Telemetry monitoring - step by step, tips, tricks, and notes to successfully demonstrate skills regarding PDF

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step by step, tips, tricks, and notes to successfully demonstrate skills regarding telemoetry monitoring and assessment...

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SKILL COMPETENCY CHECKLIST

Telemetry Monitoring

. Standard Met/Initials

Competency Areas Prerequisite Skills Knowledge of the purpose of and indications for telemetry monitoring, and understanding of the distinction between remote and centralized telemetry Knowledge of cardiovascular assessment and EKG interpretation necessary to be able to recognize and understand the significance of ST segment elevation or depression and to recognize and provide emergency care for a variety of arrhythmias Understanding of telemetry components, their functionality, and relevant terminology (e.g., electrodes, cables, leads), and knowledge of how to program and operate the cardiac monitor Knowledge of which leads to use for assessment of the electrical activity in various regions of the heart Verbalizes accurate electrode placement for 3-electrode system monitoring leads MCL1 or MCL6, the 3-electrode system monitoring lead II, and the 5-electrode system

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Preparation Reviews: •The facility/unit specific protocol for telemetry monitoring, if available •The treating clinician’s orders for telemetry monitoring, including heart rate and ST segment elevation/depression parameters •The patient medical record for –the patient’s current medication regimen, particularly for medications that may affect the EKG rhythm –laboratory study results that indicate electrolyte imbalances –previous EKGs or telemetry strips in the patient’s medical record which will provide a basis for comparison –any allergies (e.g., to latex, medications, or other substances); use alternative materials as appropriate •The instructions for all equipment to be used, and verifies that equipment is in good working order –Communicates with the health care professional monitoring the telemetry monitors to ensure that he/she is aware of the patient’s orders and that the centralized monitors are in good working order –Places fresh batteries in the transmission device –Sets alarm parameters on the monitor according to treating clinician’s orders Verifies completion of facility informed consent documents Gathers the supplies necessary to perform telemetry monitoring, which usually include: •Nonsterile gloves. Additional personal protective equipment (PPE; e.g., gown, cap, mask) may be necessary depending on the potential for exposure to body fluids •Electrode patches •Alcohol swabs to clean the limbs/chest prior to electrode placement •Clippers to trim excess hair, if necessary •Telemetry transmission device with new battery installed •Cables or wires to connect electrodes to the transmission device •A pouch for carrying the telemetry transmission device, if available Procedure Performs hand hygiene and dons nonsterile gloves and other necessary PPE Identifies the patient according to facility protocol Establishes privacy by closing the door to the patient’s room and/or drawing the curtain surrounding the patient’s bed

Introduces self to the patient and family member(s), if present; explains clinical role; assesses the coping ability of the patient and the family and for knowledge deficits and anxiety regarding telemetry monitoring •Determines if the patient requires special considerations regarding communication (e.g., due to illiteracy, language barriers, or deafness); makes arrangements to meet these needs if they are present –Follows facility protocols for using professional certified medical interpreters, either in person or via phone, when language barriers exist •Explains to the patient/family the procedure for telemetry monitoring and its purpose; answers all questions and provides emotional support as needed. Informs the patient/ family –that his/her heart rate and rhythm will be monitored continuously using a device that will send information to a cardiac monitor located outside the patient’s room) –that electrodes will be placed on his/her chest that are connected via wires to a small telemetry transmission device that can be carried in a pouch or pocket) –indications for telemetry monitoring in his/her particular case (e.g., recent cardiac surgery, recurrent atrial fibrillation) –that the patient will be able to be up and moving as tolerated/permissible and will have no activity restrictions related to telemetry monitoring Obtains verbal consent from the patient prior to beginning the procedure Places the patient in a supine position, raises the bed to a comfortable height, puts on gloves if there is any possibility of exposure to bodily fluids, and exposes the patient’s chest •Asks family members to leave to promote privacy, if present Determines electrode placement based on the number of electrodes to be used and the lead to be monitored Clips/trims any excess hair in the electrode placement site, as needed Cleans the site where each electrode is to be placed with soap and water or an alcohol pad, according to facility protocol; dries the site thoroughly Removes the backing from an electrode and checks to see that the gel pad is moist; discards the electrode and obtains another if the pad is not moist

Carefully places the electrode against the patient’s skin in the chosen site; presses gently around the outer edges of the electrode to secure the electrode to the skin; avoids pressing directly on the center of the electrode over the gel pad •Places the right arm (RA) electrode near the left shoulder, the left arm (LA) electrode in the 4th intercostal space to the right of the sternum, and the left leg (LL) electrode in the 5th intercostal space in the left mid-axillary line for a 3-electrode system monitoring MCL1 or MCL6 –Chooses lead I on the monitor for MCL1 and lead II for MCL6 •Places the RA electrode near the right shoulder, the LA electrode near the left shoulder, and the LL electrode below the ribs on the left side of the abdomen for a 3-electrode system monitoring lead II •Places the RA electrode near the right shoulder, the LA electrode near the left shoulder, the LL electrode below the ribs on the left side of the abdomen, the right leg (RL) electrode below the ribs on the right side of the abdomen, and the C (ground) electrode in the 4th intercostal space to the right of the sternum to monitor V1 or in the 5th intercostal space in the left midaxillary line to monitor V6 for a 5-electrode system Attaches the appropriate electrode wires to each of the electrodes Turns on the transmission device and checks the monitoring station (either remote or centralized) that the EKG is being transmitted; selects the monitoring lead most appropriate to the patient’s condition Troubleshoots according to equipment instructions if there is any difficulty obtaining a clear EKG tracing •Checks the electrodes for placement and ensures that the wires are connected correctly and not damaged; replaces electrodes one at a time, as needed •Follows all facility protocols regarding bathing while undergoing telemetry monitoring; replaces electrodes if they become wet or soiled Has the patient carry the transmission device in a pouch or gown pocket •Instructs the patient to not remove the electrodes or the wires, and to not get the electrodes, wires, or transmission device wet Disposes of all used electrode packaging, gloves and other PPE, and performs hand hygiene

Post-Procedural Responsibilities Monitors the patient on an ongoing basis to include •monitoring the electrode sites with each routine patient assessment or more frequently, as needed, and removing and repositioning the electrodes according to facility protocol or as needed if the skin under the electrodes becomes reddened or excoriated •recording a rhythm strip according to unit/facility protocol, which can include each time the patient’s vital signs are recorded, each time the monitor alarms reflecting aberrant electrical activity, and prior to discontinuing telemetry monitoring •identifying and documenting the heart rate and rhythm as well as any symptoms experienced and any nursing interventions performed •facilitating completion of a 12-lead EKG, if ordered, to more thoroughly assess the patient’s cardiac status if the patient develops a new arrhythmia or experiences myocardial ischemia Updates the patient’s plan of care, if appropriate, and documents the following information in the patient’s medical record: •Date and time telemetry monitoring was initiated, including –the indication for telemetry monitoring –the lead monitored –whether remote or centralized telemetry was utilized –alarm parameters that were set according to clinician’s orders –a recorded strip of the patient’s heart rhythm at the start of telemetry monitoring with all necessary measurements recorded •Patient assessment information, including vital signs and physical assessment, including any cardiac signs and symptoms, and nursing interventions performed •Any unexpected patient events or outcomes, interventions performed, and whether or not the treating clinician was notified •Patient/family member education, including topics presented, response to education provided/discussed, plan for follow-up education, and details regarding any barriers to communication and/or techniques that promoted successful communication . . Signature

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