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Pearson's Comprehensive
Medical Assisting
Administrative and Clinical Competencies
Second Edition
CHAPTER
CHAPTER
49
Electrocardiography
Lesson 3:
ECG-Related Diagnostic Procedures
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lesson Objectives
Upon completion of this lesson, students
should be able to …
• Define and spell the terms to learn for this
chapter.
• Understand stress testing.
• Comprehend the need for Holter
monitoring and how to attach leads.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Lesson Objectives
• Explain telemetry and identify the sites for
lead attachment.
• Comprehend the function and placement
of pacemakers.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Special ECG Tests
• There are some special ECG tests that
may be performed in the physician’s office:
– Rhythm strip: An ECG run on lead II for 20
seconds when something abnormal appears
(or if physician requests it)
– Inspiration strip: An ECG strip run on lead II
for 10 seconds with the patient holding his or
her breath
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Exercise Tolerance Testing
• Also called a stress test or treadmill test
• Evaluation of the heart’s response during
moderate exercise following a 12-lead
ECG
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Exercise Tolerance Testing
• May be used for:
– Evaluating patients with a high risk for
developing heart disease or known to have
heart disease
– Evaluating patients about to begin a
strenuous exercise program
– Evaluating patients who have cardiac
complaints
– Evaluating patients after rehabilitation
following cardiac surgery
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Exercise Tolerance Testing
• Patient should be given instructions before
test day to wear comfortable exercise or
walking shoes and loose-fitting clothes
• ECG is recorded as patient walks at a
specified pace and incline in the presence
of a physician
• Blood pressure is checked frequently
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Exercise Tolerance Testing
• Physician evaluates the effect of exercise
on the heart rate, blood pressure, and
ECG
• Test may be stopped if patient
experiences trouble breathing or
complains of chest pain
• Emergency equipment should be ready to
use
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Exercise Tolerance Testing
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Placement of Sensors for the
Stress Test
• Sensors are all placed on the torso
• Precordial sensors (V1–V6) are placed as for the
regular ECG
• Arm and leg sensors are put at the midclavicular
line on the top of the torso and on the
midclavicular line on the abdomen
• Electrodes should adhere securely to the skin
and may need to be taped in place
• A male patient with a very hairy chest may need
to be shaved to improve attachment of
electrodes
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Guidelines for the Stress Test
• The stress test is continued until 85% of
the maximum target heart rate is achieved
or the patient becomes symptomatic
• The maximum target heart rate is
calculated by using the following formula:
220 minus the patient’s age = the
maximum target heart rate for that person
• For a sixty year old patient 220 - 60 = 160
x .85 = 136 or the maximum target heart
rate for this patient
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Guidelines for the Stress Test
• For patients who have had myocardial
infarction (MI) or heart attack, the target
heart rate is set lower at 70%.
• This is known as a submaximal test
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Use of Thallium
• A radioisotope used in nuclear medicine
that emits gamma rays
• Sometimes injected into the patient’s vein
during a stress test for better
understanding of perfusion (blood flow to
the myocardium)
• Injected during the last minute of exercise
• Patient lies on a special table and a
gamma camera takes pictures
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Use of Thallium
• If the heart muscle is ischemic (receiving
less than normal amount of blood flow)
poor uptake of the thallium will occur
• Normal perfusion of the myocardium is
indicated by “hot spots” on the pictures
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pharmacologic Stress Testing
• Involves no exercise
• A medication is given to the patient that
causes the heart rate to climb to the target
heart rate
• Continuous ECGs and vital sign evaluation
are performed
• Test is useful on patients with physical
limitations or the elderly who cannot perform
enough exercise to elevate the heart rate
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Patient Safety During a Stress
Test
• Maintain emergency equipment that might be
needed
• Have the emergency equipment in the room
at the time of the test
• Oxygen equipment, a defibrillator, an airway,
intravenous solutions, and medications
should be periodically checked and replaced,
if outdated or not functioning
• Always be sure a physician is available when
a stress test is done
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Holter Monitor
• Records cardiac activity while the patient
is ambulatory
• Test is run for at least a 24-hour period
• Performed when the ECG is not
conclusive or the cardiac irregularity was
not captured on the tracing
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Holter Monitor
• A small tape recorder and a patient diary
are used to detect heart irregularities that
are infrequent and not detected with a
standard ECG
• Can record continuously or when patient
presses an “event” button when symptoms
occur
• The medical assistant may instruct the
patient and apply the chest sensors
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Holter Monitor
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Holter Monitor Diary
• The associated diary is important in Holter
monitoring procedures
• Patients should carry out all routine daily
activities except for showering and bathing
• Patients should avoid areas of high voltage
• Patients should use the diary to record their
activities during the day and when they have
pressed the “event” button
• The physician will compare the tape to the diary
log of activity to help in the evaluation of the
heart
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Holter Monitor Electrodes
• There are five special
disposable chest
sensors that are
securely attached to
the body
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Placement of Holter Monitor
Electrodes
• Third intercostal space - 2 or 3 inches to the
right of the sternum
• Third intercostal space - 2 or 3 inches to the
left of the sternum
• Fifth intercostal space - at the left sternum
margin
• Sixth intercostal space - at the right anterior
axillary line
• Sixth intercostal space - at the left anterior
axillary line
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Telemetry
• Involves using radio waves to transmit the
heart’s electrical activity to a central monitoring
station
• Allows the patient to move around the room or
other limited space while the heart is monitored
• Patient should be made aware of the range of
movement permitted
• Used in inpatient facilities but may be
encountered in ambulatory care settings as well
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pacemakers
• Involves using radio waves to transmit the
heart’s electrical activity to a central monitoring
station
• Allows the patient to move around the room or
other limited space while the heart is monitored
• Patient should be made aware of the range of
movement permitted
• Used in inpatient facilities but may be
encountered in ambulatory care settings as well
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Pacemakers
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Placement of a Pacemaker
A permanent epicardial pacemaker. The pulse generator can be placed
in subcutaneous pockets in the subclavian or abdominal regions.
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Questions?
Pearson's Comprehensive Medical Assisting: Administrative and Clinical Competencies, 2/e
Beaman • Fleming-McPhillips • Routh • Gohsman • Reagan
Copyright ©2011 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.