C'Mere & Play a New Game: "GIVE OR HOLD"?

[UM Review RN]

Do you give these meds or hold them and why?

Yes, you may call the doc, but at least take a guess as to what the doc will order.

Tell us what you decide--give or hold--and say why. Then add one or two meds of your own.

(If you have issues with someone else's answers, you may "CHALLENGE" but be prepared to back your answers up with evidence!)

Here are two to get you started. They don't necessarily go to the same patient. Assume the patients are alert & oriented X3, unless otherwise stated.

Don't forget to give the critical information necessary to make a decision.

1. Rhythmol 150 mg po. HR = 55, Rhythm = Sinus Brady with a 1st degree AV Block, BP 120/60.

2. Clonidine 0.2 mg po. HR 34-42. Rhythm SB with a BBB. BP 143/68.

[zacarias, ASN, RN]

funny that the K+ would be that low with such a severe acidosis. But I guess if they diuresed tons already and were dry, it could be that low. (I don't ever see active DKA...only resolved.)

[veegeern, BSN, RN]

oops! missed the next page...

[stn2003, RN]

as far as the natrecor goes, my 2004 mosby's says that Adverse Reactions/Side effects of natrecor can include: A-fib, tachy, v-tach, and arrhythmias. if the lungs were clear and the ekg was showing something more than a-fib or showed severe tachy, i would stop it and page the house doctor/call the md. also, this is assuming the heparin is running in a different line as they are not compatible

[Indy, LPN, LVN]

*******You didn't say, but I am gonna assume the Natrecor and Heparin were running into seperate sites, as they are incompatible.

To my understanding, Natrecor is used as a diuretic for CHF. I have not found any reference where Natrecor causes arrythmias....just bottoms BP out.

This came from the nesiritide web site. http://www.rxlist.com/cgi/generic/natrecor_ids.htm

Please set me straight if I am wrong, as we give a lot of Natrecor here.

******** (I messed up the quote function- above is a quote)

You're correct, they were in two separate sites, and her blood pressure was stable in 140's systolic while I had her. Since my protocol seemed more concerned with hypotension than just about anything else, I didn't stop the drug as her bp did fine. We do some natrecor on my unit but it isn't as popular as Inocor, for what reason I'm not sure. And it had been at least two months since I had had a patient on whom I started all the drips, AND included a natrecor drip.

So I got back to work that night and found the lady still on natrecor, but I was on a different unit so I didn't have her, all I had time to find out was that she did well, drip still running.

[Indy, LPN, LVN]

as far as the natrecor goes, my 2004 mosby's says that Adverse Reactions/Side effects of natrecor can include: A-fib, tachy, v-tach, and arrhythmias. if the lungs were clear and the ekg was showing something more than a-fib or showed severe tachy, i would stop it and page the house doctor/call the md. also, this is assuming the heparin is running in a different line as they are not compatible

Ahh... yes, her lungs were clear, and her ekg was just funky. One of the times I thought the monitor dinged for longer than 2 seconds, I glanced at it and saw wider complexes and didn't stop, just went flying down the hall, patient is asymptomatic but the ekg tech arrived. I think I scared her half to death running past her like that. But we got a good 12 lead look at the thing during her heart's irritable period. Basically most of the leads appeared to show what could have been either a bundle branch block or very close ST elevation, it was so hard to tell which it was. And the complexes looked narrow but if you get the calipers out they'd probably be right at 0.08 wide (two blocks) so I'd guess that was what was making the monitor say v-tach. Basically the charge nurse was scratching his head thinking it might technically be vtach, but it sure didn't look like it most of the time on the monitor.

The one that I saw that looked wide, didn't look quite as wide when we pulled it up again to review the strip, and so I think the concensus was that I was just too excitable over "moments" of vtach. I was sure the nurse I handed off too was gonna stop this drip, though, so I have no idea what happened to make her change her mind, maybe the doc showed up and had a look, who knows.

[Ex130Load]

Really like the flow of this thread. Dusting off a lot of cobwebs. Just sittin' back, watchin', thinking, and sucking it up like a dry sponge...

[UM Review RN, ASN, RN]

i still haven't had to use Natrecor yet, so thanks for contributing that one. I'll remember that information.

OK, here's a new one:

Good ol' lasix:

Pt has CHF, lungs diminished but clear, no coughing noted, resps even an unlabored, O2 sats 88% on RA while sleeping, so O2 @ 2L via NC started. Despite the fact that Pt has already received 2 days worth of Lasix @ 100 mg IVP three times a day, Pt still has +4 pitting edema with blistering wounds to the lower extremities, pedal pulses are weakly palpable.

Pt is in A-Fib to the monitor at a controlled rate of about 78-80, Temp is normal. BP before the next dose of Lasix is 82/50. BP since admit has been generally trending downward and Pt was given a dose of Ambien 10 mg prior to Lasix was due.

(K+ is given with this each time and K+ is well within normal.)

Oops, almost forgot. Pt is on 1200 ml fluid restrict for the past 3 days. Bun is around 70, creat. about 2.0. Pt is diuresing very well, states he's lost 20# since admit. Urine looks concentrated.

Give or hold? Why?

[hrtprncss]

i still haven't had to use Natrecor yet, so thanks for contributing that one. I'll remember that information.

OK, here's a new one:

Good ol' lasix:

Pt has CHF, lungs diminished but clear, no coughing noted, resps even an unlabored, O2 sats 88% on RA while sleeping, so O2 @ 2L via NC started. Despite the fact that Pt has already received 2 days worth of Lasix @ 100 mg IVP three times a day, Pt still has +4 pitting edema with blistering wounds to the lower extremities, pedal pulses are weakly palpable.

Pt is in A-Fib to the monitor at a controlled rate of about 78-80, Temp is normal. BP before the next dose of Lasix is 82/50. BP since admit has been generally trending downward and Pt was given a dose of Ambien 10 mg prior to Lasix was due.

(K+ is given with this each time and K+ is well within normal.)

Oops, almost forgot. Pt is on 1200 ml fluid restrict for the past 3 days. Bun is around 70, creat. about 2.0. Pt is diuresing very well, states he's lost 20# since admit. Urine looks concentrated.

Give or hold? Why?

I'll give this a try, no flaming please lol...I'll hold the lasix, patient is dry as evidenced by bun/cr ratio, conc u/o. 20lb wt loss since admission, but no admission date given...lung sounds are clear so the dose of 100mg lasix might not be needed. patient seems to have weeping edema, check albumin level, if low start albumin gtt, and if need diurese, chase with lasix. am i on the wrong path?

[neneRN, BSN, RN]

[bThe one that I saw that looked wide, didn't look quite as wide when we pulled it up again to review the strip, and so I think the concensus was that I was just too excitable over "moments" of vtach. I was sure the nurse I handed off too was gonna stop this drip, though, so I have no idea what happened to make her change her mind, maybe the doc showed up and had a look, who knows.

We had a pt in the ER the other day, rapid A-fib with 3-5 beat episodes of what the medic thought was V tach (and I thought so too, looking at his strips) Got her hooked up to our monitor, still Afib c RVR but now with more frequent longer episodes of the V tach. I grabbed one of the docs and he immediately said, no that's not V tach, those are Ashman beats. I didn't get the whole physiology, but apparently these are aberrant beats that sometimes occur with A fib- they are wider than the rest of the complexes and seem to occur in small runs, usually after a slightly longer pause between beats. First time I'd heard of if.

[Indy, LPN, LVN]

[bThe one that I saw that looked wide, didn't look quite as wide when we pulled it up again to review the strip, and so I think the concensus was that I was just too excitable over "moments" of vtach. I was sure the nurse I handed off too was gonna stop this drip, though, so I have no idea what happened to make her change her mind, maybe the doc showed up and had a look, who knows.

We had a pt in the ER the other day, rapid A-fib with 3-5 beat episodes of what the medic thought was V tach (and I thought so too, looking at his strips) Got her hooked up to our monitor, still Afib c RVR but now with more frequent longer episodes of the V tach. I grabbed one of the docs and he immediately said, no that's not V tach, those are Ashman beats. I didn't get the whole physiology, but apparently these are aberrant beats that sometimes occur with A fib- they are wider than the rest of the complexes and seem to occur in small runs, usually after a slightly longer pause between beats. First time I'd heard of if.

I've never heard of that either, wow. I'll see what I can find out about it.

[Indy, LPN, LVN]

http://www.emedicine.com/med/topic2962.htm

That's what I found on Ashman beats. Fascinating!