Just a question to understand the ER better - page 3

by sheilahdee

9,515 Unique Views | 71 Comments

so a quick run down. just wanted opinions. 59 yr old male patient in ESRF comes into the ER. wife signs him in and describes that he is "finishing dialysis (home hemodialysis), rapid heart rate, feeling of fist in throat and... Read More


  1. 0
    Quote from samadams8
    Not uncontrolled afib. There's a difference between controlled and uncontrolled, rapid afib . Focused assessment could include a quick assessment of heart. His was a rapid rate by more than 30 beats...related to stress. Why so rapid? Is it regular, etc?
    While this is true, in the initial post the first thing the pt states is the pt has "rapid heart rate" well, what is rapid. It is very broad answer. They then go on to say that turns out it is Afib with RVR. The wife couldnt state this because she did not know and of course that changes things the minute you find that out. I have had people walk in and say my heart feels like its beating out of my chest and their Pulse is 90. SO to them that was rapid. Afib RVR isnt though. This is one reason I hate triage and avoid it like the plague.
  2. 1
    Quote from That Guy
    While this is true, in the initial post the first thing the pt states is the pt has "rapid heart rate" well, what is rapid. It is very broad answer. They then go on to say that turns out it is Afib with RVR. The wife couldnt state this because she did not know and of course that changes things the minute you find that out. I have had people walk in and say my heart feels like its beating out of my chest and their Pulse is 90. SO to them that was rapid. Afib RVR isnt though. This is one reason I hate triage and avoid it like the plague.
    It is reasonable to consider that if the patient was found to be w/ a rapid rhythm--> say >130's, which, for someone that is not an infant or child is by definition abnormal, it requires the very basic assessment step of auscultating at least for regularity of rhythm along with a rate. This is basic nursing and medicine--> assessment.

    Upon auscultating, one could appreciate irregularity--which is a hallmark of AFIB. A tech or nurse's aid could do basic VS, but this is why someone with an expectation of higher skills--at least basic assessment--must be in the role of triage.

    The nursing process, which begins with assessment, is the nursing process, period.

    Afib w/ RVR is tricky. Some tolerate it for a bit, while others do not.

    The judgment call can't be based on guesswork anymore than a person would guess, "Hey? This person is c/o angina? Should I take this seriously?"

    This is an ESRD pt, just completing hemodialysis with a rapid heart rate, and a feeling of fist in throat and constant burping.
    Upon taking his CC, at least a focused assessment is required from a cardiopulmonary perspective.

    Often a more serious event occurs with this condition before it's recognized, but the initial encounter/assessment here gives the opportunity to prevent a seriously problematic outcome.
    It's imperative that this pt get evaluated and tx'd as soon as possible.

    Also refer to:
    http://www.clevelandclinicmeded.com/...-fibrillation/
    Last edit by samadams8 on Sep 21, '12
    Susie2310 likes this.
  3. 7
    samadams8, I mean this in the very best possible way, but you are thinking like a critical care nurse.

    The very first step in triage is the rapid visual assessment. This is even before you elicit the chief complaint. In the rapid visual assessment, you basically "eyeball" the person and determine how sick they are; do they need immediate assistance, or can they wait a few minutes?

    This person was apparently alert and oriented and perfusing his vital organs. He was conscious, breathing, and had a pulse. He was not in respiratory distress. He was not bleeding. Therefore, he could wait a few minutes.

    The triage nurse's role is not to do a focused assessment and start treatment. The triage nurse does a rapid visual assessment, takes some vitals, gathers a history, and determines the level of acuity, i.e. the order in which patients need to be seen, based upon all the information gathered.

    As for A-Fib with RVR, to be honest with you, it doesn't freak me out. A-Fib with RVR *rarely* deteriorates into a lethal arrhythmia, and people can generally tolerate it and compensate for a great deal of time. What the person needed in the ED setting was a 12 Lead EKG, some supplemental O2, a peripheral line, and some medication for rate control, such as Diltiazem. It sounds like he got all of that.

    Whether he needed any further treatment would be based upon the physician's exam and decision making process to determine whether the patient needed hospital admission or outpatient follow up. People do not stay in the ED.

    The OP was more concerned with one nurse's attitude, that her eyes did not "bug out" and that she *appeared* unconcerned. I'm here to tell you, my eyes would not "bug out" either, and it might appear as if I am unconcerned. I've taken care of a lot of people with arrhythmias, and I have a very calm exterior. To me, the fact that the one employee (we don't know that it was a nurse; she could have been a CNA or a Tech) appeared frightened tells me that that person is inexperienced and not very knowledgeable about cardiac arrhythmia. I'd rather have the experienced crusty old nurse out there in triage (and working triage often enough can make even the nicest, sweetest person crusty, LOL!) than the fresh, green one.

    We don't really know why he waited 15 minutes from the time he entered the lobby until he was officially triaged (I say officially, because the moment the triage nurse laid eyes on him, the triage process had started), despite the triage rooms being empty, because we don't know what was going on in that ED at that time. It could be that the triage nurse had been specifically instructed to hold off with the exception of anything emergent because they had something going on in the back. They were full, they were on divert, they were coding a child, they had just received a trauma, who knows. We don't.
    Last edit by ~*Stargazer*~ on Sep 21, '12 : Reason: formatting
    canoehead, psu_213, flyingchange, and 4 others like this.
  4. 1
    Quote from samadams8
    It is reasonable to consider that if the patient was found to be w/ a rapid rhythm--> say >130's, which, for someone that is not an infant or child is by definition abnormal, it requires the very basic assessment step of auscultating at least for regularity of rhythm along with a rate. This is basic nursing and medicine--> assessment.

    Upon auscultating, one could appreciate irregularity--which is a hallmark of AFIB. A tech or nurse's aid could do basic VS, but this is why someone with an expectation of higher skills--at least basic assessment--must be in the role of triage.

    The nursing process, which begins with assessment, is the nursing process, period.

    Afib w/ RVR is tricky. Some tolerate it for a bit, while others do not.

    The judgment call can't be based on guesswork anymore than a person would guess, "Hey? This person is c/o angina? Should I take this seriously?"

    This is an ESRD pt, just completing hemodialysis with a rapid heart rate, and a feeling of fist in throat and constant burping.
    Upon taking his CC, at least a focused assessment is required from a cardiopulmonary perspective.

    Often a more serious event occurs with this condition before it's recognized, but the initial encounter/assessment here gives the opportunity to prevent a seriously problematic outcome.
    It's imperative that this pt get evaluated and tx'd as soon as possible.

    Also refer to:
    Atrial Fibrillation
    I agree. In the OP the patient's wife reported the patient had a rapid heart rate, feeling of fist in throat and constant burping, and was finishing dialysis. Sheehy's Manual of Emergency Care, 6th edition, published by the ENA, states on page 73 that "The triage nurse performs a focused physical assessment related to the patient's chief complaint . . . Inspection, palpation, and (occasionally) auscultation can be used to gather information related to the chief complaint."
    Last edit by Susie2310 on Sep 21, '12
    samadams8 likes this.
  5. 1
    No one asked the triage RN to start tx. Someone tells you those symptoms and rapid hr, you take a look and listen. It doesn't take that long. I am not even asking you to listen foe murmurs or other untoward hear sounds.Look at it this way. If the client stated he has chest pain, you don't bloe if off, even if it tired out to be an anxiety attack. It's the same thing in this instance. No excuses. This gets a fail from me as well as some ED docs I know.Sorry.I have been a nurse in adults and critical care and you name for over two decades. Rapi AF doesn't necessarily frak me out either. That is not the point.This is suboptimal screening. The exception would be if there were numerous traumas or the like.This bull, and if it were my parent, you better believe I'd have something to say.
    Susie2310 likes this.
  6. 0
    Quote from Susie2310
    I agree. In the OP the patient's wife reported the patient had a rapid heart rate, feeling of fist in throat and constant burping, and was finishing dialysis. Sheehy's Manual of Emergency Care, 6th edition, published by the ENA, states on page 73 that "The triage nurse performs a focused physical assessment related to the patient's chief complaint . . . Inspection, palpation, and (occasionally) auscultation can be used to gather information related to the chief complaint."
    THank you Susie. Hugs and kisses. You can take care do me and my family anytime!
  7. 0
    Quote from samadams8
    THank you Susie. Hugs and kisses. You can take care do me and my family anytime!
    Thank you samadams8. The feeling is mutual.
  8. 5
    Quote from ~*Stargazer*~
    The OP was more concerned with one nurse's attitude, that her eyes did not "bug out" and that she *appeared* unconcerned. I'm here to tell you, my eyes would not "bug out" either, and it might appear as if I am unconcerned. I've taken care of a lot of people with arrhythmias, and I have a very calm exterior. To me, the fact that the one employee (we don't know that it was a nurse; she could have been a CNA or a Tech) appeared frightened tells me that that person is inexperienced and not very knowledgeable about cardiac arrhythmia. I'd rather have the experienced crusty old nurse out there in triage (and working triage often enough can make even the nicest, sweetest person crusty, LOL!) than the fresh, green one.

    We don't really know why he waited 15 minutes from the time he entered the lobby until he was officially triaged (I say officially, because the moment the triage nurse laid eyes on him, the triage process had started), despite the triage rooms being empty, because we don't know what was going on in that ED at that time. It could be that the triage nurse had been specifically instructed to hold off with the exception of anything emergent because they had something going on in the back. They were full, they were on divert, they were coding a child, they had just received a trauma, who knows. We don't.
    Completely agree -- the OP describes, at some length, treatment for her father that seems appropriate. The motivation for the post, as best I can interpret, is her perception of one triage nurse's "attitude". One person's calm, capable demeanor is another person's attitude ...

    My eyes have "bugged out" exactly once - and that was when a woman handed me a gray, cold, lifeless infant.

    Rapid a fib needs to go back *immediately* ... but we need some place to put them, now don't we? I strongly suspect there had been communication between the triage nurse and the charge nurse, and people were being shuffled. It's a judgement call whether to initate the whole triage process out front, or just hang tight for a minute to get the patient back into a room, on the monitor, and do everything in the back.
    canoehead, Daisy Doodle, samadams8, and 2 others like this.
  9. 1
    I want to apologize for my last few posts. I posted from my iPad, and it autocorrects and so forth. So there are typos and spelling errors.


    I have to say that this is basic nursing assessment--even focal. It's just good sense and critical thinking.



    To the OP, you were right in your initial concern, but don't worry about the attitude of the idiotic nurse. Screw her. It's your dad. Excellent nursing is about advocacy. Push for what you know is right. They took a risk with YOUR dad. It ended up being OK; but it just as easily could not have been a serious problem for your dad--and blowing it off for even 15 minutes could have caused your dad harm. It could have just as easily have been a bad situation w/ a bad or at the least, sub-optimal ending. Something similar occurred in an ED near me. The patiente ended up being found dead in the waiting area. Guess who got a BIG lawsuit slammed against them???? And the triage nurse got named and slammed too. The patient's family won the lawsuit; and it was not settled out of court. Bad situation all around. The guy was around the same age as YOUR dad. It was a *(&%ing embarassment. It shouldn't have happened, and it could have been prevented.
    Last edit by samadams8 on Sep 21, '12
    Susie2310 likes this.
  10. 1
    Quote from Altra
    Rapid a fib needs to go back *immediately* ... but we need some place to put them, now don't we? I strongly suspect there had been communication between the triage nurse and the charge nurse, and people were being shuffled. It's a judgement call whether to initate the whole triage process out front, or just hang tight for a minute to get the patient back into a room, on the monitor, and do everything in the back.



    Put them in the freaking hall on a monitor near the nurse's station, or better yet, listen for an apical rhythm and get an EKG. You see, if someone had taken the few seconds to listen to the person's heart for a few seconds, when they had heard o the HR is too high for being that of a merely distressed adult patient, one could, at the same time, ascertain if the rhythm was irregular. THEN they would have been justified in running an EKG, which they can take to the charge nurse or a practitioner with some sense so that the patient can be monitored, rather than found down and out on the waiting room floor--as has happened, not infrequently mind you.


    [Triage begins with a general assessment of the patient. The nurse must look at the patient and take note of the patient's condition as he or she approaches the triage desk. For example, the method of movement, noting whether the patient is ambulatory and how the gait is, also not whether the patient is using an assistive device, is the patient in a wheelchair, is the patient alone, or with a crowd must be considered in the general assessment. The most important question to consider is: does the patient look sick.

    Three other aspects of triage include obtaining a good history of the patient's presenting symptoms, obtaining a good medical history of the patient, and completing an assessment that is based on the presenting complaint. After the history and assessment have been completed, the triage nurse can make a disposition decision.
    While completing the history, the triage nurse should determine if the patient has any allergies to drugs or foods. Make sure to ask about the onset of symptoms. Ask female patients about their menstrual cycle.
    Assessing whether or not the patient is in distress is a significant part of triage. Many families wish to do all the talking for the patient. Having the patient answer the questions allows the triage nurse to determine if the patient is able to speak in complete sentences as well as assess his or her cognitive level.
    When performing the triage assessment, the triage nurse must actually lay hands on the patient and perform a quick head to toe assessment while focusing on the presenting complaint. Much information can be obtained when executing the triage assessment in this manner. For example, touching the patient tells the nurse the temperature of the skin, the moisture of the skin, the regularity or irregularity of the pulse, and the status of skin tenting. The quick head to toe assessment in the process of performing the focused assessment also tells the nurse if there are signs of abuse or neglect and other problems that could be associated with the primary complaint. (Dugle, 2010.) ]

    Dugle, P. (2010). Triage. Triage Course: ceufast.com. Retrieved from: Triage Course - Nursing Continuing Education (CE) - Nurse CE - CEUFast.com


    What is easier in some patients is listening to an apical pulse for regularity, rather than palpating one at the carotid, brachial, or radial regions. Some people with comorbidities and/or who are frail for some reason (elderly) don't give you great palpable pulses, and they can be harder and take longer to appreciate (conflicted with potentially your own pulse) as compared with an apical pulse. When you take a quick listen, at least somewhere around the precordium or S3 or PMI, you should be able to hear for the rate and regularity of the rhythm. Again, I am not asking anyone to be a superstar with ausculating discreetly problematic heart sounds. That can take a long time in both practice, and while assessing the individual--as say we do in the CCU or CICU, or SICU. I am talking about taking a basic appreciation of the heart by using your stethescope to appreciate rate and regularity. People have become too dependend on automatic devices--I say this, and I am a person that works with high-tech equipment all the time.

    I had someone close to me code on a cardiac floor that no longer had manual cuffs or suction systems set up in their rooms. I used to work cardiac at this big hospital. I was aghast when they had to run around the large floor for portable suction--and the fact that the nurses didn't know or could not do a basic systolic pressure by palpation. Really???? You have got to be freaking kidding me. The automatic BP machine made the basic process of palpating a pulse nearly impossible. No one was able to tell me if the patient had a palpable pulse--b/c there was no manual cuff--and who the hell knew where these nurses stethescopes were.

    It was a mess. I was ready to kiss the CRNA when she came down, b/c she was prepared. Whose idea was it to take away manual cuffs and wall suction from the patient's rooms?

    Guess what, this person that was coding was my MOTHER. TRUE STORY.

    Don't even let me talk about how my father was often handled in a well-known hospital in my area. He suffered a lot more than necessary over the course of his illness.


    My BP is going up just thinking about it.
    Last edit by samadams8 on Sep 21, '12
    Susie2310 likes this.


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