Cardiology

Self Learning
Package

Module 2: Understanding a 12 lead ECG,

Basic Electrophysiology and 12
lead ECG Placement
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Page 1
 CONTENT

Introduction……………………………………………………………………………………….Page 3

How to use the ECG Self Learning Package………………………………………………..Page 4

ABC of Clinical Electrocardiography…………………………………………………..…….Page 5

(Introduction – I – Leads, Rate, Rhythm & Cardiac Axis)

ABC of Clinical Electrocardiography………………………………………………..……….Page 9

(Introduction – II – Basic Terminology)

Understanding the 12 Lead ECG (Part 1)………………………………………..…………Page 13

Understanding the 12 Lead ECG (Part 2)………………………………………..…………Page 19

Precordial Electrodes Placement in Women………………………………………………Page 25

Taking a Quality 12 Lead ECG……………………………………………………………….Page 30

References………………………………………………………………………………………Page 32

Module 2 Questions……………………………………………………………………………Page 33

Module 2 Evaluation…………………………………………………………………………...Page 35

Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 2
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
 INTRODUCTION

Welcome to the ECG self learning package: Module 2. The electrocardiogram (ECG) is a
diagnostic tool that measures and records the electrical activity of the heart in exquisite detail.
This process checks for problems with the electrical activity of the heart. An ECG translates the
heart's electrical activity into line tracings on paper and interpretation of these details allows
diagnosis of a wide range of heart conditions. These conditions can vary from minor to life
threatening. This package covers basic electrophysiology and 12 lead electrode placements.

The goal of this module is to review:

Principles of electrophysiology
The normal ECG complex
Basic ECG interval measurements
Measuring heart rate

This module will form the foundation of your ECG knowledge and enable you to understand the
components of the normal ECG. You cannot learn the abnormal without first understanding the
normal.

Learning outcomes form this module are:

To state the measurements of ECG graph paper

To identify the waveform components of the normal PQRST complex
To state the normal PR interval measurement
To state the normal QRS width measurement
To describe three methods of measuring heart rate using ECG paper
How to record a 12 lead ECG
How to place a patient on telemetry.

Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 3
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
 HOW TO USE THE ECG SELF-LEARNING PACKAGE

Follow these steps to complete the self-learning module:

1) Complete the pre reading at the start:

ABC of clinical electrocardiography: Introduction. I-lead, rate, rhythm and cardiac axis.
ABC of clinical electrocardiography: Introduction. II-Basic terminology.
Understanding the 12 Lead ECG (Part 1).
Understanding the 12 Lead ECG (Part 2).
Precordial Electrodes Placement in Women.
Taking a Quality ECG.

2) Complete the multi-choice question and evaluation, then return to the Cardiology
CNE/CNS

Following the completion of this module you will receive 6 hours professional development
time, which will be credited to your individual training database.

Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 4
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 5
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 6
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 7
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 8
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 9
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 10
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 11
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 12
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 13
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 14
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 15
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 16
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 17
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 18
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 19
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 20
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 21
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 22
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 23
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 24
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 25
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 26
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 27
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 28
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 29
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 30
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 31
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
References

Aehlert, B 2006, ECGs Made Easy, 3rd edn, Mosby Elsevier, Missouri.American College of
Cardiology/American Heart Association.

Conover, B 2003, Understanding Electrocardiography, 8th edn, Mosby Elsevier, Missouri.

Dubin, D 2000, Rapid Interpretation of EKGs, 6th edn, Cover publishing Company, Florida.

Hatchett, R. & Thompson, D. (ed) 2007, Cardiac Nursing: A Comprehensive Guide, 2nd edn,
Churchill Livingstone Elsevier, London.

Huszar, R 2002, Pockrt Guide to Basic Dysrhythmias; Interpretations & Management, 3rd edn,
Mosby Elsevier, Missouri.

Woods, S, Froelicher, E, Motzer, S & Bridges, E 2005, Cardiac Nursing, 5th edn, Lippincott
Williams & Wilkins, Philadelphia.

Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 32
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
Name: …………………………………………………………………… Date:…………………………
Ward/Unit:…………………………………………………………….

Module 2: Understanding a 12 Lead ECG, Basic Electrophysiology and 12 lead ECG placement.
Questions:
1. The normal heartbeat is initiated in the 9. Which represents left axis deviation?
a. SA node. c. bundle of His. a. QRS complex positive in leads I and aVF
b. AV node. d. Purkinje fibers. b. QRS complex negative in leads I and aVF
c. QRS complex positive in lead I and
2. The structure that briefly delays an negative in lead aVF
impulse (to let the ventricles fill) is the d. QRS complex negative in lead I and
a. SA node. c. bundle of His. positive in lead aVF
b. AV node. d. Purkinje fibers.
10. Left axis deviation can be caused by
3. The QRS represents a. pulmonary embolism.
a. atrial repolarization. b. right ventricular hypertrophy.
b. atrial depolarization. c. chronic obstructive pulmonary disease.
c. ventricular depolarization. d. an inferior-wall MI.
d. ventricular repolarization.
11. Which of the following leads view the
4. Which QRS duration indicates a bundlebranch horizontal plane of the heart?
block? a. V1 through V6
a. 0.04 second c. 0.10 second b. I, II, III
b. 0.08 second d. 0.14 second c. aVR, aVL, aVF
d. I, II, III, aVR, aVL, aVF
5. The T wave represents
a. atrial depolarization. 12. Which chest lead is placed at the right
b. atrial repolarization. sternal border, fourth intercostal space?
c. ventricular depolarization. a. lead V1 c. lead V3
d. ventricular repolarization. b. lead V2 d. lead V4

6. Which reveals information about the 13. R-wave progression refers to the QRS
heart’s oxygenation status? complex becoming progressively more
a. PR interval c. ST segment a. positive from lead I to lead III.
b. QT interval d. QRS complex b. positive from lead aVR to lead aVF.
c. positive from lead V1 to V6.
7. Electrical energy generated during d. negative from lead V1 to V6.
depolarization is called
a. an axis. c. axis deviation. 14. Myocardial injury generally is represented
b. a vector. d. the cardiac cycle. by an ST segment that is

8. Which of the following represents a. above the baseline.

normal axis? b. level with the baseline.
a. QRS complex positive in leads I and aVF c. below the baseline.
b. QRS complex negative in leads I and aVF d. isoelectric.
c. QRS complex positive in lead I and negative in
lead aVF 15. On the horizontal axis, a small box on
d. QRS complex negative in lead I and positive in ECG paper is equal to
lead aVF a. 0.04 second. c. 0.1 millivolt.
b. 0.1 second. d. 1 mm.

Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 33
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
16. A bundle-branch block occurs when 24. An anterioseptal MI would have ST
one of two bundle branches can’t conduct elevation in leads
cardiac impulses to the a. V1 and V2 only. c. V5 and V6 only.
a. atria. c. myocardial cells. b. V3 and V4 only. d. V1 through V4.
b. bundle of His. d. atrioventricular node.
25. Which isn’t a possible cause of sinus
17. The most common cause of a chronic bradycardia?
bundle-branch block is a. atropine
a. ischemic heart disease. b. beta-blockers
b. an acute MI. c. acute MI
c. an acute coronary syndrome. d. a well-conditioned heart
d. trauma to one of the bundle branches.
26. Sinus tachycardia usually is related to
18. In addition to a QRS complex wider a. medications.
han 0.12 second, which ECG abnormality b. an MI.
is a key indicator of an RBBB? c. a physiologic cause.
a. a negative R wave in lead V1 d. a posterior-wall MI.
b. a positive R wave in lead V3
c. a negative R wave in lead V3 27. One hallmark of AF is
d. a positive main R wave in lead V1 a. a regularly irregular rhythm.
b. a prolonged QRS complex.
19. Which is one of the earliest changes c. an irregularly irregular rhythm.
indicative of reversible myocardial d. a prolonged PR interval.
injury?
a. QT prolongation 28. Atrial contraction just before ventricular
b. Q-wave deepening contraction is called
c. ST-segment elevation a. atrial kick. c. synchrony.
d. PR interval shortening b. repolarization. d. f waves.

20. Which leads view the inferior wall of 29. Which medication may be used to
the heart? treat AF?
a. V1 through V6 c. I and aVL a. digoxin c. captopril
b. I, II, and III d. II, III, and aVF b. atropine d. diltiazem

21. Elevated ST segments in V1 and V2 30. Premature ventricular contractions

indicate which type of MI? are characterized by wide, abnormal
a. anterior wall c. lateral wall a. QRS complexes. c. P waves.
b. septal wall d. inferior wall b. U waves. d. T waves.

22. Which heart wall is perfused by the 31. If your patient is in pulseless VT,
circumflex branch of the left coronary which action would you take first?
artery? a. Call the rapid response team.
a. lateral c. anterior b. Obtain a stat 12-lead ECG.
b. inferior d. septal c. Call a code – (arrest code/green button).
d. Ensure adequate vascular access.
23. A patient with ST-segment elevation
in leads I, aVL, V5, and V6 may have
a. an anterior-wall MI.
b. an inferior-wall MI.
c. a lateral-wall MI.
d. ischemic heart disease.
Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 34
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.
 EVALUATION FORM

Topic: Module 2: Understanding a 12 lead ECG, Basic Electrophysiology and 12 Lead ECG Placement.

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Module 2: Understanding a 12 lead ECG, Basic Electrophysiology & 12 lead ECG placement Page 35
Developed by Tony Curran (Clinical Nurse Educator) & Gill Sheppard (Clinical Nurse Specialist) Cardiology.