EKG Strips

[pagandeva2000, LPN]

I will be taking my telemetry test probably on Thursday, for those that remembered that I am pursuing this. I have been looking at my books, reviewing EKGs in my mind, and finally, after getting back from my too short vacation, I sent a file to the med surg staff educator of my certificates in interpetation of basic and 12 lead EKGs.

Today, I was looking at an EKG with a doctor and she asked me to interpet it since I told her that I took the class. I am finding that the 'live' EKGs look far different from what I have been studying. I noticed the ischemic changes in the EKG, but that was about it. She told me that I was basically correct, but, I am a bit worried that I may not be able to really pick up a problem on a real monitor when the time is right. She mentioned a few other things that were not obvious to me at all. Currently, I have been running through my head the criteria for certain strips, for example a wandering pacemaker is identified with at least 3 different P waves, and basically all of the ones that I see in my textbook. I am hoping that I won't get too confused when the time actually comes. I remember the instructor telling us when I took the class that the real EKGs will show several problems at once.

Did you all find that? Did it take a bit of time to really recognize the EKGs enough to properly interpet if there is a problem? Or is it that we are looking for things such as heart blocks, tachycardia, ventricular rhythms, etc... and, will it be a bit easier for me to see it? Do I have to identify ALL of the problems, or a main one? I am not that worried about the actual exam that they will give. I just don't want to be a horrible pest asking nurses over and over again "Is this dangerous...okay, now, what about this one?". Since I will be a per diem nurse there specifically for the monitors, I don't know how often I will be up there, and if I will have enough practice. And, of course, because I will be per diem, they may expect me to be up and running. I told them that I would sit with a nurse for a day or two as a volunteer so that I can get the feel of it. I really want to do this; I find EKGs to be so interesting!! I just want to be a help, not a hinderance.

Any help would be appreciated!

[Virgo_RN, BSN, RN]

Typically when someone is admitted to my unit, they've had a twelve lead EKG in the ED and the cardiologist has already seen it. The cardiologist is already aware of the patient's rhythm and has written orders addressing it, and they are on my floor for the purpose of treatment and/or observation.

What I am usually looking for is changes; if the rhythm starts doing something different from what it's been doing. For example, if a patient is admitted with A Fib with RVR, the cardiologist knows this and prescribes a medication. I administer the meds and monitor the patient's rhythm for a response. If the patient is admitted with chest pain and had a normal EKG, when they have an episode of chest pain, I'm taking pulse and BP and giving nitro, and checking for ST changes. If the patient comes in throwing triplets and couplets, I'll be watching to see if they're unifocal or multifocal, or if they become more frequent, or if they start having runs. If I see anything that seems suspicious, I compare it to their previous twelve lead in their chart to see if there has been a change, or if it looks the same.

I'm really fortunate to work with a monitor tech who reliably calls if she sees anything noteworthy. Because I can count on her, I don't have to be glued to the monitors myself. She can look through the trend for the day and tell me if the rhythm has done this before, how frequently, and if it's getting more or less frequent.

You'll get a sense of what you're looking for as you gain experience on the floor. Right now, just focus on your basic recognition of rhythms. It sounds like you're doing just fine!

[OC_An Khe]

EKG reading takes time and expirience. Don't be concerned about not picking up on subtle nuances when you have just completed the course. Just remember if you have doubts ask someone more expirienced then you. In fact the best way to learn now is have some one else double check your interpertation. In my expirience RNs do this as a matter of routines.

[Spatialized]

It's all about time and practice. There are differences though between 12-leads and rhythm strips.

In 12-leads, yes you can have multiple things going on, but the biggest thing as nurses we're looking for are ischemic changes. Yes, you may be able to point out left ventricular hypertrophy, or bilateral atrial enlargement, but you better be able to spot ischemic changes - those are what are going to make the most difference in the patient's life at the moment. Sure the other things inside the 12-lead can explain some things related to presentation, but they're not an urgent matter, ST elevation is.

For rhythm strips, that's what you're looking at: the rhythm. Know inside and out your "bad" rhythms: VTach, VFib, Torsades, 3rd degree heart block, AFib w/RVR, the rhythms where your patient is not perfusing well. Then know what to do - hint: ACLS will help greatly! If things start changing on the strips, start asking yourself what could be causing this? Say, like above the patient starts throwing couplets, triplets and has increased ventricular ectopy. What should you be asking yourself? How are the vitals? How's the K and Mag? Go through the things that contribute to ectopy. But first, look at your patient. Are they warm, pink and breathing? If so, should you be worried?

One of the biggest things to learn is when to treat the patient and when to treat the monitor. It takes time. I've been at this for over 2 years and still have issues in spite of being and EKG nerd . Hopefully though you can ask questions, at least to say, "Am I seeing something here?" Another set of eyes and a fresh perspective makes all the difference in the world.

Cheers,

Tom

[pagandeva2000, LPN]

Thank you all so much. So, basically, you guys are saying that there is a difference in what you would see in a 12 lead, but in the rhythm strips, we are looking for the bad guys, such as 3rd degree heart block, v-tach, v-fib, tosades de pointes, etc. So, I would be looking more at strips than I would be at a 12 lead, but, if there is a problem, the doctor may want another 12 lead done, anyhow. I feel a bit better!

[Virgo_RN, BSN, RN]

Yes, on a twelve lead, you're primarily looking for ST changes. ST changes don't always show up on a strip, because a strip is just one lead. You have to look at all the leads in that case. Our monitor system allows us to pull up a twelve lead in real time. It's not really a twelve lead, we have only five electrodes, but the computer does some kind of algorhythm that extrapolates all the information it's getting from the five leads into what it would look like on a twelve lead, if that makes sense. The monitor system will also alarm if it detects ST elevations.

Another good point raised above is treating the patient, not the monitor. For example, sometimes the monitor will alarm "V Tach", and you go in to check the patient, they're pink and warm, blood pressure and pulse are WNL, and it turns out that maybe they were just trying to get comfortable in bed or something, jerking the electrodes around, which the monitor can interpret in many different ways. Sometimes, if a person has a pacemaker, and their native beats are coming through, the monitor might interpret that as PVCs, or I've even seen the monitor interpret it as V Tach.

It's important to be able to read rhythm strips, but it's equally important to assess the patient and be able to determine if something is really going on that you should be worried about.

You can't know all of that yet. You learn by getting out there on the floor.

I'm really excited for you!

[pagandeva2000, LPN]

I'm excited too. I will just be doing this per diem, so, I will not be a regular on that floor, but I was always interested in EKGs, in fact, fascinated by them. I do know that we have to check the patient before we go nuts, but I just wanted to be sure that I can understand what the strips are saying. It seems to me that from my textbook, they look one way (the strips), but seeing them live looks far different. I was told that on the 12 lead, at the bottom, lead II shows the rhythm strip. Do you think that for practice in my clinic (the aides do 12 leads very often), I should focus on lead II? I was thinking about printing some of the EKGs that don't have names on them for practice on my own. Thanks again!

[aeauooo]

Don't forget that, like any other medical technology, EKGs are nothing but a diagnostic tool. Your clinical assessment of your patient is often more important than what you can find with the technology.

I've been in situations where a patient's rhythm converts to V-tach - true V-tach, not artifact - and someone wants to shock the patient immediately without realizing that he is awake, alert, and without complaint - which wouldn't be the case if someone put electricity through his chest!

Treat the patient, not the monitor.

[pagandeva2000, LPN]

I'll see what the actual role of the LPN is regarding monitoring the strips in that unit after I take my test. From what I am hearing, they usually sit at the monitors, observe for changes, and if there is a change, an alarm may go off. I am to go and observe the patient, then, tell the RN of my observations. If there are differences between what is happening earlier versus what I see, I have to go to the patient, too. I am sure that I would have to administer oxygen and CPR if needed as well. I did tell them I would volunteer to sit with another nurse for a day or two to observe their routine, learn their expectations and take some serious notes. I also hear that the monitors cannot be left alone; someone has to relieve you at all times, and a book has to be signed stating who relieved who and for how long. I'll keep you all posted as it occurs.