University Medical Center Corporation Tucson, Arizona
SUBJECT: Telemetry Management Policy: PM 90 Originator: Heidi Costello, Michelle Ziemba, Jayne Matte-Wilson, Gina Ragonese Responsible Person: Michelle Ziemba Effective Date: September 30, 2010 Revision Date: PURPOSE: To outline the nursing management of the telemetry monitored patient. SUPPORTIVE DATA: To provide continuous cardiac monitoring of the patient at risk for cardiac dysrhythmias and/or potential hemodynamic instability. PROCEDURE: 1.0 Treatment
1.1 Identify areas of electrode placement per system design or physician order. 1.2 Preparation of skin for electrode application: Clip hair on appropriate areas of chest as indicated. Clean areas with alcohol. Allow to dry. Apply electrodes (assess for allergies to types of electrodes) Change electrodes every 72 hours. Note: date electrodes changed on LA
Place lead wires as indicated per 1.0 above. 2.0 Assessment
2.1 Assess and interpret initial rhythm, and q 4 and prn, unless otherwise indicated. Sign and post strip. 2.1.1 Correlate rhythm with physical assessment of patient. 2.2 The RN each shift will assure that patient’s with orders for Full Disclosure (all arrhythmias stored in memory) are on Full Disclosure (if Full Disclosure available on monitoring equipment). 3.0 3NE and Remote Telemetry Monitoring
3.1 Patients who are at low risk for cardiac dysrhythmias and for the need for cardiac interventions may be admitted to a medical-surgical floor for cardiac monitoring. 3.2 Criteria for 3NE and remote telemetry monitoring: Chronic stable atrial arrhythmias Arrhythmia's which are not being medically treated Stable
3.3 Patient's with a diagnosis of rule out MI will not be admitted to a medical- surgical bed. 3.4 Intravenous cardiac medications or EMERGENCY IV push medications will NOT be administered. 3.5 Any patient requiring medical intervention for cardiac instability must be transferred to an intermediate or intensive care unit. 3.6 Rhythm strips are to be sent to the remote telemetry units every 4 hours and prn with the PR, QRS and QT intervals measured by the monitor technician. 3.6.1 The RN caring for the patient will interpret the rhythm, sign the rhythm strip and place the strip in the patient's medical record. 3.7 If the event of a significant change in the patient’s rhythm, the monitor technician will notify the remote unit through the use of the emergency phone, print a strip of the rhythm and send it to the remote unit. 4.0 Documentation
4.1 Rhythm strips are obtained and posted in the medical record. 4.1.1 PR, QRS, QT, rate, interpretation, lead, RN initials. 4.2 PRN strips to include rhythm interpretation, lead, and initials only. 4.3 For patients with Full Disclosure orders, the RN will document each shift in the patient’s medical record that Full Disclosure is on. Any interruption to Full Disclosure should be documented. 5.0 Safety Concerns
5.1 Telemetry batteries checked prior to insertion in pack.
5.1.1 If battery < 50% power, replace with new one. 5.2 Check all alarm settings, reset to patient needs and physician parameters. Alarms should not be turned off. 5.3 Telemetry packs will be appropriately protected (per manufacturer) prior to bathing.
5.4 All telemetry patients will be monitored by appropriate personnel when leaving the patient care unit. 6.0 Transport
6.1 Stable patients who have been monitored in the ED or PACU may be transported off telemetry when transferred to the admitting unit. This will not apply for extended transport times in which a patient maybe taken to a diagnostic testing area and followed by a transfer to an admitting unit. This does not apply to Critical Care Patients. Criteria to consider a patient stable:
Blood pressure and pulse within age-appropriate parameters for normal. Chronic
Arrhythmias which are not being medically treated. Stable
Chest pain without diagnostic EKG findings or elevated biomarkers 6.2 RN discretion may be used to determine the need for continuous ECG monitoring for patient transport to an admitting patient care unit. 6.3 Other patient management protocols regarding continuous ECG monitoring supersede the RN discretion (i.e. post conscious sedation monitoring requirements, post escalating doses of Haldol) 6.4 If continuous telemetry monitoring is not required transportation services may transport the patient to the appropriate floor or diagnostic area. 7.0 Patient Education
7.1 Patient instructed on purpose of telemetry. 7.2 Patient instructed on limitations of telemetry reception. 7.3 Patient instructed on the need for continuous telemetry monitoring and removal/reapplication of monitor by appropriate personnel. 7.4 Patient instructed to call appropriate personnel before bathing/showering.
7.5 Patient instructed on adverse reactions/response to telemetry electrode/monitor. 8.0 Reportable Conditions
81 Report significant changes in rhythm to the patient's physician. 8.2 Report to Biomedical Engineering any dysfunctional monitoring equipment. REFERENCES: Boggs, RL & Wooldrige-King, M. (1993). AACN Procedure Manual for Critical Care. Philadelphia: WB Saunders. Drew, B.J., Calitt, R.M., Funk, M., Kaufman, E.S., Practice Standards For Electrocardiographic Monitoring in Hospital Settings. AHA Scientific Statement 2004; 110:2721-2746. Smith & Duell. (1992). Clinical Nursing Skills. Norwalk, CT: Appleton & Lange.
Calgar, S., Leffler, S. (2006). Prevalence of life-threatening arrhythmias in ED patients transported to the radiology suite while monitored by telemetry. The American Journal of Emergency Medicine, 24, 655-657. Drew, B.J., Califf, R.M., Funk, M. Kaufman, E.S., Krucoff, M.W., Laks, M.M., Van Hare, G.F. (2004). Practice standards for electrocardiographic monitoring in hospital settings: An American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical Care Nurses. Circulation, 110, 2721-2746. Singer, A., Visram, F., Shembekar, A., Khwaga, M., Viccelio, A., (2005). Telemetry monitoring during transport of low-risk chest pain patients from the emergency department: is it necessary? Academic Emergency Medicine, 12 (10), 965-969.
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Jean-Louis Nandrino a,b , Fabrice Leroy a,b and Laurent Pezard b,c,d (a) UPRES “Temps, ´emotion et cognition”, Universit´e Lille 3(c) Neurosciences Cognitives et Imagerie c´er´ebrale LENA-CNRS UPR 640(d) Institut de Psychologie, Universit´e Paris 5Address for correspondance: L. Pezard, LENA-CNRS UPR 640, 47 Bd del’Hˆopital, 75651 Paris cedex 13. France. The development of the ma