Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies. Check that cables and wires are in good condition and are connected correctly and securely.

Promotes efficient time management and provides an organized approach to the procedure.

2 Perform hand hygiene.

Reduces transmission of microorganisms.

3 Verify that ECG monitor is plugged into an emergency power-grounded plug.

Ensures that the monitor will continue to function during an emergency that affects the electricity.

4 Turn ECG monitor on; set heart rate and respiratory alarms appropriate to age of child; silence alarm during application of electrodes.

Appropriate alarm settings minimize the number of “false” alarms.

5 Position child on his or her back. Have a family member stay at bedside, if present. In an emergency situation, child may need to be placed on cardiopulmonary monitoring immediately without waiting for parental/guardian presence. Equipment and use should be explained to family members when they do arrive at child’s bedside.

Electrode placement on the chest provides the most effective method of monitoring; if this area is not accessible, electrode placement may need to be modified. Family member presence will help reassure the child.

6a Don gloves. If needed, clean area where electrodes are to be placed with a skin preparation product or soap and water. Hair clippers or blunt scissors may need to be used to trim excessive chest hair on areas where the electrodes are to be placed.

6b Remove gloves and dispose in appropriate receptacle.

Clipping hair, rather than shaving hair, is recommended to prevent skin irritation.

caREminder

Alcohol should not be used on infants because their skin is sensitive and fragile. Adolescents may have chest hair that requires clipping before electrode application to facilitate electrode contact with the skin.

7a Place wires on electrodes and then apply electrodes (Figure 24-1); do not place directly over a bony prominence.

Connecting wires to electrodes first prevents having to push on child’s chest to connect the lead. Enhances detection of electrical impulse.

Figure 24-1 Electrode placement as follows: white, upper right chest; black, upper left chest; and green/red, left abdomen or left thigh.

7b Perform the following steps:

• Remove backing from electrode.

• Verify that conduction gel is moist.

• Apply electrode by pressing on adhesive perimeter, not center.

• Place the upper two electrodes far apart, with the path between them crossing over the heart.

• Place the upper right electrode and abdominal electrode as far apart as possible.

• Color-coded electrode placement:

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  Place white wire on upper right chest.

  
  
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  Place black wire on upper left chest.

  
  
• 
  

  Place green/red wire on left abdomen or left thigh.

• If child’s trunk is unavailable for electrode placement:

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  Place appropriate electrode on shoulders or upper arms and abdominal electrode on thigh.

Pressing on center pushes gel onto adhesive area and decreases adherence. The indicated positions enhance the monitor’s capability to detect the heart rate and enhance the monitor’s capability to detect the respiratory rate.

8a Check ECG monitor screen for correlating heart rate and respiratory rate. Adjust size of QRS complex, monitor sensitivities, and other adjustments as necessary. Leads I, II, and III are the more commonly used leads in children.

Adjustments may be needed to allow the monitor to detect the heart rate and respiratory rate correctly.

8b Check manufacturer’s manual regarding specifics on how to adjust the specific ECG monitor.

Ensures appropriate use of equipment.

9 Verify that alarms are activated before leaving bedside and that audible tone is loud enough to alert staff.

Ensures notification when heart rate or respiratory alert rates are outside of acceptable values.

caReminder

Set alarm parameters should to actionable levels to decrease the number of false alarms and to prevent staff from ignoring the alarm due to alarm fatigue.

10 Perform hand hygiene.

Reduces transmission of microorganisms.

11 Inspect site daily and ensure electrodes are correctly placed. Change electrodes as needed for infants and every 72 hours for older children and as needed. Assess skin for irritation. Rotate sites when applying new electrodes.

Improper placement of electrodes can mimic serious arrhythmias and/or lead to inaccurate identification, analysis, and treatment of cardiac conditions. Conductive gel of electrodes may dry and decrease conductivity. Sensitivity to electrode gel or adhesive may cause skin breakdown.

caREminder

Use of cellular phones near external cardiopulmonary monitoring devices can cause electromagnetic interference of the ECG. Researchers suggest that using cellular phones at a reasonable distance (at least 49-60 in) from medical devices is not likely to cause artifacts in the electrocardiographic signal.