[jnette]

Originally Posted by telehead

Agree with the others who state you should get an ABG. I've had pt's with sats in the low-mid 80's on the finger that registered a 96% on the ear! It would be a good idea to know exactly what the sat really is.

The use of Coreg is said to be better for the CHF patient because it's not only a Beta-1 blocker but a beta-2 (bronchioles- breath easier) and alpha-1 (vascular arterioles- lower bp) blocker. From what I've read, it's preferred first line over digoxin with CHF patients... fib/flutter folks without the chf history still apparently respond to dig better.

Aha ! That's the info I was looking for. So she should be doing as weel, if not better on the Coreg, then. hmmm....

OK.. so is it OK for me to ask for them to get an ABG, or would that be considered being just a bit pushy on my part? I'm really not sure of my boundaries yet in this field...

I keep assuming the docs are doing what they should be doing for these pts., but then I have to wonder sometimes. And I'm not sure when I should step in................ *sigh*

Anyway, THANK YOU for all your advice.

[jnette]

Originally Posted by Tweety

Jnette, also understand that there are going to be people who have chronic hypoxia and that's just the way they live life. Their bodies have adjusted and while not healthy, they maintain. Many people have O2 sats in the upper 80s chronically, especially with activity.

If the MD is o.k. with the hypoxia he should change the orders to allow for sats in the 80s, rather than you wasting your time trying to get her above 90.

Definately suggest an ABG. While ABGs just to get a pulse ox isn't appropriate all the time, in this case I would be very curious.

I agree, that if something could be done to maintain more optimal health, it should be tried.

I do believe she is chronic hypoxia, Tweety. But the recent increased episodes of SOB had me worried.. and yet her lungs are clear.

I guess I'll suggest an ABG just to be sure of everything, then if he feels her sats will never improve, I'll ask him to change the order to allow for those sats... now why didn't I think of that?

See... that's why I come to you all.... my heros !

[VicChic]

Didn't mean to make anyone feel like you "just don't get it." I'm just having a hard time understanding why haven't you seen Afib with occassional PAC's unless they were just assumed to be more fibrillations, which I could understand I guess. That's all.

Okay, I think now is a good time to say we agree to disagree. I never said I'm right because I'm just right and you're not. I offered knowledge that I have learned by working with cardiac pts and under the supervision of several cardiologists. That's it. Take it or leave it. The review was a nice refresher for myself actually. But I still stand by my responses 100% and so do the cardiologist I've worked with, b/c this is what they have taught me and the information is used by myself and my colleagues regularly. I don't have to argue what is fact already. Fact proves itself. So it's not "mis-information." There are professionals in health care using these very facts to treat pts. If you notice, I wasn't the only one who stated the [u]possibility[u] of Afib with PAC's. Once you have seen it, you don't ever deny its possibility. I'm just grateful for the experience, b/c as I'm learning it's not granted to everyone.
I'm just wondering why this is so unheard of to you, b/c it's really not that rare. Okay, not gonna beat that dead horse again (LOL).

Yes, it's true that I'm 22. I was wondering how long it was going to take before that came into the discussion. I'm young in nursing, but not new to it. I took prepatory classes for nursing school while still in high school and had credits towards my degree before graduating H.S. b/c it's offered like that if your serious about your training. Sort of a recruitment tool in the area, but it's training still. Before my cardiac nursing which consists of CCU and cardiac stepdown, I worked in the ER, med/surg ICU and in various outpatient centers. So very diverse considering the years in it.
So just b/c I'm young, doesn't mean I couldn't know what I'm talking about. Don't you think that's a lil' discriminatory towards age? You don't think the senior could ever learn from the freshman and vice versa? As much as healthcare changes, you bet. And I know this much is true. You might be surprised how many older nurses come to me for advice sometimes simply b/c I am young and they feel I would have the latest information on whatever the topic is b/c I have less to confuse it with from info that's now outdated b/c it's as old as I am, so to speak (LOL). And they to continue to ask even today, so that my let you know a little bit about my credibility. So may we all continue to expand our knowledge basis, both young and aged, in the ever changing world of healthcare, b/c as you more seasoned nurses know already: The only thing that's constant in nursing is that it changes...alot. We're in this together and whatever problems we have in nursing, we certainly don't solve anything by creating discord among each other, nor does the whole "aren't you 22?" arguement do much for dispelling the fact/opinion that Nurses eat their young which further contributes to a myriad of other issues in nursing. If I had a nickel for everytime someone tried to discredit my nursing knowledge just b/c it belonged to a 22 yo.... I probably could retire by age 23! But that's okay, you wouldn't be the first, and certainly not the last. Buh-bye!

[Jedi_Iatros]

Sorry, but you can't have an atrial fib along with PACs. PAC's can lead to Afib ,however.

[telehead]

Originally Posted by VicChic

Didn't mean to make anyone feel like you "just don't get it." I'm just having a hard time understanding why haven't you seen Afib with occassional PAC's unless they were just assumed to be more fibrillations, which I could understand I guess. That's all.
Okay, I think now is a good time to say we agree to disagree. I never said I'm right because I'm just right and you're not. I offered knowledge that I have learned by working with cardiac pts and under the supervision of several cardiologists. That's it. Take it or leave it. The review was a nice refresher for myself actually. But I still stand by my responses 100% and so do the cardiologist I've worked with, b/c this is what they have taught me and the information is used by myself and my colleagues regularly. I don't have to argue what is fact already. Fact proves itself. So it's not "mis-information." There are professionals in health care using these very facts to treat pts.

I haven't seen Afib with occasional PAC's because, as I work through this and try to understand it, the rhythm doesn't exist.

I'm not trying to be confrontational. This is an open discussion seeking to answer the OP's question that has grown because of differing opinions. You stated previously that you love the how/why. I believe myself, Dinith88 and others have tried to describe, physiologically, the how/why afib with pac's is not possible, at least as I/we understand it right now. I've stated more than once that I'm open to where I might be wrong. Your responses have been, repeatedly, the same thing (ectopic beats without QRS complexes) backed with "that's what other nurses and cardiologists have told me". Additionally, within your explanation, you've stated things that simply aren't true (ie., a run of pac's indicate an attempt to convert to sinus).
What many of us have tried to do, as you state, is also 'offer knowledge that we have learned' with explanation in an effort to further everyone's knowledge, mine/ours included.

Originally Posted by VicChic

If you notice, I wasn't the only one who stated the [u]possibility[u] of Afib with PAC's. Once you have seen it, you don't ever deny its possibility. I'm just grateful for the experience, b/c as I'm learning it's not granted to everyone.

Actually, outside of the first responder, you are the only one. Everyone else has disagreed with your contention. As a fan of the old movie "12 Angry Men", I don't put any weight behind the number of people agreeing or disagreeing with me as evidence of the truth. But as others have added their responses, it does count towards building the knowledge base and contributing to the most likely answer. I suspect what you "saw" wasn't afib with pac's. Someone may have incorrectly interpreted it that way, but after hashing thru the physiology, it doesn't seem to hold much water.

Originally Posted by VicChic

Yes, it's true that I'm 22. I was wondering how long it was going to take before that came into the discussion. I'm young in nursing, but not new to it. I took prepatory classes for nursing school while still in high school and had credits towards my degree before graduating H.S. b/c it's offered like that if your serious about your training. Sort of a recruitment tool in the area, but it's training still. Before my cardiac nursing which consists of CCU and cardiac stepdown, I worked in the ER, med/surg ICU and in various outpatient centers. So very diverse considering the years in it.
So just b/c I'm young, doesn't mean I couldn't know what I'm talking about.
Don't you think that's a lil' discriminatory towards age? You don't think the senior could ever learn from the freshman and vice versa? As much as healthcare changes, you bet. And I know this much is true. You might be surprised how many older nurses come to me for advice sometimes simply b/c I am young and they feel I would have the latest information on whatever the topic is b/c I have less to confuse it with from info that's now outdated b/c it's as old as I am, so to speak (LOL). And they to continue to ask even today, so that my let you know a little bit about my credibility.

Nobody questions your credibility as a nurse. We're all (mostly?) nurses here. Some certainly have more knowledge than others in certain areas and some certainly have more experience than others. To be honest, you were the first to question the level of credibility, in an effort to "understand why this was such a hard topic for us (me?) to understand."

Originally Posted by VicChic

So may we all continue to expand our knowledge basis, both young and aged, in the ever changing world of healthcare, b/c as you more seasoned nurses know already: The only thing that's constant in nursing is that it changes...alot. We're in this together and whatever problems we have in nursing, we certainly don't solve anything by creating discord among each other, nor does the whole "aren't you 22?" arguement do much for dispelling the fact/opinion that Nurses eat their young which further contributes to a myriad of other issues in nursing. If I had a nickel for everytime someone tried to discredit my nursing knowledge just b/c it belonged to a 22 yo.... I probably could retire by age 23! But that's okay, you wouldn't be the first, and certainly not the last. Buh-bye!

The vast majority of this discussion took place before the question of age ever came up. This isn't nurses eating their young. It is an honest attempt at discussion. As I've stated, I'm comfortable with my understanding on this topic and the process of hashing it out enhanced it. The value of discussion.

Don't ever stop asking questions and those people with the M.D. (or D.O.) after their names are right most of the time, but not every time.
You may have the last word, if you choose.... unless it can lead to further discussion!

[AndyB]

Originally Posted by telehead

The use of Coreg is said to be better for the CHF patient because it's not only a Beta-1 blocker but a beta-2 (bronchioles- breath easier) and alpha-1 (vascular arterioles- lower bp) blocker. From what I've read, it's preferred first line over digoxin with CHF patients... fib/flutter folks without the chf history still apparently respond to dig better.

I did a looksy on Coreg and you hit the nail on the head. The use of beta blockers in CHF decreases mortality. In CHF the heart tries to compensate for low cardiac output by increasing its rate and contractions. In the long run this will cause the heart failure to get worse. Beta blockers stop this mechanism.

I was thinking about Coreg blocking beta 2 which would block bronchodilation.

[telehead]

Originally Posted by AndyB

I did a looksy on Coreg and you hit the nail on the head. The use of beta blockers in CHF decreases mortality. In CHF the heart tries to compensate for low cardiac output by increasing its rate and contractions. In the long run this will cause the heart failure to get worse. Beta blockers stop this mechanism.

I was thinking about Coreg blocking beta 2 which would block bronchodilation.

Andy, you are right. As I was typing the Beta 2 (bronchioles, breathe easier), I had one of those "wait a minute, that doesn't look right" moments but blew it off without thinking and kept typing. Thanks for catching that.

[zookeeper]

Do you have basic or advanced arrhythmia classes you can sign up to take? You can't have PAC's in A-fib. A-fib can speed up to over 100---hence the RVR or slow down to a controlled rate (below 100). You can have lots of PAC's especially in lungers and sometimes it's a pretty strong indicator they're going to go into A-fib. There's also multi-focal atrial tach which can look like PAC's because you actually have a P.
Steelcity may have been thinking of Ashmon's Phenomenon which looks like PAC's in the middle of Atrial Fib.
Atrial Fib is a rhythm, PAC's are an incidental in a sinus rhythm.