CONTINUOUS ECG MONITORING:
STANDARDS OF NURSING CARE IN CCTC (SONC)

1. Monitor ECG
2. Maintain ECG Alarms
3. Monitor ECG Rhythm Strips

STANDARD OF NURSING CARE

1.

Monitor ECG

All CCTC patients have continuous ECG monitoring, unless otherwise ordered. Change ECG electrodes OD during bath, and prn.

ECG1 (the first waveform display) must be setup to monitor Lead I, II or a V Lead when using the Datex monitors. Select the lead that provides the tallest QRS complex.

 1.

To provide continuous monitoring with prompt detection of changes in heart rate or rhythm.

Electrodes are changed to maintain optimal contact.

The Datex monitors require Lead I, II or a V lead in ECG1.

 2.

Maintain ECG Alarms

ECG alarms must be appropriately set and turned on at all times. High and low alarm settings are assessed and documented each hour in the graphic record.

Alarm settings are selected based on the degree of fluctuation in the patient's HR. Upper and lower alarm limits that represent clinically important changes are selected for each individual patient.

Alarms may be disabled during withdrawal-of-life-support. On occasion, efforts to resolve nuisance alarms may not be successful. If ECG alarms are disabled, documentation in the AI record is required. Documentation should include the reason for disabling the alarm and troubleshooting strategies.

If HR monitoring from the ECG is not possible, change the monitor to enable heart rate monitoring from the arterial line.

 2.

To promptly detect relevant changes.

Troubleshooting

Prep skin by washing with water and drying well. Trim hair. Do not shave the skin or use alcohol or detergents. Roughen skin up with sandpaper prior to electrode placement to improve skin contact (available in tape dispensers). Connect lead to electrode before it is applied to the skin (avoid pressing electrode onto skin; this may cause loss of contact gel).

The QRS height must be 1/2 the height of the white calibration marker. Increasing the gain WILL NOT improve the monitors ability to detect the QRS. If the patient has a low QRS voltage, look at the 12-lead ECG view and select the lead with the tallest QRS. The Datex monitor requires Lead I, II or a V lead in ECG1. If the best QRS height is in a different lead (e.g., lead III), the monitor can be "fooled" by altering the leads. For example, reversing the LL and RL leads will display the true Lead III as a Lead II.

Moving the leads closer together, or placement of an anterior and posterior lead may increase the QRS height.

 3.

Analyze ECG Rhythm Strips

An ECG rhythm strip is collected, analyzed and posted in the clinical record at the time of admission, at the start of each shift, q4h if arrhythmias are present, q6h if cardiac status is stable and prn for significant changes in the ECG rhythm for all acute patients.

HR documentation frequency may be decreased to q shift and prn when patients become hemodynamically stable. Chronic patients with continuous ECG monitoring and stable rhythms require OD and prn ECG rhythm documentation.

 3.

To document ECG rhythm.