ECG Lead Placement Considerations (Nursing)

00:01 Hi, I'm Professor Lawes and I'm going to talk to you today about lead placement on an electrocardiogram. Now, this is some pretty fun stuff.

00:09 First of all, let's talk about what an ECG or EKG monitor does for us that allows you to have continuous assessment of the electrical activity that's going on in your heart.

00:20 Okay. So we put these on for patients who we're concerned about.

00:23 They might be unstable, they might be having some dysrhythmias, but we want to be able to continuously monitor the electrical activity in their heart.

00:32 Now you have to put the leads on correctly in order to get an appropriate reading.

00:37 So it's really important that you know how to do that.

00:40 And that's what we're going to talk about today.

00:42 Now, it's more common to see the five leads if you're just on a monitoring unit, but there's also a 12 lead now.

00:50 We'll get into that a little bit later.

00:51 But five lead is most likely what you're going to be in on a telemetry unit or an intensive care unit.

00:56 But if we think something else is going on, then they will do a 12 lead, which gives us even more angles about what is going on in the heart.

01:05 See, the more leads you have, the more accurate of a picture you're going to see of this complex electrical system.

01:11 So if you look at a five lead, it'll be just pretty much one lead at a time.

01:17 If you look at a 12 lead printout, you're going to see 12 different angles of electrical activity from all different sides of the body.

01:26 Okay. So keep in mind, it's really important that those leads go on correctly and firmly.

01:33 And I'm going to walk you through how to do that.

01:35 So let's talk about the kind of things that you need.

01:37 Well, you're going to need some type of monitor or machine.

01:41 If you're in a telemetry unit, they'll put a little box that they hang around their neck and they hook up the leads.

01:47 If you're in ICU, it will be a long cord that goes to a monitor unless it's wireless.

01:52 But those leads will hook up to the monitor.

01:55 So you need something that we can transmit the electrical signal to that can interpret it and put it onto a strip for us.

02:01 What do we look at that strip on a monitor or we look at it on paper.

02:05 We need a machine that's capable of doing that.

02:08 Then we need the electrodes, the things that we use to hook the patient up to the machine.

02:13 It's the electrodes that talk to the machine so we can get that detailed tracing.

02:18 So you need the machine, you need electrodes, and then we need to get the area ready.

02:23 Now, if you've ever the worst patient I've had the very first time I had to put electrodes on, he had like a sweater of fur.

02:30 He had so much hair on his chest, they just kind of hovered on his chest.

02:35 So be aware that you have to have a really good place that's clean, dry and not all fluffy where you can actually put that electrode.

02:45 So you're going to need things like alcohol swabs to clean off the skin.

02:48 You might need some gauze, you could need a razor so you can shave away some of that hair.

02:53 Otherwise it's not going to make good contact with the skin.

02:56 See, that's the goal. You need to make sure that electrode can make really tight contact with the skin and it's not going to slide off or float above because of hair.

03:06 So sometimes we'll use an electrode gel, but a lot of time the little patches that you use come with gel right in them.

03:12 But those are the types of supplies you're going to think about.

03:14 I need the electrodes that work with this machine.

03:17 I need some type of cable to hook these electrodes up to the machine.

03:22 And then I need whatever supplies it takes to have a clean, dry area to attach the electrodes. Now, last of all, be careful with those patients that are allergic to tape.

03:31 We want to make sure that that doesn't become a problem from them later.

03:35 So you might put on a little skin prep or skin barrier if you know the patient has a tape allergy. I had knee surgery.

03:42 I have minimal scarring from the knee surgery, but I have a scar this long from the tape because I have a tape allergy.

03:49 When they pulled that off, I ended up with this large scar.

03:52 So listen.

03:53 And an emergency.

03:54 This is not our top priority.

03:56 But the patient should know if they're allergic to tape.

03:58 And you can just take care in common sense when you're trying to make them as safe and comfortable as possible.

04:05 So let's get the patient ready.

04:06 Right. You're going to explain to them what you're doing.

04:08 Again, this is not in the case of an emergency.

04:11 If someone codes, you're not explaining, you're putting electrodes on them.

04:14 Right. That's just going to happen super fast.

04:16 We're talking about somebody that you can communicate with, whether they're conscious or not. Still tell them what's going on.

04:23 Hey, we're going to put some electrodes, some stickers on your chest wall so that we can keep a really close eye on your heart.

04:30 You don't have to be any more complicated than that, right? You don't need to overload the patient with information, but help them know what you're doing. Now, sometimes they're really cold, so you might prepare them for that.

04:41 Again, not the end of the world.

04:43 Make sure the patient's comfortable.

04:45 They're in a supine position.

04:46 You have privacy because remember, you're sticking things on their chest wall.

04:50 So make sure they have the privacy that's appropriate for their level of comfort.

04:55 Now, we talked about here's where you'll clean and prep the skin to make sure that those electrodes have a great.

05:00 Surface to stick to and be careful to let it dry before you put the stickers on.

05:05 You'll have much better adhesions.

05:07 So let's talk about some of the things that are a little unusual.

05:10 Right. There are some considerations that as a nurse, you want to keep in mind.

05:14 Someone may be large breasted for patients that are large breasted or patients that have gynecomastia. You're going have to be very careful to lift the breasts and place the electrode directly on the chest wall.

05:26 You don't want to put an electrode on breast tissue.

05:31 Now, a word that nobody likes is moist.

05:34 So I want you to keep in mind moisture is not your friend when it comes to electrodes doing what they're supposed to do. So again, make sure that skin is really dry before you put that electrode on. This can be a hot mess if you have a patient who is profusely sweating, you'll be constantly replacing those leads and replacing those leads.

05:53 But keep an eye on it because a lead that is not in the right place and is not secured adequately, you're going to have a mess to try and read.

06:01 You won't have an accurate reading.

06:03 So it's our job to make sure that we monitor that and we have what the patient needs.

06:08 Now, there's other things.

06:09 My mom has an implanted she's got like a double duty thing.

06:12 She has an implanted defibrillator and pacemaker.

06:15 So she's got this lump in her chest because the box is underneath her skin.

06:20 Outpatient procedure, not a big deal.

06:22 But you may see somebody who has a port who's receiving IVs or chemotherapy, might see somebody who has an implanted device like a defibrillator or a pacemaker.

06:30 Make sure that you don't put the electrode right on top of those.

06:33 Okay. That's going to mess with the conduction.

06:35 So make sure you try and get it in as close to the right spot as you can without being on top of another device.

06:43 In fact, try to get them about 1 to 2in away from any of those devices.

06:48 Okay. So we talked about three things.

06:50 Can you remember what they are, breast moisture, and implanted devices.

06:56 Those are three challenges you might run into when you're putting on electrodes.

07:00 Want to look at three more differences in age can be a real challenge.

07:05 So pediatrics, you have to make sure that you have the appropriate size electrodes so they don't swallow up their entire body.

07:11 So you want to use smaller electrodes based on the patient's size.

07:15 You want to make sure that you have the correct anatomical placement, whether it's a small pediatric patient or a full-grown adult placement.

07:23 It's really important that you use the physical landmarks we're going to tell you about. And on a little body, of course, they're going to seem like they're crowding each other and they're right up on each other.

07:31 But as long as you have the right physical landmarks, you should be fine.

07:36 So we talked about pediatrics differences in age.

07:39 There's also differences in body size.

07:41 If a patient is obese, they have extra adipose tissue.

07:45 It's harder for a clear signal to make it through into the machine.

07:49 So just keep this in mind.

07:50 It's even more important that you have meticulous skin preparation on a patient who has excess adipose tissue.

07:57 So you want to be sure that you keep an eye on that and know that sometimes it does really impact the quality of the signal that you get.

08:05 Last one talked about that man with the human sweater, chest hair or arm or wherever.

08:11 You have hair that impedes that electrode really being secure to the skin.

08:15 You're going to have to shave it and do whatever it takes to make sure you make that easy. Now, one thing about the shaving, right? Some people are not a huge fan of it, so you're going to want to explain to the patient, you know, they're not going to want big bald patches on their chest wall.

08:29 However, if you put it on top of that hair, it's going to float and we're not going to get a good picture. The other thing is when you pull that electrode off a hairy chest, it's like having your chest waxed.

08:40 So nobody wants that.

08:43 So if they're giving you a little bit of a difficult time, like they don't want that, just explain to them, hey, we're trying to make this more comfortable for you when we do remove them and we want to get the most accurate picture so you don't have to wear these as long we can get the information that we need.

08:57 Just some tricks you can use when you're talking with them.