12.1 Apply Your Knowledge How long does an ambulatory monitor typically remain on a patient?

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1 Learning Outcomes (Cont d) 12.4 Educate the patient about ambulatory monitoring Prepare a patient for application of an ambulatory monitor Describe the procedure for applying an ambulatory monitor correctly Describe the procedure for removing the ambulatory monitor and reporting the results What Is Ambulatory Monitoring? Process of recording an ECG tracing while the patient goes about daily activities Typical ambulatory monitor is a small box strapped to the waist or shoulder for 24 to 48 hours Inside the box is a recording device 12.1 What Is Ambulatory Monitoring? (Cont d) One type is the Holter monitor, named after Norman Holter Three to five leads are attached, depending on monitor type Patient keeps diary of activities, recording symptoms and abnormal sensations 12.1 What Is Ambulatory Monitoring? (Cont d) Computer is used to view, print, and analyze tracing from monitor Cardiologist usually performs final interpretation of results 12.1 Apply Your Knowledge How long does an ambulatory monitor typically remain on a patient? Apply Your Knowledge How long does an ambulatory monitor typically remain on a patient? 9 10 ANSWER: 24 to 48 hours 12.2 How Is Ambulatory Monitoring Used? To capture abnormal heart rhythms when symptoms do not occur during 12-lead or stress ECGs To monitor effectiveness of cardiac medications To evaluate pacemaker function To evaluate the heart after a recent myocardial infarction 12.2 Apply Your Knowledge What symptoms could a patient be experiencing that the physician would order ambulatory monitoring? Apply Your Knowledge What symptoms could a patient be experiencing that the physician would order ambulatory monitoring? 1

2 Answer: Chest pain, dizziness, lightheadedness, syncope, or palpitations 12.3 Variations of Ambulatory Monitoring Continuous monitoring Intermittent monitoring Telemetry Transtelephonic monitoring 12.3 Continuous Monitoring Complete tracing from time unit is applied until removal Patient can activate event marker Traces the exact time symptoms occur Unit is equipped with a clock to correlate tracings with diary entries 12.3 Intermittent Monitoring Patient activates recording only when symptoms occur Only shows ECG tracing during the symptom Can be evaluated more quickly than continuous 12.3 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 12.3 Transtelephonic Monitoring Primarily used to evaluate pacemaker function Can be used for monitoring patients longer than 24 to 48 hrs 12.3 Transtelephonic Monitoring (Cont d) Information is stored in the monitor, then transmitted via telephone 2 types: post-symptom event and loop memory monitor 12.3 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 Post-Symptom Event Monitor (Cont d) Wristwatch type is worn at all times Used to document dysrhythmias that last more than a few seconds 12.3 Loop-memory Monitor May remain on chest for 30 days or more Memory on monitor can hold up to five minutes Loop-memory Monitor (Cont d) Provides physician with recording before, during, and after event, such as fainting New monitors have capability of a 12-lead ECG 12.3 Troubleshooting: Instruct patient to press in center of loose electrode to reapply and to return to facility if electrode falls off 2

3 23 Ambulatory monitors are sensitive and expensive; avoid dropping Which ambulatory monitor is used in the hospital setting? 24 Which ambulatory monitor is used in the hospital setting? 25 ANSWER: Telemetry monitor Which ambulatory monitor is often used to evaluate pacemaker function? 26 Which ambulatory monitor is often used to evaluate pacemaker function? ANSWER: Transtelephonic monitor 12.4 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 12.4 Diary What Is Recorded All usual and unusual activities, such as: Urinating, bowel movements Sexual activity Walking Emotional upset Eating Sleeping 12.4 Law and Ethics It is your responsibility to remind the patient of medication changes prescribed by the physician For questions regarding indications, side effects, and precautions of medications, refer the patient to the licensed practitioner 12.4 What the Patient Should Know During Ambulatory Monitoring Wear loose fitting clothing for comfort and to reduce artifact Sponge baths are allowed; no showers or tub baths 3

4 31 32 When sleeping, make sure tension is not applied to leads 12.4 What the Patient Should Know During Ambulatory Monitoring (Cont d) Avoid magnets, metal detectors, high-voltage areas, and electric blankets Check monitoring equipment for proper functioning Patient education should be written in the patient s chart 12.4 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 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. ANSWER: True. All should be included in a patient diary 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 12.5 Ambulatory Monitoring for Children Consider child s age and use terms he or she can understand Allow the child to touch the equipment prior to applying it Remember to instruct parent as well 12.5 Apply Your Knowledge What is the first step in reducing a patient s fears for the ambulatory monitoring procedure? 12.5 Apply Your Knowledge What is the first step in reducing a patient s fears for the ambulatory monitoring procedure? Answer: Help the patient understand the procedure by answering all questions Before the Procedure: Gather Equipment Monitor with holder and strap or belt Batteries and tape or disk Electrodes (3 or 5) Lead wires Alcohol and gauze Patient diary 12.6 Before the Procedure: Gather Equipment (Cont d) Skin preparation materials Shaving equipment Tape Patient education checklist 4

5 Manufacturer s directions for monitor Pen 12.6 Before the Procedure Prepare monitor and review instructions Check monitor charge Insert blank tape or disk if required 12.6 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) 12.6 Place the Electrodes Use alcohol swab and let dry Abrade skin Follow manufacturer s instructions for electrode placement 12.6 Elderly or Patients on Certain Medications Apply less pressure when abrading skin Avoid abrasive cleansers Use caution when applying and removing electrodes 12.6 Applying the Monitor 12.6 Applying the Monitor (Cont d) 12.6 Applying the Monitor (Cont d) When applying an unfamiliar type of monitor, follow manufacturer s directions If directions are unavailable, consult supervisor 12.6 Apply Your Knowledge What should you do if you are unfamiliar with the ambulatory monitor assigned to the patient? Apply Your Knowledge What should you do if you are unfamiliar with the ambulatory monitor assigned to the patient? ANSWER: First check the manufacturer s instructions. If you cannot locate them or do not understand them, consult your supervisor Removing the Ambulatory Monitor 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 12.7 Reporting Results Follow manufacturer s instructions for preparing recording for evaluation 5

6 Final interpretation may be done by a physician, usually a cardiologist within your facility, or sent to an outside laboratory 12.7 Reporting Results (Cont d) Ensure cassette or results are properly labeled, including: Patient s name Medical record number Date Physician s name Patient diary must be kept with cassette or results 12.7 Reporting Results (Cont d) 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 12.7 Abnormal Results Abnormal results may indicate: Electrical conduction defects in heart s rate and rhythm controlling system Rhythm abnormalities Premature atrial or ventricular contractions 12.7 Abnormal Results (Cont d) Additional testing that may be required: Echocardiogram Coronary angiogram CT (computerized tomography) scan MRI (magnetic resonance imaging) PET (position emission tomography) scan 12.7 Apply Your Knowledge What factors can affect the results of ambulatory monitoring? 12.7 Apply Your Knowledge What factors can affect the results of ambulatory monitoring? Answer: Improper lead attachment, incomplete patient diary, and failure of the patient to maintain a normal routine 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 Chapter Summary (Cont d) Monitoring is used to evaluate dysrhythmias, evaluate the effectiveness of cardiac medications, and check pacemaker function Patient should be educated about the ambulatory monitoring procedure 6

7 59 Chapter Summary (Cont d) 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 7

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