LECTURE NOTES
“Enhancing Clinical Readiness for Nursing Students”
Lecture 5 Notes: ‘Emergency Investigations & Diagnostic Interpretation - Part 1: ECG’
Date: 26 April 2025, Saturday Duration: 1 hour (4 – 5 pm)
Audience: B Sc Nursing Students, Kamineni College of Nursing, LB Nagar, Hyderabad
Objectives
Overview of ECG, and its application in emergencies and rapid basic interpretation of ECGs
to guide immediate care.
This lecture notes covers the essentials of recording and interpreting a standard 12-lead ECG.
You will learn the electrical basis of each waveform (P wave, QRS complex, T wave), how to
measure intervals (PR, QRS duration, QTc), and a systematic “Rate–Rhythm–Axis–Intervals–
Waves” approach to reading strips. You will be able to recognise common arrhythmias sinus
tachycardia/bradycardia, atrial fibrillation, heart blocks and link ECG changes to clinical
scenarios. Emphasis is placed on accurate measurement, pattern recognition, and correlating
findings with patient signs and symptoms to guide nursing care and prompt escalation when
needed.
1. ECG Fundamentals
1.1 What Is an ECG?
An electrocardiogram (ECG or EKG) is a surface recording of the heart’s electrical activity,
capturing depolarization and repolarization events that drive contraction and relaxation of
cardiac muscle. It is non-invasive, painless, and essential for diagnosing arrhythmias, ischemia,
conduction blocks, and electrolyte disturbances.
1.2 Waveforms and Intervals
Component Represents Normal Duration
P wave Atrial depolarization 0.08–0.12 s (2–3 small
boxes)
PR interval Conduction time atria→AV 0.12–0.20 s (3–5 small
node→ventricles boxes)
QRS complex Ventricular depolarization ≤ 0.10 s (≤ 2.5 small
boxes)
QT interval Ventricular depolarization + QTc < 0.44 s
repolarization (corrected:
QTc)
ST segment Isoelectric (plateau phase) –
T wave Ventricular repolarization –
All durations are measured on paper running at 25 mm/s, where one small square = 0.04 s
and one large square (5 small) = 0.20 s.
1.3 Lead Placement & Axis
Standard 12-lead ECG uses 4 limb electrodes and 6 precordial (chest) leads. The frontal plane
axis (mean QRS vector) is normally between –30° and +90°; axis deviation suggests chamber
enlargement or conduction defects.
2. Systematic Interpretation Method
Use the “Rate–Rhythm–Axis–Intervals–Waves (PQRST)” mnemonic to ensure no step is
missed.
2.1 Step 1: Heart Rate
Regular rhythm: 300 ÷ (# large squares between R–R).
Irregular rhythm: count QRS in 6 s strip × 10.
Normal: 60–100 bpm; < 60 = bradycardia; > 100 = tachycardia.
2.2 Step 2: Rhythm Regularity
Measure several R–R intervals; if equal (± 0.04 s), rhythm is regular.
“Irregularly irregular” → atrial fibrillation.
2.3 Step 3: P Waves & Atrial Activity
P wave present before every QRS?
Morphology: upright in lead II; consistent shape.
Absent or multiple P waves → atrial flutter or fibrillation.
2.4 Step 4: Measure Intervals
PR interval: start of P to start of QRS; prolonged (> 0.20 s) = 1° AV block; variable =
2° AV block.
QRS duration: wide (> 0.12 s) suggests bundle branch block or ventricular origin.
QT/QTc: measure end of QRS to end of T; Bazett’s correction: QTc = QT/√RR. QTc >
0.44 s = risk of torsades de pointes.
2.5 Step 5: ST Segment & T Wave
ST elevation/depression relative to baseline indicates ischemia or injury.
T-wave inversion → ischemia, LVH, or electrolyte imbalance.
2.6 Step 6: Axis Determination (optional for basic)
Look at leads I and aVF: positive QRS in both = normal axis.
3. Common Dysrhythmias & Clinical Correlation
3.1 Sinus Rhythms
Normal sinus rhythm: P–QRS–T present, rate 60–100 bpm.
Sinus bradycardia (< 60 bpm): may be normal in athletes; symptomatic → dizziness,
syncope.
Sinus tachycardia (> 100 bpm): fever, hypovolemia, pain; treat underlying cause.
3.2 Atrial Arrhythmias
Rhythm ECG Features Clinical Points
Atrial Irregularly irregular, no distinct P ↑ stroke risk; rate control &
fibrillation waves anticoagulation Simple Nursing
Atrial flutter “Saw-tooth” P waves, regular or Flutter waves; treat with rate control
variable 2:1 conduction or cardioversion
3.3 AV Blocks
1° AV block: PR > 0.20 s, each P followed by QRS.
2° AV block – Mobitz I (Wenckebach): progressive PR prolongation, then dropped
QRS.
2° AV block – Mobitz II: fixed PR, occasional dropped QRS; high risk for complete
block.
3° AV block: no AV conduction; P and QRS dissociated; emergency.
3.4 Ventricular Rhythms
Ventricular tachycardia: wide QRS > 0.12 s, rate > 100, regular; treat as emergency.
Ventricular fibrillation: chaotic baseline, no QRS; immediate defibrillation.
Asystole: flat line; poor prognosis.
4. Nursing Implications & Practice Tips
1. Always assess the patient, not just the monitor. Correlate ECG with vital signs and
symptoms (chest pain, hypotension).
2. Confirm electrode placement and lead quality before interpreting.
3. Document findings clearly: rate, rhythm, intervals, and any abnormalities.
4. Know when to call for help—e.g., new-onset atrial fibrillation with hypotension, third-
degree block, VT/VF.
5. Use previous ECGs for comparison to detect acute changes.
References (For Additional Reading)
1. Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors.
Nursing Advanced Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical
College; 2023. Chapter 7 Interpret Basic ECG.
[Link]
2. Sattar Y, Chhabra L. Electrocardiogram. [Updated 2023 Jun 5]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan.
[Link]