12/24/13

Using an External (Transcutaneous) Pacemaker

Goal: The equipment is applied correctly without adverse effect to the patient; and the patient regains signs of circulation, including the capture of at least the minimal set heart rate.

1. Bring necessary equipment to the bedside stand or overbed table.

2. Perform hand hygiene and put on PPE, if indicated.

3. Identify the patient.

4. If the patient is responsive, explain the procedure to the patient. Explain that it involves some discomfort and that you will administer medication to keep him or her comfortable and help him or her to relax. Administer analgesia and sedation, as ordered, if not an emergency situation.

5. Close curtains around bed and close the door to the room, if possible.

6. If necessary, clip the hair over the areas of electrode placement. Do not shave the area.

7. Attach cardiac monitoring electrodes to the patient in the lead I, II, and III positions. Do this even if the patient is already on telemetry monitoring. If you select the lead II position, adjust the LL (left leg) electrode placement to accommodate the anterior pacing electrode and the patient’s anatomy.

8. Attach the patient monitoring electrodes to the ECG cable and into the ECG input connection on the front of the pacing generator. Set the selector switch to the ‘Monitor on’ position.

9. Note the ECG waveform on the monitor. Adjust the R-wave beeper volume to a suitable level and activate the alarm by pressing the ‘Alarm on’ button. Set the alarm for 10 to 20 beats lower and 20 to 30 beats higher than the intrinsic rate.

10. Press the ‘Start/Stop’ button for a printout of the waveform.

11. Apply the two pacing electrodes. Make sure the patient’s skin is clean and dry to ensure good skin contact. Pull the protective strip from the posterior electrode (marked ‘Back’) and apply the electrode on the left side of the thoracic spinal column, just below the scapula.

12. Apply the anterior pacing electrode (marked ‘Front’), which has two protective strips—one covering the gelled area and one covering the outer rim. Expose the gelled area and apply it to the skin in the anterior position, to the left side of the sternum in the usual V2 to V5 position, centered close to the point of maximal cardiac impulse. Move this electrode around to get the best waveform. Then expose the electrode’s outer rim and firmly press it to the skin.

13. Prepare to pace the heart. After making sure the energy output in milliamperes (mA) is on 0, connect the electrode cable to the monitor output cable.

14. Check the waveform, looking for a tall QRS complex in lead II.

15. Check the selector switch to ‘Pacer on.’ Select synchronous (demand) or asynchronous (fixed-rate or nondemand) mode, per medical orders. Tell the patient he or she may feel a thumping or twitching sensation. Reassure the patient you will provide medication if the discomfort is intolerable.

16. Set the pacing rate dial to 10 to 20 beats higher than the intrinsic rhythm. Look for pacer artifact or spikes, which will appear as you increase the rate. If the patient does not have an intrinsic rhythm, set the rate at 80 beats/minute (Craig, 2005).

17. Set the pacing current output (in milliamperes [mA]). For patients with bradycardia, start with the minimal setting and slowly increase the amount of energy delivered to the heart by adjusting the ‘Output’ mA dial. Do this until electrical capture is achieved: you will see a pacer spike followed by a widened QRS complex and a tall broad T wave that resembles a premature ventricular contraction.

18. Increase output by 2 mA or 10%. Do not go higher because of the increased risk of discomfort to the patient.

19. Assess for mechanical capture: Presence of a pulse and signs of improved cardiac output (increased blood pressure, improved level of consciousness, improved body
temperature).

20. For patients with asystole, start with the full output. If capture occurs, slowly decrease the output until capture is lost, then add 2 mA or 10% more.

21. Secure the pacing leads and cable to the patient’s body.

22. Monitor the patient’s heart rate and rhythm to assess ventricular response to pacing. Assess the patient’s vital signs, skin color, level of consciousness, and peripheral pulses. Take blood pressure in both arms.

23. Assess the patient’s pain and administer analgesia/sedation, as ordered, to ease the discomfort of chest wall muscle contractions (Craig, 2005).

24. Perform a 12-lead ECG and additional ECG daily or with clinical changes.

25. Continually monitor the ECG readings, noting capture, sensing, rate, intrinsic beats, and competition of paced and intrinsic rhythms. If the pacemaker is sensing correctly, the sense indicator on the pulse generator should flash with each beat.

26. Remove PPE, if used. Perform hand hygiene.
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Performing Emergency Manual External Defibrillation (Asynchronous)

Goal: The procedure is performed correctly without adverse effect to the patient; and the patient regains signs of circulation.

1. Assess responsiveness. If the patient is not responsive, call for help and pull call bell, and call the facility emergency response number. Call for the AED. Put on gloves, if available. Perform cardiopulmonary resuscitation (CPR) until the defibrillator and other emergency equipment arrive.

2. Turn on the defibrillator.

3. If the defibrillator has “quick-look” capability, place the paddles on the patient’s chest. Otherwise, connect the monitoring leads of the defibrillator to the patient and assess the cardiac rhythm.

4. Expose the patient’s chest, and apply conductive pads at the paddle placement positions. For anterolateral placement, place one pad to the right of the upper sternum, just below the right clavicle, and the other over the fifth or sixth intercostal space at the left anterior axillary line. ‘Hands-free’ defibrillator pads can be used with the same placement positions, if available. For anteroposterior placement, place the anterior paddle directly over the heart at the precordium, to the left of the lower sternal border. Place the flat posterior paddle under the patient’s body beneath the heart and immediately below the scapulae (but not on the vertebral column).

5. Set the energy level for 360 J (joules) for an adult patient when using a monophasic defibrillator. Use clinically appropriate energy levels for biphasic defibrillators, beginning with 150 to 200 J (AHA, 2005b).

6. Charge the paddles by pressing the charge buttons, which are located either on the machine or on the paddles themselves.

7. Place the paddles over the conductive pads and press firmly against the patient’s chest, using 25 pound (11 kg) of pressure. If using hands-off pads, do not touch the paddles.

8. Reassess the cardiac rhythm.

9. If the patient remains in VF or pulseless VT, instruct all personnel to stand clear of the patient and the bed, including the operator.

10. Discharge the current by pressing both paddle charge buttons simultaneously. If using remote defibrillator pads, press the discharge or shock button on the machine.

11. After the shock, immediately resume CPR, beginning with chest compressions. After five cycles (about 2 minutes), reassess the cardiac rhythm. Continue until advanced care providers take over, the patient starts to move, you are too exhausted to continue, or a physician discontinues CPR. Advanced care providers will indicate when a pulse check or other therapies are appropriate.

12. If necessary, prepare to defibrillate a second time. Energy level on the monophasic defibrillator should remain at 360 J for subsequent shocks (AHA, 2005b).

13. Announce that you are preparing to defibrillate and follow the procedure described above.

14. If defibrillation restores a normal rhythm:
a. Check for signs of circulation; check the central and peripheral pulses, and obtain a blood pressure reading, heart rate, and respiratory rate.
b. If signs of circulation are present, check breathing. If breathing is inadequate, assist breathing. Start rescue breathing (one breath every 5 seconds).
c. If breathing is adequate, place the patient in the recovery position. Continue to assess the patient.
d. Assess the patient’s level of consciousness, cardiac rhythm, breath sounds, and skin color and temperature.
e. Obtain baseline ABG levels and a 12-lead ECG, if ordered.
f. Provide supplemental oxygen, ventilation, and medications, as needed.

15. Check the chest for electrical burns and treat them, as ordered, with corticosteroid- or lanolin-based creams. If using ‘hands-free’ pads, keep pads on in case of recurrent ventricular tachycardia or ventricular fibrillation.

16. Remove gloves, if used. Perform hand hygiene.

17. Prepare the defibrillator for immediate reuse.
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Performing Emergency Automated External Defibrillation

Goal: The defibrillation is performed correctly without adverse effect to the patient, and the patient regains signs of circulation, with organized electrical rhythm and pulse.

1. Assess responsiveness. If the patient is not responsive, call for help and pull call bell, and call the facility emergency response number. Call for the AED. Put on gloves, if available. Perform cardiopulmonary resuscitation (CPR) until the defibrillator and other emergency equipment arrive.

2. Prepare the AED. Power on the AED. Push the power button. Some devices will turn on automatically when the lid or case is opened.

3. Attach AED connecting cables to the AED (may be preconnected). Attach AED cables to the adhesive electrode pads (may be preconnected).

4. Stop chest compressions. Peel away the covering from the electrode pads to expose the adhesive surface. Attach the electrode pads to the patient’s chest. Place one pad on the upper right sternal border, directly below the clavicle. Place the second pad lateral to the left nipple, with the top margin of the pad a few inches below the axilla.

5. Once the pads are in place and the device is turned on, follow the prompts given by the device. Clear the patient and analyze the rhythm. Ensure no one is touching the patient. Loudly state a “Clear the patient” message. Press ‘Analyze’ button to initiate analysis, if necessary. Some devices automatically begin analysis when the pads are attached. Avoid all movement affecting the patient during analysis.

6. If ventricular tachycardia or ventricular fibrillation is present, the device will announce that a shock is indicated and begin charging. Once the AED is charged, a message will be delivered to shock the patient.

7. Before pressing the ‘Shock’ button, loudly state a “Clear the patient” message. Visually check that no one is in contact with the patient. Press the ‘Shock’ button. If the AED is fully automatic, a shock will be delivered automatically.

8. Immediately resume CPR, beginning with chest compressions. After five cycles (about 2 minutes), allow the AED to analyze the heart rhythm. If a shock is not advised, resume CPR, beginning with chest compressions. Do not recheck to see if there is a pulse. Follow the AED voice prompts. Continue until advanced care providers take over, the patient starts to move, you are too exhausted to continue, or a physician discontinues CPR. Advanced care providers will indicate when a pulse check or other therapies are appropriate (AHA, 2006,).

9. Remove gloves, if used. Perform hand hygiene.
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Performing Cardiopulmonary Resuscitation (CPR)

Goal: CPR is performed effectively without adverse effect to the patient.

1. Assess responsiveness. If the patient is not responsive, call for help, pull call bell, and call the facility emergency response number. Call for the automated external defibrillator (AED).

2. Put on gloves, if available. Position the patient supine on his or her back on a firm, flat surface, with arms alongside the body. If the patient is in bed, place a backboard or other rigid surface under the patient (often the footboard of the patient’s bed).

3. Use the head tilt–chin lift maneuver to open the airway. Place one hand on the victim’s forehead and apply firm, backward pressure with the palm to tilt the head back. Place the fingers of the other hand under the bony part of the lower jaw near the chin and lift the jaw upward to bring the chin forward and the teeth almost to occlusion. If trauma to the head or neck is present or suspected, use the jaw-thrust maneuver to open the airway. Place one hand on each side of the patient’s head. Rest elbows on the flat surface under the patient, grasp the angle of the patient’s lower jaw, and lift with both hands.

4. Look, listen, and feel for air exchange. Take at least 5 seconds and no more than 10 seconds (AHA, 2006).

5. If the patient resumes breathing or adequate respirations and signs of circulation are noted, place the patient in the recovery position.

6. If no spontaneous breathing is noted, seal the patient’s mouth and nose with the face shield, one-way valve mask, or Ambu-bag (handheld resuscitation bag), if available. If not available, seal the patient’s mouth with rescuer’s mouth.

7. Instill two breaths, each lasting 1 second, making the chest rise.

8. If you are unable to ventilate or the chest does not rise during ventilation, reposition the patient’s head and reattempt to ventilate. If still unable to ventilate, begin CPR. Each subsequent time the airway is opened to administer breaths, look for an object. If an object is visible in the mouth, remove it. If no object is visible, continue with CPR.

9. Check the carotid pulse, simultaneously evaluating for breathing, coughing, or movement. This assessment should take at least 5 seconds and no more than 10 seconds. Place the patient in the recovery position if breathing resumes.

10. If patient has a pulse, but remains without spontaneous breathing, continue rescue breathing at a rate of one breath every 5 to 6 seconds, for a rate of 10 to 12 breaths per minute.

11. If the patient is without signs of circulation, position the heel of one hand in the center of the chest between the nipples, directly over the lower half of the sternum. Place the other hand directly on top of the first hand. Extend or interlace fingers to keep fingers above the chest. Straighten arms and position shoulders directly over hands.

12. Perform 30 chest compressions at a rate of 100 per minute, counting “one, two, etc.” up to 30, keeping elbows locked, arms straight, and shoulders directly over the hands. Chest compressions should depress the sternum 11⁄2 to 2 inches. Push straight down on the patient’s sternum. Allow full chest recoil (re-expand) after each compression.

13. Give two rescue breaths after each set of 30 compressions. Do five complete cycles of 30 compressions and two ventilations.

14. Defibrillation should be provided at the earliest possible moment, as soon as AED becomes available. Refer to Skill 16-6: Automated External Defibrillation and Skill 16-7: Manual External Defibrillation.

15. Continue CPR until advanced care providers take over, the patient starts to move, you are too exhausted to continue, or a physician discontinues CPR. Advanced care providers will indicate when a pulse check or other therapies are appropriate (AHA, 2006,).

16. Remove gloves, if used. Perform hand hygiene.
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Removing Arterial and Femoral Lines

Goal: The line is removed intact and without injury to the patient.

1. Verify the order for removal of arterial or femoral line in the patient’s medical record.

2. Gather all equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Explain the procedure to the patient.

6. Ask the patient to empty his or her bladder. Maintain an IV infusion of normal saline via another venous access during the procedure, as per medical orders or facility guidelines.

7. If the bed is adjustable, raise it to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009).

8. Put on clean gloves, goggles, and gown.

9. If the line being removed is in a femoral site, use Doppler ultrasound to locate femoral artery 1 to 2 inches above the entrance site of the femoral line. Mark with ‘X’ using indelible pen.

10. Turn off the monitor alarms and then turn off the flow clamp to the flush solution. Carefully remove the dressing over the insertion site. Remove any sutures using the suture removal kit; make sure all sutures have been removed.

11. Withdraw the catheter using a gentle, steady motion. Keep the catheter parallel to the blood vessel during withdrawal. Watch for hematoma formation during catheter removal by gently palpating surrounding tissue. If hematoma starts to form, reposition your hands until optimal pressure is obtained to prevent further leakage of blood.

12. Immediately after withdrawing the catheter, apply pressure 1 or 2 inches above the site at the previously marked spot with a sterile 4 4 gauze pad. Maintain pressure for at least 10 minutes, or per facility policy (longer if bleeding or oozing persists). Apply additional pressure to a femoral site or if the patient has coagulopathy or is receiving anticoagulants.

13. Assess distal pulses every 3 to 5 minutes while pressure is being applied. Note: dorsalis pedis and posterior tibial pulses should be markedly weaker from baseline if sufficient pressure is applied to the femoral artery.

14. Cover the site with an appropriate dressing and secure the dressing with tape. If stipulated by facility policy, make a pressure dressing for a femoral site by folding four sterile 4 4 gauze pads in half, and then applying the dressing.

15. Cover the dressing with a tight adhesive bandage, per policy, and then cover the femoral bandage with a sandbag. Remove gloves. Maintain the patient on bed rest, with the head of the bed elevated less than 30ยบ, for 6 hours with the sandbag in place. Lower the bed height. Remind the patient not to lift his or her head while on bed rest.

16. Remove additional PPE. Perform hand hygiene. Send specimens to the laboratory immediately.

17. Observe the site for bleeding. Assess circulation in the extremity distal to the site by evaluating color, pulses, and sensation. Repeat this assessment every 15 minutes for the first 1 hour, every 30 minutes for the next 2 hours, hourly for the next 2 hours, then every 4 hours, or according to facility policy. Use log rolling to assist the patient in using the bedpan, if needed.
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Obtaining an Arterial Blood Sample From an Arterial Line Stopcock System

Goal: A specimen is obtained without compromise to the patency of the arterial line.

1. Verify the order for laboratory testing on the patient’s medical record.

2. Gather all equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Explain the procedure to the patient.

6. Compare specimen label with patient identification bracelet. Label should include patient’s name and identification number, time specimen was collected, route of collection, identification of the person obtaining sample, and any other information required by agency policy.

7. Put on gloves and goggles or face shield.

8. Turn off or temporarily silence the arterial pressure alarms, depending on facility policy.

9. Locate the stopcock nearest the arterial line insertion site. Use the alcohol swab or chlorhexidine to scrub the sampling port on the stopcock. Allow to air dry.

10. Attach a 5-mL syringe into the sampling port on the stopcock to obtain the discard volume. Turn off the stopcock to the flush solution. Aspirate slowly until blood enters the syringe. Stop aspirating. Note the volume in the syringe, which is the dead-space volume. Continue to aspirate until the dead-space volume has been withdrawn a total of three times. For example, if the dead-space volume is 0.8 mL, aspirate 2.4 mL of blood.

11. Turn the stopcock to the halfway position between the flush solution and the sampling port to close the system in all directions.

12. Remove the discard syringe and dispose of appropriately.

13. Place the syringe for the laboratory sample or the Vacutainer in the sampling port of the stopcock. Turn the stopcock off to the flush solution, and slowly withdraw the required amount of blood. For each additional sample required, repeat this procedure. If coagulation tests are included in the required tests, obtain blood for this from the final sample.

14. Turn the stopcock to the halfway position between the flush solution and the sampling port to close the system in all directions. Remove the syringe or Vacutainer. Apply the rubber cap to the ABG syringe hub, if necessary. 15. Insert a 5-mL syringe into the sampling port of the stopcock. Turn off the stopcock to the patient. Activate the in-line flushing device. Flush through the sampling port into the syringe to clear the stopcock and sampling port of any residual blood.

16. Turn off the stopcock to the sampling port; remove the syringe. Remove sampling port cap and replace with new sterile one. Intermittently flush the arterial catheter with the in-line flushing device until the tubing is clear of blood.

17. Remove gloves. Reactivate the monitor alarms. Record date and time the samples were obtained on the labels, as well as the required information to identify the person obtaining the samples. If ABG was collected, record oxygen flow rate (or room air) on label. Apply labels to the specimens, according to facility policy. Place in biohazard bags; place ABG sample in bag with ice.

18. Check the monitor for return of the arterial waveform and pressure reading.

19. Return the patient to a comfortable position. Lower bed height, if necessary, and adjust head of bed to a comfortable position.

20. Remove goggles and additional PPE, if used. Perform hand hygiene. Send specimens to the laboratory immediately.
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Applying a Cardiac Monitor

Goal: A clear waveform, free from artifact, is displayed on the cardiac monitor.

1. Verify the order for cardiac monitoring on the patient’s medical record.

2. Gather all equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Explain the procedure to the patient. Tell the patient that the monitoring records the heart’s electrical activity. Emphasize that no electrical current will enter his or her body. Ask the patient about allergies to adhesive, as appropriate.

6. For hardwire monitoring, plug the cardiac monitor into an electrical outlet and turn it on to warm up the unit while preparing the equipment and the patient. For telemetry monitoring, insert a new battery into the transmitter. Match the poles on the battery with the polar markings on the transmitter case. Press the button at the top of the unit, test the battery’s charge, and test the unit to ensure that the battery is operational.

7. Insert the cable into the appropriate socket in the monitor.

8. Connect the lead wires to the cable. In some systems, the lead wires are permanently secured to the cable. For telemetry, if the lead wires are not permanently affixed to the telemetry unit, attach them securely. If they must be attached individually, connect each one to the correct outlet.

9. Connect an electrode to each of the lead wires, carefully checking that each lead wire is in its correct outlet.

10. If the bed is adjustable, raise it to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009).

11. Expose the patient’s chest and determine electrode positions, based on which system and leads are being used. If necessary, clip the hair from an area about 10 cm in diameter around each electrode site. Clean the area with soap and water and dry it completely to remove skin secretions that may interfere with electrode function.

12. Remove the backing from the pregelled electrode. Check the gel for moistness. If the gel is dry, discard it and replace it with a fresh electrode. Apply the electrode to the site and press firmly to ensure a tight seal. Repeat with the remaining electrodes to complete the three-lead or fivelead system.

13. When all the electrodes are in place, connect the appropriate lead wire to each electrode. Check waveform for clarity, position, and size. To verify that the monitor is detecting each beat, compare the digital heart rate display with an auscultated count of the patient’s heart rate. If necessary, use the gain control to adjust the size of the rhythm tracing, and use the position control to adjust the waveform position on the monitor.

14. Set the upper and lower limits of the heart rate alarm, based on the patient’s condition or unit policy.

15. For telemetry, place the transmitter in the pouch in the hospital gown. If not available in gown, use a portable pouch. Tie the pouch strings around the patient’s neck and waist, making sure that the pouch fits snugly without causing discomfort. If no pouch is available, place the transmitter in the patient’s bathrobe pocket.

16. To obtain a rhythm strip, press the RECORD key either at the bedside for monitoring or at the central station for telemetry. Label the strip with the patient’s name and room number, date, time, and rhythm identification. Analyze the strip, as appropriate. Place the rhythm strip in the appropriate location in the patient’s chart.

17. Return the patient to a comfortable position. Lower bed height and adjust the head of bed to a comfortable position.

18. Remove additional PPE, if used. Perform hand hygiene.
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Obtaining an Electrocardiogram (ECG)

Goal: A cardiac electrical tracing is obtained without any complications.

1. Verify the order for an ECG on the patient’s medical record.

2. Gather all equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. As you set up the machine to record a 12-lead ECG, explain the procedure to the patient. Tell the patient that the test records the heart’s electrical activity, and it may be repeated at certain intervals. Emphasize that no electrical current will enter his or her body. Tell the patient the test typically takes about 5 minutes. Ask the patient about allergies to adhesive, as appropriate.

6. Place the ECG machine close to the patient’s bed, and plug the power cord into the wall outlet.

7. If the bed is adjustable, raise it to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009).

8. Have the patient lie supine in the center of the bed with the arms at the sides. Raise the head of the bed if necessary to promote comfort. Expose the patient’s arms and legs, and drape appropriately. Encourage the patient to relax the arms and legs. If the bed is too narrow, place the patient’s hands under the buttocks to prevent muscle tension. Also use this technique if the patient is shivering or trembling. Make sure the feet do not touch the bed’s footboard.

9. Select flat, fleshy areas on which to place the electrodes. Avoid muscular and bony areas. If the patient has an amputated limb, choose a site on the stump.

10. If an area is excessively hairy, clip the hair. Do not shave hair. Clean excess oil or other substances from the skin with soap and water and dry it completely.

11. Apply the limb lead electrodes. The tip of each lead wire is lettered and color coded for easy identification. The white or RA lead goes to the right arm; the green or RL lead to the right leg; the red or LL lead to the left leg; the black or LA lead to the left arm. Peel the contact paper off the selfsticking disposable electrode and apply directly to the prepared site, as recommended by the manufacturer. Position disposable electrodes on the legs with the lead connection pointing superiorly.

12. Connect the limb lead wires to the electrodes. Make sure the metal parts of the electrodes are clean and bright.

13. Expose the patient’s chest. Apply the precordial lead electrodes. The tip of each lead wire is lettered and color coded for easy identification. The brown or V1 to V6 leads are applied to the chest. Peel the contact paper off the selfsticking, disposable electrode and apply directly to the prepared site, as recommended by the manufacturer. Position chest electrodes as follows (Refer to Figure 1):
• V1: Fourth intercostal space at right sternal border
• V2: Fourth intercostal space at left sternal border
• V3: Halfway between V2 and V4
• V4: Fifth intercostal space at the left midclavicular line
• V5: Fifth intercostal space at anterior axillary line (halfway between V4 and V6)
• V6: Fifth intercostal space at midaxillary line, level with V4

14. Connect the precordial lead wires to the electrodes. Make sure the metal parts of the electrodes are clean and bright.

15. After the application of all the leads, make sure the paperspeed selector is set to the standard 25 m/second and that the machine is set to full voltage.

16. If necessary, enter the appropriate patient identification data into the machine.

17. Ask the patient to relax and breathe normally. Instruct the patient to lie still and not to talk while you record the ECG.

18. Press the AUTO button. Observe the tracing quality. The machine will record all 12 leads automatically, recording 3 consecutive leads simultaneously. Some machines have a display screen so you can preview waveforms before the machine records them on paper. Adjust waveform, if necessary. If any part of the waveform extends beyond the paper when you record the ECG, adjust the normal standardization to half-standardization and repeat. Note this adjustment on the ECG strip, because this will need to be considered in interpreting the results.

19. When the machine finishes recording the 12-lead ECG, remove the electrodes and clean the patient’s skin, if necessary, with adhesive remover for sticky residue.

20. After disconnecting the lead wires from the electrodes, dispose of the electrodes. Return the patient to a comfortable position. Lower bed height and adjust the head of bed to a comfortable position.

21. Clean ECG machine per facility policy. If not done electronically from data entered into the machine, label the ECG with the patient’s name, date of birth, location, date and time of recording, and other relevant information, such as symptoms that occurred during the recording (Jevon, 2007b).

22. Remove additional PPE, if used. Perform hand hygiene.
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