[NancyNurse08]

Hello all,
Had a pt. on diltiazem gtt, 10mg/hr, HR 96, A fib. Pressure was trending down, SBP 94. MD order was to titrate gtt for HR 90-100, and we have unit specific protocol.

Checked with resource RN who is very knowledgeable and experienced, who agreed we should go down to 5mg/hr due to BP trending down and rate remaining stable. An hour passed, HR increased to 107, BP back up to one teens systolic. Checked with charge, who agreed that it sounded like we had jumped the gun a bit and that we should go back up to the 10mg rate.

Back up we go, but an hour later, HR still elevated, increasing to 117 and taching into the 120s. So, again, checked with charge, and increase rate to 15mg/hr.

Within an hour, rate is 70s and patient converted to NSR, SBP holding in one teens. Back down to 10. Rate, rhythm, and pressure all still holding an hour later. I'm thinking we need to go down to 5, but by this time, it's end of shift. Oncoming nurse comes on, and I'm giving report, and he gives me a boatload of grief over "not following MD order" of keeping HR 90-100. I explained the rationale for every rate change, that I had not personally touched the pump (outside my scope of practice), and that every decision had been run by and backed up by the charge nurse.

Oncoming nurse disagrees with my charge nurse's decisions (made a face when I told him that the charge nurse had been involved), stated that *I* should have gone over the charge nurse's head and called the MD for orders (even though we have parameters that are unit specific PLUS I am an LPN so I always run things by my charge before making calls to docs). He pointed to the protocol that I had printed out and placed with the chart for my information and said the "MD's order trumps *this*." with what looked to me like a sneer.

Before I left, I asked oncoming nurse if he would like me to do anything with this situation before I went home. I didn't want to dump a load of c### in his lap (and said so; I do not want to be one of those nurses that other nurses hate to follow). He said no, that he was going to decrease the gtt to 5 (exactly what I would have done, or rather, asked my charge if we should do, and have an RN to make the rate change since I won't touch the pump).

I *thought* I had followed protocol and used sound nursing judgment. I did not personally touch the pump nor make any decisions regarding rate changes without running them past my charge. I simply monitored the patient and reported any changes to my charge, staying within my scope of practice. The gtt rate never went outside of either the MD's parameters nor our unit protocol. The outcome was positive; patient in NSR with rate in the 70s, ready to be titrated down and possibly transitioned to PO.

My confidence is shaken by my co-worker's attitude.

Did I really misjudge the situation, or was this a case of a nurse eating his young? Maybe he was just mad because he'd have to call the doctor in the middle of the night if the gtt needed to be DCd (our protocol is to call MD when gtt is DCd, and there was no "notify MD" parameter order otherwise).

Please be gentle!

[jmgrn65]

Originally Posted by NancyNurse08

Hello all,
Had a pt. on diltiazem gtt, 10mg/hr, HR 96, A fib. Pressure was trending down, SBP 94. MD order was to titrate gtt for HR 90-100, and we have unit specific protocol.

Checked with resource RN who is very knowledgeable and experienced, who agreed we should go down to 5mg/hr due to BP trending down and rate remaining stable. An hour passed, HR increased to 107, BP back up to one teens systolic. Checked with charge, who agreed that it sounded like we had jumped the gun a bit and that we should go back up to the 10mg rate.

Back up we go, but an hour later, HR still elevated, increasing to 117 and taching into the 120s. So, again, checked with charge, and increase rate to 15mg/hr.

Within an hour, rate is 70s and patient converted to NSR, SBP holding in one teens. Back down to 10. Rate, rhythm, and pressure all still holding an hour later. I'm thinking we need to go down to 5, but by this time, it's end of shift. Oncoming nurse comes on, and I'm giving report, and he gives me a boatload of grief over "not following MD order" of keeping HR 90-100. I explained the rationale for every rate change, that I had not personally touched the pump (outside my scope of practice), and that every decision had been run by and backed up by the charge nurse.

Oncoming nurse disagrees with my charge nurse's decisions (made a face when I told him that the charge nurse had been involved), stated that *I* should have gone over the charge nurse's head and called the MD for orders (even though we have parameters that are unit specific PLUS I am an LPN so I always run things by my charge before making calls to docs). He pointed to the protocol that I had printed out and placed with the chart for my information and said the "MD's order trumps *this*." with what looked to me like a sneer.

Before I left, I asked oncoming nurse if he would like me to do anything with this situation before I went home. I didn't want to dump a load of c### in his lap (and said so; I do not want to be one of those nurses that other nurses hate to follow). He said no, that he was going to decrease the gtt to 5 (exactly what I would have done, or rather, asked my charge if we should do, and have an RN to make the rate change since I won't touch the pump).

I *thought* I had followed protocol and used sound nursing judgment. I did not personally touch the pump nor make any decisions regarding rate changes without running them past my charge. I simply monitored the patient and reported any changes to my charge, staying within my scope of practice. The gtt rate never went outside of either the MD's parameters nor our unit protocol. The outcome was positive; patient in NSR with rate in the 70s, ready to be titrated down and possibly transitioned to PO.

My confidence is shaken by my co-worker's attitude.

Did I really misjudge the situation, or was this a case of a nurse eating his young? Maybe he was just mad because he'd have to call the doctor in the middle of the night if the gtt needed to be DCd (our protocol is to call MD when gtt is DCd, and there was no "notify MD" parameter order otherwise).

Please be gentle!

I would not have called the MD you had parameters. It sounds like you did what you should have done. The guy is a jerk, and is apparently on a power trip. Don't let him bother you some people just like to be that way.
You did what I would have done, I have been a cardiac nurse for over 16 years. Don't let him bug you.

[NancyNurse08]

Thank you for your reply! My SO says I should quit obsessing. I'm going to try to heed his advice and get my mind off it.

[jrwest]

i agree- this guy was being a jerk- no harm was done- you had parameters.sorry you have to work with someone like that.

[Noryn]

To keep a heart rate between 90-100? Is that even possible? I have no idea how you could keep a heart rate in that range. I am not even sure you would want to keep a resting heart rate that high unless there was some underlying perfusion problem.

I think you did everything right.

Hopefully someone will correct me if I am wrong, but if you have a converted rate in the 70s with a good bp, would that not be crazy to increase that drip?

[canoehead]

I would have done the same. He's nitpicking.

[Angie O'Plasty, RN]

My first thought was this guy's a real jerk. Or maybe a newbie?

I would've titrated for the same reasons you did -- to maintain a good BP and HR.

Next time, when the guy says to call the doc at whatever ungodly hour of the night when you already have standing orders, offer him the phone and let him make that call and get his butt so righteously chewed by the cardiologist.

[Noryn]

I cannot edit my last line of my previous post but that was not written correctly. I misunderstood the incoming nurse's intentions.

I think you did everything right. I would titrate it down gradually at 5 mcgs which you did.

[chare]

If you are working with an atrial fibrillation protocol, then the targeted heart rate pertains while the patient is in atrial fibrillation. If your atrial fibrillation protocol is like every one that I have seen, the goal is to keep the heart rate down to the target rate while in atrial fibrillation, not increase it to the target rate after the patient converts to sinus rhythm. I would suspect that as long as your patient remained in sinus rhythm with a systolic blood pressure in the 110’s, this is probably the patient’s baseline. Even if not baseline as long as he/she was mentating and did not show signs of hypoperfusion, he/she was probably doing okay.

I would not worry about this, your co-worker is just being a jerk. Above all else, do not let this shake your confidence. You did an excellent job managing this patient. When I titrate infusions I do exactly as you did with this patient, unless the patient is grossly outside of parameters and/or unstable I usually let things ride a few minutes before making any changes, often times this can keep you from chasing your tail and save you a lot of work.

Again, good job and don’t give this jerk another thought.

[NancyNurse08]

Thank you so much, everyone. I thought I had made sound clinical judgments, followed appropriate protocol, and stayed within my scope. I knew in the back of my mind that the other nurse was being a jerk, but I'm still new enough that I continue to have a lot of self doubt. My charge nurse keeps telling me he knows I can handle this stuff and that I'm doing a great job, and I have to learn how to let the positive feedback in and the BS roll off my back. I do have a much thicker skin now than when I first started, but there are still some weak spots in my armor that a well aimed dagger can easily penetrate. Fortunately, this type of treatment from co-workers is rare. We have a really cohesive and supportive group on my shift.