Basic EKG Procedures PDF

6 58 3 O Basic EKG Procedures 1. Describe patient identification, patient are most commonly used. When the EKG techni-...

6 58 3 O Basic EKG Procedures 1. Describe patient identification, patient are most commonly used. When the EKG techni- Cian introduces herself to the patient, she should preparation, and response to emergency ask the patient to state her full name and date of situations during EKG testing birth. This information is then checked against Before conducting an EKG test, the EKG techni- the provider's order. The technician should not Cian needs to identify and prepare the patient. state the patient's information and ask if it is cor- She must also identify herself by name and by rect. Patientsmay not hear well or may not un- title. Clear communication is key. Ifthe patient derstand. They may not want to ask someone to does not speak or understand English, the EKG repeat a question and may agree without under- technician must use an interpreter or interpreta- standing. A patient's address or room number tion service, following facility policy. should not be used as an identifier. These things can change. A patient may be wearing a wristband for iden- Understanding Care is a Patient Right tification. The EKG technician should always Medical interpretation ensures that patients under- make sure that the information in the patient's stand the care they receive. It allows them to answer questions from healthcare workers and ask their record matches what the patient says and what own questions. Many facilities use a telephone- or is on the wristband. If any information does not computer-based interpretation service. The EKG match, the technician should report the prob- technician should know the system used in his facil- lem. He should not perform the test until the pa- ity. A patient's friend or family member may help with initial communication, but should not interpret tient's identity is confirmed. Many facilities now medical information. use barcode scanners to identify patients and add information to their medical records. The Identification is the first step when preparing a barcode scanner may not work if the information I patient for EKG testing. Identifying the patient on the patient's wristband does not match the ensures that care is provided to the correct per- medical record. son. Failure to properly identify a patient could If a facility does not use barcodes, the EKG link the patient's information to the wrong med- technician may enter patient information manu- ical record. It could begin a second, duplicate ally into the EKG machine. In most cases, this medical record for the patient. Either situation includes full name, date of birth, gender, race, could keep the provider from finding the results. medical record number, and the name of the Identification must be checked using two identi- provider who ordered the test. Facility policy may fiers. The patient's full name and date of birth require additional information. Medications the  59 6 patient is taking, symptoms at the time of the technician should reassure the patient that the test, and special considerations (e.g., medical test is painless, and that it will give the provider conditions that require adjustments to electrode important information about the patient's heart placement) may also be entered. rate and rhythm (Fig. 6-1). 3 proper infection control practices are important o during testing. Standard Precautions are used in all situations with all patients. A higher level of precautions may be needed in some cases. u Chapter 2 provides information on Standard and Transmission-Based Precautions. The patient's skin should be observed before Fig. 6-1. The EKG technician can help put a patient at electrodes are placed. Moisture, dryness, oil, ease before conducting a test. (COURTESY OF ROYAL dirt, and body hair can all affect electrode con- tact. Open sores or scars can prevent placement of the electrodes in the standard positions. Im- Pediatric Patients planted pacemakers or defibrillators also need to Children may be scared of doctors' offices and medi- be avoided when placing electrodes. Chapter 7 cal procedures. It is important to reassure pediatric contains more information. patients that EKG tests do not hurt and only take a few minutes. Children may not understand medical Take Action Now! terms. The EKG technician should describe the tests inwords they are sure to understand. Electrodes can The EKG technician must always take precautions be called stickers. The thorax can be chest and tummy to prevent the spread of infection. Cloves should be or chest and stomach, depending on the child's age. worn (and changed when needed) if contact with Children should also be given a chance to ask any nonintact skin or body fluids is likely. Masks should questions they may have before the test is given. be worn if a patient has or may have a respiratory illness. An EKG technician should contact her super- visor if she is unsure about what PPE to use. Patients with Developmental Disabilities EKG technicians have an important role in re- Although needs differ, here are some general guide- sponding to emergency situations that develop lines for providing care to patients who have devel- during EKG testing. A patient's condition can opmental disabilities: Adult patients should always be treated as adults. change at any time. The EKG technician must Parents or other caregivers may accompany recognize emergency situations and follow the patients with developmental disabilities. They correctemergency response procedures. They should be allowed to remain in the exam room should watch carefully for changes that indicate during the test. They can be an excellent source an emergency may be developing. These situa- of information. tions are discussed in detail in Chapter 10. If a patient uses a communication board or sign language, the EKG technician should accommo- date these needs. 2. Demonstrate the performance of the Some patients do not like being touched. EKG technicians should explain procedures simply but 12-lead EKG test carefully. They should get the patient's consent A 12-lead EKG test is used in many settings. It before touching the patient. If a patient is anxious about the test, the EKG may be done as a screening procedure during a technician should give her time to become more routine physical. It is also useful as a diagnos- comfortable before starting. tic tool for suspected heart problems. The EKG 6 60 1 that would stop electrodes from sticking. Obtaining a 12-lead EKG Throughout the procedure, expose only the Equipment: EKG machine loaded with paper, lead areas necessary to prepare the skin and run wires, electrodes, gloves (if needed), patient gown, the test. towel, clippers 11. Open the package of electrodes and attach o Identify yourself by name. Identify the patient one electrode to each lead wire by snapping according to facility policy. or clipping. 2. Wash your hands. 12. Attach the electrodes in the, correct positions, 3. Explain the procedure to the patient. Speak keeping the patient covered as much as pos- sible. Avoid bony areas, broken skin, scar tis- clearly, slowly, and directly. Maintain face-to- sue, and skin over implanted devices. face contact whenever possible. For a male patient, explain that chest hair may need to 13. Ask the patient to relax and be as still as be clipped for proper electrode contact. Reas- possible. sure the patient that the test is painless and takes only a few minutes. 14. When the tracing is clear on the monitor or when the machine shows a green light, print 4. Ask the patient to undress from the waist up the EKG according to the manufacturer's and put the gown on with the opening fac- instructions. ing forward. Follow facility procedures about 15. Check the EKG for evidence of lethal dys- asking patients to remove jewelry and about rhythmias or ST segment abnormalities asking a female patient to remove or leave on her bra. The patient should also be asked (more information in Chapters 8 and 9). If to remove socks or stockings that would any are seen, tell the provider immediately. prevent electrodes from being placed on the 16. Follow facility policy for processing com- lower extremities (unless the LL and RL elec- pleted EKGs. EKGs may need to be immedi- trodes will be placed on the torso). Provide ately shown to the provider. privacy for the patient to change. 17. Disconnect lead wires, taking care not to pull 5. After returning to the room, put on gloves if or tug on the patient's skin (Fig. 6-2). Ask the needed. patient to remove and discard the electrodes. Ifthe patient is not able to do this, remove 6. Assist the patient into a supine position the electrodes gently and discard them (lying flat on his back). yourself. 7. Place the EKG machine beside the bed and plug it in to an electrical outlet. 8. Turn the machine on and wait until it com- pletes self-tests. 9. Enter the patient's information into the ma- chine or scan his barcode bracelet. Be sure the machine is showing the right patient information. 10. Prepare the patient's skin, if needed, by dry- Fig. 6-2. Be careful to avoid patient discomfort when re- ing or removing lotion or by clipping hair moving lead wires from electrodes.  6 18. Remove and discard your gloves (if used). facilities have patient gowns with a small pocket Wash your hands. in the front for a telemetry unit. The patient should be told not to remove the electrodes 19. Tell the patient where to place the gown and or wires. The patient must notify the EKG give them privacy for dressing. technician or the nurse if the electrodes or wires 20. Upload or file the EKG into the patient's med- become loose or fall off. The patient can get o ical record. Document the procedure using out of bed and move around the facility while facility guidelines. wearing the telemetry pack. 21. Clean and store the EKG machine and equip- ment. This may include cleaning the elec- trode clips and wiping the lead wires with a cleansing agent. 22. Wash your hands. NOTE: Follow facility policy regarding reuse of electrodes if more than one EKG is conducted on the same patient. Some electrodes perform less effectively once the gel has conducted electrical Fig. 6-3. Specially trained workers monitor several pa- activity. tients at once in telemetry monitoring rooms or stations. (COURTESY OF ROYAL PHILIPS,) Attaching Electrodes Electrodes can be attached first to the patient or to the lead wires. If electrodes are attached first to the patient, care is needed when snapping or clip- y, ping the lead wires in place. It is important to avoid pulling the patient's skin when attaching clip-style electrodes. It is also important to avoid putting un- comfortable pressure on the patient when attaching snap-style electrodes. Fig. 6-4. Telemetry packs can be worn around the neck or in the pocket ofa hospital gown. Patients wearing a 3. Explain patient preparation and telemetry pack are free to mope around. (COURTESY OF ROYAL monitoring for telemetry PHILIPS.) A telemetry pack (also called a telemetry unit) is used to monitor a patient's heart rate and Applying a telemetry pack rhythm. Telemetry technicians monitor signals Equipment: Telemetry pack with fresh batteries, te- from multiple patients' telemetry packs at a lemetry pack case, lead wires, electrodes, gloves (if remote location and notify a nurse or doctor of needed), towel, clippers, patient instruction sheet changes (Fig. 6-3). Identify yourself by name. Identify the patient Most telemetry units come in a small pouch. according to facility policy. The pouch has straps that allow the patient to 2. Wash your hands. tie the unit around her neck (Fig. 6-4). Some 6 62 3. Explain the procedure to the patient. Speak 13. Cive the patient an instruction sheet and any clearly, slowly, and directly. Maintain face-to- other information required by facility policy. face contact whenever possible. For a male 14. Remove and discard your gloves (if used). patient, explain that chest hair may need to Wash your hands. be clipped for proper electrode contact. o 15. 4. Ask the patient to undress from the waist up Document the procedure using facility guidelines. and put the gown on with the opening facing forward. Follow facility procedures about asking patients to remove jewelry and about asking a female patient to remove or leave 4. Demonstrate the performance ofa stress test on her bra. Provide privacy for the patient to change. A stress test measures how the heart functions 5. When the patient is ready, return to the care under controlled stress. Stress tests are used to area and place the telemetry pack near the assess heart function and predict future heart patient. Put on gloves if needed. problems. They can also be helpful in planning more invasive heart procedures. They may be 6. Prepare the patient's skin, if needed, by dry- used as a screening tool for patients 35 years ing or removing lotion or by clipping hair of age and older, especially those with a family that would stop electrodes from sticking. history of heart disease. Patients who have had Throughout the procedure, expose only the heart surgery usually have a stress test once a areas necessary to prepare the skin and apply year to monitor heart function. the electrodes. Depending on the patient's condition, cardiac 7. Open the package of electrodes and attach stress can be induced (created) in different ways. one electrode to each electrode wire by Exercise on a treadmill or stationary bicycle is snapping or clipping. the most common way to raise the heart rate. 8. Attach the electrodes in the correct positions, The provider may inject stimulant medications keeping the patient covered as much as pos- to raise the heart rate in patients who cannot ex- sible. Avoid bony areas, broken skin, scar tis- ercise. Other names for this test include exercise sue, and skin over implanted devices. stress test, exercise tolerance test, and treadmill test. When the stress is created with medications, the 9. Attach the electrode wires to the telemetry test may be called a pharmacologic stress test. pack and turn the unit on. A nuclear stress test is another type of cardiac 10. Call the telemetry monitor room to confirm stress test. During this test a harmless radioac- the unit is working properly. I tive substance called a tracer is injected into the 11. Tell the patient to inform you or the nurse if patient's bloodstream. Before the stress test is electrodes fall off or the unit is disconnected. done, the patient is placed in a supine position with her arms over her head. A special camera 12. Provide privacy for the patient to change into records the motion of the tracer through the the gown normally worn in the facility. Help heart. This is repeated after the exercise is com- the patient to store the telemetry pack in the plete. This type of test gives the provider more gown pocket or pouch. detailed information about possible blockages in coronary arteries.  63 6 The patient should receive instructions to pre- For example, a 54-year-old's maximum heart rate pare for the test. These instructions should in- would be calculated in this way: clude the following: 220 — 54 = 166 beats per minute (BPM), the Avoid caffeine (coffee, tea, soft drinks, choc- I age-predicted maximal heart rate 3 olate, certain headache medications) for 24 The heart rate the patient should achieve during o hours before the exam. Remind the patient the test is 85% of 166: that even decaffeinated tea, coffee, and cola 166 x 0.85 = 141 BPM, the target heart rate u products contain some caffeine. for the test Follow the provider's instructions about tak- I This patient must reach a heart 'rate of 141 BPM ing any regular medications for 24 hours for the test to be valid. before the test. Some medications may need to be stopped temporarily. Stress testing should only be done by workers trained in CPR. The facility must have oxygen, Do not eat or drink anything except water an automated external defibrillator (AED), and for 3 hours before the test. Patients who have a crash cart ready. (A crash cart has supplies diabetes should check with the provider for I needed immediately for a medical emergency.) specific instructions. The test should be stopped immediately if the Wear comfortable, loose clothing and rubber- patient has any of the following: soled shoes or athletic shoes. Dizziness Bring all of your medications on the day of Chest pain the test. Shortness of breath The entire procedure will last 2—4 hours. A sudden increase or decrease in systolic or A medical professional will be present or diastolic blood pressure nearby for the entire test. Systolic blood pressure greater than A 12-lead EKG is done before the patient starts exercising and then continuously during the 250 mm Hg test. The EKG is then repeated at 5, 10, and 15 Diastolic blood pressure greater than minutes after the exercise is completed. The 115 mm Hg patient's vital signs are also monitored every 2.5 Leg cramps minutes during the test. Severe fatigue In order for a stress test to be considered valid, the patient must reach a particular heart rate. Severe diaphoresis The goal is for the patient to reach 85% of a rate ST segment changes (described in Chapter 9) called the age-predicted maximal heart rate. I Worsening or possibly dangerous dysrhyth- This rate is calculated by subtracting the pa- mias (described in Chapter 9) tient's age from 220, as shown below: The test should also be stopped if the patient 220 — patient's age = age-predicted wants to stop or if the heart rate does not rise maximal heart rate above 120 BPM. Age-predicted maximal heart rate x 0.85 — target The EKG technician continues to monitor the heart rate (goal) for stress test I patient after the test is completed until the 6 64 patient's vital signs return to baseline. The pa- 11. Repeat the EKG every 2—3 minutes according tient should be told to rest and avoid stimulants to facility guidelines. for the rest of the day. 12. Monitor the patient's EKG, heart rate, blood pressure, respirations, and oxygen saturation Conducting an exer-ise test o readings during the test (Fig. 6-5). Equipment: treadmill or stationary bicycle, EKG machine, lead wires, electrodes, gloves (if needed), towel clippers, sphygmomanometer, pulse oximeter Identify yourself by name. Identify the patient according to facility policy. 2. Wash your hands. 3. Explain the procedure to the patient. Speak clearly, slowly, and directly. Maintain face-to- Fig. 6-5. An EKG technician measures vital signs before, face contact whenever possible. For a male during, and after stress testing. patient, explain that chest hair may need to be clipped for proper electrode contact. Reas- 13. Assist the provider as requested. sure the patient that the test is painless. 14. Continue to monitor the patient when the 4. Calculate the target heart rate for the stress stress test is completed. Wait until EKG, I test. Record it in the patient's chart. The tar- heart rate, blood pressure, respirations, and get rate is 85% of the age-related maximal oxygen saturation return to baseline (usually heart rate. (220 — patient's age = age-related within 15 minutes). maximal heart rate. Multiply this number by 15. Disconnect lead wires, taking care not to pull 0.85 to calculate the target rate.) or tug on the patient's skin. Ask the patient 5. Put on gloves if needed. to remove and discard the electrodes. Ifthe patient is not able to do this, remove the 6. Follow steps 6—15 of the procedure Obtaining electrodes gently and discard them yourself. a 72-lead EKG to get the patient's baseline 12-fead EKG. Place limb electrodes on the 16. Remove and discard your gloves (if used). torso or near the torso for greater freedom of Wash your hands. movement during exercise. 17. Give the patient any additional information or 7. Assist the patient to a seated position. directions, following facility policy. 8. Apply the sphygmomanometer cuff and pulse 18. Upload or file the EKG and other data into oximetry probe to the patient. the patient's medical record. Document the 9. Obtain and record baseline measurements procedure using facility guidelines. for blood pressure, oxygen saturation, heart 19. Clean and store EKG machine and equip- rate, and respirations. Set monitor to read ment. This may include cleaning the elec- blood pressure as often as directed (often trode clips and wiping the lead wires with a I every two minutes). cleaning agent. 10. Tell the provider when the patient is ready to 20. Wash your hands. start the test.  65 6 5. Discuss Holter and other ambulatory monitoring Holter monitors allow the physician to evaluate cardiac activity over a 24- to 48-hour period. The patient wears a small recording device with lead o wires. These are attached to electrodes on the patient's chest. Other types of ambulatory moni- u tors may be worn for longer periods of time. Fig. 6-7. Stress loops can reduce tugging on the elec- Most ambulatory monitors use 5 electrodes. trodes. This gives a better reading in ambulatory The skin may have to be cleaned with soap and monitoring. water or gently abraded (rubbed) with a piece of The technician should give information to the gauze. This helps the electrodes adhere (stick) to patient about ambulatory monitoring when the the skin (Fig. 6-6). The technician should make monitor is applied (Fig. 6-8). Directions vary for sure that the monitor batteries are fresh before each type of monitoring. The following infor- attaching the electrodes. Some facilities provide mation should be given to patients for Holter extra batteries to patients, along with instruc- tions for changing them if the installed batteries monitoring: fail. Call the provider's office if the electrodes be- come loose or fall off. Do not remove the lead wires. Do not get the monitor wet. Do not shower or swim with the Holter monitor in place. Continue your normal activities. Keep an and symptom diary. Press activity the event button on the monitor for any con- cerning symptom. Fig. 6-6. Gently preparing the skin ensures that electrodes Call 911 for severe chest pain, weakness, or adhere properly. (SOURCE REFERENCE: CLEANING SKIN OF HAIR. COURTESY OF 3M. 0 3M 2015. ALL RIGHTS RESERVED.) shortness of breath. Return all equipment as directed when the Because patients undergoing ambulatory moni- test is complete. toring continue their everyday activities, elec- trodes and lead wires may be tugged or strained. This can disrupt the EKG recording or make it harder to read. Some electrodes for ambulatory I monitoring have a built-in clip or slot. This al- lows the technician to create a loop with the lead wire. This is called a stress loop. It can reduce tension placed on the electrodes by the patient's movements (Fig. 6-7). A stress loop can also be created by looping the lead wire and then plac- Fig. 6-8. Patient education is an important part of setting ing tape over the loop. up ambulatory monitoring. I 6 66 Most facilities have printed instructions in bro- 9. Remove and discard your gloves (if used). chures or booklets for the patient to take home Wash your hands. and refer to if needed. 10. Give the patient privacy for dressing. Applying an ambulatory monitor 11. Give the patient instructions for the type of o monitoring ordered. This includes directions Equipment: Holter or other ambulatory monitor for returning the monitor. Allow the patient unit, lead wires, electrodes, gloves (if needed), towel, clippers, patient diary to ask any questions he may have. Reinforce instructions. Identify yourself by name. Identify the patient 12. Document the procedure using facility according to facility policy. guidelines. 2. Wash your hands. 3. Explain the procedure to the patient. Speak clearly, slowly, and directly. Maintain face-to- 6. Discuss the importance of accurate face contact whenever possible. For a male record-keeping and patient confidentiality patient, explain that chest hair may need to The EKG technician must document EKG tests be clipped for proper electrode contact. Reas- correctly after they are completed. Most medical sure the patient that the test is painless. I facilities use electronic health records (EHRs). 4. Ask the patient to undress from the waist up The completed EKG must be uploaded into the and put the gown on with the opening fac- record so it will be available for all medical pro- ing forward. Follow facility procedures about viders to view (Fig. 6-9). asking patients to remove jewelry and about asking a female patient to remove or leave on her bra. Provide privacy for the patient to change. 5. After returning to the room, put on gloves if needed. 6. Prepare the patient's skin, if needed, by drying or removing lotion or by clipping hair that would stop electrodes from sticking. Throughout the procedure, expose only the areas necessary to prepare the skin and place the electrodes. Fig. 6-9. The EKG technician is responsible for document- ing properly after tests are complete. (COURTESY OF ROYAL PHILIPS,) 7. Open the package of electrodes and attach one electrode to each lead wire by snapping Some EKG machines automatically upload EKGs or clipping. Follow facility policy about the to a patient's EHR. The technician should always use of stress loops. check that the EKG is uploaded to the correct 8. Attach the electrodes in the correct positions. patient's chart. In some settings the EKG techni- Avoid bony areas, broken skin, scar tissue, Cian may also be responsible for uploading infor- and skin over implanted devices. mation created by other healthcare professionals. This information could include the following:  This form must be signed before a patient's Discharge (d/c) summaries records can be shared with any outside person, Medications facility, or organization. Release forms can be Nurses' notes several pages long. They may ask the patient about specific situations for information release. A provider's assessment of the patient, o For example, they may ask how the patient sometimes called systems review would prefer her information to be commu- I All care team members must maintain confi- nicated (e.g., by email, fax, text, or voicemail). dentiality when dealing with patients' health An EKG technician should always check the information. Protected health information (PHI) patient's release form before sharing PHI with I must be kept private. PHI includes a patient's anyone outside the facility. If the technician has name, address, telephone number, social secu- any doubts about sharing a patient's PHI, he rity number, and other identifying information. should contact his supervisor. Facilities that use EHR assign a username and password to each team member. Computer Chapter Review systems keep a detailed record of who logs in, which records are opened, and what informa- EKG technicians must always identify pa- tion is entered or changed. It is essential to keep tients before conducting tests. They must passwords secure and to log out of the system use proper infection prevention measures when a task is complete. during all patient contact. After testing, they must document the results as directed. Several federal laws address how a patient's I medical information can be collected, viewed, If emergency situations happen during EKG and shared. One of these laws is the Health testing, the technician must immediately call Insurance Portability and Accountability Act for help, following the facility's policies and (HIPAA). Under HIPAA, healthcare workers procedures. can be fined, can lose certification, and can be After completing an EKG test, the techni- sentenced to prison for mishandling patients' Cian should follow facility policy for review PHI. This is true even if their actions were not I of results. It is the provider's job to read and intentional. The Health Information Technology interpret the completed EKG. for Economic and Clinical Health (HI TECH) Act All of a patient's medical and personal in- increased the penalties established by HIPAA formation, including EKG results, is con- and encouraged providers to adopt EHR in place fidential. It must be protected. Failing to of paper records. protect confidentiality can result in fines and Laws about protected health information apply penalties. This is true even if this is done to all members of the care team. PHI can be I unintentionally. shared only with team members involved in the patient's care or with someone who has a legal right to know. PHI should never be discussed over the phone unless the EKG technician is cer- tain she is talking to someone with a legal right to receive the information. Patients can give others the right to receive their health information by signing a release form.