New Grad, new job... My First emergency!

[beatrice1]

I am a new Grad landed a job in LTC which I LOVE! I have been on the job for 3 months now. I am still learning alot and not too sure of myself. Everyone says "use your nursing judgement" but it's hard when you don't have any experience.

Last night I had a resident who came to me to say she "just didn't feel right" She said she was dizzy and her head hurt. I took her vital signs... pulse was 180! I thought something was wrong with the pulseox, I have never heard of a pulse getting that high. I tried to take her b/p. could not hear anything, tried both arms. couldn't get it. I called another nurse in (the LPN that was passing meds) I asked her to try. she couldn't either. I immediately called her doctor and reported it and he said to send her out to the ER. Did all the necessary paperwork while the other nurse sat with her.

This was the first time I had an emergency, first time I even had to call the doctor first time filling out all the paperwork...ect. I was so overwhelmed, I feel like all my assessment skills went out the window.

Could someone give me feedback as to what more I could have/ or should have done. I would appreciate it.

and has anyone ever seen a pulse rate this high?

(she has history of A-fib and MV repair)

Thanks,

Bea

[evolvingrn, BSN, RN]

Usually when someone is in a fib you can't get it on a pulse ox machine... you get a normal pulse and then when you put your stethoscope on their chest you get the high one.

[mybrowneyedgirl, BSN, RN]

You did great! Usually with A-fib you will find their pulse bouncing around not steadily at one number ie 160-189-177. The only other quick assessment I might have done was a blood sugar. Congrats in handling it well

[beatrice1]

thank you *capecodmermaid, I didn't get respirations and was fustrated that I couldn't get a b/p.

I wasn't sure of what assessment questions I should have been asking her.... I asked if she had any shortness of breath (no) If she had any pain anywhere (no, just headache), when did it come on ( not too long ago)...

I think my documentation will be a little lacking. When I go into work tomorrow, I am going to see if my DON has any feedback for me, and ask her if I could have done anything else. I want to be more prepared next time, and more confident with myself.

Thanks for all your answers.

Bea

[Do-over, ASN, RN]

I would suggest getting an apical pulse rate to call the physician with. Sounds like you did a good job with it.

[jesskidding, LPN]

I've seen many pulses this high. ICU is a great place to see that kind of stuff. I'm confused as to what you are saying is a pulse ox. Usually when I use that term I'm thinking about how much oxygen is getting to the tissues (capillary). You said, I've never seen a pulse ox that high. They are supposed to be high 94-100%, is considered good in any hospital I've ever been.

They were probably using the hand-held pulse ox which shows pulse along with 02 sats?

[Little Panda RN, ASN, RN]

Rapid ventricular rate? Sorry this was already answered, " must read thread before answering,lol"

[drgnflydggr]

In ACLS and tele courses, I was taught that RVR = Rapid Ventricular Response.

[Deredain]

I'm only starting nursing school in January but I have been riding EMS for 25 years. When we can't get an auscultated b/p, we go for a palpated one. Would that be acceptable on a nursing level?

[PsychNurseWannaBe, BSN, RN]

Rapid Ventricular Rate

[akulahawkRN, ADN, RN, EMT-P]

AFib with RVR means "rapid ventricular response". In short, the atria are quivering and too many signals are getting through the AV node (or bypassing it altogether) at a rate that's way too fast. In this case, it was 180. Yes, I've seen rates that fast... and faster.

Typically, when you have rates that fast, the cardiac output will go through the floor. That means that BP will drop too. If you were attempting to get a BP thinking that it would be in the normal range, you probably were inflating the cuff too high and giving up before it got low enough.

As to the pulse rate, if you can't get a radial pulse, try carotid or even apical. Get the breathing rate. Just do the ABC's. If your patient is talking to you, chances are VERY good they've got a blood pressure and they're breathing.

Regardless of the quality of your assessment, it still led you to understand that this patient needs to be transferred out NOW and you got the Doc on the line to order it and you got the ball rolling. Good job!

All you have to work on the next time you get an emergency, take an instant to take a deep breath and go forth swiftly and calmly.

In all, I'd say this was a great learning experience for you!

[07302003, ASN, RN]

To Deredain: in nursing if we couldn't get a blood pressure on a machine you use a manual cuff, and can also use a hand held doppler to "hear" it. You could palpate too... it's one of those "by any means necessary" situations. We would also try a different arm, or the leg. You would just be confirming a blood pressure in the toilet and the need for the MD to insert an arterial line and a central line, in the ED or ICU.

To the OP: you did a GREAT job by listening to your patient and assessing them... that's where a lot of nurses drop the ball. You were right to double check the pulse ox reading. When you listen to heart sounds more and more, you can tell pretty soon when someone is too fast or too slow... whether her heart rate was 160 or 195, she needed to go to the ER. And when the BP is low, you can't get a reading AND the patient is symptomatic, has other things going on (like the fast heart rate) like yours was, you don't need to be 100% spot on - call the doc, let them know you tried a manual pressure on both arms, you followed your gut and were right.

Great job!

[Carrie.f.RN]

Im an ER nurse and am ACLS certified. It sounds like it could possibly be symptamatic Supraventricular tachycardia (SVT) which is a HR of > 150. when this occurs you can have the pt hold their breath and bear down (vagal maneuver). If that doesn't work then they should definitely go to ER and will possibly need meds such as adenasine or cardioversion especially if they are symptomatic. It sounds like you did a great job. Don't doubt youself.