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Introduction: What are EKGs?
Electrocardiograms (abbreviated as EKG or ECG interchangeably) are key diagnostic tools when attempting to analyze cardiac rhythm, conduction abnormalities, and for ischemia in the heart. They may also be used to evaluate the severity of certain cardiac abnormalities (E.g. heart disease, cardiomyopathy, pericarditis, and hypertension).
Before diving into EKGs, it is imperative to refresh on the basics of cardiac conduction as well as the anatomy of the heart. The heart is composed of four different chambers with two pairs of atria and ventricles. In between the chambers of the heart there are valves which open and close based on when the atrium and ventricles are contracting.
Clinicians may evaluate the sounds of the heart to detect a heart murmur utilizing a stethoscope. The normal heart will make an iconic “lub dub” sound as it beats. The “lub” sound corresponds with the closing of the mitral and tricuspid valves at the start of systole (ventricles contracting); where the “dub” sound corresponds with the closure of the aortic and pulmonic valves.
The contraction of the heart is due to the flow of electrical conduction from the sinoatrial node (SA node), commonly called the pacemaker. The SA node fires at about 60-100 bpm in the normal healthy adult, this is called normal sinus rhythm and corresponds with the patient’s heart rate. From the SA node electricity flows into the atrioventricular node (AV node).
Occasionally the SA node may fail due to certain medical conditions – from this the AV node can become the new pacemaker which fires at 40-60 bpm. Therefore, the SA node is sometimes called the backup pacemaker. Electricity then flows into the bundle of His, then into the Purkinje fibers which is responsible for squeezing the ventricles. Purkinje fibers also contain pacemaker cells which may serve as the last backup for electrical conduction in the heart – firing at 40-60 bpm.
Reading EKGs can be challenging but proves to be an important part of daily medical practice. A firm understanding of EKGs can enable nurses and other practitioners to help detect and manage patients with cardiac abnormalities. Hopefully, reviewing this NCLEX® Review of EKGs will aid in understanding this critical aspect of practice.
How are Nurses Supposed to Read EKGs?
Reading EKGs can be a challenging process – especially when attempting to do so without training. Nevertheless, reading EKGs becomes a common practice for nurses and other clinicians every day. Electrocardiograms portray several waves that corresponds with the depolarization and contraction of different parts of the heart. Overall, the EKG monitor will reveal several waves which can be read as PQRST. The P-wave corresponds with the depolarization and squeezing of the atrium, the QRS-wave signifies squeezing of the ventricles, and the T-wave demonstrates the relaxation and repolarization of the ventricles.
To read EKGs you can use a 5-step process to guide you in assessing a patient’s cardiac condition.
Step 1: Calculate sinus rate
To determine the sinus rate, count the R peaks then multiply by 10. This will represent the number of beats per minute as the monitor will only display a few seconds worth of electrical impulses. When interpreting this information, it is important to know that the normal sinus rhythm (NSR) usually leads to 60-100 pulses per minute. Normal sinus brady represents a slow rate when < 60 bpm. Normal sinus tachy is described as > 100.
Step 2: Assess the rhythm
The rhythm should be regular and evenly spaced out between peaks. When the pattern appears to reveal abnormally spaced out pulses this may indicate the patient has an arrythmia. Here you should assess all of the waves including for the presence and regularity of the P and QRS waves.
Step 3: Assess the P-wave
Determine if the P-wave looks normal – this will get easier with practice. Abnormalities in the P-wave may suggest abnormalities with atrial depolarization. The duration that is usually observed should be <0.12 seconds.
Step 4: Assess the PR interval
The PR interval includes the P-wave as well as the PR segment. Measured from the beginning of the P-wave to the first part of the QRS complex. A normal PR interval will be shown as < 5 mini boxes with a normal reading between 0.12-0.20 seconds. PR intervals are shorter with faster heart rates signifying a sympathetically mediated upregulation of AV nodal conduction. Short PR intervals may suggest Wolff-Parkinson-White syndrome, long PR intervals may represent AV node blockage.
Step 5: Asses the QRS complex
This represents the time for the ventricles to depolarize and contract. The QRS duration normally takes 0.06-0.10 second which is not influence by heart rate. Increased voltage may indicate left or right ventricular hypertrophy.
Example Questions for NCLEX® Review for EKGs:
Test Your Knowledge
A patient presents with an EKG strip with regular QRS complexes, a PR interval of 0.14 seconds, and a QRS complex of 0.05 seconds. The heart rate came back as 70 bpm. Which of the following is an appropriate assessment for the patient’s heart rhythm?
- Sinus bradycardia
- 1st degree heart block
- Beta blocker overdose
- Normal sinus rhythm
LM is a 75-year-old female who presents with an EKG strip that reveals no P waves, a wide QRS complex, and a ventricular rate of 120 bpm. Which of the following would be an appropriate evaluation of the patient’s cardiac rhythm?
- Sinus bradycardia
- Ventricular tachycardia
- Sinus tachycardia
Common Nursing Interventions for EKGs
There are several nursing interventions to keep in mind with respect to EKG analysis. The main goal is to restore the heart to normal rhythm. There are many potential causes of EKG abnormalities so treating the underlying issues should be the primary approach. Reporting abnormalities to clinicians is also an important intervention to aid in diagnosis of cardiac abnormalities.
When patients present with a normal sinus brady (< 60bpm) there are several interventions that may be made. After confirmation of normal sinus brady the patient should be assessed for signs and symptoms of low perfusion (low oxygenation). Two key signs include pale dusty skin and cyanotic blue lips. This suggests evidence of hemodynamic instability. A key treatment for patients showing these signs is atropine. This should upregulate sympathetic tone and improve the normal sinus brady. Other potential options patients can take includes dopamine or epinephrine to improve blood flow and tissue perfusion.
It is also imperative to recognize that patients with normal sinus brady may be exhibiting these symptoms as a result of drug overdose. Certain drugs that can cause this complication are those that are negative chronotropic which decrease heart rate. Examples of medications that can achieve this effect include beta blockers, certain calcium channel blockers (e.g. verapamil, diltiazem), and digoxin. Therefore, withholding the medications that can contribute to this side effect or reducing the dose is the main intervention.
Patients that present with normal sinus tachy the main approach is to determine the underlying etiology. On rare occasions patients with sinus tachycardia may have hypotension or shock related to fluid depletion – these patients should be admitted and assessed for potential heart failure, hypoxia, or for other potential conditions. Sinus tachycardia may present in patients in patients with acute myocardial ischemia. Less severe causes of tachycardia can include fear, anxiety, or due to potential medications.
Treating patients with tachycardia often involves discontinuation or reduction in the dose of certain medications. For patients where their rhythm does not appear to be resolved through these measures – it is reasonable to initiate a trial of beta blockers. For patients with persistently symptomatic tachycardia may benefit from the addition of ivabradine which helps to further decrease heart rate. Another potential treatment includes catheter ablation where small scars are created on the heart tissue to slow the electrical signals.
Common Diseases that Impact EKGs
There are many potential diseases that can impact EKG readings. It is critical to review the types of disease states and situations that can contribute to these abnormalities.
Arrhythmias can be caused by a variety of conditions including medications, genetic abnormalities, or structural abnormalities of the heart. Certain medications may increase the odds of having an arrhythmia by prolonging the QT interval. Examples of drugs that can contribute to QT prolongation includes (antidepressants, fluoroquinolones, macrolides, antipsychotics, amiodarone, antihistamines, etc.)
Treating the arrhythmia can often be complex with multiple therapeutic considerations. Occasionally patients will not be eligible to have their arrhythmia cured so they may have their heart rate suppressed instead of rhythm correction. Rhythm correction can be achieved by either cardioversion via electrical shock or via certain medications (e.g. amiodarone).
Electrolyte imbalances can contribute to abnormalities on the EKG reading. Several electrolytes may potentially alter the conduction of the heart including potassium, sodium, calcium, and magnesium. Assessing the patient’s electrolyte levels is an important intervention to consider prior to looking for other etiologies.
EKG abnormalities are likely in patients who are having a heart attack. In these patients you can observe acute ST-elevation myocardial infarction (STEMI). It is possible for patients to be having no ST-elevation despite showing signs of a heart attack as well. Myocardial ischemia and infarction can also lead to EKG changes such as T-wave inversion.
Conclusion: NCLEX® Guide for EKGs
EKGs are a very important diagnostic tool to use when evaluating patients for many kinds of medical conditions. Reading EKGs can prove to be a complicated process that will often become easier with continued practice. This includes myocardial infarction, electrolyte imbalances, and arrhythmias. For this reason, it is imperative to refer to this NCLEX® Review for EKGs to aid in studying for the NCLEX® exam and for daily practice.
Example Questions for NCLEX® Review for EKGs:
Test Your Knowledge
A patient presents to the ER with complaints of feeling extremely tired and sluggish. Upon evaluation it is observed that the patient’s heart rate is at 45 bpm. The nurse observes that the patient has pale and dry skin with blue cyanotic lips. Which of the following medications would be correct given the patient’s condition?
A patient presents to the ER after having developed atrial fibrillation. The nurse determines a ventricular rate of 160 bpm. Which of the following should the nurse assess for?
- Drug overdose
- Nausea and vomiting
- Hypotension and dizziness
- Basic Heart Sounds. http://www.stethographics.com/main/physiology_hs_introduction.html. Accessed April 12, 2020.
- UpToDate. https://www.uptodate.com/contents/ecg-tutorial-basic-principles-of-ecg-analysis Accessed April 12, 2020.
- UpToDate. https://www.uptodate.com/contents/sinus-bradycardia April 12, 2020.
- UpToDate. https://www.uptodate.com/contents/sinus-tachycardia-evaluation-and-management April 12, 2020.
- Johnson J. Abnormal EKG: Results, causes, and treatment. Medical News Today. https://www.medicalnewstoday.com/articles/324922. Published April 9, 2019. Accessed April 12, 2020.
- UpToDate. https://www.uptodate.com/contents/arrhythmia-management-for-the-primary-care-clinician?search=arrhythmia-management-for-the-primary-care-&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Accessed April 12, 2020.