1. Electrocardiography and Pulmonary Function Testing
Chapter 52
Electrocardiography and Pulmonary Function Testing
PowerPoint® presentation to accompany:
Medical Assisting
Third Edition
Booth, Whicker, Wyman, Pugh, Thompson

2. Learning Outcomes 52.1 Explain the conduction system of the heart.
52.2 Describe the basic patterns of an electrocardiogram (ECG).
52.3 Identify the components of an electrocardiograph and what each does.

3. Learning Outcomes (cont.)
52.4 Explain how to position the limb and precordial electrodes correctly.
52.5 Describe in detail how to obtain an ECG.
52.6 Identify the various types of artifacts and potential equipment problems and how to correct them.

4. Learning Outcomes (cont.)
52.7 Discuss how the ECG is interpreted.
Identify common arrhythmias.
Define exercise electrocardiography.
52.10 Explain the procedure of Holter monitoring.
52.11 Describe forced vital capacity.

5. Learning Outcomes (cont.)
52.12 Describe the procedure of performing spirometry.
52.13 Describe the procedure for obtaining a performing peak expiratory flow rate.
52.14 Describe the procedure for performing pulse oximetry testing.

6. Introduction
Patients often have cardiovascular or respiratory problems
Medical assistant
Perform screening and/or diagnostic testing
Understand the anatomy and physiology of the heart and respiratory system

7. The Medical Assistant’s Role
Electrocardiography
Graphic recording of the electrical impulses of the heart
Uses
Evaluate symptoms of heart disease
Check effectiveness or side effects of medications
General examination

8. The Medical Assistant’s Role (cont.)
Pulmonary function tests
Measure and evaluate a patient’s lung capacity and volume
Uses
Help detect and diagnose pulmonary problems
Monitor respiratory disorders
Evaluate effectiveness of treatments

9. Conduction System of the Heart
Cardiac cycle
Controlled by specialized tissues in the heart wall that transmit electrical impulses
Impulses cause muscle to contract and relax

10. Conduction System of the Heart (cont.)
SA Node
Bundle of His
Pacemaker of the heart
Sets rhythm of contractions
Located in septum between ventricles
Bundle Branches
Relay impulse to Purkinje fibers
AV Node
Bottom of right atrium
Impulse delayed slightly
Purkinje Fibers
Located in ventricle walls
Contraction of ventricles

11. Conduction System of the Heart (cont.)
Electrocardiography
Transmission, magnitude, and duration of electrical impulses of the heart
Polarity
Having a positive and negative pole
Resting cell
Positive outside
Negative inside
Depolarization
Impulse that initiates a contraction
Repolarization
Period of electrical recovery following depolarization
Prior to polarized (resting) state

12. Conduction System of the Heart (cont.)
Basic pattern of the ECG
Waves (deflections) are labeled P, Q, R, S, T, U

13. Apply Your Knowledge Truly Great! True or False ANSWER:
___ The AV node is the heart’s pacemaker.
___ The medical assistant does not perform ECGs or PFTs.
___ The bundle branches relay impulses to the Purkinje fibers in the ventricles.
___ The heart is resting in the polarized state.
___ Depolarization initiates contractions of atria and ventricles.
___ Repolarization occurs before depolarization.
ANSWER: F SA F
may T T T F
following

14. The Electrocardiograph
Electrical impulses are detected through the skin
Measures
Amplifies – signal is increased
Records using the stylus

15. The Electrocardiograph (cont.)
Types of electrocardiographs
Standard machine – 12-lead, which records 12 different views at once
Single channel – one lead and records only one view

16. The Electrocardiograph (cont.)
Electrodes and electrolyte products
Electrolyte – enhances transmissions of electric current
Electrodes
Ten areas of the body
Right and left arms
Right and left legs
Six locations on the chest
Enables physician to pinpoint origin of problems

17. The Electrocardiograph (cont.)
Leads
Provide different images of electrical activity
Marked automatically on the ECG
Limb leads
Three standard – I, II, III
Three augmented – AVF, AVR, AVL
Precordial leads – V1 through V6

18. The Electrocardiograph (cont.)
ECG paper
Single or multichannel available
Heat- and pressure-sensitive
Standardized to permit uniform interpretation
Vertical axis – strength of impulse (millivolt)
Horizontal axis – time
0.04 sec
5 mm (0.5 mV)
1 mm (0.1 mV)
1 mm
5 mm
0.2 sec

19. The Electrocardiograph (cont.)
Controls
Standardization control
Speed selector – 25mm/sec standard
Sensitivity control – adjusts height of tracing
Lead selector – enables selection of a single lead
Centering control – adjusts position of stylus
Stylus temperature control – adjusts darkness of line
Marker control – on older machines
On/Off switch

20. Superbly Matched! Apply Your Knowledge Matching: ANSWER:
___ Adjusts position of stylus A. Vertical axis
___ Adjusts height of tracing B. Sensitivity control
___ Adjusts darkness of tracing C. Precordial leads
___ Measures strength of impulse D. Horizontal axis
___ Measures time E. Limb leads
___ AVF, AVR, AVL F. Amplification
___ V1 through V6 G. Centering control
___ Increases signal H. Stylus temperature control
ANSWER: G B H A D E
Superbly Matched! C F

21. Preparing to Administer an ECG
Proper technique essential
Preparing the room and equipment
Other electrical equipment turned off
Quiet room, comfortable temperature
Check machine
Warm up
Adequate paper

22. Preparing to Administer an ECG (cont.)
Preparing the patient
Introduce yourself
Explain the procedure
Answer questions
Ensure patient comfort
Perform ECG procedure

23. Applying the Electrodes and the Connecting Wires
Electrodes – disposable are most common
Positioning electrodes
Use consistent technique
Limb electrodes – place at same level
Precordial electrodes – specific intercostal spaces
Precordial Lead Placement

24. Applying the Electrodes and the Connecting Wires (cont.)
Attaching wires
Numbers and letters correspond to those for electrodes
Connect limb wires first
Precordial in same sequence as electrodes
Avoid tension on wires

25. Operating the Electrocardiograph
Standardize
Run the ECG
Automatic
Manual
Multiple-channel
Check the tracing
Clear / free from artifact

26. Apply Your Knowledge Electrifyingly Great!
In addition to making sure the room is comfortable for the patient and the ECG machine is ready, what else should you do to prepare for performing an ECG?
ANSWER: All other electrical equipment in the room should be turned off.
Electrodes are placed at how many positions on the body?
ANSWER: Ten: four limb and six chest positions.
Electrifyingly
Great!

27. Apply Your Knowledge Electrifyingly Great!
What should you do just prior to running the ECG to see if the machine needs adjusting? What should you do upon completion of the test?
ANSWER: Standardize the electrocardiograph prior to running the tracing. Upon completion of the ECG, you should check the tracing to be sure is it clear and free from artifact.
Electrifyingly
Great!

28. Troubleshooting Artifacts Causes Improper technique Poor conduction
Outside interference
Improper handling

29. Troubleshooting: Artifacts
Wandering baseline – somatic interference or mechanical problems
Flat line – loose or disconnected wire
Extraneous marks – careless handling

30. Troubleshooting: Artifacts (cont.)
Causes
AC interference – machine picks up current from other electrical equipment
Somatic interference – muscle movement
Identifying source of interference
Check tracings for leads I, II, and III
If unable to identify source, stop and notify supervisor of problem
Leave patient connected

31. Completing the Procedure
Acceptable tracing
Label properly
Disconnect wires from electrodes
Remove electrodes / wipe off electrolyte
Assist patient up
Prepare room appropriately
Mount tracing if necessary

32. Bravo! Apply Your Knowledge What are four general causes of artifacts?
ANSWER: They are improper technique, poor conduction, outside interference, and improper handling of the tracing.
What should you after running an ECG?
ANSWER: After making sure the tracing is acceptable, you should label it properly, disconnect wires from electrodes, remove electrodes and wipe off electrolyte, assist patient up, and prepare the room appropriately for the next patient.
Bravo!

33. Interpreting the ECG Not a medical assistant responsibility
Knowing how they are interpreted will enable you to recognize a problem requiring immediate attention
Heart rate
If regular – count QRS complexes in a 6-second strip and multiply by 10
Irregularities
Conduction abnormalities
Reaction to medication

34. Interpreting the ECG (cont.)
Intervals and segments
Variations in length and position
Conduction disturbances
Myocardial infarctions
Electrolyte disturbances
Wave changes – normally similar in each lead

35. Interpreting the ECG (cont.)
Heart rhythm
Regularity of the heartbeat
Distances between complexes and waves is normally consistent
Rhythm strip obtained from lead II

36. Interpreting the ECG (cont.)
Abnormal cardiac arrhythmias
Irregularities in heart rhythm
Ventricular fibrillation – life-threatening with no cardiac output
Premature ventricular contractions – heartbeats that originate from the ventricles
Bundle branch blocks – impulse through the heart is slowed or blocked
Atrial fibrillation – electrical disturbance in the atria and/or AV node

37. Apply Your Knowledge Fantastic! Matching (may be used more than once):
___ Number of QRS complexes in 6 sec x 10 A. V-fib
___ Cannot identify “P” waves B. Heart rhythm
___ Produces no cardiac output C. Bundle branch block
___ Originates in ventricles D. Atrial fibrillation
___ Slows or stops impulse E. Heart beat
___ Multiple impulses from sites outside SA node F. PVC
___ “Saw-tooth” image
___ Regularity of heart beat
___ Due to irritable of ventricular heart muscle
ANSWER: E D A F C D A
Fantastic! B F

38. Exercise Electrocardiography
Stress test – measures the heart’s response to a constant or increasing workload
Uses
Determine how a diseased heart is functioning
Screen a patient for heart disease
Determine patient’s ability to start an exercise program

39. Ambulatory Electrocardiography
Resting ECG may not show abnormalities
Holter monitoring
Monitors heart over a 24-hour period of normal activity
Uses
Diagnosis
Evaluate status post-MI
Patient education
Record activities
What to avoid
How to check monitor

40. Ambulatory Electrocardiography (cont.)
Connecting the patient
3 or 5 electrodes
Prep skin prior to placing
Tape in place to eliminate tension and ensure that electrodes stay in place for entire time of testing
Put fresh battery in the machine
Check tape
Ensure that machine is turned on

41. Correct! Apply Your Knowledge
What is the purpose for stress testing and Holter monitor testing?
ANSWER: Stress testing is used to measure the heart’s response to a constant or increasing workload. A Holter monitor is used to obtain a tracing over a period of time when a resting ECG shows no abnormalities. Both are used for diagnosing cardiac conditions or for monitoring current treatments and medications.
Correct!

42. Pulmonary Function Testing
Evaluates lung volume and capacity
Uses
Evaluate of shortness of breath
Detect and classify of pulmonary disorders
Evaluate of effectiveness of treatments

43. Spirometry Measures air taken in by and expelled by the lungs
Forced vital capacity (FVC) – greatest volume of air that can be expelled with a rapid, forced expiration
Types of spirometers:
Computerized
Mechanical

44. Performing Spirometry
Technique similar for all types – be consistent
Patient preparation
Inform the patient about conditions and activities that could affect the test accuracy
Explain procedure and its purpose
Explain the need for a nose clip
Be sure patient forms a tight seal around the mouthpiece
Position the patient properly
Demonstrate correct procedure

45. Performing Spirometry (cont.)
Performing the maneuver
Urge patient to blow hard and to continue blowing
Provide feedback on performance
Obtain three acceptable maneuvers
Observe the patient’s symptoms
Notify physician immediately if symptoms occur

46. Performing Spirometry (cont.)
Determining effectiveness of medications
Perform test before patient takes medication for day
Repeat after patient takes the medication
Special considerations
Uncooperative patients
Patients who do not understand
Patients who cannot follow directions
Patients who cannot perform the procedure

47. Performing Spirometry (cont.)
Calibration
Daily – keep logbook
Calibration syringe – standardized measuring instrument
Detect leaks – check time/volume graph
Results
Evaluate ventilatory function
Screening for pulmonary disorders
Severity of problems
Response to therapy or medication
Infection control
Clean equipment after each patient
Discard disposable supplies appropriately
Wash hands before and after each use

48. Peak Expiratory Flow Rate
Determines amount of air that can be quickly forced from the lungs
Peak flow meter
Reveals narrowing of airways before an asthma attack
Peak flow zones
Different for each patient
Green zone – good control of asthma
Yellow zone – large airways are beginning to narrow
Red zone – medical emergency

49. Pulse Oximetry Testing
Non-invasive measurement of the oxygen saturation in arterial blood
Hemoglobin absorbs infrared light
Measures amount of light absorbed
Hypoxemia – less than 95%
Uses
Pulmonary and cardiac conditions
Post-operatively
Sleep apnea

50. Apply Your Knowledge What is the purpose of PFTs?
ANSWER: To evaluate lung volume and capacity.
What is FVC?
ANSWER: It is forced vital capacity: the greatest volume of air that can be expelled with a rapid, forced expiration. It is the measurement of the volume of air expelled and amount of time taken to expel it.

51. Apply Your Knowledge YIPPEE! 4 for 4
Joey Jackson called to ask about taking his asthma medicine. He said he as been using his peak flow meter and the readings have been in his yellow zone. What do you tell him?
ANSWER: This means that his large airways are beginning to narrow and that he should take his medication as prescribed.
Joey decided to come to the office and you check his oxygen saturation with the pulse oximeter. The reading was 93%. What does this mean and what should you do?
ANSWER: Joey is hypoxemic. You need to notify the physician and document findings.

52. In Summary
ECG and PFTs – vital to diagnosis and treatment of cardiac and pulmonary disease
Medical assistant
Understanding of anatomy and physiology of both systems
Accurate performance of procedures
Recognition of abnormalities
Patient education

53. End of Chapter 52 As the arteries grow hard, the heart grows soft.
~ H. L. Mencken