Question

John Miller, a 65-year-old male, arrives at the clinic complaining of his shoes not fitting and feeling like he cannot take a deep breath. During the patient interview, he also states that he is having intermittent pain in his chest. He is taking glyburide 2.5 mg daily, captopril 25 mg twice a day, and HCTZ 25 mg daily. He has not taken the HCTZ for 2 weeks and is hoping to get this medication refilled. The physician wants to evaluate his congestive heart failure. He orders an ECG and a stress echocardiogram. The patient has not previously had a stress echocardiogram and you need to explain it to him before the test begins.

Discussion Questions:

1. Explain to John the difference between an ECG and an echocardiogram.
2. John expresses concern about having a heart attack during the procedure. How can you alleviate his fear?
3. You must perform an ECG on this patient. Describe the steps in the procedure.

Answer 1

ECG: An electrocardiogram(ECG) is a medical test that detects cardiac ( heart) abnormalities by measuring the electrical activity generated by the heart as it contracts.The machine that records the patients ECG is called an electrocardiograph.

Echocardiogram: An echocardiogram is a text that uses ultrasound to show how your heart muscle and valves are working.The sound waves make moving pictures of your heart so your doctor can get a good look at its size and shapes.You might hear them call it “ echo “ for short.

Stress echocardiography: A stress echocardiography,also called an echocardiography stress test or stress echo,is a procedure that determines how well your heart and blood vessels are working.During a stress echocardiography,you will exercise on a treadmill or stationary bike while your doctor monitors your blood pressure and heart rhythm.It will take about 60 minutes.The actual exercise time is usually between seven and 12 minutes.

Steps in the ECG procedure:

Gather the 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

Introduction:wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patients 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 machines leads to record the tracing.

Gain consent to proceed with ECG recording.

Adequately expose the patients chest for the procedure ( offer a blanket to allow exposure only when required).Exposure of the patients lower legs and wrists is also necessary to apply the limb leads.

Ask the patient to lay on the clinical examination couch with the head of the couch at a 45 degree angle.

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

Electrode placement:

A 12- lead ECG involves the use of 10 electrodes,Six on the chest and four on the limbs.

Begin by checking the expiry date of the electrodes to ensure they are within date.

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.

Chest electrode and lead placement (V1- V6)

Apply the Six chest electrode in the following locations:

V1: 4 th intercostal space at the right sternal edge.

V2: 4 th intercostal space at the left sternal edge.

V3: midway between the V2 and V4 electrodes

V4: 5 th intercostal space in the midclavicular line.

V5 : ​​​​​​ left anterior axillary line at the same horizontal level as V4

V6: left mid- axillary line at the same horizontal level as V4 and V5.

Once all electrodes have been applied,attach the associated chest leads,with the cable for each lead lying inferior to the electrode ( to reduce tension on the wire)

Limb electrode and lead placement:

Apply the four limb electrodes on a distal bony prominence in the following locations:

Red(RA): on the ulnar styloid process of the right  arm.

Yellow( LA): on the ulnar styloid process of the left arm

Green(LL): on the medial or lateral malleolus of the left leg.

Black(RL): on the medial or lateral malleolus of the right leg.

Once all electrodes have been applied,attach the associated limb leads,with the cable for each lead lying inferior to the electrode( to reduce tension on the wire).

Recording the ECG trace:

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 him remain stilland 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 trace is poor,double check the connections to ensure there is good skin contact.

To complete the procedure:

Once an ECG trace has been obtained,switch off the 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 patients details

Name

Date of birth

Hospital number

Indication for the ECG

Dispose of PPE appropriately and wash the hands.

Document the findings in the patients notes.