Contents Page Page Abstract 1 Section 1– Correct lead placement 2 Section 2 – Incorrect lead placement5 Section 3 – Conclusion and recommendations7 References Appendices Abstract Recording an electrocardiogram or ECG, is a procedure which is performed daily all over the United Kingdom by thousands of healthcare workers and in particular nurses (Jacobson, 2000). The way in which this procedure is performed varies from geographical location to location and occasionally even more so, between staff on the same ward (Amos, 2000).
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This reason stated by Amos (2000), formed the basis of my decision to choose this topic. The recording of an ECG is often seen as a fairly mundane, routine observation as it is non-invasive and does not physically demanding for the patient or member of staff (Cowley, 2002). However, should the leads be placed incorrectly on the patient, they may well end up with inappropriate treatment for their condition. An extensive search of the both written and electronically stored literature showed very little previous research addressing the issues of ECG performance by nurses in general wards.
The key findings as a result of this essay showed that lead placement is fundamental knowledge for all those performing ECG’s, regardless of their ability to interpret ECG’s. Section One – Introduction and correct lead placement. For this assignment I have chosen the topic on Electrocardiograph or ECG lead placement. The purpose of this essay was to discover, based on the best and most recent evidence, whether ward nurses can adequately perform twelve lead ECG’s.
In this section, a brief introduction to the problem shall be discussed along with the first aim of highlighting how the correct knowledge in lead placement is essential for all those performing ECG’s. Section Two highlights how incorrect lead placement can have an effect on patient management and Section Three offers a conclusion and recommendations for practice. The importance of this subject to nursing is that according to Brannigan (1984), the use of continued cardiac monitoring in general ward areas is only useful if the nurse is able to detect abnormal changes of cardiac rhythm.
Many of the nurses who administer the care of these patients are unable to decipher what the monitor is showing, as reported by Cowley (2002). This is where ECG’s is more useful as it is seen as a routine observation, as it is non-invasive and is not physically demanding for the patient or member of staff (Cowley, 2002). Cowley (2002) suggests that the attachment of ECG electrodes and wires, any delays or perceived inability to interpret ECG’s competently may increase patient anxiety levels. Emphasis on the seriousness of the problem is evident due to the need for patient attachment to such a technical device.
Furthermore, excess levels of circulating catecholamines released during anxiety may prove detrimental to patients with existing cardiac disease (Jacobson (2000). Prior to commencing the ECG, the nurse must introduce them self to the patient and gain consent as guided by the Nursing and Midwifery Council, (2002). According to Jacobson (2000) it is also helpful at this point to check the wristband and ask the patient for their name to rule out the possibility of having stumbled upon the wrong bed as many people will happily respond to someone else’s name and have someone else’s test preformed rather than point out mistakes.
Jacobson (2000) also states that it is imperative that the patient is put at ease, suggesting that this is not only is it good practice, but it will improve the quality of trace obtained. Dougherty and Mallet (2000) describe how the procedure should be performed in the following steps; • Explain exactly what you are about to do with the patient’s consent. • Point out that having an ECG is a completely painless procedure. • Tell the patient a little about what an ECG does. Dougherty and Mallet, (2000) describe how the physical preparation means that the patient must be striped to the waist to expose the chest.
The patient’s ankles also need to be exposed at this point. In addition it is suggested that Nurses need also to remember to keep the patient’s lower half covered as much as possible and treat the patient with the utmost respect at all times (Dougherty and Mallet, 2000). If using a machine equipped with metallic stickers, it is important that the nurse wipes the patient’s skin with an alcoholic swab before applying, to ensure good electrical contact is made as this according to Ford (2002) will save time in the long run.
If the machine is supplied with the suction cups, then electrode spray must be applied to the areas of skin and where electrodes will be placed. Men with very hairy chests may require a gel based electrodes for adhesion, or in extreme cases, shaving may be needed. Lewes (1965) publish an paper stating that ketchup, mayonnaise and K-Y jelly all were as good as hospital adhesion gels, based on performance, however as Cowley (2002) points out, it is considered somewhat strange and not seen as best practice to cover your patient in ketchup or mayonnaise prior to recording an ECG.
Finally, ensure that the patient is supine on a bed, comfortable and relaxed. Cowley (2002) describes how accurate chest lead placement is essential for ensuring quality ECG output, as any misplaced leads may result in a change in ECG waveform, in turn this may cause the ECG trace to be misinterpreted. The full pictorial description of lead placement can be seen in Appendix One. Kors, Meij, Nelwan, and Van Dam (2001) state that the technological advances, by which the results are printed on top of the ECG, now mean that the nurse has even less to learn.
However, Cowley (2002) suggests that although this may eliminate problems of interpretation and encourage prompt review of ECG’s, the basics of lead placement remain essential knowledge. Section Two – Incorrect lead placement According to Cowley (2002) the analysis of the twelve lead ECG is all about measurements, the height and depth of waves which are important in the diagnosis of certain conditions such as myocardial infarction or hypertrophy. Lead placement is especially important if the extent of these onditions is to be determined and treated appropriately (Jacobson, 2000). The following changes in the twelve lead ECG have been shown to occur when the electrodes are placed incorrectly on the torso; • A shift in the cardiac axis towards the right, which has clinical significance in that, patients may be seen to have ventricular hypertrophy and subsequent incorrect medical and nursing management. • R wave becomes smaller in lead I, which could result in the missed diagnosis of ventricular hypertrophy and subsequent incorrect management. Less prominent Q waves in inferior leads, which would result in the mis-diagnosis of an established myocardial infarction and subsequent incorrect medical and nursing management. Crow, Park and Rautaharju (1998) point out that breast tissue appears to have a practically negligible effect on ECG amplitudes, and in women, the placement of chest electrodes on the breast rather than under the breast is recommended in order to facilitate the precision of electrode placement at the correct horizontal level and at the correct lateral positions.
However, Cowley (2002), argues that when nurses are working with female patients, the ECG electrodes should never placed on top of the breast unless access cannot be gained to the normal position and if this is required then it should be written on the actual recording. Based upon the literature found, this situation appears to be pertinent with the performance of twelve lead ECG’s in all general ward areas researched, as the issue of breast tissue is one which according to Amos (2002), is an area where the most common inconsistency occurs in the actual recording of an ECG.
Amos (2002) argues that the extended role of the nurse in ECG recording implies better care given to the patients. As reported by Jacobson (2000), in practice this is not so, as the overall effect on the patient, and to a lesser extent on the nurse, may be detrimental. This will occur as a result of the nurse becoming complacent in care delivery which will ultimately affect the patient. Section Three – Conclusion and recommendations for practice
In concluding this assignment, my aims initially, were to describe how lead placement is fundamental knowledge for all those performing ECG’s. In the appendices and sub-sections I believe that I have showed the correct method for lead placement and the potential effects of incorrect lead placement. Based upon the research reviewed for this assignment, I can only conclude that there appears to be a large theory-practice gap in the way in which the ECG is understood and the way in which it is performed.
This however would have to be fully supported by a thorough evaluation covering many different clinical environments and practices. The recommendations for practice, based upon this assignment would therefore be that in-house training is performed on a regular basis in order to retain skill levels amongst staff that perform ECG’s. The reason for this is that even with technological advances, providing electronic ECG interpretation; nurses must maintain a responsibility for understanding the significance of changes in the patient’s condition and respond appropriately.
Another recommendation would be that all nurses that perform ECG’s have a comprehensive knowledge of ECG’s, which ultimately contributes to the nurse’s confidence in recognising and managing effectively the intricacies of patient care. References Amos, L. (2000). Testing nurses knowledge of 12 lead ECG’s. Retrieved September 20, 2003: http://www. clininfo. health. nsw. gov. au/hospolic/stvincents/contents. html Brannigan, D. (1984), Cardiac Monitors – friends or foe? Nursing Times, 1, (3), 25-26. Cowley, M. (2002). A practical guide to ECG monitoring and recording. Retrieved September 20, 2003: http://www. ikecowley. co. uk/leads. htm. Crow, R. , Park, L. , & Rautaharju P. M. (1998). A standardized procedure for locating and documenting ECG chest electrode positions: consideration of the effect of breast tissue on ECG amplitudes in women. Journal of Electrocardiology: 31, (1):17-29. Dougherty, L. & Mallett, J. (2000). Royal Marsden Manual of Clinical Nursing Procedures. 5th edn. 406-407. Ford, S. (2002). Common errors in clinical measurement. Anaesthesia and Intensive Care Medicine, 34, 2. 466-467. Jacobson. P. (2000). Electrocardiography: a basic introduction. Retrieved September 20, 2003: http://www. abdn. ac. k/~u10rjl/page3. htm#interpret. Kors. J. A. , Meij, S. H,. Nelwan, S. P. & van Dam, T. B. (2001). Correction of ECG variations caused by lead placement. Journal of Electrocardiology 34, (4), 213-216. Lewes, P. (1965). Electrode choice for Electrocardiogram readings. British Heart Journal. , 4, (12), 610-615. Nursing and Midwifery Council. (2002). Code of Professional Conduct, retrieved September 20, 2003; http://www. nmc-uk. org/cms/content/Publications/Code%20of%20professional%20 conduct. pdf Appendices Appendix One – Chest and Limb Lead Placement. Appendix One – Chest Lead Placement Reproduced from Hampton, J.
R. (1998). The ECG Made Easy. 5th edn. Churchill Livingstone, Edinburgh. [pic] The six standard chest lead positions are as follows; 1. V1 – Fourth intercostal space, right sternal edge 2. V2 – Fourth intercostal space, left sternal edge 3. V4 – (place the fourth electrode before the third) Fifth intercostal space in the mid-clavicular line 4. V3 – Midway between V2 and V4. 5. V5 – Level with V4, left anterior axillary line. 6. V6 – Level with V4, left mid axillary line. The standard four limb lead positions are as follows; [pic] Electrode/ lead placements are denoted by dots on Figures above