What is Telemetry and Telemetry Lead Placement?

Telemetry nursing is a very specific skill set for acute care nurses. Learn all about what telemetry is, telemetry lead placement, and what telemetry nurses do. 

What is Telemetry?

Have you heard of the term “telemetry” before? If you have but aren’t sure what it means, you aren’t alone! The term ‘telemetry’ comes from the Greek roots tele meaning “remote”, and metron meaning “measure”. 

Telemetry is used in different fields and in different ways (examples include missiles, chemical plants, and spacecraft). A common example of telemetry in the medical setting would be a cardiac monitor.

The telemetry medical definition is monitoring the electrical activity of a patient’s heart and transmitting that data to a central location where healthcare providers can continually monitor and review it and watch for any sudden changes to a patient’s condition.

What is a Hospital Telemetry Unit?

The telemetry unit of a hospital is where patients go when they need continuous telemetry monitoring. Cardiac nurses (also called telemetry nurses) work in the telemetry unit because they have the training and experience necessary to help patients needing complex care. 

In a hospital, telemetry provides nurses and other healthcare professionals the ability to monitor the patient’s heart rhythms and rate remotely. Patients who have experienced certain cardiovascular events need to be closely observed by nurses and telemetry technicians through continuous monitoring.

This is usually accomplished with a portable device that continuously monitors the 5-lead ECG tracing and heart rate of a patient and transmits that information to a central monitor. Telemetry nurses and telemetry technicians (referred to as “tele techs”) regularly review the data to try to determine whether negative changes to the current heart function are likely to occur.

Telemetry monitoring may last from 24 hours to 72 hours or more, depending on the patient’s condition. For some, continuous telemetry monitoring may be required during their entire admission.

Important note: Patients who are in the step-down/intermediate care unit or the intensive care unit will require cardiac monitoring. However, it is transmitted via a cord directly to a screen in the patient’s room for the medical and nursing team to view in real-time. It is also transmitted to screens up at the nurse’s station. It is not transmitted to a different unit with telemetry technicians.

Patient situations that often require telemetry monitoring

There are several common diagnoses that lead to patients needing monitoring with telemetry.

Here’s are a few:

1. Chest pain. Of course when anyone hears “chest pain” they think “heart attack”, so we treat incoming patients complaining of chest pain as possibly having a myocardial infarction (heart attack) and immediately hook them up to telemetry to monitor their heart rate and rhythm to help determine whether they are having a heart attack. They likely will also get a 12-lead ECG in addition to being hooked up to the continuous 5-lead ECG monitoring. (Note: This is most often done in the emergency department, although admitted patients can experience new chest pain as well.)
2. Atrial Fibrillation (A-fib). This is an abnormal heart rhythm where the heart is out of a synchronous pattern so the blood doesn’t move as it should, raising the risk of developing a clot. The higher the heart rate, the more dangerous it is.
3. Congestive Heart Failure (CHF). Although this diagnosis is more chronic in nature than the others I just mentioned, telemetry nurses monitor patients with CHF to make sure they aren’t heading into a situation that needs more immediate or extensive care. However, some patients will come into the hospital with a CHF exacerbation, who are at a higher risk for developing abnormal heart rhythms.
4. Electrolytes imbalance. When electrolytes, specifically potassium and magnesium, are too high or too low, they can cause dysrhythmias which need to be monitored through telemetry while the cause and prescribed care are determined.
5. Cardiac procedures. Anytime we go in and mess with the heart in any capacity (cath, cardiac surgery) we’re increasing our risk for dysrhythmias. Therefore, patients who come in for any reason and get a car
6. Surgery. If a patient has surgery that’s serious enough to require an overnight (or more) stay in the hospital, they will typically require at least 24 hours of cardiac monitoring to ensure any cardiac complications are quickly identified. Surgery also often means lots of fluid shifts (blood loss, or large amount of IV fluid given) which can make electrolytes a bit off. This allows the post-op nursing staff to stay on top of complications resulting from that as well.

Other potential diagnoses that can be monitored include in a hospital telemetry unit include COPD, lung surgeries and procedures, patients with diagnoses that alter electrolytes (like kidney disease), major trauma, burns, and more.

Getting Accurate Readings

Accurate telemetry readings are crucial. If the leads are on incorrectly, or not adhering appropriately, your tracing can be off or have a lot of artifact (squiggly lines that means a whole lot of nothing).

Telemetry Lead Placement

Here’s a very generalized process for proper set up of a telemetry heart monitor. 

Get an Order and Verify

If the attending physician believes that telemetry is necessary, he or she will write an order for it. You need this order to be able to initiate the monitoring.

Something that is CRITICAL for patient safety is that the correct telemetry box is on the correct person. Let me throw a situation at you. Let’s say you’re admitting Mr. James Smith into Room 123, and a Mr. John Smith is in room 213 on another floor. You obtain a telemetry box and all of the supplies and hook up Mr. James Smith, but when you’re calling the telemetry monitor unit to let them know about your new patient, you accidentally say room 213. Now, it looks like this patient is physically on another unit. If he were to code or have a sudden rhythm change, we would be running to the wrong room!

This is also why whenever a patient is discharged, they are discharged from the monitor as well so new patients are not incorrectly identified.

Pro-tip: Telemetry boxes are EXPENSIVE. It is very important they are returned to the appropriate place when patients are discharged and that patients do not leave with them. This wouldn’t be common with someone being discharged home, but if an unresponsive patient is going to the nursing home, it can be easy to forget to remove the device.

Prepare the Skin

Because you’re an amazing telemetry nurse, you will clean the skin with soap and water if visibly dirty, and then remove any excess oil with an alcohol swab to prepare it. Once the skin is fully dry, then the sticky patches can be placed.

If you’ve got a patient with a very hairy chest, you’re not going to get a good tracing unfortunately. The sticky leads have trouble adhering to the skin. You likely will need to get a safety razor and shave the spots that you’ll place the leads. (Just make sure they’re not on blood thinners!)

Guys, this step is important. These sticky pads are not fun to take off, so you want to make sure that you can get them to adhere well from the get-go. Policies change, but many manufacturers say these need to be changed ever 72 hours or so to maintain a good tracing.

How to Put Leads on a Patient

Tele lead placement involves placing between your 5 electrodes on the chest and upper abdomen area. Correct placement is essential because incorrect electrode placement can lead to improper tracing.

Each sticky pad (electrode) is attached to a wire which is then attached to a small device that transmits data about the heart’s electrical activity to the centralized monitoring station. As the nurse, you’ll first apply the stick pad to the correct spots (like we just mentioned) and then attach the lead with the wire to that pad.

Here are the correct heart monitor lead placement locations for a 5-lead cardiac monitor:

1. Under the right clavicle, near the right shoulder
2. Under the left clavicle, near the left shoulder
3. Left upper quadrant of the abdomen, just below the rib cage
4. Right upper quadrant of the abdomen, just below the rib cage
5. Between the Xiphoid process and the right upper quadrant electrode

Set Up the Unit

Medical Surgical Telemetry Nurses ensure the cardiac monitor is set up correctly following this process:

1. Check that the telemetry monitor has battery power – you may need to put in fresh batteries
2. Attach the sticky electrodes to the patient
3. Attach the wires to the sticky pads
4. Attach the wires from the telemetry leads to the telemetry unit
5. Go to the central monitoring station check that the readings on the bedside monitor or nursing unit monitor are clear
6. Verify that you’ve got the correct patient, name, medical record number, and room number with the right telemetry box number
7. Ensure settings on the monitor are correct. If your telemetry unit has people monitoring the screens in a different setting (a remote location), you won’t be able to adjust the settings yourself. You’ll have to call the telemetry department to do so.

For example, if the patient has a pacemaker, there is a specific setting that must be selected for it to read correctly.

Telemetry Nurse Duties

Telemetry nurses work with patients who have cardiac problems or are recovering from cardiac procedures. They generally work in the telemetry unit of the hospital after leaving the ICU or cardiac units.

Getting ready to have patients on telemetry, but need a little refresher first?

Telemetry Basics Brush-Up from FreshRN is a self-paced mini-course where we walk through the basics of cardiac electrical conductivity and how that is reflected on your telemetry strips, discuss rhythms based on the level of urgency you should have, go over insider tips and tricks, and more.

Telemetry Nurse vs Med Surg Nurse

Telemetry nursing and med surg nursing overlap to a degree. In caring for their patients, med-surg nurses may have some patients on telemetry… but also may have quite a few who are not. Common examples of med-surg patients are altered mental status, cellulitis, infection, or post-surgery. Not all of those patients will require telemetry monitoring. As a med-surg nurse, that’s one thing you’ll ask about in report: Is my patient on the monitor?

A telemetry nurse, however, will likely have all of their patients on telemetry. You’ll get report on your patients and just assume they all require continuous cardiac monitoring. Naturally, telemetry nurses tend to care for more cardiac patients.

I hope you found this post helpful! Make sure you check out my other cardiac resources below.

More Resources for Cardiac Nurses

• Tips for Cardiac Nurse Assessment
• Cardiac Nursing For Beginners
• Cardiac Nurse – A Typical Day
• 5-Lead ECG Interpretation Tips for Nurses
• ECG Rhythm Master – self-paced online course (7.0 contact hours)
• Cardiac Confidence: A Crash Course for New Cardiac Nurses – self-paced online course (11.0 contact hours)