and explain the procedure.

















2. Apply the electrodes.

















Using alcohol pads, gently rub and cleanse the patient’s skin to obtain a good skin-to-electrode contact (reduces artifact).

















Dry each site completely by rubbing the skin with a gauze pad until it is dry.

















Shave and/or clip any hair in the areas where the electrodes will be attached.

















Wrap tape with adhesive side facing outward from hand, and pat gently to remove any loose hairs remaining on the patient’s skin.

















Remove the electrodes from their package and snap onto the patient leads. (This prevents pressure on the patient’s chest caused by applying leads to electrodes after they are placed on the chest.)

















Peel the protective backing off the electrodes one at a time as they are placed on the patient.

































2. Review patient instructions per facility policy (to ensure accuracy and prevent problems during the testing procedure).

page F-17

Procedure

3. Place the leads. Place the electrodes in the appropriate position. (Follow the physician’s preference or manufacturer’s instructions.)

















Try to center the electrodes over the ribs by gently setting the gelled center against the skin. (A wrinkled electrode or dispersed gel would cause an inaccurate tracing.)

















If the electrode wrinkles or gel is dispersed, apply a new electrode.

















Form a stress loop for each electrode and tape the cable, loop, and electrode to the skin.















page F-18

Leave enough slack between the electrode and the stress loop to allow the patient to move without pulling or stressing the electrodes (prevents inaccurate tracing).















Verify that all leads are firmly inserted into the monitor.































Insert the digital disk into the recorder.

















Insert the appropriate number and size of new batteries into the recorder.

















Slide and secure the battery cover onto the recorder.

















Once the batteries have been inserted, avoid removing the digital disk. Some disks may become unusable if this is done.

















An LED may blink as the recorder performs an initialization sequence and self-diagnostics. This will take approximately 20 seconds.

































Place the recorder in the pouch and review the instructions with the patient.

















Wait for the green LED to stop flashing and stay lit. This indicates that the recorder is collecting ECG data and functioning properly.

















Note the start time on the enrollment form and patient’s diary.

















Have the patient sign the Patient Responsibility Form, if required.

















Complete the paperwork.

















4. Prepare the equipment.

5. Start the recording.

Postprocedure

End the recording.

















Collect the patient diary—check to ensure that entries were made.

















Check with the patient to make sure no problems occurred during the recording procedure.

















Report problems to the licensed practitioner per facility policy.

















Turn off and disconnect the device per manufacturer’s instructions.

















Disconnect the cable from the ambulatory unit.

















Remove the recorder from the pouch.

















Carefully remove the electrodes from the patient. (This prevents irritation and tearing of the skin, especially for patients with paper-thin skin.)

















Clean any residual electrode gel from the patient’s skin, and assist the patient as necessary.

















Remove and discard the batteries.

















Remove the digital disk from the recorder.

















Remove excess tape, and clean cables with a nonalcohol adhesive remover.

















Turn in the recording and diary for analysis per facility policy.

















Document the completed procedure according to your facility policy.

















Explain to the patient that results may take 7 to 10 days and when they will be notified of the results.

















page F-19

Comments: Signed Evaluator: Student:

Name:

page F-20

Date:

COMPETENCY CHECKLIST: IMMEDIATE CARE FOR A CARDIAC PATIENT Practice Practice Procedure Steps (Rationale)

Yes

No

Yes

No

Test

Mastered

Yes No Date

Initials

Preprocedure 1. Use the O-P-Q-R-S-T and/or the S-A-M-P-L-E technique to assess pain level.

















2. Check vital signs, including pulse oximetry. Report additional observations for pulse and respirations.

















1. Start oxygen liters/min by nasal cannula (if required by protocol).

















2. Obtain 12-lead ECG immediately and with each set of vital signs.

















3. Notify physician or treating practitioner of patient with chest pain.

















4. Physician or treating practitioner interprets ECG.

















5. Wait for directions from treating practitioner and provide further treatment using these guidelines.

















6. Determine cardiac rhythm on monitor.

















7. An intravenous line or saline lock is started for administration of medications.

















8. A blood specimen is obtained.

















9. Laboratory tests are ordered per protocol including CBC, electrolytes, PT/PTT or PT/INR, lipid panel, and cardiac enzymes.

















10. Aspirin is administered per protocol.

















11. Nitroglycerin is administered per protocol.

















12. Assist with treatment of a hypotensive patient including an IV fluid challenge or bolus if ordered.

















13. Nitroglycerin administration repeated for two more doses, 5 minutes apart.

















14. Monitor vital signs every 15 minutes and after each dose of medication.

















15. IV morphine is started as ordered, if chest pain is not relieved by nitroglycerin and systolic pressure is above 100 mmHg.

















Procedure

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16. Beta-blocker medications are given per the protocol of the facility.

































Postprocedure 1. Perform any other tasks as needed, such as contacting radiology for a portable upright chest X-ray and cardiopulmonary or laboratory for a blood gas analysis. Comments: Signed Evaluator: Student:



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Glossary A action potential The change in the electrical potential of the heart muscle when it is stimulated. acute coronary syndrome (ACS) This is a broad term that refers to unstable angina, ST segment elevation MI (STEMI), and non-ST segment elevation MI (NSTEMI). ACS is usually associated with intracoronary plaque changes or thrombosis, where blood flow is suddenly stopped. advanced cardiac life support (ACLS) A set of clinical interventions for the urgent treatment of cardiac arrest and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions. alternating current (AC) interference ambulate

Unwanted markings on the ECG caused by other electrical current sources.

To walk; ambulating is walking.

ambulatory monitoring activities.

The process of recording an ECG tracing for an extended period of time while a patient goes about their daily

anatomically contiguous lead Two or more leads looking at the same part of the heart, or numerically consecutive chest leads. angina An oppressive pain or pressure that occurs in the chest when the heart muscle does not receive enough oxygen due to partial or complete blockage of a coronary artery. angioplasty A minimally invasive procedure performed to open narrowed or blocked blood vessels. angle of Louis A ridge about an inch or so below the suprasternal notch where the main part of the sternum and the top of the sternum, known as the manubrium, are attached. anomaly Something that deviates from what is standard, normal, or expected. anorexia Decreased or loss of appetite. anterior axillary line antidysrhythmic

An imaginary vertical line starting at the front axilla that extends down the left side of the chest.

Type of medication given to prevent cardiac rhythm abnormalities. Also known as antiarrhythmic.

aorta The largest artery of the body; transports blood from the left ventricle of the heart to the entire body. aortic semilunar valve

Valve located in the aorta that prevents the backflow of blood into the left ventricle.

apnea The absence of breathing. artifact

Unwanted marks on the ECG tracing caused by activity other than the heart’s electrical activity.

ascites

Abnormal collection of serous fluid within the abdomen (peritoneal cavity). This may occur secondary to congestive heart failure.

asystole

A condition in which no rhythm or electrical current is traveling through the cardiac conduction system.

atherosclerotic plaque

Fatty deposits accumulated due to elevated glucose levels.

atrial kick Blood that is ejected into the ventricles by the atria before ventricular contraction. Atrial kick contributes a 10%–30% increase in cardiac output. atrial pacing Electrical stimulation is delivered to the atria to cause conduction from the AV node through the ventricles resulting in ventricular contraction. atriobiventricular pacing A sequential pacemaker stimulation of the atria and then both ventricles, rather than just the right ventricle. Also known as biventricular pacing. atrioventricular (AV) node

Delays the electrical impulse to allow the atria to complete their contraction.

atrioventricular delay The measurement from the atrial spike to the ventricular spike, or from the beginning of the P wave to the

ventricular spike on a pacemaker tracing. atrioventricular sequential pacing A pacemaker stimulation of the atria and then the lower part of the right ventricle in a sequence that mimics the normal cardiac conduction system and allows for atrial kick. Top two chambers of the heart.

atrium (pl. atria) augmented leads

Normally small ECG lead tracings that are increased in size by the ECG machine in order to be interpreted.

auscultated blood pressure

Blood pressure determined while listening with a stethoscope.



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automatic external defibrillator (AED) considered a “shockable rhythm.”

A lightweight, portable device that recognizes abnormal rhythm and determines if the rhythm is

automaticity The ability of the heart to initiate an electrical impulse without being stimulated by an independent source. AV junction The AV node and surrounding tissue, including the bundle of His. axis deviation Changes that occur on a 12-lead ECG due to the orientation or position of the heart within the chest.

B Bachmann’s bundle

The structure that relays the electrical impulse from the SA node to the left atrium in a normal heart.

Drugs used to treat hypertension.

beta blockers

bigeminy Pattern in which every other complex is a premature beat (PVC). biphasic A waveform that has positive (upward) and negative (downward) deflections (phases) on the ECG tracing. When both deflections are approximately equal, a biphasic waveform is said to be equiphasic. bipolar lead A type of ECG lead that measures the flow of electrical current in both directions at the same time. blocked or nonconducted impulse occur in the ventricles.

Using movements that maintain proper posture and avoid muscle and bone injuries.

body mechanics bolus

Impulse occurs too soon after the preceding impulse, causing a period when no other impulses can

A concentrated amount of medication or fluid based upon body weight to be administered over a prescribed short period of time.

bundle branch block (BBB) The electrical impulses that control the heartbeat cannot move properly throughout the heart (ventricles specifically). A block in the branches causes the impulses (within the ventricles) to travel slower than normal. bundle branches Left and right branches of the bundle of His that conduct impulses down either side of the interventricular septum to the left and right ventricles. bundle of His (atrioventricular or AV bundle) to the ventricles.

Located next to the AV node; provides the transfer of the electrical impulse from the atria

C The contraction and relaxation of the heart.

cardiac cycle

cardiac enzymes (cardiac markers or cardiac biomarkers) Chemicals found in the bloodstream that are indicators of myocardial cell death (infarction). Common examples include troponin, CK-MB, and myoglobin. cardiac output

The volume of blood the heart pumps each minute.

cardiac output parameters Observation guidelines used to assess the blood supply to the vital organs of the body to maintain normal function includes measurements such as blood pressure, pulse, respirations, and blood oxygen saturation (SpO2). cardiogenic shock cardiologist

Inadequate flow of arterial blood, typically as a result of left heart failure.

A physician who specializes in the study of the heart.

cardiopulmonary resuscitation (CPR) The provision of ventilations (breaths) and chest compressions (blood circulation) for a person who shows no signs of breathing or having a heartbeat.

cardiovascular disease (CVD)

Disease related to the heart and blood vessels (veins and arteries).

cardiovascular technologist An individual who has advanced skills and can assist physicians with invasive cardiovascular diagnostic tests and procedures, such as angioplasty or cardiac device implants. cerebrovascular accident (CVA; brain attack, stroke) a cerebral artery.

A stroke. Caused by a hemorrhage in the brain or more often by a clot lodged in

chemical stress echocardiogram A stress echocardiogram in which the heart is stressed by chemicals, rather than physical exercise. chemical stress test Stress test performed after administering medications that cause the heart rate to increase or the coronary blood vessels to dilate; performed on patients who cannot perform the exercise required in a regular stress test. chordae tendineae Structures that connect the atrioventricular (tricuspid and mitral) valves to the papillary muscles and prevent them from opening in the wrong direction. circumflex artery One of the primary branches of the left coronary artery, which winds around, supplying blood to the lateral wall of the left ventricle. Code Blue A code blue indicates a medical emergency such as cardiac or respiratory arrest and notifies healthcare providers that assistance is needed immediately. collateral blood vessels

Small blood vessels that develop forming a natural bypass to a region of tissue.

Atrial or ventricular contractions as they appear on the ECG; complete ECG waveforms.

complex

conductivity The ability of the heart cells to receive and transmit an electrical impulse. congestive heart failure (CHF) Failure of the heart to pump an adequate amount of blood to the body tissues. Includes symptoms of shortness of breath (SOB), edema, pale skin, increased respiratory rate, and potential frothy sputum. page G-3 contractility The ability of the heart muscle cells to shorten in response to an electrical stimulus. coronary angiography An X-ray visualization of the coronary vessels after a radiopaque dye is injected into the patient. coronary artery bypass graft (CABG) surgery Surgical intervention performed by taking a grafted or transplanted blood vessel and attaching it to the heart at a point beyond an occluded coronary artery to reestablish blood flow. coronary artery disease (CAD)

Narrowing of the coronary blood vessels, causing a reduction in the blood flow to the heart.

coronary artery disease (CAD)

Narrowing of the arteries of the heart, causing a reduction of blood flow.

coronary circulation The circulation of blood to and from the heart muscle. coronary sinus An area located on the back of the heart where the left atrium and left ventricle come together called the sulcus (groove). This structure is where the coronary veins return blood from the heart itself to the circulating blood in the right atrium. Two PVCs that occur back to back.

coupling

crash cart A cart or tray containing emergency medication and equipment that can be easily transported to the location of an emergency for life support.

D defibrillator A machine that produces and sends an electrical shock to the heart in an attempt to correct the electrical pattern of the heart. delta wave

A widening at the beginning of the QRS complex due to ventricular pre-excitation.

deoxygenated blood Blood that has little or minimal oxygen (oxygen-poor blood). depolarization The electrical activation of the cells of the heart that initiates contraction of the heart muscle. dextrocardia When the heart is on the opposite or right side of the chest. diagonal artery A branch of the left anterior descending artery that supplies blood to the anterior and lateral wall of the lower left ventricle. diastole

The phase of the cardiac cycle when the heart is expanding and refilling; also known as the relaxation phase.

diastolic blood pressure The blood pressure measured when the heart relaxes, representing the minimum amount of pressure exerted against the vessel walls at all times; the number corresponding to the last Korotkoff sound heard when performing an auscultated blood pressure. dissociative

Not related at all; the atria and the ventricles beat entirely independently of each other.

dysrhythmia Abnormal heartbeat.

E ECG monitor (telemetry) technician An individual who has the technical knowledge and skills to view and evaluate the electrical tracings of patients’ hearts on an oscilloscope and, when necessary, alert the appropriate healthcare professional to treat abnormalities. echocardiogram Noninvasive diagnostic test that uses sound to study the heart, heart valves, and blood vessels. ectopic foci Abnormal cells that cause electrical impulses in the heart. An electrical impulse that comes from outside of the normal pacemaker site or electrical conduction pathway.

ectopic impulse

Einthoven’s triangle A triangle formed by three of the limb electrodes—the left arm, the right arm, and the left leg; it is used as a reference for the first six leads of the 12-lead ECG. electrical capture

Evidence of the heart’s activity on an ECG tracing, including the spacing of spikes and waveforms.

electrocardiogram (ECG)

A tracing of the heart’s electrical activity recorded by an electrocardiograph.

electrocardiograph An instrument used to record the electrical activity of the heart. electrocardiograph (ECG) technician An individual who has the technical skills and knowledge to record an ECG and prepare it for the physician. electrodes

Small sensors placed on the skin to detect the electrical activity from the heart.

electronic pacemaker An artificial source of electrical current causing depolarization of the myocardium; artificial pacemakers are electronic. embolism A traveling blood clot. enhanced external counter pulsation (EECP) Treatment for chronic angina patients who do not have other options due to health status. This procedure is performed 5 days a week for several weeks, with the intent of developing collateral blood vessels—essentially creating a “natural” bypass around narrowed or blocked arteries. Standards of behavior and concepts of right and wrong.

ethics

event monitor An event monitor is a battery-powered portable device that the patient controls to record the heart’s electrical activity (ECG) when symptoms occur.



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excitability The ability of the heart muscle cells to respond to an impulse or stimulus; also called irritability.

F false positive When a diagnostic test indicates that disease is present but, in reality, no disease is present. A false positive is never considered a negative result. It is a positive result, albeit a falsely positive one. fibrinolytic agent

Medications administered to break down the fibrin in a blood clot, essentially dissolving it.

filtering facepiece respiratory (FFR) illnesses or contagious diseases.

Specialized PPE mask to be worn when caring for patients with or with the potential for respiratory

focus (pl. foci)

A cardiac cell or group of cells that produces an ectopic beat; cells that are notably different or abnormal in some manner.

frequent PVC

Six or more PVCs per minute.

G gain A control on the ECG machine that increases or decreases the size of the deflections on the ECG tracing. gamma camera A camera that records the gamma radiation emitted by the radioactive tracers in a patient’s blood. gate

A selective technique in which a gamma camera is triggered by specific events captured by a three-lead ECG monitor.

H healthcare provider The scope of practice of each healthcare provider will determine the extent of the interpretation and treatment of each of the cardiac dysrhythmias or conditions. Each specific scope is determined by the licensure of each state. For example: Prescribing a medication is the responsibility of the physician. But some state practices allow nurse practitioners and physician assistants to prescribe medication under the guidance of the physician. hertz (Hz)

A unit of frequency measured in cycles (or events) per second.

Holter monitor An instrument that records the electrical activity of the heart during a patient’s normal daily activities; also known as an ambulatory monitor. hypercoagulopathy An increased ability of the blood to form clots. hypertension High blood pressure. hypertrophy Abnormal thickening of the ventricular wall due to chronic pressure overload; often caused by hypertension. hyperventilation To breathe at an increased rate and depth of inspiration and expiration. hypotension A lower than normal blood pressure that can cause reduction of blood flow to vital organs.

I inherent rhythm The patient’s own heart rhythm. input

Data entered into an ECG machine, usually through electrodes on the skin surface.

interatrial septum A wall of tissue that separates the left and right atria of the heart. intercostal space (ICS) interpolated PVC

The space between two ribs.

A PVC that occurs during the normal R–R interval without interrupting the underlying rhythm.

interrupted baseline

When one or more leads appear as a flat line on the ECG tracing. Usually caused by loose or unplugged leads.

interval The period of time between two activities within the heart. interventricular septum A partition or wall (septum) that divides the right and left ventricles. ischemia A sudden loss or reduction in blood supply (oxygen) to a region of the heart tissue. This occurs due to the presence of atherosclerotic plaque, blood clot, emboli, or even vascular spasm (Prinzmetal’s angina). isoelectric line seen.

The period when the electrical tracing of the ECG is at zero or a straight line, and no positive or negative deflections are

isolation precautions The second level of steps taken to prevent the spread of infection; some examples include separating the infected patient from others and using personal protective equipment. IV fluid challenge Administration of IV fluid (i.e., 0.9% NaCl) to offset the effect of administered medication or to treat for hypovolemia. Often referred to as a fluid resuscitation.

J A point on the QRS complex where the depolarization is completed and repolarization starts.

J point

junctional escape rhythm A rhythm that occurs when the SA node fails to initiate the electrical activity and one of the backup pacemaker sites takes over.

L law Rules of conduct enforced by a controlling authority such as the government. leads

Covered wires that conduct the electrical impulse from the electrodes to the ECG machine.



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left anterior descending artery One of the primary branches of the left main coronary artery supplying blood to the anterior wall of the left ventricle. left atrium The left upper chamber of the heart, which receives blood from the lungs. left bundle branch block (LBBB) Blockage of the left bundle branch, so that the current has to travel down the right bundle branch to stimulate first the right ventricle, then the septum, and then the left ventricle. left ventricle The left lower chamber of the heart, which pumps oxygenated blood through the body. It is the biggest and strongest chamber, known as the workhorse of the heart. left ventricular assist device (LVAD) A mechanical, battery-powered device that is surgically implanted in a patient’s chest to help the left ventricle pump blood throughout the body. Levine sign Named after a cardiologist this sign is seen with ischemic heart pain. It is demonstrated in patient’s through holding a clenched fist over the chest. libel Writing defamatory words about someone; this is both illegal and unethical. limb lead An ECG lead placed on an arm or a leg. loop-memory monitor A cardiac monitor that can hold up to 5 minutes of an ECG tracing and can provide the physician with an ECG tracing of the heart before, during, and after an episode or cardiac event. loss of capture The pacing activity continues to occur without evidence that the electrical activity has depolarized or captured the myocardium. Also called failure to depolarize.

M Failure of a pacemaker to send electrical impulses to the myocardium; also called failure to pace.

malfunctioning malsensing

The pacemaker does not recognize or sense the patient’s own inherent cardiac electrical activity; also called failure to sense.

marginal artery The branch of the right coronary artery that supplies the walls of the right atrium and the right ventricle. Target heart rate of 220 minus the age of the patient.

maximal exercise mechanical capture

The heart’s ability to respond to electrical impulses delivered by a natural or electronic pacemaker.

medical professional liability Legal responsibility of healthcare professionals for their performance. An imaginary vertical line that starts at the middle of the axilla (armpit) and extends down the side of the chest.

midaxillary line midclavicular line

An imaginary line on the chest that runs vertically through the center of the clavicle.

midscapular line

Imaginary line on the back that runs vertically through the center of the scapula.

millimeter (mm)

A unit of measurement to indicate time on the ECG tracing. Time is measured on the horizontal axis.

millivolt (mV)

A unit of measurement to indicate voltage on the ECG tracing. Voltage is measured on the vertical axis.

mitral (bicuspid) valve into the left atrium.

Valve with two cusps or leaflets located between the left atrium and left ventricle; it prevents backflow of blood

mobile cardiac outpatient telemetry (MCOT) Telemetry that uses a small, portable monitor that automatically sends data when a cardiac anomaly is detected. They can hold up to 96 hours of data as well, allowing licensed practitioners to capture significant events even when no symptoms are experienced. morphology Overall form and structure (shape). multichannel recorder An ECG machine that monitors all 12 leads but records three leads at a time and switches leads automatically, recording each of the four sets of three leads. multifocal PVC

Varied shapes and forms of the PVCs, suggesting more than one irritable focus.

myocardial Pertaining to the heart (cardia) muscle (myo). myocardial infarction (MI) (heart attack) heart and death of the muscle tissue.

Occlusion (blockage) of one or more of the coronary arteries causing lack of oxygen to the

myocardial injury Injury to the cardiac muscle caused by prolonged reduction or interruption of blood flow. myocardial ischemia A reduction or interruption in blood flow and oxygen to the myocardium for a short period of time.

N neurological Pertaining to the nervous system, its diseases, and its functions. neuropathy Nerve damage that causes vascular and autonomic nervous system problems, with loss of ability to maintain blood pressure and loss or impaired sensation. Common cause is chronic diabetes mellitus. non-ST segment elevation MI (NSTEMI) occlusion of a coronary artery. noninvasive

A type of heart attack in which the classic signs are not present. Caused by incomplete

Procedure that does not require entrance into a body cavity, tissue, or blood vessel. A stress test in which radionuclides (radioactive tracers) are administered to trace the path of blood through the heart.

nuclear stress test

O occasional PVC

Less than six PVCs per minute.

output display The part of the ECG machine that displays the tracing for the electrical activity of the heart, usually in an electronic or printed form on a 12-lead ECG machine.

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oversensing The pacemaker senses electrical current from other muscle movements or electrical activity outside of the body as the electrical current in the patient’s heart. oxygenated blood Blood having oxygen (oxygen-rich blood).

P pacemaker competition Competition between the pacemaker generator and the heart’s inherent rate over control of the myocardium. pacing spike

A thin spike on the ECG tracing that results from the pacemaker stimulation impulse.

pallor Pale skin. palpitations

Rapid irregular beating of the heart which may or may not be associated with complaints of chest pain. Muscles in the ventricles that anchor the chordae tendineae and atrioventricular valves.

papillary muscles paraspinous line

Imaginary line on the spine that runs vertically through the side of the spine.

parasympathetic

The branch of the autonomic nervous system (ANS) that helps to slow the heart rate.

paroxysmal event pathologic Q wave lead.

Witnessed change in any cardiac rhythm, including starting, stopping, or both. A Q wave that measures 0.04 second or wider in duration and/or is one-third or more the height of the R wave in that

pericardium A two-layered sac of tissue enclosing the heart. personal protective equipment (PPE) Devices such as gloves, gowns, face masks or shields, and eye protection designed to protect a healthcare worker from sources of infection. physiologic Q wave lead.

A normal Q wave, measuring less than 0.04 second in duration and less than one-third the height of the R wave in that

polarization The state of cellular rest in which the inside is negatively charged and the outside is positively charged. posterior axillary line

Imaginary line on the back that runs vertically from the shoulder down on the outer edge of the rib cage.

posterior descending artery One of the primary branches of the right coronary artery providing blood to the interventricular septum and the posterior wall of the heart. precordial lead A type of lead placed on the chest in front of the heart; known as a V lead. premature ventricular complex (PVC)

An ectopic impulse originating in either ventricle that occurs too early in the cycle.

pulmonary artery Large artery that transports deoxygenated blood from the right ventricle to the lungs. This is the only artery in the body that carries deoxygenated blood. pulmonary circulation The transportation of blood to and from the lungs; blood is oxygenated in the lungs during pulmonary circulation. pulmonary edema Abnormal collection of fluid within the pleural space (lungs) due to congestive heart failure (left ventricle).

pulmonary embolism A blocked artery in the lungs, usually caused by a blood clot. pulmonary semilunar valve pulmonary circulation.

A valve found in the pulmonary artery that prevents backflow of blood into the right ventricle during

pulmonary veins Transport oxygenated blood back into the left atrium of the heart. These are the only veins in the body that carry oxygenated blood. Purkinje fibers

The fibers within the heart that distribute electrical impulses from cell to cell throughout the ventricles.

Purkinje network

Spreads the electrical impulse throughout the ventricles by means of the Purkinje fibers.

Q QS complex A deep Q/S wave with no preceding R wave. Can indicate a left bundle branch block. Depolarization of the ventricles without the presence of the positive R wave typically seen. This results in the joining of the two negative wave forms (Q & S) of the QRS complex. quadgeminy Pattern in which every fourth complex is a premature complex (e.g., PVC).

R PVC occurs on the downslope of the T wave or the vulnerable period of the ventricular refractory period.

R-on-T PVC radiologist

A physician who specializes in the use of radioactive substances to diagnose and treat disease.

rales (crackles) Noisy breath sounds during inhalation caused by retained airway secretions. When caused by pulmonary edema, rales are heard as very short, soft, bubbling lung sounds. rate pressure product (RPP)

Systolic blood pressure multiplied by the heart rate; also known as double product.

renal infarction A lack of oxygen to kidney tissue due to a blocked blood vessel. repolarization The return of heart muscle cells to their resting electrical state, causing the heart muscle to relax. restenosis

The return of a blood vessel to a blocked state.

retrograde

Moving backward.



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right atrium The right upper chamber of the heart, which receives blood from the body. right bundle branch block (RBBB) branch to activate the ventricles. right ventricle

Block that occurs in the right bundle branch, so that the current has to travel down the left bundle

The right lower chamber of the heart, which pumps blood to the lungs.

run of ventricular tachycardia Three or more PVCs in a row at a rate of greater than 100 bpm. Also known as triplet PVCs or salvo.

S salvo

Three or more PVCs in a row at a rate exceeding 100 bpm; also called triplet PVCs or run of ventricular tachycardia.

segment seizure

A portion or part of the electrical tracing produced by the heart. An interruption of the electrical activity in the brain that causes involuntary muscle movement and sometimes unconsciousness.

semilunar valve A valve with half-moon-shaped cusps that open and close, allowing blood to travel only one way; located in the pulmonary artery and the aorta. serial ECG comparison Multiple and frequent ECG tracings recorded at intervals based upon the patient’s condition and compared to identify changes. sick sinus syndrome

A disease that affects the function of the SA node. It can result in bradycardia, tachycardia, or even cause pauses in

the conduction such as sinus arrest. signal processing output display.

The process within the ECG machine that amplifies the electrical impulse and converts it to a mechanical action on the

sinoatrial (SA) node

An area of specialized cells in the upper right atrium that initiates the heartbeat.

sinus bradycardia A slow heart rate, usually less than 60 beats per minute. sinus exit block Condition in which the SA node initiates an electrical impulse but the impulse is blocked and not conducted to the atria. Also known as sinus block or SA block. sinus tachycardia A fast heart rate, usually greater than 100 beats per minute. slander Making derogatory remarks about someone that jeopardizes his or her reputation or means of livelihood; slander is both illegal and unethical. somatic tremor Voluntary or involuntary muscle movement; also known as body tremor. speed control A control on the ECG machine that regulates how fast or slow the paper runs during the tracing. sphygmomanometer blood pressure cuff. ST segment elevation MI (STEMI)

Classic MI with expected ST segment deviation and development of pathologic Q wave.

standard precautions Procedures, used with all patients, that are designed to prevent the spread of infection, such as performing hand hygiene and wearing gloves. Immediately.

stat stent

A matrix of crisscrossed metal that forms a small tube to help keep an artery open after angioplasty.

stress ECG Another name for exercise electrocardiography. stress echocardiogram A test that combines an exercise stress test with an echocardiogram to assess left ventricular wall motion both before and immediately after exercise. stroke volume

The volume of blood ejected by the left ventricle with each contraction.

submaximal exercise Target heart of 220 minus the age multiplied by a percentage between 60 and 85. THR = [(220 − age) × 0.60] to THR = [(220 − age) × 0.85] sudden cardiac arrest system.

A condition in which the heart stops beating suddenly, often without warning, due to a failure of its electrical

suprasternal notch The dip you feel at the anterior base of the neck just above the manubrium, where the clavicle attaches to the sternum. supraventricular An ectopic focus originating above the ventricles in the atria or junctional region of the heart. sympathetic

The branch of the autonomic nervous system (ANS) that causes an increase in the heart rate.

symptom event monitor A type of cardiac event monitor that activates when the electrode feet (small metal discs) are pressed onto the patient’s chest and records a lead II tracing. syncope

Loss of consciousness (fainting).

systemic circulation The pathways for pumping blood throughout the body and back to the heart. systole The contraction phase of the cardiac cycle, during which the heart is pumping blood out to the pulmonary (lungs) and systemic (body) circulation. systolic blood pressure The blood pressure measured when the left ventricle of the heart contracts; the number corresponding with the first Korotkoff sound heard when performing an auscultated blood pressure.

T target heart rate (THR)

Heart rate measurement needed to truly exercise the heart.

telemedicine A monitoring system in which ECG tracings are communicated from a patient outside a medical facility to the physician via a telephone or digital system.



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telemetry monitoring Real-time monitoring in which a small transmitting device attached to the chest with three or five electrodes and sends a continuous ECG tracing of the heart directly to a monitoring station.

thrombolytic agent thrombus

Medications administered intravenously that possess the ability to lyse or dissolve a clot.

A blood clot that forms on the wall in a diseased area of the endocardium or on the wall of an injured blood vessel.

tilt table test A test to determine whether a change in a patient’s blood pressure or heart rate due to a change of position is causing symptoms of lightheadedness or fainting. torsades de pointes Type of ventricular tachycardia in which depolarization impulses move from one ventricle to the other, resulting in a “twisted ribbon” appearance on the ECG tracing. TP segment The segment of a waveform that extends from the end of the T wave to the point of initiation of the following cardiac complex, typically the P wave. transcutaneous pacemaker A type of pacemaker applied to the external skin for a temporary condition for only 24 hours at a time. tricuspid valve

Valve located between the right atrium and right ventricle; it prevents backflow of blood into the right atrium.

trigeminy Pattern in which every third complex is a premature (PVC). triggered Caused to occur; for example, electrical impulses are caused to occur if a pacemaker fails to detect the heart’s normal contractions. Three or more PVCs in a row at a rate exceeding 100 bpm; also called salvo or run of ventricular tachycardia.

triplet PVCs

U underlying rhythm The heart rhythm that would be present if the abnormal impulses were ignored or removed from the tracing. undersensing

The pacemaker is unable to detect any electric activity and never turns off.

unifocal PVC

Early complex that has shape suggesting only one irritable focus present.

unipolar lead A type of ECG lead that measures the flow of electrical current in one direction only. unstable angina (pre-infarction angina) A warning sign that the disease that has been causing angina has worsened. Signs and symptoms are less predictable, last longer, and are more painful than previously experienced.

V vagal tone

A constant tension on the vagus nerve that causes the heart to beat more slowly.

vena cava (pl. venae cavae) Largest vein in the body, which provides a pathway for deoxygenated blood to return to the heart; its upper portion, the superior vena cava, transports blood from the head, arms, and upper body; and its lower portion, the inferior vena cava, transports blood from the lower body and legs. ventricular pacing contraction. vital signs

Electrical stimulation is delivered to the ventricle(s) to stimulate ventricular depolarization and result in ventricular

Temperature, pulse, respirations, blood pressure, and pain assessment.

volume expander IV solution administered to fill fluid volume or replace the space that blood normally takes up. The context referred to in this book is referring to inert fluids, specifically 0.9% NaCl. It is given to increase blood volume in the hypotensive or potentially hypotensive patient in an effort to maintain homeostasis.

W wandering baseline

Artifact in which the tracing drifts away from the center of the graph paper. Also known as baseline shift.

Wolff-Parkinson-White syndrome A type of supraventricular tachycardia in which an extra electrical pathway allows the electrical signal to arrive at the ventricles too soon. This pre-excitation syndrome causes tachycardia and affects the morphology of the QRS complex. As a result of the abnormal conduction pathway, the QRS complex begins early and measures abnormally wide (0.12 second or greater) with a classic “delta” wave.



page I-1

Index Note: A page number followed by an f refers to a figure (graph, illustration, photograph) and t refers to a table.

6-second method calculating heart rate using, 77–79, 77f irregular rhythms, 77 12-lead ECG. See ECG 300 method, calculating heart rate using, 76, 76t 1500 method calculating heart rate using, 76–77, 77f calipers with, 134 determining heart rate, 76, 134

A Abbreviations error-prone, C–15 to C–17 medical, C–1 to C–15 AC, alternating current, 102 ACA, American College of Cardiology, 339, 346 Accelerated idioventricular rhythm, E–3 criteria for classification of, 233 definition of, 232 ECG tracing of, 232f signs and symptoms of, 233 Accelerated junctional rhythm, E–2 criteria for classification of, 190 definition of, 189 ECG tracing of, 190f signs and symptoms of, 190

Accuracy, ECG tracings, 3 ACE inhibitors action of, A–1 diseases treated by, A–1 drugs, A–1 Acetylcholine, byproduct of parasympathetic nervous system, 47 ACLS. See Advanced cardiac life support (ACLS) ACS. See Acute coronary syndrome (ACS) Action potential, definition of, 126 Acute coronary syndrome (ACS) American Heart Association and range of symptoms with, 338 definition of, 338 in elderly patients, 338 NSTEMI and STEMI symptoms of, 339 Acute myocardial infarction (AMI), 340, 370f Advanced cardiac life support (ACLS), definition of, 237 A-fib. See Atrial fibrillation (A-fib) Age-related changes, effect on blood pressure, 23 Agent. See also Medication fibrinolytic, 349 infectious, 19 thrombolytic, 349 Agonal rhythm, E–3 criteria for classification of, 229–230 definition of, 229 ECG tracing of, 229f signs and symptoms of, 230 AHA. See American Heart Association (AHA) Airborne precautions, 19, 19t when to use, B–6 Alcohol consumption cause of premature ventricular complex, 226 effect on blood pressure, 23 Alcohol-based hand rubs, 18, B–3 steps for, B–3 to B–4 Alligator-type clip, cleaning of, 97, 106f Alternating current (AC) interference

causes of, 102–103 correcting, 100t definition of, 102 ECG tracing of, 102t troubleshooting, 103t Ambulating, definition of, 304 Ambulatory care facility, ECG in, 4–5 Ambulatory monitor description of, 304 digital, 305f removing, 320–321 reporting results, 320–321 Ambulatory Monitor Patient Responsibility Form, 319f Ambulatory monitoring, 304–321, 305f definition of, 304 effectiveness of cardiac medications, 306, 314 electrode placement, 317–318, 318f necessary equipment for, 316–317 patient preparation, 316 pediatric patients, 316 preparing for procedure, 316–317, 317f purpose of, 306 stress ECG, 306 things to avoid during, 314–315 types of, 307–312 Ambulatory Monitoring Checklist, 315f American College of Cardiology (ACC), 339, 346 American Heart Association (AHA), 3, 263, 338–339, 346 AMI. See Acute myocardial infarction (AMI) Anatomical landmarks, for placement of chest electrodes, 94–97, 95f, 96t, 96f, 98f Anatomical terms, D–1 to D–3, D–1t directional, D–1f spatial, D–2f Anatomically contiguous leads, definition of, 369, 369f Anatomy, of heart, 37–41

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Angina. See also Chest pain definition of, 278, 334 Prinzmetal’s, 129 symptoms, 335 unstable, 335–336, 336t Angiography, coronary, 348 Angioplasty. See also Percutaneous coronary intervention (PCI); Percutaneous transluminal coronary (PTCA) definition of, 350 Angiotensin-converting enzyme (ACE) inhibitors, A–1 Angiotensin I and II, ACE inhibitors and, A–1 Angiotensin II receptor blockers (ARBs), A–1 to A–2 Angiotensin Receptor-Neprilysin Inhibitors (ARNIs), A–2 Angle of Louis, 94, 95f Anomaly, 311 Anorexia, 341 ANS. See Autonomic nervous system (ANS) Antecubital space, 24 Anterior axillary line, 94, 95f Anterior infarction, ECG tracing of, 367f Anterior interventricular artery, 332, 333f Antidysrhythmic medications (antiarrhythmic), 306, A–2 to A–3 action of, A–2 classes of, A–2 to A–3 diseases treated by, A–3 effect on QT interval, 129 Anticoagulants (blood thinners), 353 action of, A–2 diseases treated by, A–2 drugs, A–2 intravenous, A–2 oral, A–2 subcutaneous, A–2 Antiplatelet agents action of, A–3 diseases treated by, A–3 drugs, A–3

Aorta, 39f, 40, 41f, 43f, 45f, 333 Aortic arch, 43f Apex, of heart, 38f, 49f, 185f, 333f Apnea, definition of, 237 Aortic semilunar valve, 40, 40t, 40f, 41f, 43f Arm-ergometry, 276 Arrest, sinus, 152, 152f Arterial blood pressure, 23 Artery acute marginal, 43f anterior descending coronary, 365f anterior interventricular, 332, 333f circumflex, 43f, 332, 333f coronary, 42–43, 43f, 332, 333f diagonal, 43f, 332, 333f internal mammary (as graft), 352, 352f layers inside, 332, 334f left anterior descending, 43f, 332, 333f left coronary, 42–43, 43f, 332, 333f marginal, 332, 333f, 365f obtuse marginal, 43f, 333f, 365f posterior descending, 43f, 332, 333f, 365f posterior interventricular artery, 332, 333f pulmonary, 40, 41f, 45f, 333f right coronary, 42–43, 43f, 332, 333f Artifact abnormal-appearing ECG tracing, 131 causes of, 100, 103 definition of, 70, 99 minimizing, exercise electrocardiography, 288 Artifact filter, 70, 288 Artificial pacemaker. See Electronic pacemaker Ascites, definition of, 343 Aspirin, antiplatelet agent, A–3 Asystole, E–3

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criteria for classification of, 239 definition of, 152, 239 ECG tracing of, 239f signs and symptoms of, 239 Atherosclerotic plaque definition of, 337 diabetes and, 337 effect on blood pressure, 23 ischemia and, 129 Atrial depolarization, P wave and, 132, 135, 165 Atrial dysrhythmia, 165–166 causes of, 165 impact on P wave, 165 Atrial fibrillation (A-fib), E–2 criteria for classification of, 174 definition of, 174 ECG tracing of, 174f signs and symptoms of, 174–175 Atrial flutter (A Flutter), E–2 1500 method, 172 criteria for classification of, 172 definition of, 171 ECG tracing of, 172f signs and symptoms of, 173 Atrial kick, 47, 128, 173 Atrial pacing, definition of, 254 Atrial rhythms, types and descriptions of, E–2 Atriobiventricular pacing, definition of, 255 Atrioventricular (AV) bundle, 48, 49f Atrioventricular (AV) node, 47, 48t, 49f delay caused by, 47 inherent rate of, 48 Atrioventricular (AV) valves, 38 Atrioventricular delay definition of, 258 pacemaker ECG tracing, 259 Atrioventricular nodal re-entrant tachycardia (AVNRT), 193–194

Atrioventricular reciprocating tachycardia (AVRT), 193 Atrioventricular sequential pacing, definition of, 254 Atrioventricular sulcus (groove), 332 Atrium (pl. atria), 38 Augmented leads. See also Unipolar leads aVR, aVL, and aVF, 60–61, 62f definition of, 60 Einthoven’s triangle and, 60, 62f location of electrodes for, 59t Auscultated blood pressure definition of, 25 Korotkoff sounds and, 25 Automatic external defibrillator (AED), 8–9, 8f abnormal/shockable rhythm, 8 CPR, 8 description of, 8 improving survival rate of patients with myocardial infarction, 8f lay rescuers to help cardiac arrest patients, 8 Automaticity, definition of, 46 Autonomic nervous system (ANS), 46 parasympathetic branch of, 47 sympathetic branch of, 46 AV junction definition of, 184 pacemaker, 184 AVNRT. See Atrioventricular nodal re-entrant tachycardia AVRT. See Atrioventricular reciprocating tachycardia Axis, electrical, 378 Axis deviation causes of, 379t definition of, 378 extreme right axis, 379t, 379f, 380 indeterminate, 379f, 380 quadrants for identifying, 379f

B

Bachmann’s bundle, 47, 49f Baseline shift/wandering baseline, 101 BBB. See Bundle branch block (BBB) Beta blockers, A–3 to A–4 definition of, 284 diseases treated by, A–4 drug withdrawal before exercise electrocardiography, 284, 348 drugs, A–3 to A–4 Biatrial pacing, 256 Bicuspid valve(mitral valve), 38, 39f, 40t, 41f Bigeminy PVC, 226t Billing, reporting ECG for purpose of, 104 Biphasic definition of, 166 P wave, 166 Bipolar leads (standard/limb leads), 60 Birth defect, cause of displacement of heart, 378 Bleeding, severe hypotension and, 24 Block, sinus exit, 154–155, 155f

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Blocked/nonconducted impulse, 207 Blood deoxygenated, 41, 42, 43f, 43 oxygenated, 37, 41–42, 43f, 43 standard precautions if possibility of exposure to, 16 Blood gas analysis, for immediate cardiac care, 348 Blood pressure (mm Hg). See also Arterial blood pressure; Auscultated blood pressure; Diastolic blood pressure; Systolic blood pressure alcohol consumption and, 23 auscultated, 25 definition of, 23 ECG technician checks, 23 factors affecting, 23–24 measuring, 24–25 measuring adult (Competency Checklist), 34–35 unit for measuring (mm Hg), 23

vital sign of, 20, 20t Blood pressure cuff, 24, 24f Blood thinners, A–2 Body fluids, standard precautions if possibility of exposure to, 16 Body mechanics definition of, 91–92, 92t proper, 92t Body tremor(somatic tremor), 101 Bolus, definition of, 347 Bounding pulse, 21 Box, 300 method or large, 76 Brachial artery, location of, 24f Bradycardia, sinus, 71, 146, 147f Brain attack(cerebrovascular accident), 175 Breasts placement of V1 and V2 in female with breast implants or large, 109, 110f placing chest electrodes on female, 95–96 British Pacing and Electrophysiology Group, 255 Bruce protocol exercise electrocardiography and, 282t–283t stress testing, 290t, 291f Bundle atrioventricular (AV), 48, 49f Bachmann’s, 47 of His description/location, 48, 48t Bundle branch block (BBB), 372–375, E–3 causes of, 376 criteria for classification of, 373–374 definition of, 372 ECG tracing of, 374f signs and symptoms of, 374–375 Bundle branches, 48, 48t, 49f Bundle of His (atrioventricular or AV bundle), 48, 48t Burns placing electrodes on patient with, 109 severe hypotension and, 24

C CABG, coronary artery bypass graft, 352, 352f Cables, replace worn ECG, 106 CAD, coronary artery disease, 2, 278 Caffeine cause of premature ventricular complex, 226 effect on heart rate, 47 Calcium (Ca++), effect on heart rate, 47 Calcium channel blockers, A–3 action of, A–4 diseases treated by, A–4 drugs, A–4 Calipers 1500 method and, 134 distance between P wave and QRS complex measured with, 132, 132f P-P wave interval measured with, 133, 133f PR interval measured with, 136, 136f QRS duration and morphology, 137, 137f R-R wave interval measured with, 133 Capture loss of pacemaker, 263, 264t mechanical, 257 Carbon dioxide, 42 Cardiac arrest. See also Code Blue sudden, 8 use of AED during, 8 Cardiac biomarkers, 347 Cardiac care unit (CCU), 4 Cardiac catheterization, 11, 348 Cardiac cycle, 44–45. See also Diastole; Systole Cardiac enzymes, 347. See also Cardiac markers/ biomarkers Cardiac event recording. See also Loop-memory monitor; Symptom event monitor functions, 307–308 infrequent symptoms, 307 voice activated monitors, 309 wearable/implantable monitor with defibrillator, 309, 309f Cardiac glycosides, A–4 to A–5

digitalis, A–4 diseases treated by, A–4 drugs, A–4 Cardiac markers/biomarkers, definition of, 347 Cardiac monitor, 12-lead wireless, 310f Cardiac monitoring (Competency Checklist), 108–109, 124–125, 310 Cardiac output definition of, 21, 44, 144 effect on blood pressure, 23 estimation of, 44 formula for determining, 144 signs and symptoms of low, 145t Cardiac output parameters, definition of, 206 Cardiac stress testing, 275–293. See also Chemical stress echocardiogram; Chemical stress test; Echocardiogram; Nuclear stress test; Stress echocardiogram exercise electrocardiography, 275–276, 276f noninvasive procedure, 277 types of, 278–281 Cardioactive medications, 279t Cardiogenic shock, definition of, 341 Cardiologist chemical stress echocardiogram and, 281 chemical stress tests and, 279 definition of, 276 Cardiopulmonary resuscitation (CPR), 8, 287 Cardiotonics, A–6 Cardiovascular disease (CVD), 2 Cardiovascular system, 36–49 Cardiovascular technologist, 11 Careers, in electrocardiography, 10–11 Carotid artery measuring pulse at, 21, 21f CCU. See Cardiac care unit (CCU) CDC. See Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC), 2, 16, 20 standard precautions/isolation precautions by, 16

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Cerebrovascular accident (CVA). See also Brain attack; Stroke atrial fibrillation and, 175 definition of, 175 risk of exercise electrocardiography, 284–285 Chambers, of heart, 38–40, 39f CHB. See Complete heart block (CHB) Chemical stress echocardiogram, 281 Chemical stress test, 278–279 Chemical stress testing agents cardioactive drugs, A–5 imaging agents, A–5 Chest electrodes anatomical landmarks for, 94, 95f attaching lead cable wires, 97, 98f identifying lead wires, 97f placement of, 94–97, 95t, 96t, 96f Chest leads, 59t, 61–62, 63f. See also Precordial leads 12 Views of 12-Lead ECG, 59t placement and tracing, 61–62, 63f, 64f, 96t, 96f unipolar, 61 V1 to V6, 61, 63f, 97 Chest pain (chest discomfort), 334. See also Angina causes of, 334 female, 336, 337t nitroglycerin administration, 332 signs of, 336t Chest X-ray, immediate cardiac care and portable upright, 348 CHF. See Congestive heart failure (CHF) Cholesterol absorption inhibitor, A–5 Cholesterol-lowering agents action of, A–5 diseases treated by, A–5 drugs, A–5 statins, A–5 Chordae tendineae, function and location of, 39, 39f Circulation definition of, 37

ECG and, 37 principles, 42–44 pulmonary, 42, 43f systemic, 42, 43f Circumflex artery, 43f, 332, 333f CK-MB, cardiac enzyme, 347 Classical (Mobitz II) block, second degree, 209, 211 Clavicle, 94, 95f Clinical triad, of symptoms with right ventricular failure, 343, 343f Clostridium difficile, hand hygiene, 18 Clot. See Blood clot Clot buster. See Medication Code Blue cardiac or respiratory arrest, 113–114 definition of, 4 ECG done during, 4 using defibrillator during, 7 ventricular tachycardia and, 235 Code of ethics, 12 Collateral blood vessels, 354 Communication, 14 Competency Checklist Assisting with Exercise Electrocardiography, 300–303 Cardiac Monitoring, 123–125 Immediate Care for a Cardiac Patient, 361–362 Measuring Adult Blood Pressure, 34–35 Measuring Pulse and Respirations, 32–33 Pacemaker Evaluation, 273–274 Recording an Electrocardiogram, 122–123 Complete heart block (CHB), 211, 212. See also Third degree atrioventricular block Complex ECG waveform, 127, 128t premature junctional (PJC), 186–187 QS, 376 Computer interpretation, of ECG, 2, 66, 71, 320

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Conducting cells, qualities of heart’s, 46 Conduction pathways, 49f Conduction system, of heart, 46–49 Conductivity, definition of, 46 Confidentiality HIPAA and breach of, 12 Congestive heart failure (CHF) cause of bundle branch block, 376 definition of, 286 exercise electrocardiography and, 286 Consent informed, 14, 283, 285f obtaining, 13–14, 90 Consult form, ECG, 88 Contact precautions, 19 for hospitalized patients, 19t when to use, B–5 Continuous cardiac monitoring, 108–109, 108f, 124–125f in hospital, 4 lead II or modified chest lead, 108 placement of leads, 108, 108f purpose of, 4 Contractility, definition of, 46 Coronary angiography, 348. See also Angiography Coronary arteries function and location of, 41, 41f, 42–43, 43f, 332, 333f, 334f layers, 332, 333f Coronary artery bypass graft (CABG) antiplatelet agents, A–3 definition of, 352, 352f internal mammary artery/saphenous vein graft in, 352, 352f Coronary artery disease (CAD) description of, 2, 278 effect on QT interval of, 129 Coronary blood vessels, 39f Coronary circulation, 42–43, 43f, 365f Coronary sinus, 43, 43f, 255, 333f

Coumadin (warfarin), 353 Coupling PVCs, 227t CPR. See Cardiopulmonary resuscitation (CPR) Crash cart, definition of, 238 Critical thinking, 14 CVA. See Cerebrovascular accident (CVA) CVD. See Cardiovascular disease (CVD) Cycle cardiac, 44–45, 45f stationary, 276

D DAPT. See Dual antiplatelet therapy (DAPT) DDDRO pacemaker, 256 Deep respiration, 22 Defamatory words, derogatory remarks and, 13 Defibrillator in cardiac event monitor, 309, 309f definition of, 7–8 during Code Blue, 7 treatment of pulseless ventricular tachycardia, 7–8 treatment of ventricular fibrillation, 7–8 Deflections, isoelectric line and, 127–128 Dehydration, severe hypotension and, 24 Delay, atrioventricular, 259 Delta wave definition of, 194, 195f due to Wolff-Parkinson-White syndrome, 194, 195f Deltoids (shoulders), alternative site for limb leads, 93 Dental problems, cardiac symptoms, 334 Deoxygenated blood, 41, 42, 43f, 43 Depolarization atrial, 132, 135, 165, 172, 185, 188, 194 definition of, 126, 127f ventricular, 128–129, 132–133, 135–137, 172, 185, 188, 205, 212–213, 259, 376, 380–381 DES. See Drug-eluting stent (DES)

Dextrocardia axis deviation and, 379t definition of, 110, 111f lead placements, 111f right-side 12-lead ECG, 110–111 Diabetes atherosclerotic plaque and, 337 cardiac symptoms in patients with, 337 increased incidence of heart attack or stroke in, 337 neuropathy and, 337 Diagonal artery, 43f, 332, 333f Diaphragm, 38f Diastole, 44, 45f Diastolic blood pressure, definition of, 23 Diastolic dysfunction, 342f Digital monitoring, 9 Digital technology, 66 Digitalis, A–4 Directional terms, for body organs and parts, D–1f Dissociative, definition of, 212 Diuretics action of, A–6 diseases treated by, A–6 side effect of loss of electrolytes from, A–6 Doctor’s office, ECG in, 4–5 Documentation, 13. See also Medical record Droplet precautions, 19, 19t when to use, B–5 to B–6 Drug-eluting stent (DES), 350 Drugs. See Agents; Medications Dual antiplatelet therapy (DAPT), 352, A–3 “Dupp”, 45, 130f Dyspnea, definition of, 22 Dysrhythmia atrial, 165–166

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bundle branch block (BBB), 372 cardiac, 47 definition of, 8 heart block, 204–216 junctional, 184–197 left bundle branch block (LBBB), 372 right bundle branch block (RBBB), 372 reentry, 194 sinus, 150–151, 150f using AED in, 8 ventricular, 224–240

E ECG, 12-lead ECG, 2, 2f adolescent patient, 107 AHA recommendations on, 4 analyzing, 368 baseline tracing, 3 cleansing of equipment, 92 communication, 14, 89–90 electrical activity of heart, 2, 2f, 3f, 4, 57–58 identifying components of, E–1t immediate cardiac care, 347 infection control, 16–20 lead wires to record, 58–59 on left ventricle, 363, 364f legal and ethical issues, 11–12 maintaining safety during, 92t pediatric, 107 performing, 87–114, 89f preparing for, 11 reporting results, 104–105 with ST deviation, 368f standard views of, 363–364, 364t, 364f stress ECG, 275 troubleshooting techniques, 99t, 103t

uses of, 3–11 ECG graph paper, 72–73, 73f, 78f dot matrix, 73, 73f measurements, 77, 78f standard grid, 73, 73f ECG machines, 63–67 advancing technologies, 66–67 controls, 67–71 equipment maintenance, 105–106, 106f functions, 65–66 input, 65 multichannel recorder, 63, 65f output display, 65 paper loading, 88, 89f signal processing, 65 ECG management systems, 66 ECG monitor (telemetry) technician, 10 ECG report, 74 ECG strips, components of, E–1 to E–3 ECG technician, 10 patient education, 281 responsibilities before, during, and after stress test, 282t–283t role of, 10 vital signs, 20–23 ECG tracing, 3f cardiac medication impact on, 89 calibration marks on, 68, 69f checking, 99 documenting, 145 evaluating pacemaker function, 257 ECG waveform, 126 complexes, 127 components, 128t

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heart activity, 128f intervals, 127

P wave, 127–128, 128t PR interval, 128t, 129 QRS waves, 128, 128t QT interval, 128t, 129 R-R interval, 128t, 129 segments, 127 S wave, 128, 128t ST segment, 128t, 129 T wave, 128t, 129 U wave, 128t, 129 Echocardiogram. See also Chemical stress echocardiogram; Stress echocardiogram definition of, 280 stress, 280 Echocardiography conditions evaluated by, 5t definition of, 280f Ectopic foci, definition of, 167, 171, 193 Ectopic impulse cause of atrial dysrhythmia, 165 cause of PVC, 225 definition of, 165 Edema, pulmonary, 341 EECP, enhanced external counter pulsation, 354, 354f Einthoven, Willem (1860–1927), 2 Einthoven’s triangle augmented leads (aVR, aVL, aVF) and, 60, 62f definition of, 60, 60f limb electrodes, 60, 60f right arm, left arm, left leg, 60, 60f standard limb leads (I, II, III) and, 60, 61f Elderly patients acute coronary syndrome, 338 ambulatory monitoring, 318 Electrical axis, 378–380 Electrical capture, definition of, 257 Electrical cardioversion (defibrillation), 349 Electrocardiogram (ECG)

definition and description of, 3, 348 history and importance of, 2–3 recording (Competency Checklist), 122–123 requisition/consult form, 88 serial, 66, 72 uses of, 3–4 waveform, 127 Electrocardiograph description of, 2 invented by Einthoven, 2 technician, role of, 10 Electrocardiography, 1–25 assisting with exercise (Competency Checklist), 300–303 careers in, 10–11 exercise, 275 standard precautions related to, 16, 18t Electrodes. See also Sensors 12-lead ECG, 2f ambulatory monitoring and placing, 317–318, 318f definition of, 58 disposable, 71, 72f patient discomfort from, 72 silver, 72 telemetry monitoring and placement of, 311, 312f Electrolyte imbalance effect on QT interval of, 129 U wave on ECG indicates, 129 Electronic intensive care unit (eICU), 311f Electronic medical record advantages of, 13 digitally signed, 13 Electronic pacemakers (artificial pacemakers), 253 Embolism atrial fibrillation and, 175 definition of, 175 pulmonary, 175 Emergency department (ED), continuous cardiac monitoring in, 4

Emergency medical technicians, 7, 10 Endocardium, 37, 38t, 39f Enhanced external counter pulsation (EECP), definition of, 354, 354f Environmental cleaning, standard precaution and how to do, B–2 Enzymes. See Cardiac enzymes Epicardium (visceral pericardium), 37, 38t, 39f Error-prone abbreviations, C–15 to C–17 Escape beats, PVC and, 236 Escape rhythm, 187 junctional, 187–188, 188f ventricular, 225 Essential hypertension, 23. See also Idiopathic hypertension Ethics code of, 12 definition of, 11 practicing, 12 Event, paroxysmal, 227t Event monitors, 7 ambulatory ECG, 7 cardiac, 309 symptom, 307 Excitability (irritability), 46 Excretions, use standard precautions for possible exposure to body, 16 Exercise electrocardiography, 291 maximal, 291 submaximal, 291 target heart rate and, 291 Exercise electrocardiography. See also Stress ECG; Treadmill stress test assisting with (Competency Checklist), 300–303 cardiac stress testing, 275–276, 276f common protocols for, 289–292, 290t, 291f contraindications, 286 performing, 287–288 monitoring after, 292–293

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patient instructions after, 293 patient preparation, 281, 282t–283t patient’s refusal to give consent, 283t preparing for emergencies during, 286t responsibilities during, 277 results of test, 293 use of, 277–278 Exercise tolerance test, 275 Exercise treadmill, 276, 276f Exercise treadmill test, 275 Exercise heart rate and, 47 maximal, 291 submaximal, 291 Eye protection, 16, 17t personal protective equipment, 16 when to use and rules for using, B–4t

F F wave, associated with atrial flutter, 171–172 f wave, associated with atrial fibrillation, 174 Face mask, personal protective equipment, 16, B–1 Face shield, personal protective equipment, 16, 17f, 18t Failure, congestive heart (CHF), 23, 145, 286 Failure to depolarize, definition of pacemaker, 263, 263t Failure to pace, malfunctioning of pacemaker and, 263, 263f Fainting. See Syncope False positive, definition of, 293 Fear, reducing patient’s, 289, 316 Females cardiac symptoms in, 337t heart attack symptoms, 336–337 Fever, heart rate and, 47 Fibrillation. See Atrial fibrillation; Ventricular fibrillation Fibrinolytic agents, 349–350 Fibrinolytics (clot busters), 349–350

action of, A–6 diseases treated by, A–6 side effect of bleeding from, A–6 Filtering facepiece respirators (FFR), 16, 17f, B–1 First-degree atrioventricular (AV) block, 204–206 criteria for classification of, 205 ECG tracing of, 205f normal and delayed electrical impulses in, 205f signs and symptoms of, 206 Flat-line ECG tracing, 103 Flutter. See Atrial flutter Focus (pl. foci), definition of, 167 Fowler’s position, alternative ECG position, 112, 113f Frequent PVC, 226t

G Gain (sensitivity), 68 Gamma camera, 279 Gas exchange, 42 Gastric irritation, 334 Gate, 280 Generator, pacemaker, 253 Genetics, effect on blood pressure, 23 Geriatric patient, placing electrodes, 110 Gloves contact precautions, 19, 19t personal protective equipment, 16, 17f standard precaution and when to use, 18t, B–1 when to use and rules for using, B–3t Goggles, for droplet precautions, 19, B–1 Gown contact precautions, 19 personal protective equipment, 16 standard precaution and when to use, 18t, B–1 when to use and rules for using, B–4t Groove. See Sulcus



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H HAIs, healthcare-associated infections, 16 Hand hygiene, 18. See also Handwashing indications for, B–2 to B–3 recommended practices, B–2 when to do, 18t Hand rubs advantages of alcohol-based (foam or gel), B–3 steps for using alcohol-based, B–3 to B–4 Handwashing, 16f, 18. See also Hand hygiene standard precaution and when to use, 18t, B–1 steps for, B–3 Health Insurance Portability and Accountability (HIPAA) (1996), 12 protecting ECG records, 67 protecting patient information, 12 Healthcare provider description of, 3 licensure by state, 3 uses of ECG by, 3 Healthcare-associated infections (HAIs), 16 Heart anatomy, 37, 38f apex of, 38f, 333f base of, 38f chambers of, 38–40, 39f conduction system of, 46–49 displacement of, 378 layers, 37, 38t left side, 39–40 as pump, 44 regulation of, 46–47 right side, 39–40 valves of, 38–40, 39f, 40t Heart attack. See also Myocardial infarction

atrial fibrillation and, 175 chest pain and, 336 diabetes and, 337 female, 336, 337t sudden cardiac arrest and, 339 symptoms of, 334 treatment, 349–354 Heartbeat average, 44 regulation of, 46 Heart block comparing, 214, 215f complete (CHB), 211–215, 213f, E–2 first degree AV, 204–206, 205f, E–2 second degree AV, Type I (Mobitz I or Wenckebach), 206–208, 207f, 208f, E–2 second degree AV, Type II (Mobitz II), 209–211, 209f, 210f, 211t, E–2 third degree AV (complete heart block or CHB), 212–215, 213f, E–2 Heart block dysrhythmias, 204–216 Heart block rhythms, types and descriptions of, E–2 to E–3 Heart Card monitor, 308f Heart failure, 341–343. See also Congestive heart failure cause of myocardial infarction, 341 congestive, 145, 286 left ventricular, 341–342 right ventricular, 342–343, 343f severe hypotension and, 24 Heart–lung machine, 352 Heart rate average adult, 45 blood volume and, 44 calculating, 75–77 factors affecting, 47 Heart rhythm strip, 109 Heart sounds, “lubb” and “dupp,” 45 “Heartstrings,” chordae tendineae, 39 Heart transplant, LVAD, 353 Hertz (Hz), definition of, 70

High blood pressure, 23 His, bundle of, description/location, 48, 48t Holter, Norman, 304 Holter monitor, 6. See also Ambulatory monitor ambulatory monitoring of ECG using, 6, 6f definition of, 304, 305f patient education, 313–315 Holter monitoring, 307 diary, 307 Hormonal changes, cause of premature ventricular complex, 226 Hospital 12-lead ECG in, 4 isolation precautions for patients in, 19t Hypercalcemia, 47 Hypercoagulopathy, definition of, 353 Hyperkalemia, 47 Hyperpnea, definition of, 22 Hypertension/ high blood pressure categories of, 23 definition of, 23, 286 Hypertrophy, 378 left ventricular (LVH), 280f, 381, 382f

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Hyperventilation definition of, 22, 286 during exercise electrocardiography, 286 Hypocalcemia, 47 Hypokalemia, 47 Hypotension definition and causes of, 24, 153, 187, 342 premature junctional complex and, 187

I ICD-10 code, 105 ICS. See Intercostal space (ICS)

ICU. See Intensive care unit (ICU) Idiopathic hypertension, 23 Idioventricular rhythm, E–3 classic “wide” QRS and, 231 criteria for classification of, 231 definition of, 231 ECG tracing of, 231f signs and symptoms of, 231 Immediate care, ACA/AHA guidelines, 346–348 Implied consent, 14 Impulse, blocked/nonconducted, definition of, 207 Infection control, 16–20 Inferior infarction, 365f Inferior vena cava, 39f, 40, 41f, 333f Informed consent, 14, 283, 285f documentation in medical record, 13t ECG procedure, 13–14 for exercise electrocardiography, 283, 285f handling patient’s refusal to grant consent, 283t Inherent rhythm, definition of, 259 Inhibited (I), 256 Inotropic agents actions of, A–6 diseases treated by, A–6 drugs, A–6 Input, ECG machine, 65 Insertable loop recorder, 310, 310f Institute for Safe Medical Practice (ISMP), C–15 Intensive care unit (ICU), 4 Interatrial septum, 38 Intercostal space (ICS), 38f, 94, 95f Interference, alternating current (AC), 102, 102f Internal mammary artery, use in CABG, 352, 352f Internodal pathways, 47, 49f Interpolated PVC, 226t Interrupted baseline correcting, 100t

definition of, 103 Intervals definition of ECG waveform, 127, 128t on ECG tracing, 131f Interventricular septum, 38, 39f, 41f, 49f Intravenous line (IV), part of immediate cardiac care, 347 Irregular rhythm, 134–135 Irritability (excitability), 46 Ischemia blood clot and, 332 definition of, 129, 153, 369 injury and, 368 myocardial, 369 T wave inversion and, 369 Isoelectric line definition of, 127 ST segment on, 129 Isolation (transmission-based) precautions, 19, B–5 to B–7 airborne precautions, B–6 in ambulatory and home care settings, B–7 application of, B–6, B–7 contact precautions, B–5 discontinuation of, B–6 droplet precautions, B–5 to B–6 for hospitalized patients, 19t IV. See Intravenous line (IV) IV fluid challenge, definition of, 347

J J point definition of, 137, 137f ECG location and, 128f, 129 on ECG, 128f, 131f Jaw pain, 334–335 The Joint Commission (TJC), patient identification and, 89, C–15 Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,

23 Jugular vein, right ventricular failure and bulging of, 343 Junctional dysrhythmias, 184–197 Junctional escape rhythm, E–2 criteria for classification of, 188 definition of, 187 ECG tracing of, 188f signs and symptoms of, 188

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Junctional rhythm, 184–185, 185f, 187, E–2. See also Junctional escape rhythm accelerated, 189–190 types and descriptions of, 184, E–2 Junctional tachycardia criteria for classification of, 191–192 definition of, 191 ECG tracing of, 192f signs and symptoms of, 192

K Kidneys, effect of cardiogenic shock on, 341 Korotkoff sound, 25

L Lateral infarction, 366f Law, definition of, 11 LBBB. See Left bundle branch block (LBBB) LCD (liquid crystal diode) display, 70, 70f Lead I, 60 Lead II, 60 Lead III, 60 Lead selector, 71 Lead wires, 4 for 12-lead ECG, 2f, 58 checking, 59

coded by color and letters, 58, 58f Leads, 58. See also Limb leads anatomically contiguous, 369, 369f augmented, 59t, 60–61 bipolar, 60 chest, 59t, 61–62, 63f definitions of, 58 identification of ECG, 60t limb, 60 precordial, 61 procedure for applying, 98t standard, 59t, 60, 61f unipolar, 60 Left anterior descending artery, 43f, 332, 333f Left atrium, 38, 39f, 41f, 43f, 333f Left bundle branch block (LBBB), E–3 definition of, 372 electrical conduction of, 373f vs. right bundle branch block, 376–377, 376f, 377f Left coronary artery, location and branches of, 332, 333f Left ventricle, 38, 39f, 41f, 43f, 333f, 341 Left ventricular assist device (LVAD) battery-powered device that is surgically implanted, 353 definition of and uses, 353 Left ventricular failure leads to right heart failure, 341 symptoms of, 341–342 Left ventricular hypertrophy (LVH) cause of heart displacement, 378 definition of, 378, 381–382 ECG tracing of, 382f on echocardiography, 280f Levine sign, 335 Liability, medical professional, 12 Libel, definition and examples of, 13 Limb leads, 60. See also Bipolar leads; Standard limb leads Line

anterior axillary, 94, 95f isoelectric, 127, 340f midaxillary, 63f, 94, 95f midclavicular, 38f, 63f, 94, 95f midscapular, 112 paraspinous, 112 posterior axillary, 112 Liver, effect of cardiogenic shock on, 341 Loop-memory monitor advantages of, 307 description of, 307–308 Loss of capture, 263 ECG tracing of, 264t pacemaker complications, 263, 263t Lumen, of artery or vein, 334f Lungs, 42, 43f LVAD. See Left ventricular assist device (LVAD) LVH. See Left ventricular hypertrophy (LVH)

M Machine, 12-lead ECG, 2f Malfunctioning (failure to pace), 263, 263t Malsensing, pacemaker, 263, 263t Manubrium, 95f Marginal artery, 332, 333f Mask/face mask for droplet precautions, 19 personal protective equipment, 16 standard precaution and when to use, 16, 18t, B–1 when to use and rules for using, B–4t Mason-Likar placement technique, during exercise electrocardiography, 288, 288f Mastectomy, placing electrodes on patient with, 109 Maximal exercise, exercise electrocardiography and, 291 MCL. See Modified chest lead (MCL)

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MCOT. See Mobile cardiac outpatient telemetry (MCOT) Mechanical capture, definition of, 257 Medical assistants, working with ECG, 10 Medical abbreviations, acronyms, and symbols, C–1 to C–15 Medical equipment, 18t Medical professional liability, definition of, 12 Medical record, 13. See also Documentation required entries in, 13t Medication. See also Agent; specific category names ambulatory monitoring to evaluate effectiveness of, 314 aspirin, 347 beta blocker, 284, 348, A–3 cardioactive, 279t documentation in medical record, 13 errors involving numbers and doses, C–16 drug-eluting stents (DESs), 350, 352 dual antiplatelet therapy (DAPT), 352 fibrinolytic, 349–350 heart rate and, 47 morphine for immediate cardiac care, 348 nitroglycerin for chest pain, 332, 347 platelet receptor blocker, 352 thrombolytic, 349–350 Medline-Plus, 334 MI. See Myocardial infarction Midaxillary line, 63f, 94, 95f Midclavicular line, 38f, 63f, 94, 95f Midscapular line, 112 Millimeters (mm), definition of, 67 Millivolts (mV), definition of, 68, 74 Misfeasance, definition and examples of, 12 Mitral (bicuspid) valve, 38, 39f, 40f, 41f mm Hg, unit of measurement for blood pressure, 23 Mnemonic device for continuous cardiac monitoring placement of leads, 108 O-P-Q-R-S-T pain assessment, 344, 344f S-A-M-P-L-E patient information, 344–346, 345f

Mobile cardiac outpatient telemetry (MCOT), definition of, 311 Mobitz, Dr. Woldemar, 207 Mobitz I Mobitz II vs., 211, 211t second degree atrioventricular block, 206–208, 207f, 208f Mobitz II, second-degree atrioventricular block, 209–211, 209f, 210f “Modified” Bruce protocol, for stress testing, 290t Modified chest lead (MCL), 108 Monitor ambulatory, 304 Heart Card, 308f Holter, 304, 305f symptom event, 307 Monitoring ambulatory, 304–321, 305f continuous cardiac, 108–109, 108f, 124–125f telemetry, 311–312 Morphine, as part of immediate cardiac care, 348 Morphology, 132 P wave, 132, 135 QRS duration and, 132, 137, 138f Mucous membranes, standard precautions if possible exposure to, 16 Multichannel recorder, ECG machine, 63, 65f Multifocal atrial tachycardia (MAT), 170, E–2 criteria for classification of, 170 ECG tracing of, 170f signs and symptoms of, 170 Multifocal PVC, 226t MUSE Cardiology Information System (GE Healthcare), 66 Myocardial cells, 46 Myocardial infarction (MI). See also Heart attack acute (AMI), 370 atrial fibrillation and, 175 cause of bundle branch block, 376 cause of heart failure, 341 definition of, 2, 370 elevation of ST segment and, 129

during exercise electrocardiography, 284 presenting symptom of STEMI, 339 survival rates improved with AEDs, 8f Myocardial injury, definition of, 370 Myocardial ischemia, 369. See also Ischemia Myocardium, 37, 38t, 39f

N Nails, artificial, 16 Nasal cannula, 347 National Heart, Lung, and Blood Institute (National Institutes of Health), 23 National Institute of Health, 334 National Library of Medicine, 334 Naughton protocol, for stress testing, 290t Nausea, female heart attack symptom, 336, 337t Negative inotropic effect, from hypocalcemia, 47 Neurological definition of, 166 signs of decreased cardiac output, 145t Neuropathy (nerve damage) definition of, 337 from diabetes, 337 Nicotinic acids, A–5 Nitrates (vasodilators) action of, A–7 administering, A–7 diseases treated by, A–7 drugs, A–7 precautions, A–7 Nitroglycerin for chest pain, 332 immediate cardiac care, 347–348 tunica media and, 332 Node

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atrioventricular (AV), 47 sinoatrial (SA), 47 Nonfeasance, definition and examples of, 12 Nonintact skin, standard precautions if possibility of exposure to, 16 Noninvasive procedure, definition of, 276 No Man’s Land, extreme right axis deviation, 379t Non-ST segment elevation MI (NSTEMI) cause of, 339 definition of, 339 “silent” MI, 339 sudden cardiac arrest and, 339 Norepinephrine, 46 Normal sinus rhythm, 144, E–1 criteria for classification of, 144 ECG tracing of, 144f signs and symptoms of, 144 North American Society of Pacing and Electrophysiology, 255 NSTEMI. See Non-ST segment elevation MI (NSTEMI) Nuclear stress test, definition of, 279 Nurses, working with ECG, 10 NW territory, extreme right axis deviation, 379t

O Obtuse marginal artery, 43f, 333f, 365f Occasional PVC, 226t O-P-Q-R-S-T evaluating pain, 344, 344f mnemonic device, 344 Order form, prior to ECG procedure, 88 Outpatient setting, treadmill stress testing in, 5 Output, cardiac, 19, 21, 40, 137, 138t Output display, ECG machine, 66 Oversensing definition of, 263, 263t ECG tracing of pacemaker, 264t Overweight, effect on blood pressure, 23

Oxygen, 42 at liters/min by nasal cannula, 347 Oxygen saturation (SpO2), 277, 346 Oxygenated blood, 37, 41–42, 43f, 43

P P2Y inhibitor, A–3 P wave, 127 affecting by atrial dysrhythmias, 165 analyzing, 135 atrial depolarization and, 132, 135, 165 biphasic or equiphasic, 166 ECG waveform and heart activity, 127, 128t, 128f junctional dysrhythmia and, 185, 185f, 189, 193 morphology, 132 PAC. See Premature atrial complexes (PAC) Pacemakers chamber depolarization characteristics, 257–258 DDDRO, 256 complications, 262–263, 263t–264t demand (synchronous), 255 dual-chamber (D), 255 dual-site atrial pacing, 255 electrical capture, 257 electronic, 253 evaluating ECG tracing from, 258–260 evaluating function of, 257–260 evaluation (Competency Checklist), 273–274 failure to depolarize, 263, 263t failure to pace, 263, 263t fixed-rate (asynchronous), 255 function of, 254–255 implanted, 253, 254f loss of capture, 263, 263f malfunctioning, 263, 263t malsensing, 263, 263t

oversensing, 263, 263t rate-responsive, 255 SA node, 47, 48t transcutaneous, 375 types of, 255–256 undersensing, 263, 264t Pacemaker Codes, Letters I through V, 255–256, 256t Pacemaker competition, definition of, 262 Pacemaker function, 254–255 evaluating, 257–260 Pacemaker rhythms, 253–265 evaluating, 258–260 Pacemaker spikes, ECG and, 70 Pacing, biatrial, 256 Pacing spike, definition of, 257, 258f Pain assessment, vital sign of, 20 Pain scale, 345f Pallor, definition of, 341 Palpitations, definition of, 306 Papillary muscles, 39, 39f Paramedics, 10 Paraspinous line, 112 Parasympathetic nervous system, 47 Parietal pericardium, 37, 38t, 39f Paroxysmal event, 227t Pathogens, gram-negative, 16 Pathologic Q wave definition of, 339, 370 ECG tracing of, 371f ECG tracing of patient with STEMI, 339 Patient care equipment, standard precaution and how to handle, B–1 Patient education, 14 communication and, 13 prior to Holter monitor, 313–315 Patient identification, 91

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Patient data, bar code scanner for, 70f Patient instructions, for ambulatory monitoring, 314, 315f Patient placement, standard precaution and how to do, B–2 Patient resuscitation, standard precaution and how to do, B–2 Pediatric electrodes, 107 Pediatric ECG, 109–110, 110f Percutaneous coronary intervention (PCI), 350 Percutaneous transluminal coronary angioplasty (PTCA), 350 Pericardial space, fluid in, 37, 39f Pericardium, 37, 38t, 39f. See also Parietal pericardium; Visceral pericardium function and purpose of, 37 layers, 37 Personal protective equipment (PPE) definition of, 16, 17f mask, 16 types of, 16, B–4t Physiologic Q wave definition of, 370 ECG tracing of, 371f Picket fence pattern, atrial flutter and, 171 PJC. See Premature junctional complex (PJC) Plaque. See Atherosclerotic plaque Platelet receptor blocker, 352 Polarization, definition of, 126 Portable ECG monitor, 7f Positive inotropic effect, from hypercalcemia, 47 Posterior 12-lead ECG, 112, 112f standard 12-lead ECG vs., 111–113 Posterior axillary line, 112 Posterior descending artery, 43f, 332, 333f Posterior infarction, 367f Posterior interventricular artery, 332, 333f Potassium (K+) channel blockers, A–3 effect on heart rate, 47 P-P wave interval determining atrial rate, 134

measuring, 133, 133f PR interval, 128t, 128f, 129 ECG waveform and heart activity, 127, 128t, 128f definition of, 136 measuring, 136 normal length of, 129 prior to ventricular depolarization, 136 Precautions, isolation, 19 Precordial leads (chest leads), 61 Pregnancy, cause of displacement of heart, 378 Pre-infarction angina, 335 Premature atrial complexes (PAC), E–2 criteria for classification of, 166–167 definition and cause of, 166 ECG tracing of, 166f signs and symptoms of, 167 Premature junctional complex (PJC), E–2 criteria for classification of, 186 definition of, 186 ECG tracing of, 186f signs and symptoms of, 187f Premature ventricular complexes (PVCs), E–3 causes of, 225–226 criteria for classification of, 227–228 definition of, 225–226, 226t ECG tracing of, 225f frequent, 226t signs and symptoms of, 228 types and ECG tracings of, 227t–228t Pre-syncope, 377 Prinzmetal’s angina, 129 Problem-solving process, 15 Professional liability, definition and types of, 12–14 Protocols, common exercise electrocardiography, 289, 290t Pulmonary artery, 39f, 40, 41f, 45f, 333f

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Pulmonary circulation, 41f, 42 Pulmonary edema, definition of, 341 Pulmonary embolism, atrial fibrillation and, 175 Pulmonary semilunar valve, 40, 40f, 40t, 41f Pulmonary trunk, 39f, 43f, 45f, 333f Pulmonary veins, 39f, 41f, 41, 333f Pulse bounding, 21, 347 definition of, 21 rate, 21 measuring pulse and respirations (Competency Checklist), 32–33 normal range for, 20, 20t respiration and, 21–23 vital sign of, 20, 20t, 21f Pulse oximeter, vital signs, 346, 356f Pulse point, of brachial artery, 24, 24f Pulseless ventricular tachycardia, E–3 treated with AED, 8 treated with defibrillator, 7 Purkinje fibers, 48, 48t, 49f pacemaker, 48 U wave and, 129 ventricular pacemaker cells and, 224 Purkinje network, 48, 48t PVC bigeminy and, 226t interpolated, 226t multifocal, 226t occasional, 226t premature ventricular complex, 225–228 trigeminy and, 226t triplet, 227t unifocal, 226t

Q Q wave

ECG waveform and heart activity, 128, 128f pathologic, 339, 370, 371f pathologic and patient with STEMI, 339 physiologic, 370, 371f QRS complex determining rhythm of, 132–134 ECG waveform and heart activity, 127–129, 128t, 128f Mobitz I (Wenckebach) missing, 207, 208f R wave of, 133, 134f ventricular depolarization and, 128–129, 132wide, 137, 231–232 QRS duration, measurement, 137, 138f QS complex, definition of, 376 QT interval ECG waveform and heart activity., 128t, 128f, 129 on ECG tracing, 131f variables affecting, 129, 135 Quadgeminy PVC, 227t

R R-on-T PVC, 227t R to R method (300 method), 76 R wave, 128 calculating heart rate, 76, 129 on ECG waveform and heart activity, 128f, 129 Radial artery, measuring pulse at, 21, 21f Radiologist, 279 Rales (crackles), 22–23 definition of, 341 left ventricular failure and, 341 Rate atrial, 134 of rhythm, 132 ventricular, 134 Rate pressure product (RPP), definition of, 292 RBBB. See Right bundle branch block (RBBB) Recorder, multichannel, 63–65, 65f

Reentry dysrhythmia, types of, 194 Regular rhythm 1500 method, 134 heart rate for, 134 Relaxation phase (diastole), 44 Renal infarction, atrial fibrillation and, 175 Repolarization, definition of, 127 Requisition form, ECG, 88 Respiration counting, 22 definition of, 21, 22 measuring pulse and respirations (Competency Checklist), 32–33 pulse and, 21–23, 21f, 22f tracheal tugging, 347 vital sign of, 20, 20t Respiratory arrest (Code Blue), 113–114 Respiratory hygiene/cough etiquette, standard precautions, B–2 Restenosis, definition of, 350 Retrograde definition of, 184 junctional rhythm and flow of electrical impulses, 184, 185f Rhonchi, 22–23 Rhythm accelerated idioventricular, 232–233, E–3 accelerated junctional, 189–190 agonal, 229–230, E–3 components, 132–138 escape, 187 idioventricular, 231, E–3 junctional escape, 187 normal sinus, 144, 144f pacemaker, 253–265 rate and regularity of, 132–134 sinus, 143 sinus node and origin of, 143

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ventricular escape, 225 Wenckebach, 207 Rhythm strip, 109, 132, 235, 368 Right arm (RA), 60 Right atrium, 38, 39f, 41f, 43f, 254f, 333f Right bundle branch block (RBBB), E–3 definition of, 372 electrical conduction of, 373f vs. LBBB, 376–377 Right coronary artery, location and branches of, 332, 333f, 365f Right leg (RL), 60t, 60 Right ventricle, 35, 37f, 38f, 336f, 337f Right ventricular failure, 342–343 causes of, 343 clinical triad, 343f jugular vein distention in, 343 signs and symptoms of, 343 RPP. See Rate pressure product (RPP) R-R interval, 129 on ECG tracing, 131f R-R wave interval, 133, 133f Run of ventricular tachycardia, 227t

S S wave, on ECG, 128, 128t SA node, sinoatrial, 47, 48t Safety, precautions during exercise electrocardiography, 284–285 Saline lock, part of immediate cardiac care, 347 Salt intake, effect on blood pressure, 23 Salvo, 227t S-A-M-P-L-E patient information tool, 344–346, 345f Saphenous vein graft, for CABG, 352, 352f Sawtooth pattern, atrial flutter, 171, 172 Second-degree atrioventricular (AV) block, 206–211, 207f, 208f, 209f, 210f blocked electrical impulses in, 207f, 210f criteria for classification of, 208, 210–

ECG tracing of, 208f, 209f signs and symptoms of, 208, 211 types of, 206–211 Secondary hypertension, 23 Secretions, use standard precautions if possible exposure to body, 16 Segment, TP, definition of, 131f, 369 Segments, ECG waveform, 127, 128t, 131f Seizure, 114 Semilunar valve, 40. See also Aortic semilunar valve; Pulmonary semilunar valve Septal infarction ECG tracing of, 366f Septum interatrial, 38 interventricular, 38, 39f, 41f, 49f, 185f Serial ECG comparison, 66 Sharps, standard precaution and how to handle, B–2 Shield. See Face shield; Mask Shock cardiogenic, 341 severe hypotension and, 24 “Shockable rhythm,”, 8 Sick sinus syndrome, definition of, 280 Signal processing, ECG machine, 65 “Silent MI”, definition of, 337, 339 Sinoatrial (SA) node description and location of, 47, 48t, 49f rhythms originating from, 143–145 Sinus, coronary, 255, 333f Sinus arrest, E–2 criteria for classification of, 152 definition of, 152 ECG tracing of, 152f signs and symptoms of, 153 Sinus bradycardia, E–1 criteria for classification of, 146–147

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definition of, 71, 146 ECG tracing of, 147f signs and symptoms of, 147 Sinus dysrhythmia (sinus arrhythmia), E–1 criteria for classification of, 150 definition of, 150 ECG tracing of, 150f signs and symptoms of, 151 Sinus exit block, E–2 criteria for classification of, 154–155 definition of, 154 ECG tracing of, 154f signs and symptoms of, 155 Sinus node, rhythm originates from, 143–145 Sinus rhythm definition of, 143 types and descriptions of, E–1 to E–2 Sinus tachycardia, E–1 criteria for classification of, 148 definition of, 71, 148 ECG tracing of, 148f signs and symptoms of, 149 Slander, definition and examples of, 13 Sodium channel blockers, A–3 Soiled linen, standard precaution and how to handle, B–1 Somatic tremor correcting, 100t definition of, 101 ECG tracing of, 101f Sonographer chemical stress echocardiogram and, 281 stress echocardiogram and, 280 Space, intercostal, 38f, 94 Spatial terms, for planes through body, D–2f Speed control, ECG machine, 67 Sphygmomanometer, 24 Spike, pacing, 257, 258f

ST deviation, on 12-lead ECG, 368f ST segment on ECG tracing, 131f ECG waveform and heart activity, 127, 128t, 128f ST segment depression, 368–369 exercise electrocardiography and, 278, 278f signs of myocardial ischemia, 369 ST segment elevation, 371 ST segment elevation MI (STEMI), 339, 342 Standard precautions, 16, B1–B4 Standard leads (bipolar/ limb leads), 60, 61f Standard precautions hand hygiene and wearing gloves, 16 implemented by CDC, 16 key components of, B–1 related to electrocardiography, 18t Stat, definition of, 4 Stat ECG during Code Blue, 113 reporting results, 104 symptoms require, 4 Stationary bicycle, 276 Statins, A–5 STEMI, ST segment elevation MI definition of, 339 ECG tracing changes, 339 sudden cardiac arrest and, 339 Stent definition of coronary artery, 350, 351f drug-eluting (DES), 350 Sternum, 37, 38f, 94, 95f Stethoscope, 22, 22f, 45 Stress cause of premature ventricular complex, 226 effect on blood pressure, 23 heart rate and, 47 vital signs, 20

Stress ECG, cardiac stress testing, 275, 306 Stress echocardiogram, 280 Stress test, 289, 290t Stroke, 175 Stroke volume, 44, 144–145 Submaximal exercise, target heart rate and, 291 Sudden cardiac arrest, definition of, 339 heart attack and, 339 Sulcus (groove), atrioventricular, 332 Superior vena cava, 39f, 40, 41f, 43, 333f Suprasternal notch, 94, 95f Supraventricular, definition of, 193 Supraventricular tachycardia (SVT), E–2 criteria for classification of, 194–195 definition of, 193 ECG tracing of, 194f signs and symptoms of, 195 types of, 193 Surgery, ECG done before, 4 Surgical intensive care unit (SICU), continuous cardiac monitoring in, 4 SVT. See Supraventricular tachycardia (SVT) Sympathetic nervous system, 46 Symptom event monitor, definition of, 307 Syncope (fainting) bundle branch block and, 377 definition of, 153, 306 during exercise electrocardiography, 290 hypotension and, 24 pre-syncope, 377 use of loop-memory monitor with patient, 307 Syndrome acute coronary (ACS), 338 Wolff-Parkinson-White, 194, 195f System cardiovascular system, 36–49

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conduction, 46–49 parasympathetic nervous, 47 sympathetic nervous, 47 Systemic circulation, 41f, 42, 43f Systole. See also Diastole description of, 44–45, 45f dysfunction, 342f Systolic blood pressure, definition of, 23

T T wave ECG tracing of, 370f ECG waveform and heart activity, 128t, 128f, 129 inversion and ischemia, 369, 370f inversion with STEMI, 339 Tachycardia atrioventricular nodal re-entrant (AVNRT), 193–194 atrioventricular reciprocating (AVRT), 193 junctional, 191 sinus, 71, 148, 148f supraventricular (SVT), 193 ventricular, 234, E–3 Tachypnea definition of, 22 report symptom during exercise electrocardiography, 277 Target heart rate (THR) definition of, 291 submaximal exercise and, 291 Technician ECG monitor (telemetry), 10 electrocardiograph (ECG), 10 MOCT and certified monitor, 311 Technologist, cardiovascular, 10 Telemedicine description of, 9 ECG tracing, 9

Telemetry mobile cardiac output telemetry (MCOT), 311 Telemetry monitoring chest hair, 317 definition of, 4, 311 patient diary with, 311 placement of electrodes for, 318f real-time monitoring and, 311 Telemetry unit, hospital, 4 Temperature, vital sign, 20 Test cardiac stress, 275–276 chemical stress, 278 exercise tolerance, 275 exercise treadmill, 275 nuclear stress, 279 tilt table, 24 treadmill stress, 275–277 Third-degree atrioventricular (AV) block (third degree heart block) blocked electrical impulses in, 213f criteria for classification of, 214 definition of, 212–213, 213f ECG tracing of, 213f signs and symptoms of, 214 THR. See Target heart rate (THR) Thrombolytic agent, 349 Thrombus, atrial fibrillation and, 175 Tilt table test, description of, 24 TJC. See The Joint Commission Torsades de pointes, E–3 definition of, 234 ECG tracing of, 235f TP segment, definition of, 131f, 369 Tracheal tugging, on respirations, 347 Transcutaneous pacemaker, 375 Transmission-based precautions, B–5 to B–7 airborne precautions, B–6

in ambulatory and home care settings, B–7 application of, B–6, B–7 contact precautions, B–5 discontinuation of, B–6 droplet precautions, B–5 to B–6 Transmission of microorganisms, reduce risk of, 16 Transtelephonic monitoring, description of, 9 Treadmill exercise, 275–276, 276f incline of, 289

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Treadmill stress test (exercise electrocardiography) cardiac stress testing, 275–277 description and use of, 5, 6f Tricuspid valve, 38, 39f, 40t, 40f Trigeminy definition of, 167 PVC, 226t Triggered (T), 256 Triplet PVCs, 227t Troponin, cardiac enzyme, 347 Troubleshooting AC interference, 103t ECG procedure, 15 techniques during ECG, 99t Trunk, pulmonary, 39f, 43f, 45f, 333f Tunica adventitia, location and function of, 332, 334f Tunica intima, 332, 334f Tunica media, 332, 334f

U U wave ECG waveform and heart activity, 128t, 128f, 129 electrolyte imbalance, 129 repolarization of Purkinje fibers, 129

Ultrasound, 11 Underlying rhythm, definition of, 167, 372 Undersensing, pacemaker, 263, 264t Unifocal PVC, 226t Unipolar leads (augmented leads), 60, 61 Unstable angina (pre-infarction angina) definition of, 335–336 signs of, 336t Unstable vital signs, 21 USB connection, 66

V V lead (precordial lead), 61 V1 lead 12 Views provided by 12-Lead ECG, 59t, 109, 110f lead identification, 58t, 58f lead placement, 96t, 96f standard 12-lead ECG, 364t, 364f V1R lead, 111, 111f V2 lead, 109, 110f 12 Views provided by 12-Lead ECG, 59t lead identification, 58t, 58f lead placement, 96t, 96f standard 12-lead ECG, 364t, 364f V3 lead 12 Views provided by 12-Lead ECG, 59t, 96t for pediatric patients, 107, 108f standard 12-lead ECG, 364t, 364f V3R, pediatric patient placement of lead, 107, 108f V4 lead 12 Views provided by 12-Lead ECG, 59t, 96t lead identification, 58t, 58f lead placement, 96t, 96f standard 12-lead ECG, 364t, 364f V4R lead, 107, 108f V5 lead

12 Views provided by 12-Lead ECG, 59t, 96t lead identification, 58t, 58f lead placement, 96t, 96f standard 12-lead ECG, 364t, 364f V6 lead 12 Views provided by 12-Lead ECG, 59t, 96t lead identification, 58t, 58f lead placement, 96t, 96f standard 12-lead ECG, 364t, 364f V7 lead, posterior 12-lead ECG, 112 V7R lead, posterior 12-lead ECG, 113 V8 lead, posterior 12-lead ECG, 112 V8R lead, posterior 12-lead ECG, 113 V9 lead, posterior 12-lead ECG, 112 V9R lead, posterior 12-lead ECG, 112 Vagal tone, definition of, 150 Valve aortic semilunar, 40, 40t, 40f, 41f, 43f atrioventricular, 38 bicuspid, 38, 39f, 40t, 41f of heart, 38–40, 39f, 40t mitral, 38, 39f, 40f, 41f pulmonary semilunar, 40, 40f, 40t, 41f semilunar, 40 tricuspid, 38, 39f, 40t, 40f in vein, 334f Vasoconstriction effect on blood pressure, 23 Vasodilators, A–7 Vein cardiac, 333f coronary, 43 great cardiac, 43f, 333f layers, 334f middle cardiac, 43f, 333f pulmonary, 39f, 41f, 41, 333f saphenous grafts, 352, 352f

valve in, 334f vena cava, 40, 45f Vena cava (pl. venae cavae), 40, 45f Ventricle, right, 333f Ventricular depolarization PR interval, 136 QRS complex and, 128, 132 Ventricular dysrhythmias, 224–240 Ventricular escape rhythm, 225 Ventricular fibrillation, E–3 AED, 8 coarse and fine, 237 criteria for classification of, 237 definition of, 236–237 ECG tracing of, 237f sign and symptoms of, 237–238 Ventricular pacing, definition of, 254 Ventricular rhythms, types and descriptions of, E–3 Ventricular tachycardia, E–3 criteria for classification of, 235 defibrillator, 7 definition of, 234 difference between torsades de pointes and, 234 ECG tracing of, 234f signs and symptoms of, 235 Visceral pericardium (epicardium), 37, 38t, 39f Vital signs changes in, 20 definition of, 20, 20t measuring pulse and respirations (Competency Checklist), 32–33 types and descriptions of, 21–25 unstable, 21 Vitamin K, 353 Voltage, ECG tracing, 68 Volume expander, definition of, 347

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VVI, ventricle, ventricle inhibited, 256

W Wandering atrial pacemaker (WAP), E–2 criteria for classification of, 168–169 definition of, 168 ECG tracing of, 168f signs and symptoms of, 169 Wandering baseline (baseline shift) causes of, 101–102 correcting, 100t definition of, 101 on ECG tracing, 101f WAP . See Wandering atrial pacemaker (WAP) Wave, delta, 194, 195f Waves, on ECG, 127, 128t, 128f Weight, vital sign, 20 Wenckebach, Dr. Karel, 207 Wenckebach rhythm, 207 Wenckebach second degree heart block, 209 Wolff-Parkinson-White syndrome, E–2 criteria for classification of, 194–195 definition of, 194 delta wave due to, 194 ECG tracing of, 195f signs and symptoms of, 195

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