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

[Esme12, ASN, BSN, RN]

atrial fibrillation (af or a-fib) is the most common [color=#0645ad]cardiac arrhythmia (abnormal heart rhythm). it is a common cause of irregular heart beat, identified clinically by taking a [color=#0645ad]pulse. chaotic electrical activity in the two upper chambers ([color=#0645ad]atria) of the [color=#0645ad]heart result in the muscle fibrillating (i.e., quivering), instead of achieving coordinated contraction. the presence of af can be confirmed with an [color=#0645ad]electrocardiogram (ecg or ekg) by the absence of [color=#0645ad]p waves and an irregular ventricular rate. presence of af in a population increases with age, with 8% of people over 80 having af.

atrial fibrillation is usually accompanied by symptoms related to a rapid heart rate. rapid and irregular heart rates may be perceived as [color=#0645ad]palpitations, [color=#0645ad]exercise intolerance, and occasionally produce [color=#0645ad]angina (if the rate is faster and puts the heart under strain) and [color=#0645ad]congestive symptoms of [color=#0645ad]shortness of breath or [color=#0645ad]edema.

presentation is similar to other forms of rapid heart rate ([color=#0645ad]tachycardia), and in some cases may actually be asymptomatic. the patient may complain of [color=#0645ad]palpitations or chest discomfort. the rapid heart rate may result in the heart being unable to provide adequate blood flow and oxygen delivery to the rest of the body. therefore, common symptoms may include shortness of breath which often worsens with exertion ([color=#0645ad]dyspnea on exertion), shortness of breath when lying flat ([color=#0645ad]orthopnea), and sudden onset of shortness of breath during the night ([color=#0645ad]paroxysmal nocturnal dyspnea), and may progress to swelling of the lower extremities ([color=#0645ad]peripheral edema). owing to inadequate blood flow, patients may also complain of [color=#0645ad]lightheadedness, may feel like they are about to faint ([color=#0645ad]presyncope), or may actually lose consciousness ([color=#0645ad]syncope).

the patient may be in significant [color=#0645ad]respiratory distress. because of inadequate oxygen delivery, the patient may appear blue ([color=#0645ad]cyanosis). by definition, the heart rate will be greater than 100 beats per minute. blood pressure will be variable, and often difficult to measure as the beat-by-beat variability causes problems for most digital (oscillometric) [color=#0645ad]non-invasive blood pressure monitors. it is most concerning if consistently lower than usual ([color=#0645ad]hypotension). respiratory rate will be increased in the presence of respiratory distress. pulse oximetry may confirm the presence of [color=#0645ad]hypoxia related to any precipitating factors such as [color=#0645ad]pneumonia. examination of the [color=#0645ad]jugular veins may reveal elevated [color=#0645ad]pressure (jugular venous distention). lung exam may reveal [color=#0645ad]rales or crackles, which are suggestive of [color=#0645ad]pulmonary edema. heart exam will reveal an irregular but rapid rhythm.

http://en.wikipedia.org/wiki/atrial_fibrillation

the rate itself can reach to greater than 200 bpm when you have an uncontrolled ventricular response (rvr). atrial fib can be a long term chronic rhythm and is a common dysrhythmia in patients that have had open heart (mitral valve repair). shortness of breath usually accompanies a rapid ventricular response as the hear is not functioning properly and the patient feels just as if they have been running. i have found that a non-invasive cuff sometimes has difficulty with a-fib due tot he irregularity of the rhythm and sometime palpating the pulse at the antecubital will help you obtain a b/p. placing the patient on o2 was the appropriate response and the only other thing i would do would be to hear an apical pulse as to be sure the pulse ox was accurate and not reading shaky hands. you can also ask the patient to bear down like they are having a bm, but this is usually ineffective in the elderly due to their poor vagal tone. if you can't obtain a b/p rest take some confidence in the fact that the patient has no complaints, is not sob, diaphoretic and pale.

you did a good job....remember when an emergency arises.......take your own pulse first.:heartbeat

[Do-over, ASN, RN]

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?

When I can't hear a BP I use the doppler. Probably the "same-difference" (as we used to say)...

[Do-over, ASN, RN]

Years ago (EMS training) I learned about using vagal manuevers, but were cautioned about trying it with the elderly (because you don't want them to vagal down to cardiac arrest, say). I still kind of think all you'd get with the elderly is a code brown. Just my hunch, however.

Tried it not too long ago with a younger man in SVT - no dice.

[sapphire18]

RVR = rapid ventricular response. A serious situation whereas plain old afib (as long as it is not new onset and the pt is on the proper medications ie. anticoagulants to prevent MI/CVA) is not.

[akulahawkRN, ADN, RN, EMT-P]

The one thing that worries me with atrial fibrillation and RVR is the drop in cardiac output. This drop can be substantial. Normally when the rate goes above 160 you see a drop in cardiac output anyway, with the loss of the atrial kick in atrial fibrillation that drop is even worse. This, of course, is bad and should be avoided. The other issue with AF with RVR is that such rapid rates can be very tiring for hearts that aren't accustomed to beating that fast for long. When they tucker out... watch out!

[Do-over, ASN, RN]

Just curious what you all think, I was asking around at work the other day...

In a-fib, what rate equals RVR? >100? >120? >140?

I suppose I could look it up, but don't recall seeing it defined anywhere?

[akulahawkRN, ADN, RN, EMT-P]

IMHO, in AF, if the rate would otherwise be considered "Sinus Tach" or even SVT, I'd call it "RVR" and document the rate. SVT is (to me) is nothing more than a catch-all for any fast, narrow complex heart rate that's >160. In my mind, AF with RVR is more descriptive of why the heart's beating that fast in an irregularly irregular pattern.

Of course, I'm no authority in the matter...

[Do-over, ASN, RN]

I've thought of SVT or PSVT as a regular rhythm, where a-fib is irregular. Also not an authority.

I guess in the big picture >150 equals "too fast" and "do something to slow it down"

[akulahawkRN, ADN, RN, EMT-P]

Rates >150 without a reason to be going that fast is too fast and something should be done to "slow it down" especially if the patient is symptomatic.

[Good Morning, Gil]

Rapid ventricular rate. Yes, pulses can get that high, and it would be hard to count if it were that high. If it's too high to count, then intervention is needed. Sounds like you did a good job for your first time. You listened to your patient, and followed up. She got the care she needed. Maybe she converted into a-fib, maybe she went into SVT, maybe she was internally bleeding. Who knows? Without a work-up, you can't possibly say what's wrong with her. Kudos to you! It will get easier with time. I am a newer nurse, too, so I empathize. Everything gets easier the more often you handle something.

What did you learn from this? That you can trust yourself? Yes, it's good to ask for help when you need it, but if you know your patient is in trouble (which HR of 180..yes, you can delegate). Stay with your patient, and ask someone to call to get her sent out. What would I have done? If I was sure she needed to be sent out (like definitely needed acute care) Called EMS and sent her out immediately, then right after calling EMS, I would call the doc to get the order (b/c sometimes there's a delay until they call you back), but you have to do what you are comfortable with (that's what I used to do at the facility I worked at previously), but my first time dealing with something like that, I did exactly what you did. Then, I changed how I responded.

[croppyRN]

I agree with the other posters, you did the right thing. You used your assessment skills by immediately taking her vitals. Even though it was difficult to obtain her BP, you were aware that her pulse was dangerously high and warranted a call to the doctor.

I, too would be nervous about this type of emergency because I'm a new nurse as well. Just remember that you went with your instincts and ended up doing the right thing! We've all been taught to listen to our patients: If they tell you they "don't feel right" pay attention and assess them carefully. That's what you did. Don't be hard on yourself. It is going to take us new nurses time to pick all of this up. (Something I have to remind myself a lot!)

Good luck with your job and your nursing career! :)

[noahsmama]

As a nurse, I've only seen heart rates that high in newborns :)

As a patient though, I have had two episodes of SVT, and both times, my heart was going at about 240. I kid you not. I counted it myself -- carotid pulse, 6 second count multiplied by 10, and yes, it is difficult to count. I was so shocked by the number I was getting that I checked several times.

Both episodes were preceded by about 5 seconds of extreme dizziness. Only other symptoms were the extremely rapid heart rate, tightness (but not pain) in my chest, and feeling a bit too cold. The first episode resolved on its own in about 5 minutes. I had called the on call doctor at my PMD's office, and by the time they called back, it had stopped. They told me if it happened again I should go to the ER.

Next time it happened, about 5 months ago, I called 911. Normally I'm an easy stick, but it took the paramedics 4 tries to get an IV in (blood doesn't circulate efficiently when your heart is beating that fast) and two tries at getting the right dose of adenosine (which makes your heart stop for several seconds and was the most indescribably horrible thing I've ever felt in my life) before they got my heart rate back to normal. My heart had been beating a good 30 minutes at that rate -- it was such a relief when they finally got it to go back to normal!

Lots of things can trigger SVT, but in my case the likely culprit was caffeine -- during my first episode, I had had 5 cups of coffee on an empty stomach!!! These days I limit myself to at most one caffeinated beverage per day, and even that's probably too much (but I can't quite quit entirely).

Anyway, don't mean to hijack the thread, but since we're on the topic of things that can cause ridiculously high heart rates in adults, thought I'd share my experience.

OP, I think you did exactly the right thing for your patient, including calling a more experienced nurse to help you deal with the situation. Next time one of your patients has a high heart rate, you'll know it's likely real (though double checking manually is, of course, an excellent idea!). Chalk it up as experience, and give yourself a pat on the back for doing the right thing!