NURSING PATIENT CARE POLICY & PROCEDURE
Nursing Manual (Red)
Policy #: 1.31AP
Title: Caring for Adult & Pediatric Patients
Requiring Cardiorespiratory Monitoring
To assure recognition and treatment of dysrhythmias and proper documentation of the
cardiac rhythm for patients undergoing cardiac monitoring.
For pediatric patients, assure recognition and treatment of arrhythmias including bradycardia
with potentially corresponding apnea requiring cardiorespiratory monitoring.
The competent staff member caring for the patient whose cardiac rhythm is being monitored
is accountable for the interpretation of the patient's cardiac rhythm. The Registered Nurse
(RN) will assess the patient's response to the rhythm, notify the provider of dysrhythmias,
evaluate the patient's response to treatment and document these actions and findings in the
Patients requiring a continuous infusion of intravenous (IV) medication for the treatment of
dysrhythmias can only be cared for in one of the following clinical locations: Heart &
Vascular Service line units, intermediate care units (IMC), Intensive Care Units (ICU) or
Emergency Departments. Refer to UWHC Hospital Administrative Policy 8.31, Guidelines
for Hospital Location Specific Administration of IV Medications and UWHC Guidelines for
the Intravenous Administration of Formulary Drugs in Adults or Pediatrics available on U-
Connect. These documents outline the levels of IV medications and the patient care units
where each may be administered.
Competence for all staff assigned responsibility for cardiac monitoring of patients will be
deemed by completion of the following:
a) Obtaining a passing score on the competency examination upon employment or
obtaining a passing score on competency exam upon initial transfer to a clinical area
where staff have responsibility for cardiac monitoring,
b) Annual testing,
c) Demonstrating competence in operation of the monitoring system.
In the event a staff member, who has not successfully completed the competency requirements is
assigned to care for a patient on cardiorespiratory monitoring, the Care Team Leader or Senior
Team Member will assign monitoring and pager responsibilities to a competent staff member.
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A. Three methods for cardiac monitoring:
1. Wireless: Telemetry box with 3- or 5-lead ECG wires
2. Hardwire: ECG monitoring cable directly connected to a system
3. Portable monitor as needed
4. Pediatrics only: cardio and/or respiratory monitor
C. ECG wires
D. New battery (for telemetry boxes)
E. Calipers or ECG ruler
F. Gauze pads or terry cloth washcloth
G. Clippers to clip chest hair as needed
A. Initiation of Cardiac Monitoring
1. Obtain an order for all patients requiring cardiac monitoring.
a. For pediatrics:
i. The order should include notification parameters for apnea and
ii. Cardiac monitoring is required for moderate sedation.
2. IV Access
a. IV access is required for adult patients with cardiac monitoring. If there is
no IV access, a physician order stating such must be obtained.
b. Pediatrics: Pediatric patients may not require IV access at the discretion of
3. A baseline weight needs to be obtained in the event that medications are required
to treat dysrhythmias.
4. Obtain necessary equipment
5. For all inpatient adult and pediatric units:
a. Admit patient to the central monitor by using the ADT function assuring
medical record number (MRN), first and last name and date of birth is
present. The MRN does not display on the screen. Exceptions to this are
b. Exceptions to entering in the first and last name for patients:
i. With privacy status according to UWHC Hospital Administrative
Policy 1.44, Privacy Status and Pseudonym (alias) Patient Name
i. Under legal custody according to UWHC Hospital Administrative
Policy 4.42, Care of Patients Under Legal Custody, or
ii. With confidential psychiatric status according to UWHC Clinical
Policy 10.15, Confidential Psychiatric Admissions and Notification
iii. Enter only the MRN when admitting the patient to the monitor.
Patients in i, ii, or iii above on a cardiac monitor must have a
patient label affixed to each cardiac rhythm printout.
c. If the unit utilizes pocket pagers for telemetry monitoring, the appropriate
pager number is to be entered at this time.
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d. Patients are not admitted to the monitor in the emergency department or
6. Educate the patient and family about the purpose of cardiac monitoring, range of
telemetry signal (if appropriate) and when to call RN.
7. Perform hand hygiene according to UWHC Hospital Administrative Policy 13.08,
8. Skin Prep: Clip any chest hair at the site that the electrodes are to be placed.
Prepare the skin and place patient on the monitor using chest landmarks for
correct electrode placement. If there is difficult maintaining adhesion, follow
manufacture’s recommendations if cleaning the skin with soap and water or “skin
prep” does not help. Electrodes should be the same size and brand and taken out
of the package at the same time.
a. 5 Lead System Lead Configuration
i. Lead Locations:
White electrode – under right clavicle
Black electrode – under left clavicle
Brown electrode – fourth intercostals space in the right side
of the sternum
Green electrode – on the right side of abdomen below the
Red electrode – on the left side of the abdomen below the
9. 3 lead system:
a. Right arm- under right clavicle
b. Left arm- under left clavicle
c. Left leg: on left side of abdomen below rib cage
10. Print baseline rhythm strip using laser printer. Measure intervals (PR, QRS, and
QT) and interpret the rhythm. Ensure paper printout of baseline rhythm is placed
in clinical record. Ensure patient’s MRN and first and last name are on the
11. Validate arrhythmia and heart rate alarms appropriate for the patient. Alarm
parameter adjustments should be done as indicated. Physiologic parameters are
evaluated at least once a shift for inpatient units.
a. For Pediatric Patients: Validate respiratory alarm parameters. Assess
patient history for cardiac dysrhythmias or pertinent cardiac abnormalities
that may guide the selection of monitoring leads.
B. In the ED, the RN will print a rhythm strip if the patient’s rhythm deteriorates or there is
a clinical deterioration with the patient. The rhythm strip will be placed in the clinical
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C. Ongoing Cardiac Monitoring-Inpatient Units and Pediatrics
1. All staff assigned responsibility for telemetry monitoring will complete the
following to ensure proper pager notification of telemetry alarm events.
a. Off-going shift personnel will maintain responsibility for telemetry
monitoring until report and hand-off have been completed.
b. Reassignment of patients to the pagers of their respective nurses within the
telemetry system is done manually and must occur within 30 minutes of
the beginning of the on-coming shift. Oncoming personnel or designee
enter the pager number into the nurse call system.
c. If the telemetry pager is worn in vibrate mode, it must be worn on the
waist of pants or pocket next to the body. Pagers in vibrate mode are not
placed in lab coat/uniform jacket pockets.
2. During the shift, if a competent staff member elects or is required to leave the
clinical unit, he/she will hand-off the pocket pager and use SBAR method to
convey information to another competent staff member in cardiac monitoring
before leaving the unit according to UW Health Clinical Policy 3.3.1 Hand-Off
Communication. The competent staff member accepting the pocket pager will be
responsible for acting on all alarm notifications as required.
3. Alarms and Alarm Review:
a. Red/High Alarms: All red/high alarms should be validated immediately by
a competent staff member. Staff will assess the patient and/or
immediately notify the provider of all true red alarms as appropriate. Staff
will document the alarm, patient symptoms, and response to any treatment
in the clinical record. All true red alarms/arrhythmias must be printed out
on paper and placed in the clinical record. Duplicative or repetitive alarms
need not be printed.
b. Notify the provider of any clinically significant yellow/medium alarms;
they should be printed and placed in the clinical record.
c. The competent staff member assigned to a patient with cardiac monitoring
should review all other patient alarms, minimally, at the end of the shift.
D. Treatment of Dysrhythmias
Perform patient assessment and visualize the cardiac rhythm (using a portable cardiac
monitor if necessary) to provide immediate evaluation of patient response to
E. Transport of Patients Requiring Cardiac Monitoring Off the Clinical Unit
F. All patients requiring continuous cardiac monitoring (as ordered) must be placed on a
portable cardiac monitor when leaving the clinical unit for diagnostic testing or other
reasons. A competent staff member must accompany the monitored patient when leaving
the clinical unit. The competent staff member must remain with the patient unless a
competent staff member at the diagnostic location assumes responsibility for cardiac
monitoring and patient information is exchanged using the SBAR method. End of
cardiorespiratory monitoring: All patients whose cardiorespiratory monitoring is
complete must be discharged or have their case ended from the bedside or central monitor
after each encounter.
G. Documentation in the Inpatient's Clinical Record
1. Printouts of rhythm strips will be saved in the clinical record upon initiation of
cardiac monitoring (see IV, A, 11 above) and with any clinically significant
change in rhythm or heart rate. The RN will document any significant rhythm or
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rate changes, associated patient condition changes, treatment administered and
a. For Pediatrics: The RN will document any significant rhythm or rate
changes, apnea or bradycardia episodes, associated patient condition
changes, treatment administered and patient response.
b. The rhythm strips are scanned into the electronic medical record post
patient discharge. During the stay, the strips are kept in the paper chart on
the unit. Two systems are available to print strips.
i. The preferred process produces an 8½ x 11 inch page with a single
strip printed on the page.
ii. The second method yields a strip that is 2 inches wide and up to 8
inches long (needs to be secured to a page that is 8½ x 11 inch).
Secure the strip to the Orders/Photo/Telemetry Strip Mounting
H. QT and QTc Monitoring
1. The QT interval should be corrected (QTc) for patients at risk for Torsades de
Pointes or with a prolonged QT interval. To obtain the QTc, measure the R-R and
QT intervals using the electronic calipers on the monitor. Transcribe the QTc into
the clinical record.
I. Equipment Cleaning
1. Cables and telemetry boxes are to be thoroughly cleaned with hospital
disinfectant before and after use by nursing staff. A toothbrush and hospital
disinfectant may be needed to clean the clips of non-disposable ECG leads.
2. Remove battery and store cables and telemetry boxes on the nursing unit.
J. Electromagnetic Interference (EMI)
1. See Administrative (Non-Clinical) Policy 12.23, Use of Wireless
Communications and Control Devices (Electromagnetic Interference (EMI)),
regarding the use of cellular phones and electronic devices near clinical
monitoring equipment and antenna systems.
V. UWHC CROSS REFERENCES
A. Intravenous Administration of Formulary Medications–Adult- Inpatient, September 2015.
B. Intravenous Administration of Formulary Medications-Pediatrics- Inpatient/Ambulatory,
C. Health Facts For You (HFFY) 5144, Telemetry, May 2014.
D. Hospital Administrative Policy 1.44, Privacy Status and Pseudonym (alias) Patient Name
E. Hospital Administrative Policy 4.42, Care of Patients Under Legal Custody
F. Hospital Administrative Policy 8.31, Guidelines for Hospital Location Specific
Administration of IV Medications
G. UW Health Clinical Policy 3.3.1 Hand-Off Communication
H. UWHC Clinical Policy 10.15, Confidential Psychiatric Admissions and Notification of
I. Administrative (Non-Clinical) Policy 12.23, Use of Wireless Communications and
Control Devices (Electromagnetic Interference (EMI))
J. Hospital Administrative Policy 13.08, Hand Hygiene
K. Orders/Photo/Telemetry Strip Mounting Form (UWH# 300138)
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A. American Association of Critical-Care Nurses (2011). AACN Procedure manual for
critical care (6th Ed.). Philadelphia, PA: WB Saunders.
B. American Association of Critical Care Nurses Practice Alert: dysrhythmia monitoring.
C. American Association of Critical Care Nurses Practice Alert: alarm management. May
D. Drew, B. J., Califf, R. M., Funk, M., & et al. (2005). 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. Journal of Cardiovascular Nursing, 20(2), 76-106.
E. Kuma, D. W. (2007). Cardiac monitoring: new trends and capabilities. ED Insider, Fall,
F. GE Healthcare Clinical Information Center Pro v5 (CIC Pro) Instructor Reference Guide,
G. GE Healthcare Carescape: Modular Monitors Instructors Guide, 2013.
VII. REVIEWED BY
Clinical Nurse Specialist, Cardiology
Clinical Nurse Specialist, Cardiothoracic Surgery
Clinical Nurse Specialist, Universal Care
Clinical Nurse Specialist, Pediatric Intensive Care Unit
Nursing Education Specialist, Heart, Vascular and Thoracic
Pediatric Emergency Care Coordinator, Emergency Services
Nursing Patient Care Policy and Procedure Committee, December 2015
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer