Continuous cardiac (electrocardiographic) monitoring provides constant observation of the heart's electrical activity. It is used to monitor a patient's heart rate and rhythm or the effects of a therapy (Morton & Fontaine, 2018). Cardiac monitoring is used for patients with conduction disturbances, for those at risk for life-threatening arrhythmias; such as postoperative patients and patients who are sedated; to diagnose myocardial ischemia; and in whom the administration of certain medications could result in dysrhythmias (Burns & Delgado, 2019; Sampson, 2018a). As with other forms of electrocardiography, cardiac monitoring uses electrodes placed on the patient's chest to transmit electrical signals that are converted into a tracing of cardiac rhythm on an oscilloscope. Either 3- or 5-lead systems may be used (Figure 1). The 3-lead-wire monitoring system facilitates monitoring of the patient in limb leads I, II, and III (Morton & Fontaine, 2018). The 5-lead-wire monitoring system facilitates monitoring of the patient in any one of the standard 12 leads.

Two types of monitoring may be performed: hardwire or telemetry. In hardwire monitoring, the patient is connected to a monitor at the bedside. The rhythm display appears at the bedside but may also be transmitted to a console at a remote location. Telemetry uses a small transmitter (connected to a patient) to send electrical signals to another location, where the electrical signals are displayed on a monitor screen, providing remote viewing of the heart's electrical activity. Battery-powered and portable, telemetry frees patients from cumbersome wires and cables and lets them be comfortably mobile. Telemetry is especially useful for monitoring arrhythmias that occur during sleep, rest, exercise, and stressful situations.

Regardless of the type, cardiac monitors can display the patient's heart rate and rhythm, produce a printed record of cardiac rhythm, and sound an alarm if the heart rate exceeds or falls below specified limits. Monitors also recognize and count abnormal heartbeats as well as changes. Cardiac monitoring systems may incorporate computer systems that store, analyze, and trend monitored data; automatic chart documentation; and wireless communication devices that provide data and alarms that can be carried by the nurse (Morton & Fontaine, 2018).

Gel foam electrodes are commonly used. Electrodes should be changed every 24 hours to prevent skin irritation and maintain quality of data (AACN, 2018; McGuffin & Ortiz, 2019). Hypoallergenic electrodes are available for patients with hypersensitivity to tape or adhesive. Any loose or nonadhering electrode should be replaced immediately to prevent inaccurate or missing data.

Assessment

Review the patient's health record and care plan for information about their need for cardiac monitoring. Assess the patient's cardiac status, including heart rate, blood pressure, and auscultation of heart sounds. Inspect the patient's chest for areas of irritation, skin breakdown, or excessive hair that might interfere with electrode placement. Electrode sites must be dry, with minimal hair. The patient may be sitting or supine, in a bed or a chair.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Impaired cardiac output
• Acute pain
• Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve when performing cardiac monitoring is that a clear waveform, free from artifacts, is displayed on the cardiac monitor. Other appropriate outcomes may include that the patient demonstrates an understanding of the reason for monitoring.

Implementation

Action	Rationale
1. Verify the prescribed intervention for cardiac monitoring in the patient's health record.	Verifying the prescribed intervention ensures that the correct intervention is administered to the right patient.
2. Gather equipment.	Assembling equipment provides for an organized approach to the task.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Tell the patient that the monitoring records their heart's electrical activity. Emphasize that no electrical current will enter their body. Ask the patient about allergies to adhesive, as appropriate.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Possible allergies may exist related to the adhesive on ECG leads.
6. For hardwire monitoring, plug the cardiac monitor into an electrical outlet and turn it on to warm up the unit while preparing the equipment and the patient. For telemetry monitoring, insert a new battery into the transmitter. Match the poles on the battery with the polar markings on the transmitter case. Press the button at the top of the unit, test the battery's charge, and test the unit to ensure that the battery is operational.	Proper setup ensures proper functioning. Not all models have a test button. Test according to the manufacturer's directions.
7. Insert the cable into the appropriate socket in the monitor.	Proper setup ensures proper functioning.
8. Connect the lead wires to the cable. In some systems, the lead wires are permanently secured to the cable. For telemetry, if the lead wires are not permanently affixed to the telemetry unit, attach them securely. If they must be attached individually, connect each one to the correct outlet.	Proper setup ensures proper functioning.
9. Connect an electrode to each of the lead wires, carefully checking that each lead wire is in its correct outlet.	Proper setup ensures proper functioning.
10. If the bed is adjustable, raise it to a comfortable working height (VHACEOSH, 2016).	Having the bed at the proper height prevents back and muscle strain on the part of the nurse.
11. Expose the patient's chest and determine electrode positions, based on which system and leads are being used (refer to Figure 1). If necessary, prepare the skin for electrode placement (AACN, 2018). If an area is excessively hairy, clip the hair (AACN, 2018; Oster, n.d.) or shave the hair with a single-use razor (Campbell et al., 2017), according to facility policy. Clean excess oil or other substances from the skin with a skin cleanser and water. Use a gauze pad to vigorously rub and dry the skin.	Shaving may cause microabrasions on the skin, possibly resulting in portals of entry for microorganisms. Oils and excess hair interfere with electrode contact and function. Rubbing with gauze abrades and dries the skin. Proper skin preparation is essential to reduce artifacts in and increase quality of the ECG tracing (AACN, 2018; Campbell et al., 2017; Garcia, 2015; Oster, n.d.). Proper skin preparation and application of electrodes are imperative for good ECG monitoring (Morton & Fontaine, 2018, p. 215).
12. Remove the backing from the pregelled electrode. Check the gel for moistness. If the gel is dry, discard it and replace it with a fresh electrode. Apply the electrode to the site and press it firmly to ensure a tight seal. Repeat with the remaining electrodes to complete the 3- or 5-lead system (Figure 2).	Gel acts as a conduit and must be moist and secured tightly.
13. When all the electrodes are in place, connect the appropriate lead wire to each electrode. Select the appropriate monitoring lead based on the patient's clinical situation (AACN, 2018; Burns & Delgado, 2019; Sampson, 2018b). Check the waveform for clarity, position, and size. To verify that the monitor is detecting each beat, compare the digital heart rate display with an auscultated count of the patient's heart rate. If necessary, use the gain control to adjust the size of the rhythm tracing, and use the position control to adjust the waveform position on the monitor.	This ensures accuracy of the reading and relevant information for the individual patient.
14. Set the upper and lower limits of the heart rate alarm and other alarm settings, based on the patient's condition and the goals of patient care (AACN, 2018).	Setting alarms allows for audible notification if the heart rate or other variables are beyond limits. The default setting for the monitor automatically turns on all alarms; limits should be set for each patient.
15. For telemetry, place the transmitter in the pouch in the patient's gown. If no pouch is available in the gown, use a portable pouch. Tie the pouch strings around the patient's neck and waist, making sure that the pouch fits snugly without causing discomfort. If no pouch is available, place the transmitter in the patient's bathrobe pocket.	This prevents tension on the lead wires and promotes patient comfort.
16. Return the patient to a comfortable position. Lower the bed height and adjust the head of the bed to a comfortable position.	Repositioning promotes patient comfort. Lowering the bed promotes patient safety.
17. To obtain a rhythm strip, press the RECORD key, either at the bedside for monitoring or at the central station for telemetry. Analyze the strip, as appropriate. If the rhythm strip is a printed copy, label the strip with the patient's name and room number, date, time, and rhythm identification. Place the rhythm strip in the appropriate location in the patient's health record, based on facility policy.	A rhythm strip provides a baseline for future comparison. Accurate labeling ensures the ECG is recorded for the correct patient and accurate and reliable interpretation.
18. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when a clear waveform, free from artifacts, has been displayed on the cardiac monitor and the patient has demonstrated an understanding of the reason for monitoring.