01.07 Performing Cardiac (Heart) Monitoring

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Overview

  1. Cardiac monitoring
    1. Assess signs and symptoms
    2. Montitoring devices

Nursing Points

General

  1. Why monitor heart?
    1. Abnormal heart rhythm/rate
      1. Current or history
    2. Chest pain
    3. Syncope
    4. Electrolyte imbalance
    5. Alcohol withdrawal

Assessment

  1. How to monitor
    1. Nursing judgement
      1. Pulse oximetry
      2. Listen to heart
      3. Palpate pulses
    2. Doctor orders
      1. Electrocardiogram (EKG)
        1. Single measurement
      2. Telemetry
        1. Short term, while in hospital
      3. Holter monitors
        1. Long term, home
      4. Troponin lab value elevated
        1. Detects heart injury

Therapeutic Management

  1. Clean skin, apply leads
    1.  EKG 5 Lead placement
      1. White lead on right upper chest
      2. Green lead under white
      3. Black lead on left upper chest
      4. Red lead below black
      5. Brown lead mid-right
    2. Change daily
    3. Assess skin
  2. Read telemetry strips
    1. Assess rate/rhythm
  3. Check pulse oximeter
    1. Pulseless electrical activity (PEA)
      1. Keep heart pumping!
      2. CPR
      3. Epinephrine

Nursing Concepts

  1. Clinical Judgement
    1. Decide when to monitor heart–>history, signs and symptoms
  2. EKG
    1. Shows rate and rhythm of heart on strip
  3. Lab Values
    1. Troponin levels drawn with any chest pain

Patient Education

  1. Alert nurse if…
    1. Chest pain
    2. Heart racing

Reference Links

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Video Transcript

Hey guys! I’m excited you’re here listening! In this lesson I am going to talk about performing cardiac monitoring on the patient.

So cardiac monitoring should be performed on a patient with any heart concerns by EKG, Telemetry, auscultation, and pulse palpation to assess the rate and rhythm of the heart. This is the main thing I want you to remember throughout everything that I talk about in this lesson.

So, with cardiac monitoring we want to assess signs and symptoms of a patient, and we want to consider the different monitoring devices that we will be using on our patients.

Why should we monitor our patient’s heart? Well, there are many reasons. If a patient has an abnormal heart rate or rhythm, current or history, we should be monitoring their heart. If a patient comes in and complains of chest pain or if they’ve already been admitted for a few days and suddenly they have chest pain we should be considering heart monitoring. Another example is if your patient comes in and they have syncope or dizziness, sweating, and they feel like they’re going to pass out, they may be having heart issues and require monitoring. Electrolyte imbalances can affect the heart, so the doctor may want to put a heart monitor on them. Another thing to think about is if a patient comes in with alcohol withdrawal because their electrolytes are probably out of balance.

How do we monitor a patient’s heart? Well, there are two separate things I want you to think about which are nursing judgement and doctor’s orders. Our nursing judgement includes different things that we can do on our own without a doctor order such as listening to the patient’s heart and palpate their pulses. We are also able to put on a pulse oximetry device without a doctor’s order. What a pulse oximetry device does is it helps us to keep an eye on the patient’s pulse and it shows us how much oxygen they have in their blood for their body to use. Now, if you are concerned about your patient’s heart, you may need to call the doctor and get different orders. For example, if your patient is having symptoms or their pulse is feeling off you may decide that it would be helpful to monitor their heart. Doctor’s orders that we may implement include electrocardiogram, or EKG which shows a single measurement of their heart rate and rhythm. EKGs are a little more advanced than just telemetry because they can show if a patient has had a heart attack or something recently that may have occurred with their heart. Telemetry is more short-term, and we may put it on our patient while they are in the hospital so that we can watch what their heart is doing on the monitor. A Holter monitor is something that the patient may go home with and they may wear a little more long-term and the doctor will be able to review it to see what their heart has been doing. Troponin lab values are able to detect heart injury in the patient. You might see different guidelines depending on what facility you are at, for example 0.01-0.035 may be considered okay, but above that would bring concern to the physician. So if a patient has a troponin that’s greater than the guidelines, it is very likely that the doctor will want to check troponin levels often like every 4 hours or so to make sure that they are going down and not up. If the patient’s troponin levels are going up, the doctor may be concerned that the heart is damaged.

Okay, so when we are doing telemetry monitoring, we usually use a 5 lead EKG placement, the white patch will go on the right upper chest. The green goes below the white. The black goes in the upper left chest, and the red below the black. The brown lead goes kind of in the mid right area of the chest. A great way to memorize the lead placement is to use fun sayings like “white on right”, “snow above the grass”, “smoke over the fire”, and “chocolate warms my heart”. You will find once you begin nursing that there are different telemetry packs that will tell you specific ways to put the patches on the patient and that is okay make sure you do follow what the pack says. You may also use a 3 lead EKG which involves just the white, black, and red leads.

Some important things I want you to remember is that you should clean the skin before you place the patches. The patches should be changed daily at least. You can even delegate to your CNA to take them off while they bathe the patient and put new ones on an inch or so to the left or right. When you change the patches, it’s important to assess the skin under. If patches are left on the patient for too long they may develop wounds.

Something I want you guys to remember is that you should always check the pulse oximeter. If you look at the pulse oximeter and it’s showing that the patient does not have a pulse they may be in pulseless electrical activity, or PEA, which needs immediate intervention. You may notice when a patient is in PEA that the Telemetry still shows a heart rate. This is because the electrical activity is still occurring in the heart but the heart is not pumping. A pulse is the mechanical activity, and the heart rate is the electrical activity that happens in the heart muscle. In this situation I want you to keep the heart pumping and perform CPR. In this situation you would want to call a code. You may give epinephrine per doctor order.

If a patient has chest pain or starts to feel their heart racing, they need to be notifying you so please let them know this so they know if this happens they should be contacting you right away so that you may assess the patient.

Alright guys, our nursing concepts for performing cardiac monitoring include clinical judgment, EKG, and lab values.

Okay, so key points that I would like you to remember include one, the nurse assessment. You will listen to the heart and feel the patient’s pulses . Second, I want you to remember the reasons to monitor the patient’s  heart, which includes syncope, chest pain, heart history, electrolyte imbalances. You may discover these signs and symptoms during your assessment and realize that the patient really needs their heart monitored by device. The devices you may use include telemetry,  pulse oximetry, EKG, and holter monitors. Remember, you may use a pulse oximeter anytime with nursing judgement and vital signs. Telemetry, EKG, and holter monitors require doctor orders to implement. In some departments there may be standing orders in which you would be able to place telemetry on the patient if they qualify per protocol. The fourth important thing is the EKG lead placement. Remember, white on right,  snow over grass, black upper left, smoke over fire, and chocolate warms my heart. The last key point I would like you to remember is that PEA means pulseless electrical activity, and it is an emergent situation where the patient actually does not have a pulse.

Thank you so much for listening to my lesson on performing cardiac monitoring. Make sure you check the resources that I have attached to this lesson. We discusses performing cardiac monitoring in this video, but we did not address the EKG strips and how to read them. Please check out the EKG course to learn about reading the telemetry and EKG monitors. Now go out and be your best self today, and as always happy nursing. 

Read more

  • Question 1 of 5

An 87-year-old client is connected to both telemetry and the continuous pulse oximetry. The pulse oximeter shows no pulse, but the telemetry monitor shows a rhythm. The nurse verifies that the finger probe on the pulse oximeter is reading correctly and it is but the nurse is not able to palpate a pulse on the client. Which of the following should the nurse do next?

  • Question 2 of 5

A client is admitted by the nurse for alcohol detox and drinks a pint of vodka each day. The last drink was 8 am this morning. Which of the following orders should the nurse implement upon admission? Select all that apply.

  • Question 3 of 5

A client that has been hospitalized for three days complains of sudden chest pain to the nurse and has no history of heart disease. The nurse knows that which of the following orders should be implemented?

  • Question 4 of 5

A nurse is assigned 4 clients with various diagnoses and is reviewing their orders. The nurse would expect to put the client with which of the following diagnosis on continuous cardiac monitoring telemetry?

  • Question 5 of 5

A cardiac client is being discharged home today and will require home heart monitoring. The client’s current vitals are: blood pressure 133/86 heart rate 87 pulse oximeter 98% room air temperature 98.7F respirations 18. The nurse knows to expect which of the following discharge orders?