call MD if HR <60

  1. Hi everyone, I'm a new grad and just started working on a med-surg tele unit for nights. I had a patient on tele that got bradycardic but not even anything <52. The patient was asymptomatic and was also sleeping so I didn't mind it. Patient also does not have any past cardiac issues.

    While giving report to the AM shift, this one nurse saw the admit parameters that said "call MD if HR <60" and there was also the corresponding "call MD if HR >100". So the oncoming nurse kinda gave an attitude as to why I didn't call MD. While we were talking, an MD who was handling the patient asked an unrelated question, so I brought up that the pt was bradycardic last night but would usually return to normal. The doctor didn't even care about this.

    Was I right for not calling an MD for that HR? I know parameters were in place but we should also always look at the patient and not just the numbers.
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  2. 17 Comments

  3. by   Sour Lemon
    Quote from Ehhh15
    Hi everyone, I'm a new grad and just started working on a med-surg tele unit for nights. I had a patient on tele that got bradycardic but not even anything <52. The patient was asymptomatic and was also sleeping so I didn't mind it. Patient also does not have any past cardiac issues.

    While giving report to the AM shift, this one nurse saw the admit parameters that said "call MD if HR <60" and there was also the corresponding "call MD if HR >100". So the oncoming nurse kinda gave an attitude as to why I didn't call MD. While we were talking, an MD who was handling the patient asked an unrelated question, so I brought up that the pt was bradycardic last night but would usually return to normal. The doctor didn't even care about this.

    Was I right for not calling an MD for that HR? I know parameters were in place but we should also always look at the patient and not just the numbers.
    I despise generic orders like that that certain MDs enter for every patient. I wouldn't be bothered if I were the nurse following you ...but you should probably be cautious of the fact that you may be thrown under the bus if something goes wrong and you ignored a "call me if" order.
    Along with mentioning the decreased heart rate, it might have been a good idea to ask for an order adjustment.
  4. by   NuGuyNurse2b
    And always document! If you brought that up with the MD, even after the event, document that you notified him, and if there isn't a check box, write no orders given. You want to remain professional also, so don't put something like "MD ignored it". Something generic, covers the bases, but still professional.
  5. by   Purple_roses
    I would call. You can never be wrong for following the orders, but it can look bad on you for not following them. Something similar happened to me and I reported the abnormal and then asked the doctor if she still wanted to have the order listed as it was--she ended up rewriting the order.

    I wouldn't have gotten mad at you if I was the nurse coming on. You weren't skipping out on assessments. But personally, I would have called.
  6. by   RotorRunner
    That sounds like one of those ridiculous generic admissions orders they toss in on every patient. I would call the first time, just to cover myself, and say "the patient had a heart rate that dipped down below 60, was asymptomatic and hemodynamically stable with a BP of 120/70 and denial of any complaint. Would you like to change this order"?
  7. by   Guy in Babyland
    It should have been sustained HR<60. I had a co-worker who was a an avid runner. He told staff when he had surgery that his normal sleeping HR is in the 40s so don't treat me for bradycardia.
  8. by   KelRN215
    Quote from RotorRunner
    That sounds like one of those ridiculous generic admissions orders they toss in on every patient. I would call the first time, just to cover myself, and say "the patient had a heart rate that dipped down below 60, was asymptomatic and hemodynamically stable with a BP of 120/70 and denial of any complaint. Would you like to change this order"?
    Agree. I would call and if the MD doesn't want to be notified for a HR of 52, he should d/c that order. I once had a patient with an order to call for a MAP < 70 or something. The patient had a perfectly normal blood pressure for a child of her age- something like 108/50 but her MAP was 69. So I paged the Resident, FYI Pt Brown MAP is 69, there is an order to call for MAP < 70. That order was left over from the ICU and was promptly discontinued.

    And then on the flip side we had Neurosurgery kids with orders to call for HR < 60/80/100 etc (parameters based on age) but when we did call to say "hey, this 2 month old baby's HR is 83 and she is having symptoms of acute hydrocephalus" the Resident would just be like "it's ok, she's asleep." Yeah, not ok for an infant to have a heart rate of 83, sleeping or not. That baby was rushed to the OR within an hr. Our running joke on the floor was that anytime we reported bradycardia, the Resident's response would be like "the patient is probably an athlete" even if the patient was an infant.
  9. by   blondy2061h
    Quote from KelRN215
    Our running joke on the floor was that anytime we reported bradycardia, the Resident's response would be like "the patient is probably an athlete" even if the patient was an infant.
    That's kind of a joke at my hospital too when we have elderly people with multiple comorbidities whose families want EVERYTHING done, so they're on tele. Then we get to watch them brady down with various heart blocks. "Probably an athlete."
  10. by   MissNurs2016
    You will gain more confidence with this with time. I do appreciate parameters but after you gain more experience you will be able to assess if the patient is symptomatic, you'll be able to look back and see how he has been trending before, you assess all the factors playing in etc. I have had patients dip down into the 30s without needing to make a phone call. Others might be symptomatic at 50. New grads typically hold meds more often and call MDs more often. This is ok. Don't worry about anyone giving you attitude. That's about them and not you. But do ask more experienced nurses for advice. I used my charge nurses and senior nurses a lot in the beginning if I was uncertain if I should contact the provider.
  11. by   NuGuyNurse2b
    Quote from blondy2061h
    That's kind of a joke at my hospital too when we have elderly people with multiple comorbidities whose families want EVERYTHING done, so they're on tele. Then we get to watch them brady down with various heart blocks. "Probably an athlete."
    Arrggghhh the comfort care with tele order. That along with a regular diet for a patient on a drip. Like really...you get all these food trays stacked up in the corner of the room when you walk in.
  12. by   VioletKaliLPN
    I always advise to use Nursing judgment. I work in a SNF, we have short term rehab as well as 75 LTC beds. We have sliding scale insulin orders for our diabetic patients which include parameters in which we call the physician. This is background info.

    I have an overweight non compliant type 2 diabetic. She is 400+ pounds and munches on candy and treats all day long, so her blood sugars can be exciting stuff.

    I would be ripped a "new one" if I called the physician at 0600 for this patient. She regularly runs "Hi" on the FSBS monitor! It does not even have the ability to give the reading!
  13. by   blondy2061h
    Quote from NuGuyNurse2b
    Arrggghhh the comfort care with tele order. That along with a regular diet for a patient on a drip. Like really...you get all these food trays stacked up in the corner of the room when you walk in.
    "Why are they on tele?"

    "So we can watch them die in real time."
  14. by   dream'n
    If parameters are specified, I call. Covers me, covers any issues that may arise. I worked Oncology and would have system generated critical lab values that the hospital wanted called to the Drs within a certain amount of time. Most of my chemotherapy patients had critical lab values come back, but with numbers that were steadily improving. Even thought I KNEW the Dr would not order anything, I did what PPs recommend. I informed the Dr of the result and then requested a change in lab value orders to call about in the future. The Drs eventually got sick of the calls and remembered to override the system order during admission.
    Also, since you missed the order until the morning, I recommend making it a habit to check all current patient orders as early as possible in the shift. Sometimes you won't believe the orders that have been missed and it saves you from seeing it at 5 AM and thinking "Oh S***!"

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