Download Cardiac Monitoring: Cardiac Rhythm Assessment and Telemetry

INTERDISCIPLINARY CLINICAL MANUAL
Policy & Procedure
NUMBER:
CC 10-013
Section:
Cardiac Monitoring: Cardiac
Rhythm Assessment and
Telemetry Monitoring
Cardiovascular
Date Issued:
May 2006
Source:
Distribution:
Heart Health Resource Team
All
Date To Be Reviewed:
Issuing Authority:
May 2009
Karen MacRury-Sweet
Health Services
Director
TITLE:
THIS INCORPORATES POST-ENTRY LEVEL SKILLS FOR RNS AND
LPNS, WHICH REQUIRE COMPETENCY ASSESSMENTS PRIOR TO
PERFORMING
POLICY
1. Skin preparation and lead application for cardiac monitoring is a:
1.1. post-entry level competency for LPNs that requires certification before performing.
1.2. basic nursing procedure for RNs.
2. Cardiac rhythm assessment is a post-entry level competency for RNs (applicable in specific
units/areas) that requires certification before performing.
3. As the use of cellular phones and two-way radios can interfere with medical equipment, signage
restricting use is to be posted in patient care areas where cardiac monitoring or telemetry occurs.
GUIDING PRINCIPLES
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
1
1. Cardiac Monitoring provides a means to:
1.1. monitor a patient's cardiac electrical activity.
1.2. document cardiac electrical activity for diagnostic reasons or documentation.
1.3. identify ECG changes indicating ischemia.
1.4. identify arrhythmias.
1.5. determine effect of drugs and/or electrolytes on the heart’s electrical system.
2. Adequate skin contact and accurate lead placement are necessary to ensure quality tracings.
Consider:
2.1. Anatomical landmarks for accurate lead placement
2.2. Shaving hair from appropriate areas
2.3. Gently rubbing skin surfaces with alcohol swab, dry gauze, or soap and water to remove oily
residue and dead skin cells.
2.4. Allowing skin to dry thoroughly before applying electrodes.
2.5. Changing electrodes every 48 hours to avoid skin irritation and to ensure electrode gel is
sufficient for conduction.
3. Troubleshoot as necessary to ensure the ECG pattern is clear and distinct. Monitor or lead
adjustments may be required to improve quality of recording.
4. Lead II is most commonly used because it produces a clear QRS complex (which reflects
ventricular activity) and a positive P wave (which shows atrial activity.)
5. Multi-lead ECG monitoring (5 & 6 Lead) can help eliminate nuisance alarms, give a clearer
recording and improve arrhythmia analysis.
6. Avoid placing electrodes over pacemaker site or automatic implantable cardioverter defibrillator
(AICD) to prevent possible electrical interference and inappropriate alarms. Refer to equipment
specific manual for electrode placement recommendations.
7. When using 6 leads, the V5 lead is recommended for ST depression monitoring.
8. The V1 lead is recommended for arrhythmia detection.
EQUIPMENT
•
•
•
•
•
•
•
•
3, 5 or 6 electrodes
monitor or telemetry unit & batteries if applicable
cable (s) / leadwire (s)
alcohol prep
disposable razor or shave clippers
soap and water
washcloth
tape
PROCEDURE
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
2
RNs and LPNs
1. Explain procedure to patient and family.
2. Shave hair from chosen sites.
3. Gently rub skin surface to remove dead skin cells at selected sites.
4. Wash site with soap and water or alcohol to remove oily residue or dead skin cells.
5. Allow skin to dry thoroughly.
6. Apply electrodes as recommended. Connect the lead wires to the electrodes that snap on before
placement on patient. Refer to diagrams – Appendixes A, B, and C.
7. To prevent rotation of the leadwire, tugging & artifact, make a stress loop on each leadwire and
tape the stress loop to the patient. Do not tape across the electrode.
8. Connect the cable to monitor or telemetry unit.
9. Instruct the telemetry patient re activating the graph button and pressing the nurse call bell.
Reinforce transmission range; i.e. Not able to leave unit.
RNs only
10. Select monitoring features from ECG menu, i.e. lead(s) displayed, ECG size, pacemaker
detection, alarm limits, QRS volume, and arrhythmia and where applicable, ST monitoring &
lead analysis.
11. Observe cardiac rhythm on monitor.
12. For trouble-shooting, refer to attached trouble shooting guide and/or manufacturer’s instructions
/ operation manual.
13. Systematically assess cardiac rhythm.
14. Assess for life threatening arrhythmias.
15. Document assessment of cardiac rhythm strip at the beginning of each shift, with rhythm
changes and/or with changes in patient’s clinical condition. Refer to unit-specific policy and
procedure, guideline or protocol, if applicable. Include the following in the documentation:
15.1.
heart rate,
15.2.
rhythm,
15.3.
PR,
15.4.
QRS,
15.5.
QT,
15.6.
ST
15.7.
rhythm assessment.
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
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15.8.
interventions.
RELATED CAPITAL HEALTH DOCUMENTS
Policies
Cellular Phones and Two-Way Radios, Use of Q100-030.000 (1998) QEII Health Sciences Centre
Administrative Policy & Procedure.
Site-related policies addressing the use of cellular phones and Two-Way Radios
Appendixes
Appendix A – Using 3 Leads
Appendix B - Using 5 Leads
Appendix C – Using 6 Leads
Appendix D – Troubleshooting Guide
REFERENCES
Beverage, D., Haworth, K., Labus, D., Mayer, B.H., Munson, C. (Eds.). (2005). ECG Interpretation
Made Incredibly Easy (3rd ed.). New York: Lippincott Williams & Wilkins.
Dubin, Dale (2000). Rapid Interpretation of EKG’s (6th ed.). Hong Kong: Cover Inc.
Marquette Medical Systems Inc., Milwaukee, Wisconsin, USA.
Jackson, Kate (2001). ECG Interpretation: Made Incredibly Easy (2nd ed.). Springhouse,
Pennsylvania.
Lynn-McHale, D. and Carlson, Karen (2001. American Association of Critical Care Nurses (AACN)
Procedure Manual for Critical Care (4th ed), W.B. Saunders Company, Pennsylvania.
Woods, S; Sivarajan Froelicher, E. and Underhill Motzer, S. (2000). Cardiac Nursing (4th ed.).
Lippincott, Philadelphia.
HISTORICAL DATES
Integrated – May 2006 1
1
Replaces:
•
QEII: Application of Telemetry Transmitter NC-10-30-51
Cardiac Monitor Electrode Placement NC-10-30-50
•
Cobequid: Interpret & Document Cardiac rhythm Strips & life Threatening Dysrhythmias
Initiation of Cardiac Monitoring
•
HCH: Electrode Placement (Unit 200)
Attachment of Skin Electrodes for Cardiac Monitoring (Unit 200)
Attachment of Skin Electrodes for Cardiac Monitoring (Outpatients)
•
DGH: Cardiac Monitoring
•
ESM: Cardiac monitors II-e – not equipment specific content
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
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Appendix A
3 Leads
Figure 1:
Using 3 Leads: Lead II
•
•
•
Negative (RA) electrode is placed in the right clavicular hollow, mid-clavicular
line (MCL). (2nd intercostal space, right MCL)
Positive (LL) electrode is placed on the left side of the chest below the lowest
palpable rib.
Ground (LA) electrode is placed in the left clavicular hollow, MCL.
(2nd intercostal space left MCL)
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
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Appendix B
5 Leads
Figure 2:
Using 5 Leads
•
Negative (RA) electrode is placed in the right clavicular hollow, mid-clavicular
line (MCL). (2nd intercostal space, right MCL).
•
Ground (LA) electrode is placed in the left clavicular hollow, MCL. (2nd
intercostal space left MCL)
•
(R) leg (RL) and (L) leg (LL) electrodes should be placed below the lowest
palpable ribs (R) and (L).
•
V Lead (V1) is placed at 4th ICS (R) sternal border.
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
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Appendix C
6 Leads
Figure 3:
Using 6 Leads
• Negative (RA) electrode is placed in the right clavicular hollow, mid-clavicular
line (MCL). (2nd intercostal space, right MCL).
•
Ground (LA) electrode is placed in the left clavicular hollow, MCL. (2nd
intercostal space left MCL)
•
Any Two V leads may be used.
•
V1 Lead is placed at 4th ICS (R) sternal border. V1 is recommended for
arrhythmia detection.
•
V5 lead is placed at 5th ICS (L) anterior axillary line. V5 is recommended for ST
depression monitoring.
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
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Appendix D
TROUBLE SHOOTING GUIDE
PROBLEM
1.
Artifact
POSSIBLE CAUSE
a.
b.
c.
d.
2.
Thick, fuzzy baseline (60 cycle
interference)
a.
restless patient
electrical interference (e.g. static
electricity)
defective lead wire
conduction interference from leads
b.
electrical interference from improperly
grounded equipment.
damaged lead wire or patient cable
3.
Straight baseline despite normal
heart rhythm and rate.
a.
b.
c.
d.
size (gain control set too low)
damaged or disconnected lead wire
wrong lead setting
electrode or lead has come off
4.
Alarm sounds repeatedly despite
normal heart rhythm and rate.
a.
b.
c.
d.
e.
alarm is set too close to patient's normal
rate
QRS complex is too small to register
restless patient
damaged lead wire or patient cable
sensitivity control is too high or too low
5.
Wandering baseline
a.
b.
c.
d.
restless patient
chest wall moves during respiration
electrode positioned over bone
dried electrodes
6.
Telemetry
• low battery signal/alarm
• out of range signal
• no tracing screen
a.
b.
c.
change battery
locate patient if out of range
pause alarms if patient out of range for
tests, etc.
Cardiac Monitoring:
CC 10-013
Cardiac Rhythm Assessment and Telemetry Monitoring
Learning Module
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