V Tach

ally_rn · Mar 15, 2006

Having had this happen to me several times what I do is your #2...2) Don't call MD as it is the middle of the night and pt is asymptomatic but print the strip and place on the chart so he will see during rounds. However if we have to call the MD for anything else I will notify him then and I also make the in charge aware and the other staff that is on to watch, print and check if I am busy. Also by letting them know what is going on they are not going to get all freaked out if it occurs and they see it.

I firmly believe if the pt is asymptomatic then I need not wake the MD and just chart about each occurence and make sure that the MD is made aware as soon as he/she steps foot on the floor in the am.

HTH!

icunurse1955 · Mar 15, 2006

I would probably not call for the first run of V tach if the patient is asymptomatic but would put the strip on the chart. If the patient had further runs of V tach, then I would call and at least make the physician aware of what was happening. He will probably not order anything at that point but will tell you to "just watch" the patient; however, if the patient would go into v-fib or get worse then you have covered yourself by making sure that the doctor was informed of the condition. He is the physician and I never feel too guilty about waking them in the night.

TennRN2004 · Mar 15, 2006

I'm a new grad working nights on a tele med/surg floor. I've had the following scenario happen several times and always get different answers depending on who the charge nurse is, or who I ask.
The patient comes up from ER and placed on tele monitor. Sometime in the night they have a 7 beat run of VTach. I check on pt & he is asymptomatic. I find no documentation in the ER notes of any previous episodes. An hour or 2 later pt has another run of VTach. Pt is still asymptomatic. For this situation I've been told the following by different nurses at different times: 1) Call MD and make him aware this is happening 2) Don't call MD as it is the middle of the night and pt is asymptomatic but print the strip and place on the chart so he will see during rounds 3) Continue to monitor pt but do nothing b/c pt isn't presenting symptoms.
Which is really the most appropriate action. It's a little confusing to be told "not to worry about it" when another nurse suggested I call the MD for the same thing when it happend in the past. I appreciate any input.

Just something to keep in mind, whenevey you have a patient with ventricular ectopy, make sure electrolytes have been checked recently. Low K and Mag levels can contribute to an irritable heart rhythm. Some people normally throw PVCs and it's documented on old EKGs, so if they have a few beat runs of it, then you probably figure it is normal for that person. No reason to call in the middle of the night if that is the case and the patient is completely asymptomatic. However, when deciding to call MDs or not, I think part of the catch is knowing your docs and their groups. Cardiology group A may not want to be bothered, but Cardiology group B may want to be called so they can order further workup if they want it. If you are getting different answers from the charge nurses, ask your nurse manager for a little guidance about which docs may want to be called and which would want to be notified in the am. Majority probably will not want to be called in the middle of the night. There really is no right or wrong answer. These situations are where you develop your nursing judgement in deciding what warrants a call, but if I am ever questioning a patients status, I would rather call and get chewed out and the patient be okay than not call and something bad happen, and think man I should have called the MD sooner.

SReece · Mar 16, 2006

Most hospitals actually have a policy pertaining to cardiac arrythmias and when is the appropriate time to contact the physician. For example, at my hospital all new onset V-tach > than 10 beats must be reported.

zacarias, ASN, RN · Mar 16, 2006

I'm so glad this thread came up. This EXACT same thing occured at my unit. I had a patient with a four beat run of VT and didn't call the doc. I charted it and of course the tele is available. The day nurse was like "oh you have to call the doc, they need to know." And she said "are you new?? That's why..." This nurse who said this is type A but still her comments kind of hurt my feelings since while I'm newish, I certainly have some good critical thinking skills and reasons for why or why I don't do things.

If a patient has a run of three beats VT, it is only three PVCs in a row. Because it's three, they call it VT. MOST important is the patient's symptoms. If they are totally fine and vitals OK, I would not call the doc at night or even in the afternoon. I might leave a note if it's a new thing, or request labs etc (some hospitals can order metabolic panel without MD order I guess?)

It ALL is about reasonableness. There will always be those who say "oh you have to call the doc now!!!" and those that hardly blink when someone has four beat VT.

melanie1126 · Mar 16, 2006

Thanks for all of the helpful input. By the time our pts come up from ER, we normally have current lab values available. With low Mag or out of range K I would automatically call anticipating an order for a bolus. Our patients spend such a long time in ER though, usually electrolyte issues have already been dealt with or even resolved by the time the patient makes it to the floor. TennRN brings up a good point though about different groups wanting to be notified for different things. That's one of the most frustrating parts of being a nurse in a new area. Working nights, I don't get a lot of interaction with the doc's so it's difficult for me to figure out who wants what. I guess that will just come with time and as TennRN stated developing my nursing judgement. Sometimes I think the Charge Nurse gets a little tired of my asking" should I call the Doc", but I've gotten so many different answers in the past that I really don't feel like I've learned how to handle this from past experience. That's why I wanted to start this thread, to create a guideline for myself so that when this happens I'll already have a plan. I will usually go ahead and call the Doc's for things I am unsure of, but at the same time I try to be respectful of their time. When issues come up I try to do everything I can on my own (with standing orders, prn meds, etc.) before I call unless it's something they need to know immediately. I guess I don't have a lot of confidence in my own judgement yet, b/c I alway worry about doing the wrong thing and causing harm to my pt.

TennRN2004 · Mar 17, 2006

Sometimes I think the Charge Nurse gets a little tired of my asking" should I call the Doc", but I've gotten so many different answers in the past that I really don't feel like I've learned how to handle this from past experience. I guess I don't have a lot of confidence in my own judgement yet, b/c I alway worry about doing the wrong thing and causing harm to my pt.

It takes time to develop that judgement, sometimes it is a fine line deciding who to listen to between the six nurses on your floor that may tell you different things. Two may say go ahead and call and four may say don't worry about it. It is totally frustrating being a new nurse especially, and then other nurses in report making you feel like you didn't respond appropriately. The important thing to realize is that you are picking on things like this and questioning your experienced nurses. That is a sign that you are critically thinking about the situation and trying to decide the most appropriate response. Just remember, it is not black and white, most of these type nursing decisions are a grey area where different nurses do things different, one is not necessarily better than the other, just different. Don't worry about charge nurse getting tired of you asking questions- they had to learn too when they were new. Try to find and resource with a few experienced good nurses that you feel confident in their judgement and learn from them. Also know that the mark of a good nurse is caution--even our most experienced nurses ask for oppinions of "what do you think" in these types of situations. It gets easier with time, and before you know it, others will be coming up to asking you to be a resource for them in these situations.

tridil2000, MSN, RN · Mar 18, 2006

i would not only check the lytes but the enzymes as well. i might even do a 12 lead and look for any changes. after a second episode of vt on a new admit (greater than 8 beats) i would call.

think of it this way- if you call, what will happen, dr might be annoyed...other nurses might roll their eyes... no harm to pt.

if you DON'T call and he goes into sustained vt the third time, you'll hear nothing BUT 'why didn't you call'- possible harm to pt.

always be confident enough to do what's right by the pt. they are counting on you to do just that, and the only think that will save your butt. screw the rest of them!

vamedic4, EMT-P · Mar 19, 2006

I'm a new grad working nights on a tele med/surg floor. I've had the following scenario happen several times and always get different answers depending on who the charge nurse is, or who I ask.
The patient comes up from ER and placed on tele monitor. Sometime in the night they have a 7 beat run of VTach. I check on pt & he is asymptomatic. I find no documentation in the ER notes of any previous episodes. An hour or 2 later pt has another run of VTach. Pt is still asymptomatic. For this situation I've been told the following by different nurses at different times: 1) Call MD and make him aware this is happening 2) Don't call MD as it is the middle of the night and pt is asymptomatic but print the strip and place on the chart so he will see during rounds 3) Continue to monitor pt but do nothing b/c pt isn't presenting symptoms.
Which is really the most appropriate action. It's a little confusing to be told "not to worry about it" when another nurse suggested I call the MD for the same thing when it happend in the past. I appreciate any input.

This is a good question. I work peds cardiac and since it's a teaching hospital we generally notify the doc (resident) for VT unless otherwise specified. The attending cardiologist will make the determination of "when to notify", and they'll write an order to specify.

Rule of thumb and common sense?? Notify the doc. His money is made by taking care of his patients and he can only do that if he has the info.

He could have lab values that are off...K, Ca,...I agree with other posters..are his labs ok? What's his fluid status?

So friggin' what if he's awake in the middle of the night? Whether he does anything or not is up to him..he's the doc. But your ass is covered "just in case" anything happens.

The last thing you want is to work a code on this patient's third run of VT, I guarantee you.

The more experienced you get, the more you trust yourself to make decisions like these. Me? I'd be more than grateful for you to err on the side of my grandmother and notify her doc.

Have a great day.

vamedic4

H

I'm a new grad working nights on a tele med/surg floor. I've had the following scenario happen several times and always get different answers depending on who the charge nurse is, or who I ask.
The patient comes up from ER and placed on tele monitor. Sometime in the night they have a 7 beat run of VTach. I check on pt & he is asymptomatic. I find no documentation in the ER notes of any previous episodes. An hour or 2 later pt has another run of VTach. Pt is still asymptomatic. For this situation I've been told the following by different nurses at different times: 1) Call MD and make him aware this is happening 2) Don't call MD as it is the middle of the night and pt is asymptomatic but print the strip and place on the chart so he will see during rounds 3) Continue to monitor pt but do nothing b/c pt isn't presenting symptoms.
Which is really the most appropriate action. It's a little confusing to be told "not to worry about it" when another nurse suggested I call the MD for the same thing when it happend in the past. I appreciate any input.

outlierrn · Mar 19, 2006

Good question,

Allow me to suggest calling the ER nurse if they're still on to see if this happened there. I take questions from floor nurses all the time. Sometimes the ER doc wrote holding orders that we can clarify, sometimes I tell them they have to call the admitting for that. If the pt has a history of this ectopy you SHOULD have gotten this in report, but it's worth checking before you make the call. Let me add that in addition to checking your most recent labs and ekg, you should check to see when they're next due, I would expect to be supported if I got my routine am labs at 2-3:00 so I had the results when I called.

pricklypear · Mar 25, 2006

This is one of those "iffy" situations - especially for a new nurse. My first job, on telemetry at a large teaching hospital, it was expected to call for new runs of V-tach (greater than 6bts) whether symptomatic or not. Docs usually ordered a mag level to be looked at in the morning unless critically low. Never had a doc get peeved at me calling at 2am for new runs.

However, I now work in ICU in a much smaller hospital and I would never call a run of Vtach unless sustained for greater than 10-15 bts, or symptomatic. Our cardiologists don't want to hear from us in the middle of the night - period - unless something needs to be done immediately.

You need to find out what is generally accepted for the cardiologists you work with. My advice would be to ask your NM, or the most experienced (or most respected) nurse you work with.

Good luck!!