1. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Electrocardiography for Health Care Personnel Chapter 12: Ambulatory Monitoring 1

2. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 2

3. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Ambulatory Monitoring 3

4. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Ambulatory Monitoring 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 4

5. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Ambulatory Monitoring 5

6. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge How long does an ambulatory monitor typically remain on a patient? 6

7. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge ANSWER: 24 to 48 hours 7

8. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 8

9. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Variations of Ambulatory Monitoring Continuous monitoring Intermittent monitoring Telemetry Transtelephonic monitoring 9

10. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 10

11. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 11

12. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 12

13. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 3. Telemetry Monitoring 13

14. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 14

15. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 4. Transtelephonic Monitoring 15

16. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 16

17. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 4 A - Post-Symptom Event Monitor 17

18. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 12- lead ECG 18

19. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 4 B - Loop-memory Monitor 19

20. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Safety Ambulatory monitors are sensitive and expensive; avoid dropping 20

21. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Troubleshooting: Loose Electrodes Instruct patient to press in center of loose electrode to reapply and to return to facility if electrode falls off 21

22. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge 22 Which ambulatory monitor is used in the hospital setting?

23. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge ANSWER: Telemetry monitor 23

24. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge 24 Which ambulatory monitor is often used to evaluate pacemaker function?

25. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge ANSWER: Transtelephonic monitor 25

26. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 26

27. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Educating the Patient 27

28. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Diary All usual and unusual activities, such as: Urinating Bowel movements Sexual activity Walking Emotional upset Eating Sleeping 28

29. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Law and Ethics For questions regarding indications, side effects, and precautions of medications, refer the patient to the licensed practitioner 29

30. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Patient Education 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, high- voltage areas, and electric blankets Check monitoring equipment for proper functioning 30

31. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Document! Document! Document! Patient education should be written in the patient’s chart 31

32. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 32

33. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Ambulatory Monitoring for Children Consider child’s age and use terms he or she can understand Remember to instruct parent as well 33

34. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge 34 True or False: A diary should record all usual and unusual activities, including bowel and bladder function, sexual activity, exercise, and emotional upset.

35. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge ANSWER: True All should be included in a patient diary. 35

36. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 Skin preparation materials Shaving equipment Tape Patient education checklist Manufacturer’s directions for monitor Pen 36

37. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Before the Procedure Prepare monitor and review instructions Check monitor charge Insert blank tape or disk if required 37

38. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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) 38

39. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Place the Electrodes Clean the skin Abrade skin Follow manufacturer’s instructions for electrode placement 39

40. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Elderly or Patients on Certain Medications Apply less pressure when abrading skin Avoid abrasive cleansers Use caution when applying and removing electrodes 40

41. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Applying the Monitor Attach lead wires to electrodes Arrange lead wires comfortably on patient Tape each electrode in place Attach cable to electrocardiograph and run baseline ECG 41

42. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 42

43. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Law and Ethics Always follow manufacturer’s directions If directions are unavailable, consult supervisor 43

44. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge 44 What should you do if you are unfamiliar with the ambulatory monitor assigned to the patient?

45. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge ANSWER: First check the manufacturer’s instructions. If you cannot, consult your supervisor. 45

46. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 46

47. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Troubleshooting If patient has forgotten to bring diary, monitor should not be removed because results cannot be evaluated 47

48. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 48

49. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 49

50. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 50

51. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Abnormal Results Abnormal results may indicate: Electrical conduction defects in heart’s rate and rhythm controlling system Rhythm abnormalities Premature Atrial or ventricular contractions 51

52. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 52

53. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge 53 Should an ambulatory monitor be removed if the patient forgets to bring the diary?

54. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge ANSWER: No, the monitor should not be removed because the results cannot be monitored. 54

55. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge 55 Name three factors that may affect the accuracy of the tracing results.

56. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. Apply Your Knowledge ANSWER: Improper lead attachment, incomplete patient diary, and failure of patient to maintain a normal routine 56

57. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 57

58. Copyright © The McGraw-Hill company, Inc. Permission required for reproduction or display. 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 58

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