Situation: pt has chronic a-fib with new orders to hold Coumadin x4 days.. Its been held off and on the past few weeks due to PT/INRs.
Walked down hallway to talk to nurse and found said pt lethargic,labored breathing,pale. Asked nurse what she new about pt. she stated "oh, shes been like that for weeks" and walked away..
I grabbed my stethoscope and went to listen to lung sounds - she was wet in all lobes, but when i got to her heart it made my jaw drop. She was just all over the place- no beat at all really. Ran to get the nurse in charge of pt- told her to listen to pts heart. Nurse placed stethoscope for probably 4secs and asked "what am i suppose to be listening for?". /facepalm.
VS 140/58, pulse 37-140 on machine, pulse ox was 60% with no O2, resp 30. Dr said to send out immediately.
Question is: what do u guys make ur nurses do daily on a-fib pts? Currently our facility relies on common knowledge (which obviously not there) and s/s in care plan (which no floor nurse looks at)