[TachyBrady]

When you say "standing orders" or "protocol", are these actual written order sets that go on the pt's chart after the fact? If our pts do not have chest pain standing orders, we do the O2, EKG, NTG and nothing is placed in the pt's chart... we just do it automatically and it is not covered by any written order.

Thanks for your replies. I've only worked in Telemetry and in one hospital my whole nursing career so it is interesting for me to see how others do it.

[ZASHAGALKA]

It's a preprinted standard order that is ordered and placed on the chart.

We also have 'protocols' that cover certain situations, and can be placed on the chart, if those situations are triggered: example - electrolyte replacement protocol which allows the admin of say, K+ if it falls below 3.4

Standard orders are already on the chart. If a protocol is activated, we not only place it on the chart, we write it down as an order: example -

5/29/06 1800 Potassium 40 MEQ PO x 1 now and repeat K+ level in am
per Electrolyte Replacement Protocol
signed off by me, here.

Our protocols are approved by the Medical Committee and are considered to be orders on all pts unless specifically contra-manded.

If you do something of a medical scope (order a med, o2, etc), whether there is an order on the chart or not, that action must be documented on the order sheet and the origin of the order should be noted. Otherwise, you set yourself up for legal problems.

~faith,
Timothy.

[Indy]

What I meant is that ACLS is based on some literature, somewhere, most of which I don't have. But the recommendations for ischemic CP or unstable angina come from somewhere. That'd be a good start if looking for literature to support some type of protocol.

If your hospital expects you to take care of patients with angina, like Timothy said, they need to have orders for it. I'm a bit spoiled as even the hospitalists don't admit patients to our unit for angina unless the O2, NTG, morphine, ekg, ASA orders are in place. If they did I might be 15 minutes into treating CP before calling the doc for orders, and so to avoid that situation of the nurse calling for orders on what we already did, they seem to have some sense and just do the orders right to begin with.

If you're seeing a lot of patients with CP and without sensible orders, I'd say start documenting it and go up the chain of command with some statistics.

[Sylv]

What's the cutoff point for the BP where you wouldn't give nitro? How low? What would they do instead for pain? Morphine will also lower the BP, right? What if the BP is low to start, but okay to give the nitro, then after 3 doses the BP goes to like 80/40 or something what do they usually do then for the low BP?

Just trying to learn here.

[pickledpepperRN]

Our admitting orders page (both computer and hard copy) has chest pain protocol stating beside a small box, "Unless checked implement chest pain protocol per RN assessmtnt.
It includes:
o O2 2-4L/m per nasal cannula
o Nitroglycerine 0.4mg SL stat x 1
o 12-lead ECG stat
o IV fluids 250cc NS at TKO

If ST elevation is present on the 12 lead we may give NTG twice more. Before that we have the cardiologist on the phone. We can always call a resident too.

[Indy]

For nitro the blood pressure cutoff depends on the patient. I take BP before giving it, each time. So if the first nitro after 5 minutes drops the systolic 20 points ... and it's NOT a post pacemaker insertion patient... (will explain in a bit) and the patient is not relieved of pain, and the systolic now is say, 130's... then I might give another nitro.

Some people drop a lot then not at all. Some people drop so much with the first one that they're not eligible for another. Usually if the systolic is around 100 I stop. Or if they're normally 100's stystolic I might give one but I don't have the intention of giving three of them, especially if they start out low. I would like the SBP to stay over 90.

Post pacemaker insertion, that is, not a battery replacement but the actual leads, is a little different. Sometimes the little screw can poke through the ventricle wall and cause a little chest pain, and/or a little tamponade. Nitro can make the patient (any patient really) more symptomatic with a good drop in BP, can cause diaphoresis, cold clamminess, etc. So can tamponade, so with a post pacemaker insertion, I'd shy away from nitro in order to see more "real" symptoms and less symptoms caused by nitro.

The last paragraph is advice from a real incident where the cardiologist who inserted the pacemaker gave me direction, for future patients. Yes, the standard CP orders were in effect on the patient, but since I was so worried about her, he explained a bit. With tamponade, if it's slow, the patient will just not be able to get comfortable. They'll whine, and be really vague with their symptoms, before they crash.

Did that help any? Sorry for the rambling.

[Indy]

Sorry. I'm silly and can't figure out how to edit tonight.

I didn't answer your other question. I haven't seen morphine drop BP as quickly or as drastically as nitro can but that's because I'm slow with morphine for chest pain. One milligram per minute, reevaluate. If the patient simply can't keep a systolic over 90 then they're going to get a fluid bolus, I'm gonna call the doc, they're probably going to ICU where, depending on if they are still in pain, they'll get some combination of NTG drip (if pain unrelieved), dopamine maybe, fluids, etc.

Hope that helps!

[Sylv]

Thank you Indy, that did help!

[rninme]

I just got back from a cardiac drug conference....and they are cautioning the routine use of NTG in rx'ing chest pain.
"Just say no to nitro"!!!! without first establishing an IV; r/o a RVMI or hx of aortic stenosis; and r/o pt's use of ....let's call them "enhanced-performance drugs"....especially cialis.....which has a 72 hour "performance window".

Interesting....don't know if it will become a standard of care or not.

[zookeeper]

I had a pt, say 5 yrs ago maybe, that I was giving his ordered nitropaste to. (It was just after we had had an inservice mentioning nitro in an RV MI and the result if you do) It wasn't 5 minutes later the wife came out of the room a little nervous---said something wasn't right. This guy was gray and BP was 60. All I remembered from the inservice was GIVE FLUIDS in a Right-sided MI. So I ran for the fluids while someone else called a code. We hung the fluids, respiratory ended up having to intubate, but he died in the code despite our efforts. Profiles; hot of the press -positive. (we weren't doing Troponins back then). Yeah, I definitely wanna know what type of MI if I can.
By the way, thanks, Indy, for the tip about "post pacer" CP I've never heard that.