[Indy]

Oh, and btw, you're right about the thing with aortic stenosis. We've had a few people with that, severe enough that the doc said "NO NITRO." If I see that in the history and physical, but not written as an order, I'll put it on the computer as a nitro allergy so pharmacy will see it, and pass it off in report. It would probably be a good idea to put a sign over the bed that said "no nitro" - kind of like how we do signs for "no bp or sticks in -- arm" for post mastectomy/ AV shut patients.

And I do ask my male patients about viagra type drugs. I explain that I don't care if they use them, but some people are too embarrassed to admit to them on admission, and I don't want to harm them by giving them nitro if they do use them. They mostly all blush over that little speech.

[RegisteredNurse06]

Originally Posted by wellstar

Does anyone have standing orders or a practice guidline for pts with chest pain at thier facility?

It seems to me that pts get faster care for chest pain if they out in the community than if they are already in the hosp. If 911 is called they get O2, S/L Nitro, aspirin and an EKG as soon as the EMTs arrive. In the hosp they have to wait until the MD calls back and the nurse gets orders.

Please let me know what the procedure is at your facility and what literature supports your practice.

Our facility has telemetry protocol orders. Anyone admitted to our unit automatically has PRN orders for SL NTG, tylenol, O2 @2-4L/NC, EKG, and some other goofy stuff like MOM, Mylanta & a couple other things. What we don't have is orders for obtaining cardiac enzymes and for giving morphine. I HATE that. I called a doc this morning about a patient who was having CP and he gave me the order for morphine but didn't give an order for cardiac enzymes. That bothers me.

[lmessajumper]

Here is the "Chest Pain Protocol" from the hospital I am on assignment on. These are automatically done on our MS/Tele unit on every patient - unless otherwise ordered.

1. O2 @ 2-4l NC
2. Record O2 saturation
3. Obtain STAT 12 lead EKG prior to NTG.
4. Give NTG 0.4mg SL every 3-5 min x 2 for SBP >90 or _______ mm Hg. If SBP <90 or __________ mm Hg, notify physician immediately.
5. If no relief with NTG, give Morphine 2-5mg IVP and notify physician immediately.
6. Mount EKG strips with chest pain onset.

These are good for nurses that do not always work tele. This is a small 10 bed unit.

[rehabrn11]

Yes we have standing orders for patients with chest pain that come from ER or the floor.

[mandykal]

Originally Posted by RegisteredNurse06

Our facility has telemetry protocol orders. Anyone admitted to our unit automatically has PRN orders for SL NTG, tylenol, O2 @2-4L/NC, EKG, and some other goofy stuff like MOM, Mylanta & a couple other things. What we don't have is orders for obtaining cardiac enzymes and for giving morphine. I HATE that. I called a doc this morning about a patient who was having CP and he gave me the order for morphine but didn't give an order for cardiac enzymes. That bothers me.

hey, remember that we are in a position to advocate for our clients so don't be afraid to ask what you think may additionally be appropriate for your pts and you may document the morphine order and also "no cardiac enzymes order given at this time when questioned." So, it would show your interest...

KAL

[CyndieRN2007]

I'm sorry if I missed this, but I didnt notice anybody saying that IV access part is of the standard protocol. In our facility, Its O2, EKG, IV access x2, until doc gives us order for NTG, asprin chew and swallow, morphine, then enzymes. Our docs always get there pretty fast. If pt is coming to hospital via ambulance, the doc is usually there before pt. gets there.

[mamason]

1: O2
2:STAT EKG
3: Nitro sublingual x3 if BP can withstand
4:Morphine
5:Cardiac Enzymes STAT
6:Notify MD

All Pt's were required to have IV access by minimal 20 guage upon admission to floor.

[keypit2yrself]

Written protocols in hospitals advocating NTG for CP should rethink their practice. One of our cardiologists said that giving NTG to a patient w/ RV AMI is risky and he would not do it. We don't have standing orders for that very reason (756 bed -teaching hospital) In 9 out of 10 patients C/P NTG is probably beneficial. However, an earlier member said it best--a patient w/ a RV MI died following an administration of "routine" NTG. Oxygen, IV access, EKG w/ CP, and aspirin are fairly benign. Morphine is usually safe although I always go slow and dilute first. (Duh!)

FIRST... Do no harm.

[RegisteredNurse06]

Originally Posted by mandykal

hey, remember that we are in a position to advocate for our clients so don't be afraid to ask what you think may additionally be appropriate for your pts and you may document the morphine order and also "no cardiac enzymes order given at this time when questioned." So, it would show your interest...

KAL

I did ask about enzymes and the doc didn't feel it was necessary, which is unusual for that particular doctor. Our docs are usually good about ordering enzymes, particularly when we request an order for them. I later found out that patient ended up being transferred for intervention later that morning.

[muffie]

O-2, ntg prn q 5 min., mos 2 mg iv [with a max of 10 mg/hr], ecg, ativan as standing orders

everyone is usually already on plavix and asa