Steps

Rationale/Points of Emphasis

1a Perform hand hygiene.

Reduces transmission of microorganisms.

1b Gather monitor, leads, and monitor belt or patches.

Promotes efficient time management.

2 Inspect the electrodes and lead wires for breaks or cracks.

Faulty electrodes and wires will not transmit the information needed to monitor the cardiorespiratory status of the infant.

3 Place the monitor on a sturdy level surface at least 6 in away from walls or curtains.

The monitor operates most effectively from a firm surface. Placing the monitor against walls or curtains or on a crib mattress will muffle the sound of the alarm.

4 If an apnea monitor belt is used, inspect it for cleanliness and integrity.

Pathogens may grow in an unclean environment. Broken wires will not work effectively.

caREminder

The electrode belt can be kept clean by handwashing it in warm soapy water and then laying it out to dry naturally. The belt should not be placed in an automatic washer or dryer because it is generally made of backed foam rubber and will come apart if exposed to harsh mechanical treatment.

5 Position the infant on his or her back.

Several studies support the finding that healthy term infants and high-risk preterm infants are at risk for increased episodes of apnea when placed in the side or prone position. In particular, the preterm infant has a higher vulnerability to SIDS because of the longer and deeper sleep period and fewer awakenings associated with this sleep position. Yet the prone position in preterm infants is also associated with improved arterial oxygen saturation, improved lung and chest wall synchrony of respiratory movements, and decreased gastroesophageal reflux. The prone position in preterm infants is also associated with increased postural abnormalities, orthopedic abnormalities of the feet, and delayed developmental musculature.

The “Back to Sleep” campaign promoted by the American Academy of Pediatrics recommends that all infants be placed to sleep in the supine position. If the preterm infant is placed in the prone position, the infant should have continuous cardiorespiratory and oxygen saturation monitoring. In addition, preterm infants should be placed in a properly supported position to ensure functional support of all parts of the body as well as ensure physical safety.

Steps

Rationale/Points of Emphasis

1 With the child lying on his or her back, place the electrode belt under the child’s back, halfway between the armpits and the bottom of the rib cage. Cut belt material to size (Figure 14-1A).

Electrodes should be placed where the greatest amount of chest excursion or respiratory movement occurs and where the heart rate can be clearly noted to monitor for either bradycardia or tachycardia. The belt covers most of the rib cage in infants and very small children because of the relatively small chest area.

Figure 14-1 (A) With the child lying on his or her back, place the electrode belt under the child’s back halfway between the armpits and the bottom of the rib cage. Cut belt material to size. (B) Place electrodes with lead wires attached directly below the armpits and close the Velcro fastener on the outer surface of the belt so that it fits snugly but not tightly.

2 Connect lead wires to each electrode. The white-tipped lead wire should be connected to the electrode that is located on the infant’s right side. The black-tipped wire should be connected to the electrode that is located on the infant’s left side.

Wires and electrodes conduct the chest movement and heartbeat information to the monitor.

caREminder

Hold the lead wires only by the reinforced plastic grips at each end and insert them as far as possible into the electrodes to minimize wire damage and increase the conductivity of the electrodes.

3 Place electrodes, with lead wires attached, directly below armpits, one on each side of the chest (Figure 14-1B). The lead wires should point toward the bottom of the belt.

Wires should be as far away from the infant’s head and hands as possible. Being placed under the armpit makes them proximal to the apnea monitor and distal from the hands and mouth of the infant.

KidKare As the infant grows, the best electrode placement to pick up respirations and heartbeat may change slightly. The apex of the heart is located at the fourth intercostal space in children younger than 7 years of age and the fifth intercostal space in children older than 7 years of age.

4 With the electrodes in their proper position, close the Velcro fastener on the outer surface of the belt so that the belt fits snugly but not tightly.

Ensures constant contact between the infant’s skin and the electrodes. Electrodes are encased in plastic with Velcro on one side. This arrangement makes it easy to adjust their placement. The belt must not hamper the breathing movements of the chest or upper abdomen.

caREminder

After securing the belt around the infant, an adult should be able to fit two fingers easily between the belt and the chest of the infant. Unlike adults, infants rely on the diaphragm for breathing. Anything that fits too snugly can impede respiration.

5 Plug the distal ends of the lead wires into the apnea monitor according to the specific directions for the apnea monitor used.

Connections may be slightly different according to the specific apnea monitor that is in use.

6 Turn on the apnea monitor. The apnea/alarm time lapse should be preset by the respiratory therapist or by the vendor for the monitor.

Generally, when the order is given for an infant to undergo apnea monitoring, the ordering healthcare prescriber determines what is to be considered apnea, bradycardia, or tachycardia. The monitor alarms are then set accordingly. The U.S. Food and Drug Administration established that 20 seconds of apnea or a heart rate drop below 80 beats/minute is cause for alarm.

7 Discontinue monitor when ordered by healthcare prescriber.

Continued use of the monitor when no longer needed may cause breakdown of skin under electrodes and unnecessarily limits the child’s movement and activities.