Telemetry Monitoring For Nurses And Monitor Technicians-Books Pdf

Telemetry Monitoring For Nurses and Monitor Technicians
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Telemetry ECG Monitoring for Nurses and Monitor Technicians. This self study packet is designed to introduce the telemetry monitoring users to the basic principles and. procedures for ECG monitoring on the Nihon Kohden telemetry system. Learning Objectives, By completing this self study packet you will be able to. 1 Describe proper ECG electrode placement and skin preparation procedures for continuous. ECG monitoring, 2 Discuss the ST segment monitoring capabilities. 3 Describe the cleaning procedures and interventions for troubleshooting ECG monitoring issues. Introduction, The 12 lead ECG is used to help identify primary conduction abnormalities arrhythmias cardiac hypertrophy. pericarditis electrolyte imbalances myocardial infarction or ischemia and the site and extent of these disorders. The benefits of the 12 lead are expanded as we continuously monitor this ECG tracing on the bedside and. telemetry monitoring systems today, This packet will quickly review the cardiac anatomy and describe how the ECG tracing correlates to it It will. review how the telemetry monitor processes the ECG waveform for heart rate and arrhythmias and for. pacemaker detection and lastly it will discuss the ST segment monitoring capabilities on the Nihon Kohden. telemetry system, The way that this heart is stimulated to pump is through its own internal electrical system the heart s generator.
if you will This electrical system consists of impulse generator cells as well as impulse conductor cells that. conduct these impulses to the myocardium to stimulate it to contract and pump the blood The Sino atrial SA. node which is located high in the right atrium is the normal pacemaker in the heart that sets the rhythm and. rate for the cardiac function Once the impulse is generated in the SA node it spreads throughout the atria and. down to the Atrio Ventricular AV node where is it held so that the atria can contract When the impulse. leaves the AV node it travels through the Bundle of His down through the right and left Bundle branches to the. Purkinje fibers that are in contact with the ventricular myocardium Once these cells are stimulated they. contract and squeeze the blood from the ventricles and out to the body It is this ventricular contraction that. produces the palpable pulses The electrical activity MUST precede the mechanical activity so it is the. electrical activity that we capture on the monitor as the ECG signal NOT the mechanical contraction that. generates the pulse, The Electrocardiogram, The electrocardiogram ECG is the electrical activity that is captured by placing conductive electrodes onto the. patient As the impulses travel throughout the heart s chambers specific components are produced on the ECG. The p wave represents atrial depolarization which are the electrical changes that are required in order for the. muscle to contract The PR segment represents the length of time that the impulse is held in the AV node and. Bundle of His before it proceeds through to the Bundle branches The QRS represents the wave of ventricular. depolarization as it travels through the right and left Bundle branches and the Purkinje fibers to stimulate these. cells The t wave represents ventricular depolarization where the myocardial cells return to the normal. electrical state and prepare to receive the next impulse Our interest lies in the lengths of time that it takes for. each of these events to occur and the normal times are listed below. Telemetry ECG Monitoring for Nurses and Monitor Technicians. ST Segment, Another component of the ECG is the ST segment. This represents the beginning of ventricular, repolarization and should be a flat portion of the. tracing This is referred to as isoelectric and it is. considered to be abnormal when it is elevated or, depressed Either of these conditions indicates an. abnormal and or ischemic condition within the, myocardial cells.
ST Segment Measurement, PR 0 12 to 20 seconds, QRS 0 12 seconds. Isoelectric line, QT 0 38 seconds ST segment, relative to isoelectric. Normally measured in millimeters, ECG Electrode Placement. In order to capture this electrical signal from within the patient we must place conductive electrodes on. strategic positions on the body and the exact placement is crucial to accurate interpretation Since the heart. rests within the patient s chest for continuous ECG monitoring we place the electrodes on the chest at the. mid clavicular lines and at the anterior axillary lines on the lower ribs Each lead wire is labeled for the. anatomical position such as right arm RA left arm LA right leg RL left leg LL and Chest V 1 6. Placing them in these positions minimizes motion artifact and provides for good quality tracings The exact. placement is delineated below with the V1 and V3 positions used with the six electrode sets. Telemetry ECG Monitoring for Nurses and Monitor Technicians. Chest Leads, The six electrode lead set allows you to continuously monitor eight leads of the 12 lead ECG I II III aVR. aVL aVF and two V leads The recommended starting V leads are V1 and V3 as V1 is used to evaluate QRS. morphology in tachy arrhythmias and V3 is the most sensitive lead for detecting anterior wall ischemia in the. left ventricular ST segment If the patient has ischemia in another wall of the left ventricle the second V lead. can be placed in a different position to monitor for that condition Or if the patient has chest dressings V6 can. be used instead of V1 It is recommended that you check with the physician for the best placement for the. But not only is it important to place the electrodes correctly but it is even more important to prepare the skin to. conduct the impulses from the patient to the monitor The following procedure for continuous ECG monitoring. is accepted as policy at Renown and is supported by the American Association of Critical Care Nurses AACN. Skin Preparation, 1 Select electrode site according to placement diagram and the patient s condition.
2 Clip excess hair, 3 Gently abrade skin with dry gauze to remove dead cells Dead cells interfere with electrical conduction. and cause inadequate tracings for analysis, 4 If the skin is oily clean site with alcohol and friction if necessary to remove skin oils and allow the site. to dry This step is not required for every patient. 5 Attach lead wire to electrode, 6 Attach electrode to patient pressing circumference of electrode to secure. 7 Change electrodes according manufacturers recommendations to insure adequacy of adhesive and. conduction medium, NOTE Fasten lead wire to skin with tape to minimize interference from patient motion Stress Loop. if necessary, ECG Electrode sidebar, ECG electrodes conduct the small electrical currents less than 1mV from the patient to the monitor.
The monitor or transmitter then amplifies this current so that it can be displayed on the screen If an. electrode becomes dry or does not make good contact with the skin it cannot conduct the current but. rather holds onto it causing a saturation of the ECG signal When this occurs the signal is too strong. for the monitor to display until the electrode discharges it much like a static electricity discharge An. offset is seen on the ECG tracing and a loss of signal is detected until the charge is released. Telemetry ECG Monitoring for Nurses and Monitor Technicians. Selecting the ECG lead, The ECG lead choices are presented in the ECG Lead Select menu on the central monitor To access this. menu touch the patient window and then touch his heart rate value to enter the ECG parameter setup menu. The Trace 1 and Trace 2 ECG leads are used for heart rate pacemaker and arrhythmia processing using the. single or multi lead analysis controls To change the lead touch the desired option for each trace. In addition to changing the lead s that are used for processing this also controls the leads that are displayed in. the All Beds and Individual Beds real time displays and in the full disclosure storage for the first and second. tracings Trace 1 and Trace 2 When you change the ECG leads the full disclosure will store the new lead as. Trace 1 and Trace 2 based on this screen selection. There are times when the patient s condition warrants monitoring other than the V1 and V3 chest leads In this. case the electrode positions are moved to the appropriate chest position on the patient and the lead label is. changed for the Va and Vb leads in the ECG Lead Name menu to reflect the actual position. Auto Lead Change, The AUTO LEAD CHANGE function ECG Other Settings Tab allows the monitor to switch between leads I. II III when single limb lead monitoring electrodes are lost RA LA LL to continue ECG monitoring and. arrhythmia processing When this occurs an AUTO LEAD CHANGE message appears on the screen to. indicate that the selected lead is not available When the electrode is replaced the selected monitored lead is. NOTE The right leg electrode is the ground for the system If this electrode is lost all ECG waveforms. are lost and a CHECK ELECTRODE message is displayed until this electrode lead wire is replaced Lost. V lead electrodes result in the CHECK ELECTRODE message as well. Telemetry ECG Monitoring for Nurses and Monitor Technicians. Arrhythmia Monitoring, The ECG waveform is monitored for heart rate arrhythmias ST segment measurements and pacemaker. activity Single or multi lead analysis is available and when ARRHYTHMIA ANALYSIS setting is set to ON. the monitor uses a template matching method to determine the ECG rhythm in the monitored analysis lead or. leads It learns the rhythm over about a 10 second period and displays the dominant QRS when the patient is. attached to the monitor when the lead is changed when a CHECK ELECTRODE alarm is resolved or when. the patient s dominant ECG waveform changes This dominant QRS s is displayed in the ECG menu and is. the reference waveform that is used to compare with each beat of the real time waveform and to label. arrhythmias accordingly Up to eight templates are created if the complexes are variable such as with atrial. fibrillation and with demand pacemakers If the new beat exceeds the criteria for a normal beat the monitor. will analyze it and make a call based on the following criteria. Event Description, Asystole 3 10 seconds selectable with no QRS most select 3 seconds. VF Greater than four seconds of ventricular fibrillation. VT Ventricular Tachycardia 9 or more consecutive VPC s at a rate 100 min. VPC Run VPC short run User selects 3 8 consecutive VPC s most select 3. Couplet Paired VPC s, Early VPC VPC with a time interval from the preceding normal QRS of approx 40 of normal R R.
Bigeminy 3 or more consecutive pairs of VPC and normal QRS. Freq VPC VPC rate minute reaching or exceeding preset VPC limit. Tachycardia Reaching the upper HR limit, Bradycardia Reaching the lower HR limit. When abnormal beats are identified by the monitor it labels them in the algorithm and it annotates them on the. on the stored event in the Arrhythmia Recall screens The following annotations are used. N Normal beat, V Ventricular premature contraction VPC. P Paced beat, Cannot classify learning, These annotations are helpful in determining the cause of an alarm as the clinician can determine if the beats. are true if there is NOISE in the tracing that prevented the monitor for being able to analyze the rhythm or if. the monitor is labeling artifact as ventricular beats The clinician can take appropriate action based on his or her. interpretation of the call, Telemetry ECG Monitoring for Nurses and Monitor Technicians. Optimal QRS Morphology in the Monitored Lead s, To determine the best lead or leads for arrhythmia monitoring on an individual patient Trace 1 and or Trace.
2 insure that the electrodes are placed in the appropriate positions on the patient and then view all leads in the. ECG 12 lead Display screen to decide which lead best meets the following criteria. o Normal QRS must be greater than 0 5 mV one large box at x1 sensitivity on the ECG paper and. less than 2 0 mV four large boxes amplitude for arrhythmia detection. o Normal QRS should have similar amplitude to VPC beat or paced beat. o P wave should be less than 0 2 mV 2 small boxes at x1 sensitivity amplitude otherwise may be. counted as another QRS, o T wave amplitude should be less than 1 3 of the normal QRS otherwise may be counted as. another QRS, o The selected lead should have minimal baseline noise to provide for accurate QRS detection. QRS1 Normal QRS, The ECG QRS Detection Sensitivity is set to AUTO for the monitor to automatically find the optimal. sensitivity for arrhythmia processing which should be x1 or x2 If you find that the ECG waveform requires a. x4 display setting this indicates that the amplitude of the ECG signal is adequate and you risk having events go. undetected or for having false asystole or bradycardia alarms Insure that the left leg electrode is positioned. appropriately to provide the tallest QRS complex in lead II. The monitor will analyze the rhythm and annotate the beats but it is possible that a V tach rhythm could be. interpreted as v fib and vice versa due to the varying morphology of some complexes If the true event is. labeled as either V tach or V fib the interpretation is considered to be accurate. Telemetry ECG Monitoring for Nurses and Monitor Technicians. There are times when you should manually relearn the reference ECG waveform such as when the patient s. Telemetry Monitoring For Nurses and Monitor Technicians May 2011 Telemetry ECG Monitoring for Nurses and Monitor Technicians May 2011 2 of 18 Purpose This self study packet is designed to introduce the telemetry monitoring users to the basic principles and procedures for ECG monitoring on the Nihon Kohden telemetry system Learning Objectives By completing this self study packet you will

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