[msaaaz]

so it is NSR at 70s with 110 SBP on 10mg /hr diltiazem

for me i will say well done and i will decrease it to 7.5 mg /hr

thanks

[Indy]

Until the patient converted, dropping his rate to 5mg/hr wasn't good for him. Afterwards, sure, he probably could have been dropped right down with no problem. Except that it's shift change, and I don't like to titrate down then leave the oncoming nurse with something that I just turned down, because I'm used to watching it more frequently right after making adjustments in the rate.

So it's courtesy to let the oncoming nurse do the final titration. And they probably left it at 5mg/hr until a couple hours after the first P.O. dose just to make sure, unless the pt dropped their heart rate some more.

And that particular oncoming nurse needs to quit eating the cornflakes after people **** in them.

[jlsRN]

You sound like you did everything right and your co-worker was the type who likes to use report as a chance to belittle and intimidate. I would have called and left a message for MD when pt converted to SR.

Sometimes it's a balancing act, trying to reduce the rate, yet keep the BP where is should be. The beauty of a protocol to titrate is that you can keep tinkering with it.

[NancyNurse08]

I followed up and had a chat with my CN about the situation. What I walked away with were a couple of things; 1) I should consider the source. 2) Even though the MD (a hospitalist, not a cardiologist) had written an order with vague parameters, I could not be faulted for following protocol.

I had another dilt gtt recently, where the patient converted back to NSR and we stopped it due to bradycardia. I did call the cardiologist for some parameters for night shift this time, which the next nurse appreciated.

Hey, I'm learning!

[CloudHidden]

I'm am just about to graduate so I'm totally not trying to sound like I know everything (or anything for that matter!) but I am just confused here. I though you didn't want to convert an a-fib until it's been determined there's no clot in the atria that we're now going to send flying into the circulation. Obviously I don't know the specifics of your patient, but I know there are some sort of parameters, i.e. if we know for a fact they've been in a-fib less than 24 hours, or they've been on anticoagulants x amount of days and maybe there is some sort of imaging or something they do to rule out a clot (I have no idea on that last one just a guess). So anyway, I guess my point is I thought conversion was sometimes actually considered an adverse effect of the gtt, and that it is mainly for rate control and hemodynamic stability in rapid a-fib patients who are not yet ready to be converted. Maybe that's why the doc wanted to be conservative with the gtt and left such high HR parameters (even though I agree expecting you to keep it within 10 bpm is a little lofty), because he didn't want the patient converted, just hemodynamically stable until ready for conversion. That's just what I have been taught and observed in my CCU internship, we didn't want those people to convert that was a bad thing.
And also yeah like somebody else said we would always call the doc for any rhythm change. Maybe that along with the whole clot thing was what the guy's problem was. Sorry not trying to criticize or say I agree with his attitude, but I really am curious as to why none of the experienced cardiac nurses questioned this?

Also, and sorry I'm really not trying to sound like a smart-ass, but from what I know from my schooling and cardiac internship and working as a tech in intensive care for four years, if a doctor writes specific parameters those are the ones you follow. If they wanted you to follow unit protocol they wouldn't have written specific parameters. But either way I think the responsibility for all of this is on your charge nurse, she was the one actually titrating the pump. So yeah you didn't do anything wrong IMO but I'm thinking the charge nurse might have, depending on if this was a patient they actually wanted to convert.

Somebody please tell me if I'm wrong so I can just sound stupid on here instead of when I'm on a unit!

[Angie O'Plasty, RN]

Originally Posted by CloudHidden

I'm am just about to graduate so I'm totally not trying to sound like I know everything (or anything for that matter!) but I am just confused here. I though you didn't want to convert an a-fib until it's been determined there's no clot in the atria that we're now going to send flying into the circulation. Obviously I don't know the specifics of your patient, but I know there are some sort of parameters, i.e. if we know for a fact they've been in a-fib less than 24 hours, or they've been on anticoagulants x amount of days and maybe there is some sort of imaging or something they do to rule out a clot (I have no idea on that last one just a guess). So anyway, I guess my point is I thought conversion was sometimes actually considered an adverse effect of the gtt, and that it is mainly for rate control and hemodynamic stability in rapid a-fib patients who are not yet ready to be converted. Maybe that's why the doc wanted to be conservative with the gtt and left such high HR parameters (even though I agree expecting you to keep it within 10 bpm is a little lofty), because he didn't want the patient converted, just hemodynamically stable until ready for conversion. That's just what I have been taught and observed in my CCU internship, we didn't want those people to convert that was a bad thing.
And also yeah like somebody else said we would always call the doc for any rhythm change. Maybe that along with the whole clot thing was what the guy's problem was. Sorry not trying to criticize or say I agree with his attitude, but I really am curious as to why none of the experienced cardiac nurses questioned this?

Also, and sorry I'm really not trying to sound like a smart-ass, but from what I know from my schooling and cardiac internship and working as a tech in intensive care for four years, if a doctor writes specific parameters those are the ones you follow. If they wanted you to follow unit protocol they wouldn't have written specific parameters. But either way I think the responsibility for all of this is on your charge nurse, she was the one actually titrating the pump. So yeah you didn't do anything wrong IMO but I'm thinking the charge nurse might have, depending on if this was a patient they actually wanted to convert.

Somebody please tell me if I'm wrong so I can just sound stupid on here instead of when I'm on a unit!

Diltiazem is a form of chemical cardioversion, so I'd have to assume that its use presumes that the doc wanted the patient to convert.

If the patient converts on the cardizem gtt, then all's well, and the patient's probably already had a shot or two of Lovenox and begun Coumadin. There's really no way to tell if patients have been throwing microclots, they're just assumed to be doing so and are treated immediately with anticoagulants.

[NancyNurse08]

It's been a little while, but as I recall, the patient was on LMWH and warfarin.