SPP/2014/CARDMONI CARDIAC MONITORING 1

North Shore University Hospital PATIENT CARE SERVICES

Policy Title: CARDIAC MONITORING Prepared by: K. Buckley, RN J. Melchione, RN D. Kerner, RN R. Vahldieck, Telemetry Technician

Approval Date:

6/2/14

Effective Date:

6/9/14

Last Revised/Reviewed:

4/14, 7/12, 1/10, 6/09, 6/07, 10/04, 9/01

4 pages

PURPOSE This document describes the policy and procedures for cardiac monitoring.

POLICY STATEMENT A patient on cardiac monitoring shall be continuously monitored for cardiac arrhythmias. SCOPE This policy applies to all members of the North Shore University Hospital workforce including, but not limited to employees, medical staff, volunteers, students, physician office staff, and other persons performing work for or at North Shore University Hospital.

PROCEDURE Equipment • Cardiac monitor • Connecting Wires/Leads • Electrode pads • Warm water and soap Procedure 1. Explain the purpose of cardiac monitoring to the patient/significant other. 2. Prepare monitor in the following manner:

• Plug monitor in outlet • Turn monitor on • Plug EKG cable into monitor

3. Clean electrode site with warm, soapy water. Dry electrode site with a clean cloth. • Clip hair on chest, as needed, to allow good contact between electrodes and skin. • Do not shave electrode site, as this could irritate skin. • Avoid the use of isopropyl alcohol to prepare sites unless adhesion is a problem. • Alcohol can severely irritate skin. If you must use alcohol, allow it to dry thoroughly

before applying electrodes. 4. Apply electrodes to skin as follows (unless directed differently by manufacturer or

prescriber):

SPP/2014/CARDMONI CARDIAC MONITORING 2

For 3-lead placement (see picture below): • RA/White – Near right midclavicular line, directly below the clavicle. • LA/Black – Near the left midclavicular line, directly below the clavicle. • LL/Red – Below the left pectoral muscle on the left midclavicular line.

3-Lead Placement

For 5-lead placement (see picture below): • RA/White – Near right midclavicular line, directly below the clavicle. • LA/Black – Near the left midclavicular line, directly below the clavicle. • LL/Red – Below the left pectoral muscle on the left midclavicular line. • Ground/Green – Below the right pectoral muscle on the right midclavicular line. • Modified V1 / Brown – Fourth intercostal space on the right of the sternum.

5-Lead Placement

SPP/2014/CARDMONI CARDIAC MONITORING 3

For lead placement using EASI™ (see picture below): The EASI™ system is a derived 12-Lead ECG used with Philips monitors. The system uses an advanced algorithm and only 5 electrodes in a unique configuration to derive continuous 12-lead ECG data.

Color Electrode placement Black Upper part of the sternum Brown Lower part of the sternum, at the level of the fifth intercostal space Red Left midaxillary line, at the level of the fifth intercostal space White Right midaxillary line, at the level of the fifth intercostal space Green Anywhere (ground)

5. For patients pre- and post-open heart or thoracic procedures, avoid placing electrodes near

any incisions; place electrodes several inches from the incision to prevent occurrence of infection, skin irritation, or dermatitis.

6. Electrodes must be changed every 48 hours or when site becomes irritated/ soiled. 7. Select appropriate “Lead” for display. 8. Set alarm limits according to patient’s heart rate/ clinical condition (Refer to Clinical Alarms

policy). Patient Teaching 1. Cardiac monitor graphs the electrical impulses of the heart so that constant observation of the

heart rhythm and rate can be observed. 2. Inform patient he/she will be closely monitored by the nursing staff. 3. Inform patient he/she may position himself for comfort. 4. Inform patient that the monitor is equipped with an alarm system and that false alarms do

occur. 5. Instruct the patient to inform nursing staff of any discomfort or itching at electrode site.

SPP/2014/CARDMONI CARDIAC MONITORING 4

Documentation 1. Record cardiac rhythm and heart rate in electronic medical record. 2. Record changes in cardiac rhythm. 3. Review alarm parameters every shift. 4. Document alarms as “activated and audible” every shift (Assessment & Intervention

Flowsheet> Safety Interventions.) For intensive care units: 1. Mount ECG rhythm strip once per shift and prn for any change in cardiac rhythm. Place

strips in the medical record. For units with telemetry: (Refer to the Telemetry Manual ) 1. The ECG rhythm strip is mounted on the ECG rhythm strip sheet at the beginning of each

shift by the telemetry technician. • The date and time on the ECG rhythm strip is reviewed for accuracy. • Two separate leads should be displayed on the ECG rhythm strip. • The ECG rhythm strip is interpreted and documented in the telemetry book.

2. The RN verifies the telemetry transmitter number / room number registered to the patient at the telemetry station to the telemetry transmitter number / room number of the patient.

3. The RN confirms the interpretation in the telemetry book and documents the rhythm in the electronic medical record.

4. All ECG rhythm strips are kept in the telemetry book at the telemetry station while the patient is being monitored.

5. When the patient is no longer on telemetry, discharged, or transferred, the ECG rhythm strips are placed in the medical record*. * If the patient is remotely monitored, the ECG rhythm strips are sent to the remote unit for placement in the medical record.

6. For Remote Telemetry Units: the telemetry technician faxes a remote telemetry monitoring report sheet to the designated remote telemetry monitoring unit at the beginning of each nursing shift. The RN verifies the patient’s ECG rhythm, signs the remote telemetry monitoring report sheet and faxes it back to the telemetry technician.

REFERENCES LIPPINCOTT MANUAL OF NURSING PRACTICE. Eighth ed. 2006. NSUH. Cardiac Patient Care Service. Telemetry Manual.