LESSON PLAN

ON
ELECTROCARDIOGRAM

Submitted To Submitted By

Mrs. Raji Raju Ms. Sumy Saji

HOD, Mental Health Nursing Second Year Msc Nursing

Vijaya College of Nursing Vijaya College of Nursing

Kottarakkara Kottarakkra

Submitted on: 10-3-19

 LESSON PLAN ON ECG

Name of the student teacher : Ms. Sumy Saji

Subject : Medical surgical nursing

Unit :

Topic : Electrocardiogram

Group : 3rd year B.sc students

Place : 3rd year class room

Duration : 1 hr

Date and time :22/5/17

Previous knowledge of the class: from previous theory class

Method of teaching : lecture cum discussion

A.V. AIDS : Blackboard, PPT, OHP, handouts, charts.

CENTRAL OBJECTIVES

On completion of the class, the students will acquire knowledge regarding ECG, develop skill in interpreting
electrocardiogram and apply this knowledge in various health care settings.

SPECIFIC OBJECTIVE

On completion of the class students:

1. define ECG
2. list out the purpose of taking ECG
3. enlist the indications
4. enumerate the procedure for taking an ECG.
5. learn the basics of ECG.
6. identify the abnormalities in ECG.
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1 1 introduce INTRODUCTION lecture Lcd Teacher
min the topic. teaches
ECG represents the electrical activity of heart and helps the
students
healthcare members to identify heart conduction abnormality, blocks,
listen
ischemia/ infarct of the myocardial cells, heart rate, heart rhythm. So
that the patient can be given the exact treatment needed to restore
normal heart function.

2. 1 define
DEFINITION Teacher
min ECG. Lectur ohp What do you
The electrocardiogram is a graphic tracing of the electrical impulses teaches mean by
e
students ECG?
produced in the heart.
listen What are the
Lectur ohp purposes?
e cum
PURPOSE discuss
3. 1 list out the
min purpose of  To detect heart rhythm (arrhythmias) ion
taking
ECG  To detect the type of myocardial infarction.
 To identify heart conduction abnormalities.
 To identify heart structural problems
 To detect the electrolyte imbalance
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INDICATIONS FOR TAKING ECG Lectur hand Teacher What are the
1 enlist the e cum outs teaches indications
4. min indications  Atypical Chest pain discuss students for taking
ECG?
 Epigastric pain ion listen

 Palpitation
 Left side radiating chest pain
 Syncope
 Pulmonary edema
 Exertional dyspnea
 Diaphoresis associated with chest discomfort.

5. 2 PROCEDURE FOR TAKING AN ECG Lectur Teacher How do we

enumerate
min the e cum teaches take an ECG?
Make the patient lie down in a supine position and shave off the students
procedure discuss demo
for taking chest hair in male patients to easily place the leads. There are 6 ion ask
an ECG. chest leads and 4 limb leads. 4th ICS is the right of the sternum is doubts

the place for placing chest lead V1, V2 in 4th ICS left of the
sternum, V4 lies in the 5th ICS mid clavicular line left of the
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sternum, V3 lies midway between the V2 and V4. V5 lies in the 5th
ICS in the nipple line, and V6 lies in the 5th ICS mid axillary line
left of sternum. The limb leads are connected as white coded lead
on the right arm, black on the left arm, green on the right leg and
red on left leg. Attach the leads well and on the machine. look
ECG tracings on screen for clarity then if clear click print button.
Write the name, date and time of ECG.
Electrocardiography (ECG, EKG). ECG records the electrical
activity generated by heart muscle depolarizations, which
propagate in pulsating electrical waves towards the skin. Although
the electricity is in fact very small, it can be picked up reliably
with ECG electrodes attached to the skin (data unit: microvolt,
uv). The full ECG setup comprises at least six electrodes which
are placed on the chest or at the four extremities according to
standard nomenclature (RA = right arm; LA = left arm; RL = right
leg; LL = left leg). Of course, variations of this setup exist in
order to allow more flexible and less intrusive recordings, for
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example, by attaching the electrodes to the forearms and legs.
ECG electrodes are typically wet sensors, requiring the use of a
conductive gel to increase conductivity between skin and
electrodes.

Lectur
e cum Teacher
6. 10 learn the discuss teaches What are the
ECG WAVES
min basics of mode students durations of
ion
s ECG. l waves in
ask
ECG?
doubts
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Normal ECG
A normal ECG is illustrated above. Note that the heart is beating in a
regular sinus rhythm between 60 - 100 beats per minute (specifically
82 bpm).

BASICS OF ECG

ECG graph paper

In ECG graph the vertical lines indicate voltage and
horizontal line indicate time. There are big and small squares in graph
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which helps us to understand the differences or abnormal deviation
from a normal ECG recording. One small square is equal to 1 mm
=0.04 sec. One big square contains 25 small squares.one big square
=0.2 secs which is 5 mm. In the first before the ECG waves lies a
dumble shaped (∏ ) symbol which determines the size of graph to be
recorded and is called standardisation and is always set as 10 mm.

NORMAL WAVES

1. P wave:
 First positive deflection indicates atrial depolarisation
 P wave upright in leads I,II, III, aVL.
 normal duration is less than or equal to 0.11 seconds( 3 small
squares width and height)
 p wave depressed in aVR, V1
 shape is generally smooth, not notched or peaked
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2. PR interval:
 it starts from the beginning of P wave to end of R wave.
 Normally between 0.12 and 0.20 seconds (5 small squares).

3. QRS complex:

 Duration less than or equal to 0.12 seconds (2 small squares),

amplitude greater than 0.5 mV in at least one standard lead,
and greater than 1.0 mV in at least one precordial lead.
 QRS indicates ventricular ventricular depolarisation
 small septal Q waves in I, aVL, V5 and V6 (duration less than
or equal to 0.04 seconds; amplitude less than 1/3 of the
amplitude of the R wave in the same lead).
 R wave is represented by a positive deflection with a large
upright R wave (thick walls of ventricles eject blood to great
vessels so the electrical voltage is high) in leads I, II, V4 - V6
and a negative deflection with a large, deep S in aVR, V1 and
V2
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 in general, proceeding from V1 to V6, the R waves get taller
while the S waves get smaller. At V3 or V4, these waves are
usually equal. This is called the transitional zone.
 S wave is the second negative deflection and occurs due to the
depolarisation of purkinje fibres.

4. ST segment:
 isoelectric, slanting upwards to the T wave in the normal ECG
 can be slightly elevated (up to 2.0 mm in some precordial
leads)
 never normally depressed greater than 0.5 mm in any lead,
depression indicates MI

5. T wave:
 T wave deflection should be in the same direction as the QRS
complex in at least 5 of the 6 limb leads.
 It is the electrical recovery of ventricles (ventricular
repolarization).
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 normally rounded and asymmetrical, with a more gradual
ascent than descent
 should be upright in leads V2 - V6, inverted in aVR
 amplitude of at least 0.2 mV in leads V3 and V4 and at least
0.1 mV in leads V5 and V6
 T wave inversion indicates ischemia / previous myocardial
infarction.

6. QT interval:
 Durations normally less than or equal to 0.40 seconds for
males and 0.44 seconds for females.
 It is measured from beginning of QRS interval to end of T
wave.

7. Q wave:
 First negative deflection. Not clearly seen in normal ECG.
 If the Q wave is 1/3rd of R wave it indicate old MI.
 If Q wave is more than 1/3rdof R wave it indicates
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pathological Q (necrosis).

8. U wave
 Not seen in normal ECG, seen in hypokalemia.
 It is due to the repolarization of purkinje fibres.

HEART RATE CALCULATION

To calculate the heart rate we need to divide 300 by the number

of large squares between two R waves or 1500 divided by
number of small squares.

7. 10 identify the ECG ABNORMALITIES

min abnormaliti
es in ECG. During various MI the ECG graph changes.some are given Lectur Teacher
e cum Interpret
below: teaches
discuss LCD these ECG
ion students tracings?
ask
 IWMI- ST↑ in lead II, III, aVF and ST ↓ in lead I, aVL, V1,
doubts
V2
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 AWMI- ST ↑ in lead I, Avl, V1 –V6 and ST ↓ in lead II, III,
aVF.
 LWMI- ST↑ in lead I aVL or V5 , V6 and ST ↓ in II, III aVF.
 PWMI- ST ↑ in lead V7 –V9 and ST ↓ in V1, V2.
 RVMI- ST ↑ in lead V3R- V4R.

AV BLOCK

 First degree block: rate and rhythm will be normal, P wave

will be normal PR interval prolonged(> 0.02 secs) QRS
normal or ≤ 0.10 sec.
 Second degree AV block: here some atrial impulses fails to
reach the ventricles.
 Mobitz type I: progressive prolongation of P-R interval and
one P wave fails to get conducted.
 Mobitz type II: 2/ more QRS complex, PR interval will be
constant and one or more P wave fails to get conducted.
 Third degree AV block: R-R interval will be regular, R-R
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varying and P-P constant. P wave will be normal but unrelated
to QRS interval.

AIVR(axillary idioventricular rhythm)

Here QRS is wide and P wave is absent, HR less than 100 if
progressed leads to ventricular tachycardia.
VENTRICULAR TACHYCARDIA
It It is a fast heart rhythm that originates in one of the ventricles of
heart. Repetitive firing of irritable ventricular ectopics focus at a
rate of 140-250 bts/ min. In ecg slurred or notched S wave will
appear with widened QRS. According to Brugada’s criteria
absence of RS complex in all precordial leads, R to S interval > 100
ms in one precordial leads, AV dissociation are the criteria to detect
VT.
PULSELESS VENTRICULAR TACHYCARDIA
Here some part of the myocardium is ischemic with some normal
part of myocardium. Here the ECG waves P, QRS, T are not
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recognizable with sharp ups and downs. There is no pulse in the
patient body.
BUNDLE BRANCH BLOCK
Left bundle branch block: ‘M’ pattern R S wave in V5-V6 and broad
QRS in I, Avl.
Right bundle branch block: ‘M’ pattern in V1-V2 and broad QRS in
lead II, III.
SINUS TACHYCARDIA
The normal sinus rhythm will be present but rate will be more than
100 beats/min. PR ≤ 0.20 sec with normal QRS interval. Metalor may
be given.

SINUS BRADYCARDIA
The patient heart rate will be less than 60 bts/min, regular PR
interval. Impulse originates at the SA node at a slow. Inj. Atropine is
given if HR goes below 50
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ATRIAL FIBRILLATION
Atrial fibrillation is the most common type of irregular heartbeat.
Atrial fibrillation causes the heart to work inefficiently so it can
reduce the person’s ability to exercise and may lead to heart failure.
Atrial fibrillation makes the blood flow inside the heart somewhat
irregular, which can cause blood clots to form there. Rate increases
and irregular R-R interval with unclear P waves. Cordarone is the
drug of choice.
ATRIAL FLUTTER
Regular rhythm is present with atrial rhythm 2-1/ 3-1 and has no
true P waves.ECG waves appear like a saw tooth pattern flutter
waves.
TORSADES DE POINTES
It starts a spindle shaped negative deflection and increasing QRS
amplitude then again end of spindles and start of node this pattern
continues. We cannot determine atrial; ventricular rate of 150-250
complexes/ min, irregular ventricular rhythm, non existent P and PR
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waves, QRS displays spindle node.
ELECTROLYTE CHANGES IN ECG
Hyperkalemia: QT interval shortened, T wave tall and peaked, ST
segment elevated.
Hypokalemia: QT interval wide T wave flattens, U wave increased,
PR interval prolonged.
ASYSTOLE
Asystole indicates heart has stopped and ECG shows a straight line.
Immediately CPR should be initiated to revert back the pa
 SUMMARY

So far we learned about the definition of ECG, its purpose is to identify heart rhythm and rate, indications like atypical chest
pain, epigastric pain, Palpitation, left side radiating chest pain, diaphoresis with chest discomfort, procedure of taking ECG like
placement of chest and limb leads, abnormalities in ecg like myocardial infarction, AV block, ventricular tachycardia, bradycardia,
asystole, axillary idioventricular rhythm, bundle branch block, atrial fibrillation, flutter, torsades pointes, electrolyte imbalances, etc.

CONCLUSION
So from this class we learn that electrocardiogram is a graphic tracing of the electrical impulses produced in the heart and
helps us to identify the abnormal heart rhythms and conduction abnormalities. It is one of the easiest, non invasive technique widely
used all over the world. Based on ECG medical treatments, shocks or other mode of treatment can be initiated. It is a very important
part of care in critical areas of hospital.

BIBLIOGRAPHY

 sr Nancy, ‘a reference manual for nurses on coronary care nursing’, published by kumar publishing house, delhi.
Pg no: 97-100
 Lewis ‘textbook of medical surgical Nursing’, second south Asian edition, published by elseviers Pg No: -1610-1620
 Joye.M. Black. Textbook of medical surgical Nursing’, 8th edition, 2010, published by elseviers pvt, Ltd, New Delhi, page No:
1571 – 1580