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

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


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 • 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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• 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

• 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 12-

lead 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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22

Which ambulatory monitor is used in the hospital setting?



• ANSWER: Telemetry monitor

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24

Which ambulatory monitor is often used to evaluate pacemaker function?



• 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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DiaryAll 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• 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

functioning30


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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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.

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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

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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• 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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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, consult your supervisor.

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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

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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 49


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 ResultsAbnormal 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)

scan52



53

Should an ambulatory monitor be removed if the patient forgets to bring the diary?



• ANSWER:• No, • the monitor should not be removed because

the results cannot be monitored.

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55

Name three factors that may affect the accuracy of the tracing results.



• 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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