Question on reacting to tachycardic afib

[DatMurse]

So I have a question for you cardiac nurses.

-Quick rundown. patient used to be on 120mg of cardizem ER.

-patient was running brady and possible syncope on admittance

-doctor dc cardizem.

-pt is running afib/aflutter in the 130s-150s over the past few days, asymptomatic.

-I wasnt worried about it and the tele monitor is calling em and harassing me over something that has been unchanged.

-The hospitalist has known about this for the past few days.

-I get a call from their charge nurse asking em if the hospitalist knows about this. The day hospitalist knew about this and I felt that this can wait. She paged the night hospitalist to come over to my floor, the hospitalist wasnt worried, neither were any nurse on my floor.

So did I do the right thing? For something that has been unchanged over the past few days, is it necessary to call the hospitalist if the patient is asymptomatic? Day hospitalist even charted it in his progress notes.

side note: This telemonitor has overstepped her boundaries in the past and trying to get me to give an oncology patient fluids because her admitting diagnosis was for dehydration(The lady was on her last leg and she was changed to a palliative care the next day because of the metastasis of her cancer). She has also told her charge nurse to call me and even at a point told me that her charge nurse recommended me push adenosine on someone that had orthostatic tachycardia.

[DatMurse]

Good :-) Sorry if I sounded harsh but I wanted to make sure you knew that.

its all gravy. I'm here to learn

[MallysMama]

I'm surprised your cardiologist didn't have the patient transferred to a higher level of care and off the med/surg floor and had an Amio drip started that first night! Afib w/ RVR shouldn't be allowed to continue that long.

I think it's great you are wanting to learn more and recognized that something was "off" with the situation. It's just frustrating to hear that the docs didn't act faster to help this patient!

[Been there,done that, ASN, RN]

Just because the hospitalist is aware, is does not mean nursing is doing the "right" thing.

The fact that an uncontrolled fib has been going on so long.... it was then seen as the normal rhythm.. is frightening. Aghast that it took so long for cardiology to be consulted.

The patient needed immediate rate control... are they in CHF?

I worked nights... I realize the communication problems. However, if I had a patient that remained at that rate all day, I would have pursued up the chain of command to get an order for something to control the rate.

[gassy2be]

I am not experienced/comfortable(with cardiac meds) enough to request specific cardiac medications(other than metoprolol).

I don't mean you should've requested another medication, I mean you should've called and asked, "Are there any other medications that may work that you would like to order?" On a med/one floor you don't need to know specific meds for a fib with RVR, but there's almost always another option to try with any kind of condition.

[Been there,done that, ASN, RN]

The doctor was consulted when she bradied down to 30 on day 1 of admit(she was admitted for a dumb reason) and then is started snowballing from tehre.

Cardiologist agreed to dc cardizem. apparently started rising in the 130s where the hospitalist was aware. I guess the cardiologist came back in 2 days. We had 75mg of metoprolol ordered and 5ml ordered to push IV q6. the metoprolol didnt touch the patient. The patient was on eliquis for the afib.

The cardizem was on oral. I am on a med/onc floor and wanted to ask some more to cardiac nurses. amiodarone stabilized her hr. 400mg bid. I have been with holding the oral metoprolol just because her heart has been in the 50s and that I'd in parameters to hold. They are thinking about a possible pacemaker in a few weeks with a f/u.

She was "admitted for a dumb reason". Please expound on that. Thought she was admitted for bradycardia, possible syncope?

[MunoRN, RN]

Glad that the patient's HR has come down with the Amioderone. You seem to be conscientious w/ a desire to learn and do what's best for your patients. With that said, concerning holding the Metoprolol: have you spoken with the MD and gotten an order to hold it? Or, are there written parameters that the pt. is meeting in order to hold it? You cannot hold it "just because her heart has been so stable". It may be stable in part b/c of the Metoprolol. Holding it without an MD order to hold it is practicing medicine w/o a license.

Sorry to go off topic but this an important distinction. It's not actually "practicing medicine w/o a license" for a nurse to determine that a medication is unsafe to give and to then not give it, that's actually well within our scope and is the expectation of any nurse administering medications. The nurse should always notify the ordering provider that they are unable to give the medication, at which point the MD is free to try and convince them otherwise, but if that fails then the nurse is well within their scope and expectations to not give the med.

[DatMurse]

Thanks for your responses everyone. means alot(srs)

I don't mean you should've requested another medication, I mean you should've called and asked, "Are there any other medications that may work that you would like to order?" On a med/one floor you don't need to know specific meds for a fib with RVR, but there's almost always another option to try with any kind of condition.

The night hospitalist came over and went over medication. I am not too familiar with why the dced it.

She was "admitted for a dumb reason". Please expound on that. Thought she was admitted for bradycardia, possible syncope?

incontinence x 3. The ER doctor said she had syncope, which she didnt. It is good that she was there. so the cardiologist could alter meds, I am not sure of why she was on our floor(I think tele was slammed and full)

I'm surprised your cardiologist didn't have the patient transferred to a higher level of care and off the med/surg floor and had an Amio drip started that first night! Afib w/ RVR shouldn't be allowed to continue that long.

I think it's great you are wanting to learn more and recognized that something was "off" with the situation. It's just frustrating to hear that the docs didn't act faster to help this patient!

I think its more frustrating that the doctor's help cause her to tank to the 30s... I didnt know why the cardizem was dced. Stuff like that bothers the hell out of me when stuff isnt reported. Ex. Patient gets regualrly restless and ativan or haldol gives an undesired reaction... I am a new nurse, but I am starting to learn my pet peeves.

[Anna Flaxis, BSN, RN]

incontinence x 3. The ER doctor said she had syncope, which she didnt. It is good that she was there. so the cardiologist could alter meds, I am not sure of why she was on our floor(I think tele was slammed and full)

Most likely, the ER doc was sharp enough to know this person was not safe to send home and needed to come in. Incontinence is not an admissable diagnosis. I would imagine that during his/her interview with the patient, she admitted to feeling dizzy or lightheaded at times (she was probably tanking into the 30s at home, which may have precipitated the incontinence). In the absence of any chest pain/increase in cardiac enzymes or neuro symptoms suggesting stroke/TIA, syncope would be the best shot at getting the hospitalist to accept the admit. She *may* have come to your floor because the tele unit was short beds or nurses, or this could have been a really soft admit, with the hospitalist reluctant to admit her on such vague symptoms, and I'm assuming, in the absence of any diagnostics to suggest anything was wrong, and so she came to your floor (maybe the hospitalist ordered tele to cover their behind). Clearly, the ER doctor was right in his or her "gut feeling" that this patient needed to come in. Not "stupid" at all, but rather, very smart, and an example of practicing good medicine.

[DatMurse]

Most likely, the ER doc was sharp enough to know this person was not safe to send home and needed to come in. Incontinence is not an admissable diagnosis. I would imagine that during his/her interview with the patient, she admitted to feeling dizzy or lightheaded at times (she was probably tanking into the 30s at home, which may have precipitated the incontinence). In the absence of any chest pain/increase in cardiac enzymes or neuro symptoms suggesting stroke/TIA, syncope would be the best shot at getting the hospitalist to accept the admit. She *may* have come to your floor because the tele unit was short beds or nurses, or this could have been a really soft admit, with the hospitalist reluctant to admit her on such vague symptoms, and I'm assuming, in the absence of any diagnostics to suggest anything was wrong, and so she came to your floor (maybe the hospitalist ordered tele to cover their behind). Clearly, the ER doctor was right in his or her "gut feeling" that this patient needed to come in. Not "stupid" at all, but rather, very smart, and an example of practicing good medicine.[/QUOTe]

I guess you are right. Although... she had incontinenace x 3 and called the ambulance.

[Anna Flaxis, BSN, RN]

I understand that incontinence was her chief complaint- it's what brought her in. If it's not normal for her, and it happened three times, she has good reason to be concerned. If she was having any other symptoms along with it, such as dizziness or light headedness, then she made the prudent decision to call the ambulance.

[DatMurse]

I understand that incontinence was her chief complaint- it's what brought her in. If it's not normal for her, and it happened three times, she has good reason to be concerned. If she was having any other symptoms along with it, such as dizziness or light headedness, then she made the prudent decision to call the ambulance.

Appreciate the angle of your outlook. It really opens up alot for me to think about an odd admitting diagnosis.

[annie.rn]

Sorry to go off topic but this an important distinction. It's not actually "practicing medicine w/o a license" for a nurse to determine that a medication is unsafe to give and to then not give it, that's actually well within our scope and is the expectation of any nurse administering medications. The nurse should always notify the ordering provider that they are unable to give the medication, at which point the MD is free to try and convince them otherwise, but if that fails then the nurse is well within their scope and expectations to not give the med.

Thank you for the clarification. I didn't mean to imply that a nurse cannot hold a med based on nursing judgement and then get an order later. You explained it very well and I'm sorry for speaking out of line. I actually never saw it that way until I began working where I do now and the manager is constantly harping on getting an order if we hold a medication. If we don't, we are practicing medicine. Shouldn't have taken that at face value and shouldn't have passed it on to a new nurse on a public forum. I will research it further and then talk to my manager about it.