The nurse is notified by the cardiac monitoring technician that a patient on continuous cardiac monitoring is having frequent alarms. When the nurse enters the patient's room, the patient is in no apparent distress, is sitting in the chair and eating
Which are appropriate nursing interventions?
Select all that apply.
1. Confirm that lead wires are properly connected.
2. Assess placement of electrodes.
3. Remove and reapply new electrodes if nonadherent.
4. Assess skin sites and move an electrode if the skin appears irritated.
5. Call for assistance.
Correct Answer: 1, 2, 3, 4
Alarms may be triggered by loose or disconnected lead wires, poor electrode contact, excessive movement, electrical interference, or equipment malfunction. Nursing actions include assessing lead wire connections; assessing placement of electrodes and changing electrodes every 24 to 48 hours or removing and reapplying electrodes that are dislodged or non-adherent; assessing and documenting skin condition under the pads and moving pads to alternate sites to avoid skin irritation; and documenting ECG strips according to unit policy. Since the patient is in no apparent distress, assistance is not required.
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