Skill List > Cardiac Monitoring
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Based on Nicol: Essential Nursing Skills 4E
Adapted by: Desmond Cawley MSc(Hons) HDipCritCareN RGN RCN
Updated by: Tanya Middlehurst MSc BSc(Hons) RN
Last updated: November 2016

ECG of one cardiac cycle. (From Brooker C, Nicol M (eds) 2011 Alexander’s Nursing Practice, 4th edn. Edinburgh: Churchill Livingstone Elsevier.)
Position of electrodes for cardiac monitoring. (From Nicol M, Bavin C, Cronin P, et al. 2012 Essential Nursing Skills, 4th edn. Mosby Elsevier, Edinburgh.)
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of cardiac monitoring.


Continuous cardiac monitoring developed in the 1960s and allows healthcare professionals to constantly monitor patients for variety of reasons (Table 1) (Hannibal 2011). It provides a graphical display of the electrical conductivity within the heart and provides health practitioners with a continual view of the heart’s electrical activity (Figure 1).

Table 1 Indications for cardiac monitoring. (Adapted from Jevon P 2007 Cardiac monitoring part 1: electrocardiography (ECG). Nursing Times 103(1):26–27; Webner C 2011 Applying evidence at the bedside: a journey to excellence in bedside cardiac monitoring. Dimensions of Critical Care Nursing 30(1):8–18.)

Cardiac indications



  • Chest pain
  • Myocardial infarction
  • Shock
  • Heart failure
  • Palpitations
  • History of syncope
  • Cardiopulmonary resuscitation (CPR)

Non-cardiac indications


  • Post-anaesthetic care
  • Critical care
  • Following drug ingestion
  • During some drug therapies

Continuous cardiac monitoring can be initiated using a variety of devices:

  • Fixed wall monitor.
  • Portable monitor.
  • Telemetry.
  • Remote access device (e.g., Holter monitor).

No matter what device is used, the principles for lead placement are the same: the first should be placed over the right clavicle, the second over the left clavicle, and the third just below the rib cage on the left (Figure 2). An additional two leads may be used with some devices. The electrodes should be placed over bone rather than muscle, as muscle tremor will cause disruption on the ECG tracing. 

Preparation and safety

  • Explain the procedure, to gain consent and cooperation.
  • In acute situations, most patients with cardiac monitors are required to rest in bed; however, patients undergoing investigations for cardiac rhythm abnormalities may have a 24 h tape (Holter monitor) or ambulatory monitoring system (telemetry), in which case they may move around but should always inform the nurses of their whereabouts (Kumar 2007).
  • Raise the bed to a safe working height to avoid stooping.
  • If the patient’s chest is very hairy, shave a small patch at each site to allow good contact and adhesion of the electrodes.
  • The electrodes should be placed over bone and not muscle, as muscle tremor will cause disruption on the ECG tracing, and away from areas that may be used for the placement of defibrillator pads or insertion of implantable cardioverter defibrillators.
  • Ensure privacy.
  • The hands should be clean and an apron should be worn.
  • Additional protective clothing may be necessary if indicated by the patient’s condition.


  1. Perform hand hygiene and explain the procedure to the patient.
    Rationale – To prevent cross-infection and gain the patient’s consent.
  2. Move the water jug away from the cardiac monitor.
    Rationale – The monitor is electrically powered and water spillage onto the monitor could result in electrical injury to the patient and/or damage the equipment.
  3. Expose the patient’s chest and examine the sites that will be used for the electrodes. Ensure that the skin is dry and intact, hair (in the male) has been removed, and medicine patches are changed to a new position. Avoid placing electrodes over an implanted pacemaker or defibrillator.
    Rationale – To improve contact and adherence and reduce interference when monitoring the patient’s condition.
  4. If the electrode has a small raised patch on the back, show the patient how this will feel by rubbing it on their hand first.
    Rationale – This should be part of the explanation to the patient to allow them to become familiar with this stage of the procedure.
  5. Remove the backing paper and, taking care not to touch the gel in the middle, stick the electrodes firmly to the chest wall. The first should be over the right clavicle, the second over the left clavicle, and the third just below the rib cage on the left (Figure 2).
    Rationale – To improve adhesion and the life span of the electrodes in use; it can be up to 72 h provided electrode packaging is intact and in date. Electrodes should be placed over bone, namely the clavicles and just below the rib cage, to reduce interference from muscle movement. The leads are referred to as limb leads even though they are attached to the chest. This is because they represent that area of the body, that is, right arm, left arm, and left leg.
  6. Connect the leads to the electrodes. Red is connected to the right shoulder, yellow to the left shoulder, and green to the third electrode (Figure 2). If using a four-lead system, the additional black lead is placed on the lower right side of the abdomen. If a five-lead system is used, place the first four leads as detailed above and place the white lead in the middle of the chest.
    Rationale – This creates the Einthoven triangle, which allows clinicians to view the electrical activity within the heart from several angles, if the monitor allows. Leads II and AVF give inferior views, while leads I and AVL give lateral views (Hannibal 2011, Jevon 2007).
  7. Turn on the monitor and select lead II, which should produce the most positive (upright looking) display. Press the ‘size’ button to make the display larger and easier to see.
    Rationale – An increase in amplitude or size makes it easier to view the cardiac complexes. Lead II usually provides the largest complexes as its vector runs parallel to the normal current pathway in the heart, that is, from right to left (Webner 2011).
  8. Ask or assist the patient to replace their clothing.
    Rationale – To ensure patient comfort and prevent the patient from getting cold, and to ensure that leads are not tangled as the patient may be reluctant to put on their clothes for fear of disturbing or disconnecting the lead.
  9. Set the alarms to safe parameters, according to the patient’s condition and local protocol. Demonstrate what the alarms sound like and what will happen if the patient moves or disturbs the electrodes (i.e., an abnormal-looking pattern).
    Rationale – This can help reduce patient anxiety, as the sound of the alarm can be frightening. Alarms should be set to meet patient needs; the patient’s condition can often result in bradycardia or tachycardia so alarm limits should be set accordingly. Print off a tracing of the initial rhythm and document in the patient’s care plan.
    Rationale – Provides a baseline and allows later comparison if there are changes in the patient’s condition.
  10. Remove apron and perform hand hygiene.

Ongoing care, monitoring and support

  • Lower the bed, adjusting the bed height for the patient’s safety and convenience to enhance patient comfort (Nicol et al. 2012).
  • Make sure all electrical cables are in good condition and are not under tension or trapped in any way (e.g., in back rest or bed rails). This reduces the risk of accident or injury to the patient and damage to the equipment.
  • If lead II does not produce a good display, try lead I or lead III (Jevon 2007).
  • Electrodes can usually remain in place for 24–72 h, but may need replacing more frequently if the patient sweats a lot, if the electrode gel dries out, or if the patient’s skin shows signs of sensitivity (Nicol et al. 2012).
  • Observe for signs of deterioration and report as appropriate (Shaman 2007).

Documentation and reporting

  • Note the rhythm shown on the monitor and, if possible, take a printout; it is a good idea to do this at the beginning of each shift. Write down the patient’s name, the date and time on the printout, and sign the printout before filing it in the notes.
  • The Nursing and Midwifery Council advises that all care should be accurately and promptly documented (NMC 2015).
  • If arrhythmia is detected, a 12-lead ECG should be recorded. The senior nurse or physician should be informed of the patient’s status; this information should include patient symptoms (if any) and be supported with empirical data such as vital signs, in line with National Institute of Clinical Excellence guidelines to use reporting systems such as Early Warning Scores (EWS) (NICE 2007).
  • The nurse should document all care provided in line with local policy. Use a recognised nursing framework to allow the ongoing evaluation of patient care and ensure the provision of the highest quality of care available.
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