5-Wire Telemetry. Which lead tracing do I interpret?

  1. I'm a novice at reading telemetry strips. I'm mostly self taught but also took an intro course. If given a given 6 second strip, I'll analyze for about half a minute and I usually get the interpretation right. But my question is this, on a 5-wire telemetry, what lead am I supposed to interpret and WHY?

    I've searched forums and there seems to be emphasis on lead placement...I don't need to know about WHERE to place the leads. I'm not concerned with 12 lead interpretation either, I'm not responsible for 12 lead stuff on my unit (yah yah, I know it's "good to know" but that's not what I'm asking). I just want to know why a tracing from Lead I looks quite different than a tracing from Lead II.

    Yesterday, I saw SVT on the monitor of a telemetry patient and this was reading on lead II. Switched it to lead I and it suddenly looked like VTach?

    1) What lead should I read on a 5-wire telemetry?
    2) Why does the tracing look so different from Lead I vs Lead II, etc?

    Any input would be appreciated.
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  2. 15 Comments

  3. by   SierraBravo
    1. It depends on which area of the heart you want to look at.

    2. Each lead looks at the heart from a different position (i.e. II, III, and aVF look at the inferior part of the heart, V1-V4 look at the antero-septal area of the heart, etc...).
  4. by   winzer
    Thanks! That sums it up nicely.

    So, depending on what "direction" the leads are looking, is it possible for one part of the heart to display a tracing that looks like SVT in one lead but another part of the heart to trace a VTACH when looking from a different lead? How would that even be interpreted? "Oh, well the patient is having VTACH in lead I but that's OK, because it looks like SVT in lead II..."

    Sorry, I'm just frustrated
  5. by   HouTx
    Your organization will have a policy that guides nursing practice. If not, it needs to be created. Most policies contain specific guidelines; 'rhythm monitor' lead is usually determined by the patient's underlying issues. For instance, in the PP's previous example, aVF may be used if the patient has suffered an inferior MI. The 'chosen' lead should be clearly documented & used by everyone... if a strip from another lead is run, that lead needs to be documented on the strip so that everyone will know & not jump to any bizarre conclusions.
  6. by   icuRNmaggie
    Dysrhythmia Monitoring

    There is a link here to the pdf of the AACN practice alert.
  7. by   winzer
    Thanks a lot for the prompt response guys! This clears things up a bit.

    This issue, especially the one discussed on the AACN website, adds a bit of complexity to my (mis) understanding.
  8. by   FitNurseTrish
    My favorite is lead II because if there are p waves that's where I can find them Its a positive lead so the tracings usually look nice and pretty
  9. by   Okami_CCRN
    I usually use lead II as p waves and QRS complexes tend to be upright. If my patient is doing something funky I tend to look at another lead just to confirm what they are doing or even a 12-lead EKG.

    It's important to know which how each lead interprets the electrical activity because the p wave my be inverted on one lead and that may be a normal appearance and not junctional at all.
  10. by   hherrn
    If you are actually choosing leads, you are already ahead of a lot of telemetry nurses. Many couldn't monitor v6 if asked. Many believe there is a "V Lead", and it sits in the middle of the chest. (Same applies to ER, and less frequently, ICU.)

    Most nurses don't even know the difference between a lead and an electrode. This confusion is actually furthered by the AACN literature, as well as anything else that refers to a "5 lead system", or a "3 lead system".

    A lead is a view of the heart. It looks at the electrical pathway from a particular direction of travel.

    There are 12 leads commonly used to monitor the heart. There are a bunch of other leads occasionally used, including v4r, v7-9.

    Most of us use a 5 electrode system, sometimes called a 5 lead system. At any given time, the "5 lead" system can display any of 7 leads. I, II, III, AVL, AVF, AVR, and a choice of v leads.

    As a nurse, you can choose which v lead the machine will be monitoring by choosing the placement of the precordial (brown) electrode. You can then choose any of 7 leads for the machine to display. Often, you can choose for the machine to display 2 leads at once.

    Most nurses don't really care which lead are monitored or displayed. The overwhelming majority of the time, any lead shows us what we want to know: too fast, too slow, or not beating. But, when you r monitor alarms V-tach, it sure would be nice to know that the patient has a rate dependent bundle branch block. Or, if you knew your patient had had an event resulting in some ischemia to the lateral wall of the heart, you might really want to watch v6 for elevation.

    It cool stuff to know, and fun to learn. I am not an expert b any means, but I enjoy studying the stuff, and periodically pick up on an important change in patient condition.
  11. by   MendedHeart
    Ive been taught to go with Lead II for initial interpretation and measurements and is our protocol for QT and QTcs
  12. by   ms.minchin
    can you see ST elevation on a 5 lead system?
  13. by   Lev <3
    Quote from ms.minchin
    can you see ST elevation on a 5 lead system?
    Yes you can. However, it will not show the whole picture.
  14. by   Mel24522
    Lead II will not show ST elevation. We are told to measure in lead II but monitor in lead III.

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