Holter Monitor

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.

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

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

  • Inform the patient this procedure can assist in evaluating the heart's response to exercise or medication.
  • Review the procedure with the patient. Address concerns about pain related to the procedure and explain that no electricity is delivered to the body during this procedure and no discomfort is experienced during monitoring.
  • Inform the patient that it may be necessary to remove hair from the site before the procedure.
  • Explain that the electrocardiography (ECG) recorder is worn for 24 to 48 hr. Afterwards, the patient is to return to the laboratory with an activity log to have the monitor and strip removed for interpretation.
  • Instruct the patient to wear loose-fitting clothing over the electrodes and not to disturb or disconnect the electrodes or wires.
  • Advise the patient to avoid contact with magnetic or electrical devices that can affect the strip tracings (e.g., shavers, toothbrush, massager, blanket, microwave, metal detector) and to avoid showers and tub bathing.
  • Explain the importance of performing normal activities, such as walking, sleeping, climbing stairs, sexual activity, bowel or urinary elimination, cigarette smoking, emotional upsets, and medications and of recording them in an activity log.
  • Explain the importance of pressing the record button upon experiencing pain or discomfort.
  • Positioning for electrode attachment will be in the supine position.
  • The skin surface will be prepared with alcohol and excess hair removal. Clippers may be used to remove hair from the site if appropriate, then the skin will be cleansed thoroughly with alcohol and rubbed until red in color.
  • Electropaste will be applied to the skin sites to provide conduction between the skin and electrodes. Alternatively, prelubricated disposable disk electrodes may be applied.
  • Two negative electrodes will be 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 will also be placed and secured to the skin of the chest or abdomen.
  • Electrodes will be checked to ensure they are secure, then the electrode cable will be attached to the monitor and the lead wires to the electrodes.
  • The monitor will be checked for paper supply and battery, then the tape will be inserted and the recorder turned on. All wires are taped to the chest, and the belt or shoulder strap is placed in the proper position.

After the Study: Potential Nursing Actions

Treatment Considerations

  • 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.
  • Explain that the activity log and tape recording will be compared for changes during the monitoring period.

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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