Holter Monitor

General

Synonym/Acronym:

Ambulatory electrocardiography, ambulatory monitoring, event recorder, Holter electrocardiography.

Rationale

To evaluate cardiac symptoms associated with activity to assist with diagnosis of dysrhythmias and cardiomegaly.

Patient Preparation

There are no food, fluid, activity, or medication restrictions unless by medical direction.

Normal Findings

Normal sinus rhythm.

Critical Findings and Potential Interventions

N/A

Overview

(Study type: Electrophysiologic; related body system: Circulatory system.)

The Holter monitor records electrical cardiac activity on a continuous basis for 24 to 72 hr. This noninvasive study entails the use of a portable device worn around the waist or over the shoulder that records cardiac electrical impulses on a magnetic tape. The recorder has a clock that allows accurate time markings on the tape, and the patient is asked to keep a log or diary of daily activities and record any occurrence of cardiac symptoms. When the patient pushes a button indicating that symptoms (e.g., pain, palpitations, dyspnea, syncope) have occurred, an event marker is placed on the tape for later comparison with the cardiac activity recordings and the daily activity log. Some recorders allow the data to be transferred to the health-care provider (HCP)’s office by telephone, where the tape is interpreted by a computer to detect any significantly abnormal variations in the recorded waveform patterns.

Technology for cardiac event monitoring has made some advances beyond the standard Holter monitor. Wearable and wireless products allow patients to automatically transmit data to their HCP; some units can be worn continuously for up to 3 wk. There are also event recording devices that can be implanted beneath the surface of the skin and are designed to capture significant but infrequent events that occur over even longer periods of time.

Indications

Detect dysrhythmias that occur during normal daily activities and correlate them with symptoms experienced by the patient.
Evaluate activity intolerance related to oxygen supply and demand imbalance.
Evaluate chest pain, dizziness, syncope, and palpitations.
Evaluate the effectiveness of antidysrhythmic medications for dosage adjustment, if needed.
Evaluate pacemaker function.
Monitor for ischemia and dysrhythmias after myocardial infarction or cardiac surgery before changing rehabilitation and other therapy regimens.

Interfering Factors

Factors that may alter the results of the study

Improper placement of the electrodes or movement of the electrodes.
Failure of the patient to maintain a daily log of symptoms or to push the button to produce a mark on the strip when experiencing a symptom.

Potential Medical Diagnosis: Clinical Significance of Results

Abnormal Findings In:

Dysrhythmias such as premature ventricular contractions, bradycardias, tachycardias, conduction defects, and bradycardia
Cardiomyopathy
Hypoxic or ischemic changes
Mitral valve abnormality
Palpitations

Nursing Implications, Nursing Process, Clinical Judgement

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

Discuss how this procedure can assist in evaluating the heart’s response to exercise or medication.
Review the procedure with the patient.
Explain that the electrocardiography (ECG) recorder is worn for 24 to 48 hr.
Explain that no electricity is delivered to the body during this procedure and no discomfort is experienced during monitoring.

Procedural Information

The patient will be instructed to:
- Wear loose-fitting clothing over the electrodes and to avoid disturbing or disconnecting the electrodes or wires.
- Avoid contact with magnetic or electrical devices that can affect the strip tracings (e.g., shavers, toothbrush, massager, blanket, microwave, metal detector).
- Avoid showers and tub bathing.
- Perform and record normal activities in an activity log
  (e.g., walking, sleeping, climbing stairs, sexual activity, bowel or urinary elimination, cigarette smoking, emotional upsets, and medications).
- Press the record button upon experiencing pain or discomfort.
Positioning for electrode attachment is in the supine position.
Clippers may be used to remove hair from the site; then the skin is cleansed thoroughly with alcohol and rubbed until red in color.
Electropaste or prelubricated disposable disk electrodes are applied to the skin sites to provide conduction between the skin and electrodes.
Two negative electrodes are applied on the manubrium, one in the V₁ position (fourth intercostal space at the border of the right sternum) and one at the V₅ position (level of the fifth intercostal space at the midclavicular line, horizontally and at the left axillary line). A ground electrode is also placed and secured to the skin of the chest or abdomen.
Electrodes are checked to ensure they are secure, then the electrode cable is attached to the monitor and the lead wires to the electrodes.
The monitor is checked for paper supply and battery, then the tape is inserted and the recorder turned on.
The patient is advised that all wires are taped to the chest; the belt or shoulder strap is placed in the proper position.
The patient is instructed to return to the laboratory with the activity log once the procedure time has elapsed to have the monitor and strip removed for interpretation.

After the Study: Implementation & Evaluation Potential Nursing Actions

Treatment Considerations

Inform the patient that the activity log and tape recording will be compared for changes during the monitoring period.
Explain that after wearing the monitor for the required 24 to 48 hr, the tape and other items securing the electrodes will be gently removed.

Clinical Judgement

Consider how to decrease anxiety associated with this procedure and the expected outcome.

Followup Evaluation and Desired Outcomes

Understands the importance of reporting symptoms such as fast heart rate or difficulty breathing.
Accepts that additional testing may be needed to evaluate or monitor progression of the disease process and determine the need for a change in therapy.

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