ECG
1.
2.
3.
4.
5.
6.
7.
Perform hand hygiene before patient contact.
Verify the correct patient using two identifiers.
Assess the patient for chest pain, shortness of breath, and palpitations.
Assess the patient’s history for cardiac arrhythmias or cardiac problems.
Assess the patient’s medications.
Assess the patient’s previous 12-lead ECGs.
Ensure that the patient and family understand preprocedure teaching. Answer
questions as they arise, and reinforce information as needed.
8. Place the patient in a resting supine position in bed and expose the patient’s
torso while maintaining modesty. Pull the curtains around the bed or close the
door to the room.
9. Perform hand hygiene and don gloves.
10. Check the cables and lead wires for fraying, broken wires, or discoloration. If
equipment is damaged, obtain alternative equipment and notify the
biomedical engineer for repair.
11. Plug the ECG machine into a grounded AC wall outlet or ensure that the
battery-operated machine is functioning.
12. Turn the ECG machine on and input the information required. Follow the
manufacturer's recommendations and requirements for inputting
information and warm-up time.
13. Ensure that the patient is in the supine position and is not touching the bedrails
or footboard. Ensure that subsequent ECGs are recorded in the same
position to ensure that tracing changes are not caused by changes in body
position. If another position is clinically required, note the position on the
tracing or in the comment space of the machine input.
14. Expose only the necessary parts of the patient’s legs, arms, and chest to provide
privacy and warmth.
15. Identify the lead sites before placement. Mark the sites with an indelible marker
if serial ECGs are anticipated.
16. Wash the skin with soap and water and dry it briskly with gauze pads or a
washcloth. Do not use alcohol for skin preparation because it can dry the
skin. To ensure good skin contact with the electrodes, clip chest hair with
surgical clippers as necessary.
17. Prepare the electrodes.
a. For pregelled electrodes, remove the backing and test for
moistness. Ensure that the gel is moist. Replace the electrodes if they
are not moist.
b. For adhesive electrodes, remove the backing and ensure that the adhesive
pad is sticky or moist. Replace adhesive electrodes if they are not
sticky.
18. Place the limb leads (Figure 4) in fleshy areas, equidistant from the heart, and in
approximately the same place on each limb. Avoid bony prominences.
19. Place the chest leads (Figure 5), ensuring accurate placement.
a. Identify the angle of Louis or the sternal notch.
b. Palpate the upper sternum to identify where the clavicle joins the sternum
(suprasternal notch). Slide fingers down the center of the sternum to the
obvious bony prominence. This is the sternal notch, which identifies the
second rib and provides a landmark for noting the fourth ICS.
c. When the fourth ICS is located, place the V leads in the appropriate
locations. If leads cannot be accurately placed, clearly document the
actual location of the lead placement on the 12-lead ECG. Place
precordial leads under the breasts of a woman who has large breasts.
i. V1 at the fourth ICS, right sternal border
ii. V2 at the fourth ICS, left sternal border
iii. V3 equidistant between V2 and V4
iv. V4 at the fifth ICS, midclavicular line
v. V5 horizontal level to V4 at the anterior axillary line
vi. V6 horizontal level to V4 at the midaxillary line
20. Attach the lead wires to the electrodes.
21. Turn the ECG machine on and program the machine.
a. Paper speed: 25 mm/sec
b. Calibration: 10 mm/mV
c. Filter settings: 0.05 to 100 Hz
22. Obtain a 12-lead ECG recording.
a. Instruct the patient to remain still while the machine senses and translates
the electrical activity of the heart to electrical waveforms on paper.
b. Obtain a rhythm strip if needed. Refer to the manufacturer’s manual
for instructions on obtaining a rhythm strip.
23. Examine the 12-lead ECG tracing to ensure that it is clear; repeat the ECG if it
is not clear. Compare the 12-lead ECG with previous 12-lead ECGs.Examine
the ECG and determine whether the recording must be repeated while the
patient is still connected to the machine.
24. Interpret the recording, and look for the following:
a. Rhythm
b. Rate
c. Presence and configuration of P waves
d. Length of P–R intervals
e. Length of QRS complexes
f. Configuration and deviation of the ST segments
g. Presence and configuration of T waves, length of Q–T intervals, presence
of extra waves
h. Arrhythmias
25. Evaluate the 12-lead ECG for any signs of ischemia, injury, infarct, and other
significant myocardial alterations. Notify the practitioner of any changes in the
12-lead ECG.
26. Disconnect the equipment, clean the gel off of the patient (if necessary), and
prepare the equipment for future use. Follow the manufacturer's directions
and the organization’s practice for electrode use and removal; some
pregelled electrodes can be left in place for repeat ECGs.
27. Assess, treat, and reassess pain.
28. Discard supplies, remove gloves, and perform hand hygiene.
29. Document the procedure in the patient’s record.
Adapted from Wiegand, D.L. (2011). AACN procedure manual for critical care (6th
ed.). St. Louis: Saunders
Clinical Review: Kimberly Leotta, MSN, CRNP, FNP-BC, December 2014
SUPPLIES

12-lead ECG machine and recorder with patient cable and lead wires
 Soap and water in a basin
 Gauze pads or washcloth
 Electrodes
Additional equipment to have available as needed includes the following:


Surgical clippers
Indelible marker

CHECK LIST
S = Satisfactory | U = Unsatisfactory | NP = Not Performed
S
Performed hand hygiene before patient
contact.
Verified the correct patient using two
identifiers.
Assessed the patient for chest pain, shortness
of breath, and palpitations.
Assessed the patient’s history for cardiac
arrhythmias or cardiac problems.
Assessed the patient’s medications.
Assessed the patient’s previous 12-lead ECGs.
Ensured that the patient and family understood
preprocedure teaching. Answered questions as
they arose, and reinforced information as
needed.
Placed the patient in a resting supine position
in bed and exposed the patient’s torso while
maintaining modesty. Pulled the curtains
around the bed or closed the door to the room.
Performed hand hygiene and donned gloves.
Checked the cables and lead wires for fraying,
broken wires, or discoloration.
Plugged the ECG machine into a grounded AC
wall outlet or ensured that the battery-operated
machine was functioning.
Turned the ECG machine on and input the
information required.
Ensured that the patient was in the supine
position and was not touching the bedrails or
footboard.
U
NP
Comments
Exposed only the necessary parts of the
patient’s legs, arms, and chest.
Identified the lead sites before placement.
Marked the sites with an indelible marker if
serial ECGs were anticipated.
Washed the skin with soap and water and dried
it briskly with gauze pads or a washcloth.
Prepared the electrodes.
Placed the limb leads in fleshy areas,
equidistant from the heart, and in
approximately the same place on each limb.
Avoided bony prominences.
Placed the chest leads, ensuring accurate
placement.
Attached the lead wires to the electrodes.
Turned the ECG machine on and programmed
the machine.
Obtained a 12-lead ECG recording.
Examined the 12-lead ECG tracing to ensure
that it was clear; repeated the ECG if it was
not clear. Compared the 12-lead ECGwith
previous 12-lead ECGs.
Interpreted the recording.
Evaluated the 12-lead ECG for any signs of
ischemia, injury, infarct, and other significant
myocardial alterations. Notified the
practitioner of any changes in the 12lead ECG.
Disconnected the equipment, cleaned the gel
off of the patient if necessary, and prepared the
equipment for future use.
Assessed, treated, and reassessed pain.
Discarded supplies, removed gloves, and
performed hand hygiene.
Documented the procedure in the patient’s
record.

Evaluator:____________________________
Signature:____________________________
Date:____ / ____ / _________