EKG & Vital Signs Training...Learn normal Vital Sign values and plan for abnormal values Become familiar with equipment used to obtain Vital Signs and EKG’s •Begin to develop comfort

EKG & Vital Signs Trainingfor Clinical Research Coordinators

CCI Nursing Team – Instructors

Chelsea Nickerson – Research Education Program Manager

Adapted from content provided by CCI

Agenda – 8:30AM to 12:30PM

• Lecture▫ Vital Signs (~45 min)▫ Break (~5 min)▫ EKG (~45 min)

• Break (~10 min)

• Hands-On Practice in Small Groups▫ Vital Signs (~1 hr)▫ Break (~5 min)▫ EKG (~45 min)

Please note that you must perform additional practice within the context of your research setting and be officially cleared by your PI/Study Staff MD

• Course Evaluations (~10 min)

Training Objectives

• Develop understanding of necessary background knowledge Become familiar with BWH policies and procedures

Learn normal Vital Sign values and plan for abnormal values

Become familiar with equipment used to obtain Vital Signs and EKG’s

• Begin to develop comfort with conducting the procedures Plan to continue to practice the skills you have learned

Perform task for PI/Study Staff MD in order to obtain data independently

Vital Signs

Important Considerations• Standard Precautions▫ Use Purell before and after contact with patient or patient’s environment

• Patient Interaction▫ Acquire 2 patient identifiers

▫ Explain the procedures to the patient

▫ Maintain patient privacy

• Research Context▫ Ensure you know the normal ranges (vital signs) for your research population

▫ ALWAYS have a plan in place: If a patient’s vital signs are abnormal or if something goes wrong, what will you do?

Will you need an MD to check your patient’s results before the appt. is over?

Do you know what documentation is required?

Vital Signs

• Temperature (T)

• Pulse (P)

• Respiration (RR)

• Oxygen Saturation (SaO2)

• Blood Pressure (B/P)

Temperature

• Definition: Measurement of body temperature

• Normal Range: 96⁰F to 100⁰F ▫ Varies in different parts of the body

▫ Make sure you know parameters for your research population

• Equipment: Thermometer▫ Oral or axillary

Temperature – Procedure

• Placement of Thermometer▫ Oral (po) – under the tongue, either side of the frenulum▫ Axillary (ax) – in the center of the armpit against the skin

• Put probe cover on thermometer

• Hold thermometer in place until you hear “beep”

• Remove and read display

• Document

Temperature – Additional Tips

• Do not take temp if patient:▫ Has just had a hot or cold beverage (wait 10 min)

▫ Has an injured mouth or nose

▫ Has a mask over his/her face

▫ Is confused or uncooperative

Pulse

• Definition: Measurement of heart rate

• Normal Adult Range: 60 to 100 beats per min (bpm) ▫ Higher in infant or child

▫ Make sure you know parameters for your research population

• Note Rhythm: ▫ Regular: beats follow one after the other in same pattern

▫ Irregular: varying time between beats

Counting Pulse – Procedure

• Locate the radial artery (most common) on the thumb side of the wrist

• Feel for the pulse by placing the second and third fingers on radial artery

• Count number of beats for 1 min, OR 30 seconds (then multiply by 2)▫ If pulse is irregular, count for the full 60 seconds

• Document

Respiration

• Definition: Measurement of rise/fall of chest/abdomen▫ Rise = inspiration; Fall = expiration▫ 1 Respiration = 1 Rise + 1 Fall

• Normal Adult Range: 12 to 24 breaths per minute▫ Higher in infant or child▫ Make sure you know parameters for your research population

• Note Pattern: ▫ Regular: same amount of time between breaths ▫ Irregular: varying time between breaths

Counting Respirations – Procedure

• Observe patient’s chest/abdomen to see rise and fall

• Count for a full minute, OR 30 seconds (then multiply by 2)▫ If breathing is irregular, count for full 60 seconds

▫ Important Consideration: Telling the patient you will be watching their chest can make patient feel awkward and lead to irregular breathing.

▫ Tip: Tell patient you are taking their pulse. Use first 30 seconds to count beats (pulse), keep fingers on their wrist and use second 30 seconds to count their breaths (respirations).

Counting Respirations – Dyspnea

• Dyspnea: difficulty breathing

• Signs/Symptoms:▫ May state they’re having trouble breathing▫ Breathing is irregular (fast or slow)▫ May be restless, disoriented, or confused▫ May have cyanosis (blue color) around the mouth, lips, skin, or fingernails

• Can be life-threatening

• ALWAYS notify PI / Study Staff MD

Oxygen Saturation

• Definition: Pulse oximetry measures peripheral arterial oxygen saturation (SaO2).

• Normal Adult Range: 95% to 100%. Make sure you know parameters for your research population

• Equipment: Probe consists of 2 light emitting diodes and photodetector

• Important Notes: Movement, nail polish, poor perfusion, and disease processes can all interfere with SaO2 readings

Blood Pressure

• Definition: Measurement of blood pressing or pushing against the walls of the artery. Measures 2 different values:▫ Systolic (Upper) Number: pressure in blood vessels as heart contracts and blood is pumped into

the aorta▫ Diastolic (Lower) Number: pressure when the heart is relaxed and fills with blood

• Normal Adult Range: ▫ Systolic: >90 and <120 mmHg▫ Diastolic: >60 and <80 mmHg▫ Make sure you know parameters for your research population

• Equipment Options: ▫ Dinamap (automated monitor)▫ Sphygmomanometer (manual cuff)

Blood Pressure – Sphygmomanometer

• Blood pressure cuff attached to a gauge

• Bulb to inflate cuff

• Used with a stethoscope

Blood Pressure – Cuffs

• Cuffs come in different sizes

• Accurate blood pressure measurement requires correct cuff size to fit the patient’s arm

• Do NOT use B/P cuff on an arm with any injury, surgery, weakness, swelling, or intravenous (IV) line

Blood Pressure w/Sphygmomanometer

• Wrap the cuff around the patient’s arm above the elbow with the arrow over the brachial pulse

• Feel for the brachial pulse with your fingers (antecubital space located at the bend on the inside of the elbow)

• If patient knows their usual BP or you have their chart, inflate the cuffs to ~20 units above their baseline systolic pressure

Blood Pressure w/Sphygmomanometer

• Once inflated, open the screw SLOWLY to deflate the cuff with your thumb and index fingers

• Listen and note the number on the dial of the first strong beat (systolic number)

• Then listen and note the last strong beat (diastolic number)

• After, open the screw completely to deflate the cuff

• Document

Blood Pressure – Additional Tips• Wipe the earpieces of the stethoscope with an alcohol

wipe before putting them in your ears (less often if it’s personal stethoscope)

• Turn the tips of the earpieces so that they point toward the tip of your nose (hear the sounds more clearly)

• Always read the gauge at eye level• Never leave an inflated cuff on a patient more than a

minute (prevents blood from circulating to lower arm) • Always deflate the cuff completely after taking the blood

pressure• Do not try to get a measurement more than 2 times on the

same arm (try the other arm)

Vitals Signs Questions?

12-Lead EKG

What is an EKG?

• Also called ECG▫ Electocardiogram ▫ Electrokardiogram

• A recording of electrical activity of the heart• Does NOT provide information about mechanical function of heart• Information provided by an EKG:▫ Rate: fast, slow, normal▫ Rhythm: regular, irregular▫ Conduction Pathways: normal, abnormal▫ Conditions affecting the heart muscle, chambers, or valves

e.g. heart attack, angina, enlarged atria or ventricles, infection

▫ Response to medications

Why do an EKG?

• Protocols for research trials to detect any changes in the electrical properties of the heart

What is the heart?

• Organ responsible for pumping oxygen-rich blood to the lungs and all parts of the body

• Located in center of chest

• Approximately size of a fist

Heart Chambers

• The heart has…▫ 2 atria: small upper chambers

▫ 2 ventricles: large lower chambers

• To pump blood, heart must have an electrical system that functions

Heart Valves

• Blood is pumped through the heart via four valves that are dependent on pressure changes to open and close

Where does the electricity come from?

• Each heartbeat begins with an impulse in the upper right atrium – this is the heart’s pacemaker

• This impulse activates both upper chambers of the heart (the atria)

• The atria contract and pump blood into the lower chambers

Where does the electricity come from?

• Next, electrical current flows down to both lower chambers (the ventricles)

• Both ventricular chambers then contract and pump blood to the body and lungs via large arteries

EKG Representation of Electricity

Electricity of Several Heart Beats

12-Lead EKG Recording

How is electricity recorded?

• Via electrodes that are placed on the skin

• Electrodes sense electrical activity as it passes through the heart

• Each electrode is attached to a wire called a lead wire

• Lead wires are connected to the EKG machine

Preparation of Participant

• Introduce yourself to the patient and tell him/her you are going to take an EKG

• Explain:▫ EKG is a recording of electrical activity of

the heart

▫ It’s painless

▫ Takes ~15 min (including set up)

Preparation of Participant

• Maintain privacy▫ Close door AND curtain

▫ Explain you need access to their wrists/arms, lower legs, and chest to apply electrodes

• Ensure patient comfort▫ Assist them to lie down or recline – in recliner

with legs up or bed at 30⁰/45⁰

▫ Arms resting at sides

▫ Legs flat, not touching, and parallel

▫ Pillow supporting the head

▫ Blanket to keep warm

Prepare Skin for Electrode Placement

• Wash with soap and water and/or alcohol

• Cut or clip excess hair if necessary

• Do not shave skin

• Do not place electrodes over bony prominences (e.g. wrists, ankles, sternum)

Standard Placement of Electrodes

• 10 electrodes are placed on designated areas of the body▫ 6 on chest▫ 1 on each limb (4 total):

Above wrist/below shoulder (arms) Above ankles/below hips (legs)

▫ Avoid bony prominences

• These electrodes record 12 views of the heart’s electrode activity ▫ 12-lead EKG, even though there are only 10

leads

Performing the EKG

• Place the EKG machine to one side of patient (reduce tension on wires)

• Plug machine into electrical outlet▫ Make sure you know if the phone jack

needs to be connected to transmit your EKGs to the hospital or sponsor

• Turn on power

Performing the EKG

• Enter participant data ▫ Differs with each machine model▫ Check with your research team

• Lead Setup▫ Place electrodes in standard 10 positions▫ Attached electrodes to designated lead wires▫ Instruct participant to relax, breathe

normally, and remain still▫ Tell patient recording will only take ~12 sec

• EKG Acquisition▫ Record – review machine with your research

team for specifics

EKG Questions?