How to perform ECG?

Anita Wyrzykowska MSN, RN

Anita Wyrzykowska MSN, RN 1

Definition
Electrocardiography provides a graphic recording of the heart’s electrical activity.
Electrodes placed on the skin transmit the electrical impulses to an oscilloscope or
graphic recorder.
With the waveforms recorded, the electrocardiogram (ECG) can then be examined to
detect dysrhythmias and alterations in conduction indicative of myocardial damage,
enlargement of the heart, or drug effects.

British Journal of Nursing:

https://www.britishjournalofnursing.com/content/clinical/recording-a-12-lead-electrocardiog
ram-ecg/

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What to expect of the ECG?
The ECG has its limitations. Remember that it provides a picture of the electrical activity of the heart, but
gives only an indirect indication of the heart’s structure and function. It is, however, invaluable or
assessing patients whose symptoms may be due to electrical malfunction in the heart, especially
patients with conduction problems and those with arrhythmias.

In healthy people, finding an apparently normal ECG may be reassuring. Unfortunately, the ECG can be
totally normal in patients with severe coronary disease. Conversely, the range of normality is such that a
healthy subject may quite wrongly be labelled as having heart disease on the basis of the ECG. Some
ECG patterns that are undoubtedly abnormal (e.g. right bundle branch block) are seen in perfectly
healthy people. It is a good working principle that it is the individual’s clinical state that matters, not the
ECG. When a patient complains of palpitations or syncope,the diagnosis of a cardiac cause is only
certain i an ECG is recorded at the time of symptoms – but even when the patient is symptom-free, the
ECG may provide a clue or the prepared mind. In patients with chest pain the ECG may indicate the
diagnosis, and treatment can be based upon it, but it is essential to remember that the ECG may remain
normal or a few hours after the onset of a myocardial infarction. In breathless patients a totally normal
ECG probably rules out heart failure, but it is not a good way of diagnosing lung disease or pulmonary
embolism. Finally it must be remembered that the ECG can be quite abnormal in a patient with a variety
of non-cardiac conditions, and one must not jump to the conclusion that an abnormal ECG indicates
cardiac pathology.

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 Accurate lead position
● ECG findings should always be interpreted in the
clinical context in which it was taken.

● Accurate lead position is key as misplaced leads

change the appearances of the trace and may
lead to misinterpretation.

● For example, limb lead switches can resemble

abnormalities of the cardiac axis.

● Incorrect placement can lead to inaccurate signal

patterns and strengths. Proper lead placement
ensures that the electrocardiogram captures a
true representation of the heart's rhythm and is
essential for accurate diagnosis and treatment
planning.

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Indications
● As part of a treatment pathway
● As part of a routine health check
● Changes to heart rate or rhythm
● Preoperative and postoperative assessment
● Chest pain (recorded during and after)
● Upper abdominal pain
● Symptoms associated with breathing
● Blood pressure abnormalities
● Suspected acute coronary syndrome
● Suspected heart failure
● During a peri-arrest period or after successful cardiopulmonary resuscitation
● History of dizziness
● Collapse or history of falls
● Palpitations

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 12-lead ECG
A 12-lead ECG paints a complete
picture of the heart’s electrical activity
by recording information through 12
different perspectives. Think of it as
12 different points of view of an object
woven together to create a cohesive
story — the ECG interpretation.

https://www.youtube.com/watch?v=RY
Z4daFwMa8 Cardiac Conduction
System

Anita Wyrzykowska MSN, RN 6

The 12 Lead Groups
● A lead is a glimpse of the electrical
activity of the heart from a
particular angle.

Put simply, a lead is like a

perspective. In 12-lead ECG, there
are 10 electrodes providing 12
perspectives of the heart’s activity
using different angles through two
electrical planes — vertical and
horizontal planes.

Anita Wyrzykowska MSN, RN 7

Einthoven’s Triangle
● The Einthoven’s triangle explains why there are 6
frontal leads when there are just 4 limb electrodes.
● The principle behind Einthoven’s triangle describes
how electrodes RA, LA and LL do not only record the
electrical activity of the heart in relation to
themselves through the aVR, aVL and aVF leads.
They also correspond with each other to form leads
I (RA to LA), II (RA to LL) and III (LL to LA).
● As a result, they form an equilateral triangle. Hence
it’s called the Einthoven’s triangle, named
after Willem Einthoven who invented the first
practical ECG.
● Keep in mind that RL is neutral (also known as point
zero where the electrical current is measured). RL
doesn’t come up in ECG readings, and is considered
as a grounding lead that helps minimize ECG
artifact.

Anita Wyrzykowska MSN, RN 8

Electrodes
● These 12 views are collected by placing electrodes
on the chest (precordial), wrists, and ankles.
● To measure the heart’s electrical activity
accurately, proper electrode placement is crucial.
● In a 12-lead ECG, there are 12 leads calculated
using 10 electrodes.

Anita Wyrzykowska MSN, RN 9

 Chest (Precordial) Electrodes and
Placement

» V1 - Fourth intercostal space at the right border of the

sternum
» V2 - Fourth intercostal space at the left border of the
sternum
» V3 - Midway between placement of V2 and V4
» V4 - Fifth intercostal space at the midclavicular line
» V5 - Anterior axillary line
(on the same horizontal level as V4)
» V6 - Mid-axillary line
(on the same horizontal level as V4 and V5)

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 Limb (Extremity) Electrodes and Placement

» RA (Right Arm) - Anywhere between the right

shoulder and right elbow

» RL (Right Leg) - Anywhere below the right torso

and above the right ankle

» LA(Left Arm) - Anywhere between the left

shoulder and the left elbow

» LL (Left Leg) - Anywhere below the left torso and

above the left ankle

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The “normal” ECG
Sinus rhythm is the only normal sustained rhythm.

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A normal ECG contains waves, intervals, segments and complex.
★ Wave: A positive or
negative deflection from
baseline that indicates a
specific electrical event.
The waves on an ECG
include the P wave, Q
wave, R wave, S wave, T
wave and U wave.

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Interval
★ Interval: The time between two
specific ECG events. The
intervals commonly measured
on an ECG include the PR
interval, QRS interval (also called
QRS duration), QT interval and
RR interval.

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Segment
★ The length between two
specific points on an ECG
that are supposed to be at
the baseline amplitude (not
negative or positive). The
segments on an ECG
include the PR segment, ST
segment and TP segment.

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18
Complex
★ Complex: The combination of
multiple waves grouped
together. The only main
complex on an ECG is the QRS
complex.

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Point
★ Point: There is only one point on
an ECG termed the J point,
which is where the QRS complex
ends and the ST segment
begins.

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★ The main part of an ECG contains a P wave, QRS complex and T wave.

★ The P wave indicates atrial depolarization. The QRS complex consists

of a Q wave, R wave and S wave and represents ventricular
depolarization. The T wave comes after the QRS complex and
indicates ventricular repolarization.

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Horizontal Plane (Transverse Leads)

● By using 6 chest electrodes, you get 6 transverse leads that provide

information about the heart’s horizontal plane: V1, V2, V3, V4, V5,
and V6.

● Like the augmented leads, the transverse leads are unipolar and
requires only a positive electrode. The negative pole of all 6 leads is
found at the center of the heart. This is calculated with the ECG.

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 Patient Positioning for
12-Lead ECG Placement
• Ensure that electronic devices (e.g. smartphone) are
removed from the patient. These devices can produce
artifact (interference) and cause problems with the
readings.

• Place patient in supine or Semi-Fowler’s position. If both

positions are impossible, you can perform ECG with the
patient in a more elevated position.

• With arms lying flat on the side, ask the patient to relax
the shoulders and keep the legs uncrossed.

• Ask the patient to lie still and quietly until the test is
done.

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Skin Preparation

● Skin should be dry and hairless.

Shave hair that can possibly impede
electrode placement.

● For better electrode adhesion rub the

area with an alcohol prep pad.

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 ECG Variations

APART FROM THE STANDARD 12-LEAD ECG, 3-LEAD ECG 5-LEAD ECGA 5-LEAD ECG USES 4 LIMB LEADS
OTHER VARIANTS INCLUDE: A 3-LEAD ECG USES 3 ELECTRODES THAT ARE AND 1 CHEST LEAD. IT HELPS IMPROVE ST
LABELED WHITE, BLACK, AND RED. THESE ELEVATION READINGS BUT IT’S STILL INFERIOR
COLORS ARE NOT UNIVERSAL AS TWO TO THE 12-LEAD ECG.
COLORING STANDARDS EXIST FOR THE ECG
(DISCUSSED BELOW). THESE 3 LEADS MONITOR
RHYTHM MONITORING BUT DOESN’T REVEAL
SUFFICIENT INFORMATION ON ST ELEVATION
ACTIVITY.

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Color Coding
Standards for the
12-Lead ECG

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Gather the appropriate equipment:

• ECG machine: to record the ECG.

• Self-adhesive ECG electrodes: to attach the ECG leads to the
patient.
• Razor: may be required to remove hair to provide adequate
electrode contact with the skin.

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 ● Wash your hands and put on PPE if appropriate.

● Introduce yourself to the patient including

your name and role.

Introduction
● Confirm the patient’s name and date of birth.

● Briefly explain what the procedure will involve

using patient-friendly language: “I need to record an ECG which
is an electrical trace of the heart. The procedure will involve
placing some sticky pads onto your chest and limbs. I will then
connect these sticky pads to the ECG machine’s leads to record
the tracing.”

● Gain consent to proceed with ECG recording.

● Adequately expose the patient’s chest for the procedure (offer

a blanket to allow exposure only when required). Exposure of
the patient’s lower legs and wrists is also necessary to apply
the limb leads.

● Ask the patient to lay on the clinical examination couch

● Check if the patient has any pain before continuing with the
clinical procedure.

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Electrode placement
● A 12-lead ECG involves the use of 10 electrodes, six on the
chest and four on the limbs.
● It is important to ensure each electrode has good skin contact, which
may involve cleaning or shaving the areas where you need to place
electrodes. If this is the case, make sure to explain this clearly to the
patient and gain consent before proceeding. See below for more
details on how to improve skin contact with electrodes.
● Apply the six chest electrodes
● Apply the four limb electrodes on a distal bony prominence
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Performing
1. Turn the ECG machine on and ensure ECG paper has been
loaded into the machine.
2. Double-check all the electrodes are attached in the
appropriate locations.
3. Politely ask the patient to remain still and not talk during the
recording as muscle activity can interfere with the ECG trace.
4. Press the appropriate button on the ECG machine to record
the ECG trace. If the ECG trace is poor, double-check the
connections to ensure there is good skin contact.

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To complete the procedure…
● Once an ECG trace has been obtained, switch off the ECG machine.
● Detach the ECG leads from the electrodes and then remove the
electrodes carefully, warning the patient this may feel uncomfortable.
● Explain to the patient that the procedure is now complete. Thank the
patient for their time.
● Label the ECG with the patient’s details.
● Dispose of PPE appropriately and wash your hands.
● Document procedure.

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