Transcript Chapter 7 Ambulatory Monitoring

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Electrocardiography for Health
Care Personnel
Chapter 12: Ambulatory Monitoring
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Ambulatory Monitoring
• Process of recording an ECG tracing while
the patient doing daily activities
• A small box strapped to the waist or
shoulder for 24 to 48 hours
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Ambulatory Monitoring
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Ambulatory Monitoring
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Named after Norman Holter
Three to five leads are attached
Patient keeps diary of activities,
Recording symptoms and abnormal
sensations
• Computer is used to view, print, and
analyze tracing from monitor
• Cardiologist usually performs final
interpretation of results
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Ambulatory Monitoring
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Apply Your Knowledge
How long does an ambulatory monitor typically
remain on a patient?
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Apply Your Knowledge
• ANSWER:
• 24 to 48 hours
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Ambulatory Monitoring - Use
• To capture abnormal heart rhythms
during ambulation
To evaluate
• Effectiveness of cardiac medications
• Pacemaker function
• The heart function after a recent MI
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Variations of Ambulatory Monitoring
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Continuous monitoring
Intermittent monitoring
Telemetry
Transtelephonic monitoring
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1. Continuous Monitoring
• Complete tracing from time unit is
applied until removal
• Patient can activate “event marker”
–Traces the exact time symptoms occur
–Clock to correlate tracings with diary
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2. Intermittent Monitoring
• Patient activates recording only when
symptoms occur
–May not show abnormalities prior to
symptoms
• Can be evaluated more quickly than
continuous
• May be voice activated
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3. Telemetry Monitoring
• Performed inside medical facility
• Uses three or five electrodes on chest
• Transmits to a central location where
multiple patients may be monitored
• Patient diary not required
• Telemetry monitoring technicians may
require certification
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3. Telemetry Monitoring
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4. Transtelephonic Monitoring
• Primarily used to evaluate pacemaker
function
• Can be used for monitoring patients
longer than 24 to 48 hrs
• Information is stored in the monitor, then
transmitted via telephone
• 2 types: post-symptom event and loop
memory monitor
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4. Transtelephonic Monitoring
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4 A - Post-Symptom Event Monitor
• Used when patient is experiencing
symptoms
• Can be worn like a wristwatch or be
hand-held
• Handheld type is placed against chest
when experiencing symptoms
• Wristwatch type is worn at all times
• Used to document dysrhythmia that last
more than a few seconds
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4 A - Post-Symptom Event Monitor
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4 B - Loop-memory Monitor
• May remain for 30 days or more
• Memory on monitor can hold up to five
minutes
• Provides physician with recording before,
during, and after event, such as fainting
• New monitors have capability of a 12lead ECG
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4 B - Loop-memory Monitor
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Safety
Ambulatory monitors are sensitive and
expensive; avoid dropping
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Troubleshooting: Loose Electrodes
• Instruct patient to
press in center of
loose electrode to
reapply and to return
to facility if electrode
falls off
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Apply Your Knowledge
Which ambulatory monitor is used in the
hospital setting?
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Apply Your Knowledge
• ANSWER: Telemetry monitor
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Apply Your Knowledge
Which ambulatory monitor is often used to
evaluate pacemaker function?
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Apply Your Knowledge
• ANSWER: Transtelephonic monitor
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Educating the Patient
• Diary
–A record of events and symptoms that
occur while monitor is in place
–Used in conjunction with ECG tracing
• Have patient repeat diary instructions
• Remind patient of any medication changes
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Educating the Patient
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Diary
All usual and unusual activities, such as:
• Urinating
• Bowel movements
• Sexual activity
• Walking
• Emotional upset
• Eating
• Sleeping
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Law and Ethics
• For questions regarding indications, side effects,
and precautions of medications, refer the patient
to the licensed practitioner
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Patient Education
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Wear loose fitting clothing
Sponge baths are allowed;
no showers or tub baths
When sleeping, make sure tension is not
applied to leads
• Avoid magnets, metal detectors, highvoltage areas, and electric blankets
• Check monitoring equipment for proper
functioning
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Document! Document! Document!
• Patient
education
should be
written in the
patient’s chart
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Patient Education and Communication
• Have patients tell you what they already
know about ambulatory monitoring,
• then explain to them what they don’t know
• Explaining the procedure and answering
questions should alleviate patient fears
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Ambulatory Monitoring for Children
• Consider child’s age and use terms he or she can
understand
• Remember to instruct parent as well
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Apply Your Knowledge
True or False:
A diary should record all usual and unusual
activities, including bowel and bladder
function, sexual activity, exercise, and
emotional upset.
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Apply Your Knowledge
• ANSWER:
• True
• All should be included in a patient diary.
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Before the Procedure: Gather Equipment
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Monitor with holder and strap or belt
Batteries and tape or disk
Electrodes (3 or 5)
Lead wires
Alcohol and gauze
Patient diary
Skin preparation materials
Shaving equipment
Tape
Patient education checklist
Manufacturer’s directions for monitor
Pen
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Before the Procedure
• Prepare monitor
and review
instructions
• Check monitor
charge
• Insert blank tape
or disk if required
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Prepare the Patient
Clothing should be removed from
waist up
Provide drape
Have patient sit or lie down and relax
Dry shave electrode sites, if
necessary (clip hair for telemetry
monitoring)
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Place the Electrodes
• Clean the skin
• Abrade skin
• Follow manufacturer’s
instructions for
electrode placement
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Elderly or Patients on Certain Medications
• Apply less pressure
when abrading skin
• Avoid abrasive cleansers
• Use caution when
applying and removing
electrodes
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Applying the Monitor
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Attach lead wires to electrodes
Arrange lead wires comfortably on patient
Tape each electrode in place
Attach cable to electrocardiograph and run
baseline ECG
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Applying the Monitor
• Have patient dress,
then attach cable to
monitor
• Check lead wires and
electrodes
• Start monitor, have
patient make first diary
entry
• Review all patient
instructions
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Law and Ethics
• Always follow
manufacturer’s
directions
• If directions are
unavailable, consult
supervisor
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Apply Your Knowledge
What should you do if you are unfamiliar with
the ambulatory monitor assigned to the
patient?
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Apply Your Knowledge
• ANSWER:
• First check the manufacturer’s instructions.
• If you cannot, consult your supervisor.
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Removing the Ambulatory Monitor
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Review patient’s diary
Turn off monitor and detach lead wires
Detach lead wires and cable from patient
Remove tape and electrodes
Clean skin
Record removal procedure on patient’s
chart
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Troubleshooting
• If patient has forgotten to bring diary,
monitor should not be removed
• because results cannot be evaluated
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Reporting Results
• Follow manufacturer’s instructions for
preparing recording for evaluation
• Final interpretation may be done by a
physician, usually a cardiologist within
your facility, or sent to an outside
laboratory
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Reporting Results
• Ensure cassette or results are properly
labeled, including:
–Patient’s name
–Medical record number
–Date
–Physician’s name
–Other identifying information
• Patient diary must be kept with cassette or
results
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Reporting Results
• Factors affecting accuracy of tracing
results:
–Improper lead attachment
–Incomplete patient diary
–Failure of patient to maintain normal
routine
• If results are sent to an outside lab,
report can take seven to ten days
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Abnormal Results
Abnormal results may indicate:
• Electrical conduction defects in
heart’s rate and rhythm controlling
system
• Rhythm abnormalities
• Premature Atrial or ventricular
contractions
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Abnormal Results
• Additional testing that may be required
after results are known include:
–Echocardiogram
–Coronary angiogram
–CT (computerized tomography) scan
–MRI (magnetic resonance imaging)
–PET (position emission tomography)
scan
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Apply Your Knowledge
Should an ambulatory monitor be removed if
the patient forgets to bring the diary?
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Apply Your Knowledge
• ANSWER:
• No,
• the monitor should not be removed because
the results cannot be monitored.
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Apply Your Knowledge
Name three factors that may affect the
accuracy of the tracing results.
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Apply Your Knowledge
• ANSWER:
• Improper lead attachment, incomplete patient
diary, and failure of patient to maintain a
normal routine
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Chapter Summary
• Common ambulatory monitors include: Holter (most
common), telemetry, and Transtelephonic
• Ambulatory monitoring can be either continuous or
intermittent
• Ambulatory monitoring is used to monitor the heart
during a long period of time
• Monitoring is used to evaluate dysrhythmia, evaluate
the effectiveness of cardiac medications, and check
pacemaker function
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Chapter Summary
• Patient should be educated about the
procedure
• Equipment should be gathered and prepared,
and electrodes should be placed on the
patient
• Diary must be completed before removing the
monitor
• Recording must be prepared for review and
evaluation
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