Electrocardiography is the non-invasive diagnostic test in cardiology recording electrical changes in the heart and helps to the diagnosis and management of patients with cardiac disorders. An electrocardiogram depicts the series of waves that relate to the electrical impulses which occur during each beat of the heart.

1. EDUCATIONAL PROGRAMME
ON
ELECTROCARDIOGRAPHY
INTERPRETATION

2. GUIDE:
DR. PALLAVI PATHANIA
ASSOCIATE PROFESSOR
MEDICAL SURGICAL NURSING
SHIMLA NURSING COLLEGE
PRESENTED BY:
SABNAM KUMARI
M.SC. NURSING 2ND YEAR
MEDICAL SURGICAL NURSING
SHIMLA NURSING COLLEGE
DATED: 04/11/2022:

3. INDEX
S.NO. CONTENT
1. INTRODUCTION OF HEART
2. CONDUCTION SYSTEM OF HEART AND ITS SEQUENCE
3. ELECTROCARDIOGRAM
4. TYPES OF ECG AND TYPES OF ECG MACHINE
5. ELECTROCARDIOGRAPHY, ELECTROCARDIOGRAPHY
INTERPRETATION
6. 12 LEAD ECG AND ITS PLACEMENT
7. NORMAL ECG WAVES AND THEIR DURATION
8. CHARACTERISTICS OF NORMAL ECG
9. ECG PROCEDURE
10. ABNORMAL ECG WAVE CHANGES
11. ECG WAVE CHANGES IN CARDIOVASCULAR DISORDER
12. NURSING RESPONSIBILITIES
13. CONCLUSION
14. SUMMARY
15. BIBLIOGRAPHY

4. INTRODUCTION OF HEART
The heart is an essential pumping organ in the
cardiovascular system where the right heart
pumps deoxygenated blood (returned from
body tissues) to the lungs for gas exchange,
while the left heart pumps oxygenated blood
(returned from the lungs) to tissues cells for
sustaining cellular respiration.

5. LOCATION OF HEART
 The heart is located underneath the
sternum in a thoracic compartment
called the mediastinum, which occupies
the space between the lungs.
 It is approximately the size of a man’s
fist.

6. HEART WALLS
 Epicardium (Protective outer
Layer)
 Myocardium (Muscular
layer)
 Endocardium (Inner Layer)

7. CHAMBERS OF HEART
 Right atrium
 Right ventricle
 Left atrium
 Left ventricle

8. VALVES OF HEART
 Tricuspid Valve
 Mitral Valve
 Pulmonary Valve
 Aortic Valve

9. HORMONES OF HEART
ATRIAL NATRIURETIC PEPTIDE (ANP)
 Atrial natriuretic factor (ANF) also called an atrial natriuretic peptide (ANP),
is a peptide hormone which is secreted by cardiac cells of the body. Heart
cells of atrial walls release this hormone to regulate the blood volume and
arterial blood pressure. The atrial natriuretic factor is a potential vasodilator, it
dilates the blood vessels to reduce the pressure. This hormone is used in
response to the high blood pressure, where cardiac cells secrete the Atrial
natriuretic factor which leads to vasodilatation (dilation of the blood vessels)
and thus, decreases the blood pressure.

10. CONTINUED……………
B-TYPE NATRIURETIC PEPTIDE (BNP)
 B-type natriuretic peptide (BNP) belongs to a family of protein hormones
called natriuretic peptides. These natriuretic peptides have an important
role in regulating the circulation. They act on blood vessels, causing them
to dilate, or widen. They also work on the kidneys, causing them to excrete
more salt and water. In addition, the natriuretic peptides reduce the
production of various hormones that narrow blood vessels, boost the heart
rate, or affect fluid retention; examples include adrenaline,
angiotensin, and aldosterone.

11. CONTINUED…………
C-TYPE NATRIURETIC PEPTIDE (CNP)
 CNP is produced by the endothelium and the heart and appears to
play a prominent role in vascular and cardiac function, both
physiologically and pathologically.

12. ENZYMES OF HEART
Myoglobin
 Myoglobin is released into circulation with any damage to
muscle tissue, including myocardial necrosis. Because skeletal
muscle contains myoglobin, this measurement is quite
nonspecific for MIs. The benefit in myoglobin is that a
detectable increase is seen only 30 minutes after injury occurs,
unlike in troponin and creatine kinase, which can take between
3 and 4 hours.

13. CONTINUED…………..
CREATINE PHOSPHOKINASE
 Creatine kinase ― also known as creatine phosphokinase, or
CPK ― is a muscle enzyme. The CK level increases
approximately 3 to 4 hours after MI and remains elevated for 3
to 4 days.

14. CONTINUED………………..
Creatine kinase-MB (CK-MB)
 It is a form of an enzyme found primarily in heart muscle cells.CK-MB is
one of three forms (isoenzymes) of the enzyme creatine kinase (CK). These
isoenzymes include:
 CK-MM (found in skeletal muscles and the heart)
 CK-MB (found mostly in the heart, but small amounts found in skeletal
muscles).
 CK-BB (found mostly in the brain and smooth muscle, such as the
intestines and uterus)

15. CONTINUED…………….
Troponin
 The enzymes troponin I and troponin T are normal proteins
that are important in the contractile apparatus of the cardiac
myocyte. The proteins are released into the circulation
between 3 and 4 hours after myocardial infarction and remain
detectable for 10 days.

16. CONDUCTION SYSTEM OF HEART
 The conducting system of the heart consists of
cardiac muscle cells and conducting fibres (not
nervous tissue) that are specialized for initiating
impulses and conducting them rapidly through
the heart.
 Both atria contract together, as do the ventricles,
but atrial contraction occurs first.

17. CONTINUED………
 The conducting system provides the heart its
automatic rhythmic beat.
 SA NODE generates: 60-100 beats per min
 AV NODE generates: 40-60 beats/min

18. PROCESS OF CONDUCTION IN HEART
 An excitation signal (an action potential or depolarization
stimulus) is created by the sinoatrial (SA) node (natural
pacemaker of heart).
 The wave of excitation spreads across the atria, causing
them to contract.
 Upon reaching the atrioventricular (AV) node also
called gatekeeper, the signal is delayed.

19. CONTINUED……………
 It is then conducted into the bundle of
His, down the interventricular septum.
 The bundle of His and the Purkinje
fibres spread the wave impulses along
the ventricles, causing them to contract.

21. ELECTROCARDIOGRAM
 An electrocardiogram (ECG or EKG)
records the electrical signal from the heart
to check for different heart conditions.
Electrodes are placed on the chest to record
the heart's electrical signals, which cause
the heart to beat. The signals are shown as
waves on an attached computer monitor or
printer

22. TYPES OF ECG
 Resting ECG

23. CONTINUED……..
 Holter monitoring

24. CONTINUED……………
 Exercise stress test

25. TYPES OF ECG MACHINES
12 LEAD ECG MACHINE

26. 3 LEAD ECG MACHINE

27. HOLTER MONITORING ECG MACHINE WIRELESS ECG MACHINE

28. WHY IT IS DONE???
To determine
 Irregular heart rhythms
 Blockage or narrowing in arteries in the
heart
 Having history of heart attack
 How well certain heart disease treatments,
such as pacemaker, ae working.

29. WHEN IT IS DONE???
 Anxiety
 Chest pain
 Palpitations
 Tachycardia
 Shortness of breath or dizziness
 For investigation purpose

30. ELECTROCARDIOGRAPHY
Electrocardiography (ECG) is a quick, simple,
painless procedure in which the heart’s electrical
impulses are amplified and recorded. This record,
the electrocardiogram (also known as an ECG),
provides information about the:
 Part of the heart that triggers each heartbeat (the
pacemaker, called the sinoatrial or sinus node)
 Nerve conduction pathways of the heart
 Rate and rhythm of the heart

31. FACTS
The first EKG machine weighed 600 pounds.
In 1947, the first Holter Monitor was like an 80-
pound backpack.
The first electrocardiogram (ECG) from the intact
human heart was recorded with a mercury capillary
electrometer by Augustus Waller in May 1887 at St.
Mary's Hospital, London.

32. CONTINUED………….
ECG first developed by WILLIAM
EINTHOVEN in 1902.
The First ECG Machine in India that was brought
from the United State of America by Dr.
Shreenivas.
First ever electrocardiography (ECG) machine
was used in K.E.M. Hospital, Mumbai in the
late 40 ' s.

33. ELECTROCARDIOGRAPHY
INTERPRETATION
 ECG interpretation includes an assessment of the morphology
(appearance) of the waves and intervals on ECG curve. Therefore, ECG
interpretation requires a structured assessment of the waves and intervals.

34. 12 LEAD ECG PLACEMENT

35. 12 LEAD ECG
 A 12-lead Electrocardiogram (ECG) is a medical test that is
recorded using leads, or nodes, attached to the body.

36. CONTINUED………………
 The 12 lead ECG displays, as the
name implies, 12 leads which are
derived by means of 10 electrodes.
Three of these leads are easy to
understand, since they are simply the
result of comparing electrical
potentials recorded by two
electrodes; one electrode is exploring
electrode.in the remaining 9 leads the
exploring electrodes is still just one
electrode but the reference is
obtained by combining two or three
electrodes.

37. CONTINUED…………
Bipolar limb leads (frontal plane):
 Lead I: RA (-) to LA (+) (Right Left, or
lateral)
 Lead II: RA (-) to LL (+) (Superior
Inferior)
 Lead III: LA (-) to LL (+) (Superior
Inferior)

38. CONTINUED………………
Augmented unipolar limb leads (frontal
plane):
 Lead aVR: RA (+) to [LA & LL] (-)
(Rightward)
 Lead aVL: LA (+) to [RA & LL] (-)
(Leftward)
 Lead aVF: LL (+) to [RA & LA] (-)
(Inferior)

39. CONTINUED……….
Unipolar (+) chest leads or precordial leads
(horizontal plane):
 Leads V1, V2, V3: (Posterior Anterior)
 Leads V4, V5, V6:(Right Left, or lateral)

41. ECG RECORD SHEET
 ECG record sheet shows graphic record of the direction and magnitude of
the electrical activity generated by the depolarization and repolarization of the
atria and ventricles of the heart.
 Normal speed of ECG paper is 25 mm/sec.

43. NORMAL DUARTION OF ECG RECORD SHEET
SQUARES
 The standard paper speed is 25 mm/sec
 1 small square (1mm) = 0.04 sec (40ms)
 5 small squares (5mm) = 1 large square = 0.2
sec (200 ms).
 5 large squares = 1 second
 250 small squares = 50 large squares = 10 sec
 1500 small squares = 300 large squares =
1min

45. NORMAL ECG WAVES
PQRST is the normal ECG Wave pattern.
 P wave indicated atrial depolarization or
contraction of atrium
 QRS complex indicates ventricular
depolarization, contraction of the ventricles. QRS
interval start at the end of the PR interval (or
beginning of the Q wave) to the end of the S
wave.

46. CONTINUED…..
 T wave indicates ventricular repolarization.
The interval from the beginning of the QRS
complex to the apex of the T wave is referred
to as the absolute refractory period.
 QRS complex to the apex of the T wave is
referred to as the absolute refractory period.

47. CONTINUED………
 ST segment indicates ventricular repolarization. ST
interval, is the time between the end of the QRS
complex and the start of T wave.
 PR interval indicates AV conduction time. The PR
interval is the time between the first deflection of the P
wave and the first deflection of the QRS complex. QT
interval indicates ventricular depolarization or
repolarization.

48. NORMAL DURATION OF ECG WAVES
 P wave = 0.08- 0.10 sec
 P-R interval = 0.12 - 0.20 sec (3 - 5
small squares)
 QRS width = 0.08 - 0.12 sec (2 - 3
small squares)
 Q-T interval = 0.35 - 0.43 sec

49. HEART RATE CLACULATION
FORMULA BY SQUARE METHOD
FOR REGULAR RHYTMS
 SMALL SQUARE METHOD = 1500/No. of
small squares in between R-R interval
 LARGE SQUARE METHOD = 300/ No. of large
squares in between R-R interval

51. CONTINUED…………
FOR IRREGULAR RHYTHMS (R Wave method)
• Rate = Number of R waves (rhythm strip) X 6
• The number of complexes (count R waves) on the rhythm strip gives
the average rate over a ten-second period. This is multiplied by 6 (10
seconds x 6 = 1 minute) to give the average beats per minute (bpm).

52. CHARACTERISTICS OF NORMAL ECG
 STANDARIZATION
 RATE
 RHYTHM
 P Wave
 PR Wave
 QRS Wave
 QT Wave

53. INTERPRETATION OF HEART RATE IN ADULTS
 Normal = 60-100 beats/min
 Abnormal = >100 bpm
 Bradycardia = < 50 bpm

54. NORMAL HEART RATES IN CHILDREN
 NEWBORN:110-150 bpm
 2 YEARS: 85-125 bpm
 4 YEARS: 75-115 bpm
 6 YEARS: 60-100 bpm

55. PROCEDURE OF ECG
BEFORE PROCEDURE
 Take a verbal permission from the patient for
ECG and give instructions related to ECG.
 Place patient in supine position.
 With arms lying flat on the side, ask the patient to
relax the shoulders and keep the legs uncrossed.
 Skin should be dry, hairless, and oil-free. Shave
hair that can possibly impede electrode
placement.

56. CONTINUED……….
 DURING PROCEDURE
 Electrodes should have full contact with the
patient's skin.
 For better electrode adhesion and oil-free skin,
rub the area with an alcohol prep pad or gauze
paid with benzoin tincture.
 Promote an environment that prevents the patient
from sweating profusely.
 Make sure the electrode conducting gel is fresh
and adequately moist. A dry electrode with
inadequate gel reduces the conduction of the
ECG signal.

57. CONTINUED…………
 Often, electrode gel dry-out is a result of incorrect
storage. Store electrodes as instructed by manufacturer
and do not remove from their pouch until they're ready
for use.
 Do not place electrodes on skin over bones, incisions,
irritated skin, and body parts where there is lots of
possible muscle movement.

58. CONTINUED……..
 Use electrodes of the same brand. Using
different brands with dissimilar composition can
hinder an accurate ECG trace.
 Obtain an ECG-on-ECG record sheet.
AFTER PROCEDURE
 Remove the electrodes and clean the patient
body.
 Record the important findings.

59. ABNORMAL ECG
 An abnormal EKG can mean many things. Sometimes an EKG
abnormality is a normal variation of a heart’s rhythm, which does not
affect your health. Other times, an abnormal EKG can signal a medical
emergency, such as a myocardial infarction (heart attack) or a
dangerous arrhythmia.

60. CAUSES
 Myocardial infarction
 Cardiac arrest
 Coronary artery disease
 Cardiomyopathies
 Atrial or mitral valve stenosis
 Cardiac tamponade
 Bundle branch block
 Heart block
 Heart failure

61. WHAT AN ABNORMAL EKG INDICATES??
 Defects or abnormalities in the heart’s shape and size:
 Electrolyte imbalances
 Heart attack or ischemia
 Heart rate abnormalities
 Heart rhythm abnormalities:
 Medication side effects: include beta-blockers, sodium
channel blockers, and calcium channel blockers.

62. ARRHYTHMIAS
 An arrhythmia (also called
dysrhythmia) is an irregular or
abnormal heartbeat.
 Arrhythmia describes a group of
conditions that affect the heart’s natural
rhythm. Different types of arrhythmias
cause the heart to beat too fast, too
slowly, or in an irregular pattern.

63. TYPES OF ARRHYTHMIAS
Supraventricular arrhythmias
 Premature atrial contractions.
 Atrial fibrillation
 Atrial flutter
 Paroxysmal supraventricular tachycardia
 Ventricular arrhythmias include:
 Premature ventricular contractions
 Ventricular tachycardia
 Ventricular fibrillation

64. ECG WAVE CHANGES

65. ECG WAVE CHANGES IN CARDIOVASCULAR
DISORDERS
MYOCARDIAL INFARCTION

67. CARDIAC TEMPONADE

68. HEART FAILURE

69. ABNORMAL CHANGES IN ECG WAVES
 P wave changes: If the p-wave is
enlarged, the atria are enlarged. If
the P wave is inverted, it is most likely
an ectopic atrial rhythm not originating
from the sinus node. Altered P wave
morphology is seen in left or
right atrial enlargement.

70. CONTINUED……….
 QRS Complex: A QRS duration of greater than 0.12
seconds is considered abnormal.
 Causes of a widened QRS complex include right or left
bundle branch block, pacemaker, Hyperkalemia,
hypermagnesemia, ventricular preexcitation as is seen in Wolf-
Parkinson-White pattern
 Ventricular arrhythmias (VENTICULAR
FIBRILLATION)are characterized by IRREGULAR QRS
complexes that are not preceded by P waves.

71. CONTINUED………..
PR INTERVAL: Alterations in the PR interval may be
physiologic or may represent abnormal progression of
electrical conduction from the atria to the ventricles
through the AV node.
 Prolongation (PR interval >= 0.2 s) indicates
Hyperkalemia, hypermagnesemia or 1st degree Heart
Block or shortening of (PR interval <= 0.12s) indicates
Wolff Parkinson White Syndrome (WPW).

72. CONTINUED……..
ST SEGMENT:
 The ST Segment represents the interval between
ventricular depolarization and repolarization.
 ST segment elevation indicates myocardial
infarction or ST SEGMENT depression indicates
ischemia, Hypokalemia or hypomagnesemia.
 Shortened ST segment indicates hypercalcemia.

73. CONTINUED…........
T WAVE
 T wave inversion: Myocardial ischemia and
infarction, Hypokalemia
 Tall T wave: Hyperkalemia, hypomagnesemia
 Widened T wave: Hypercalcemia
QT INTERVAL:
• Prolonged QT: hypocalcaemia, Hypokalemia,
hypomagnesemia

75. CONTINUED……………
U wave – U wave is a small (0.5mm), rounded deflection
sometimes seen after the T wave. Best seen in leads V2 and
V3. It reflect the late repolarization process of His-Purkinje
cells and certain left ventricular myocytes.
ABNORMALITIES OF THE U WAVES
 Prominent U wave: Bradycardia, severe hypokalaemia,
hypocalcaemia, hypomagnesemia, left ventricular
hypertrophy.

77. HYPOMAGNESEMIA

78. CONTINUED…………
 Inverted U wave: Coronary artery disease,
hypertension, valvular heart disease, congenital heart
disease, cardiomyopathy, hyperthyroidism.
 In patients presenting with chest pain, inverted U
waves:
 Are a very specific sign of myocardial ischemia.
 May be the earliest marker of unstable angina and
evolving myocardial infarction.

80. NURSING RESPONSIBILITIES
 Verify the Physician order.
 Take verbal consent with instruction.
 Identify the patient according to hospital policy.

81. CONTINUED………..
 Provide privacy and explain the procedure to the
client. Explain that the test records the heart's
electrical activity and that it may be repeated at
certain intervals. Emphasize that no electrical
current will enter the body. Tell the client that the
test typically takes about 5 minutes.

82. CONTINUED………..
 Advice the client lie supine position in the centre of
the bed with arms at his sides.
 If the client has an amputated limb, choose a site on
the stump.
If an area is excessively hairy, clip it.
 Clean excess oil or other substances from the skin
with alcohol pad to enhance electrode contact.

83. CONTINUED………….
 Label ECG recording with-Patient’s
name, Medical record no, Date, Time,
Signature.
 Document the procedure in Nurses notes.

84. CONCLUSION
 An electrocardiogram (ECG or EKG) records the electrical signal
from the heart to check for different heart conditions. Electrodes
are placed on the chest to record the heart's electrical signals, which
cause the heart to beat. The signals are shown as waves on an attached
computer monitor or printer.

85. CONTINUED……………….
I recently conducted a research study on the topic:
 A study to assess the effectiveness of an informational booklet on
knowledge regarding electrocardiography interpretation among nursing
officers working in selected areas of Indira Gandhi Medical College and
Hospital, Shimla, Himachal Pradesh, 2020-2022.”
 Result: The findings of the study revealed that mean post-test knowledge
score 40.6 was significantly higher than the mean pre-test knowledge
score 28.3 as evident by paired t-test 24.583 ( p value- < 0.001*) at 0.05
level of significance among nursing officers. It showed that the
informational booklet was effective in increasing knowledge of the
nursing officers.

86. CONTINUED
 This states that even the staff working in hospital setting needs to get
knowledge related to electrocardiography interpretation.
 As per my 2 years experience of conducting study on electrocardiography
interpretation I felt that the nursing personnel including students and nursing
officers must have appropriate knowledge regarding electrocardiography
interpretation.
 Nursing personnel's are the one who are responsible for performing ECG in
hospitals. Therefore, if the nursing officers or students will have adequate
knowledge about electrocardiography interpretation, they improve the
quality of care as well as quality of life in patients.
 So we are providing this educational programme to clear some basic
concepts of the students regarding electrocardiography as they are going to
work in hospitals in future. It will help in early identification of various heart
problems and saving life of the patient.

87. SUMMARY
Today we had discussed about: OF HEART
Introduction Of Heart
Conduction System Of Heart And Its Sequence
Electrocardiogram
Types Of ECG
Electrocardiography, Electrocardiography Interpretation
12 Lead ECG And Its Placement
Normal ECG Waves And Their Duration
Characteristics Of Normal ECG
ECG Procedure
Abnormal ECG Wave Changes
ECG Wave Changes In Cardiovascular Disorder
Nursing Responsibilities
Conclusion

88. ASSIGNMENT
 Make an booklet on ECG.

89. BIBLIOGRAPHY
 https://www.mayoclinic.org/tests-procedures/ekg/about/pac-
20384983#:~:text=An%20electrocardiogram%20(ECG%20or%20EKG,
attached%20computer%20monitor%20or%20printer.
 https://en.wikipedia.org/wiki/Electrocardiography
 https://www.nhs.uk/conditions/electrocardiogram/
 https://www.hopkinsmedicine.org/health/treatment-tests-and-
therapies/electrocardiogram
 https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-
attack/electrocardiogram-ecg-or-ekg