A fib with rvr

Nurses General Nursing

Published

Ok so I had a pt go into AFIB in the middle of my shift. Hr was 12- 148. They had no previous history and was a DNR. I contacted the doctor and he told me to give 5mg lopressor IVP and start po Cardizem 30mg Q6 hrs.this did not change anything. I tried to page the doctor several times but he never clled back. The pt was asymptomatic. SBP was 105. Even before the tx. My charge nurse said I couldn't leave the patient ticking along at 130 and counseled me about not having g asked for a gtt or a cardiology consult. This was the pt primary MD so he knows the pt and I figured the dr knows what he wants so who am I to suggest anything. I wasnt that concerned as the pt was atable. Should I have been more concerned? Should I have done more. I documented that he never responded.

Up Vote Up Vote ×
Specializes in Family Nurse Practitioner.

Was this new onset a-fib? Was that SBP before or after the lopressor? If before the lopressor then that could be borderline symptomatic. Was the patient febrile? Was he dehydrated? Was IV diltiazem an option? Make sure that you are documenting everything. If unable to reach a provider, call a rapid response.

Up Vote Up Vote ×
Specializes in Post Anesthesia.
Ok so I had a pt go into AFIB in the middle of my shift. Hr was 12- 148. They had no previous history and was a DNR.......

The patient has no significant health history but is a DNR status? Dosn't his family love him, or is thier a BIG will? Anyone discuss with the patient the fact that if he codes we are just gonna watch him die even though ther may be an eaqsily treatable problem that we can manade.? I'm not sure I get this post.

Up Vote Up Vote ×
Specializes in Cath/EP lab, CCU, Cardiac stepdown.

Is the patient on any anticoagulants?

Up Vote Up Vote ×
The patient has no significant health history but is a DNR status? Dosn't his family love him, or is thier a BIG will? Anyone discuss with the patient the fact that if he codes we are just gonna watch him die even though ther may be an eaqsily treatable problem that we can manade.? I'm not sure I get this post.

OP said the patient had no previous history after stating that the patient went into afib, not that the patient had no significant health history. I took that to mean that the patient had no previous history of afib. And, speculating that the patient's family doesn't love him or that there's a big will because of his DNR status...I'm not sure I get your post. Just sayin'.

Up Vote Up Vote ×

Dehydration could be a reason, but usually a bolus of cardizem IV, then a cardizem drip helps. VS Q15MINS! G=Make sure you go up the ladder, contact your charge, supervisor. DOCUMENT, DOCUMENT! every time you made a call to the MD.

Up Vote Up Vote ×
Ok so I had a pt go into AFIB in the middle of my shift. Hr was 12- 148. They had no previous history and was a DNR. I contacted the doctor and he told me to give 5mg lopressor IVP and start po Cardizem 30mg Q6 hrs.this did not change anything. I tried to page the doctor several times but he never clled back. The pt was asymptomatic. SBP was 105. Even before the tx. My charge nurse said I couldn't leave the patient ticking along at 130 and counseled me about not having g asked for a gtt or a cardiology consult. This was the pt primary MD so he knows the pt and I figured the dr knows what he wants so who am I to suggest anything. I wasnt that concerned as the pt was atable. Should I have been more concerned? Should I have done more. I documented that he never responded.

You noticed a change in patient condition, notified the physician, received orders, implemented those orders, assessed the effectiveness of the treatment, and attempted to notify the physician of the results. I don't see that you did anything wrong.

You would not/should not call a Rapid Response on a hemodynamically stable, unsymptomatic patient. However, you would/should monitor the patient's condition and VS frequently, and document your observations, as well as your attempts to reach the physician and his or her response- and naturally, should the patient begin to decompensate, call the Rapid Response.

I'm uncertain how you could request a gtt or a cardiology consult if the physician is not returning your pages.

In the future, any time you are attempting to contact a physician and are not getting a timely (or any) response, make sure you let your charge nurse know. S/he may be able to assist.

Up Vote Up Vote ×

Your charge nurse was being kind of stupid. You can suggest a cardiology consult, but generally A. fib with RVR can be managed by an internal medicine doctor. We're not talking about ventricular arrhythmias or severe CHF, for example. If the patient was asymptomatic and hemodynamically stable, a rapid response would be highly inappropriate. If the doctor was not returning your pages, the charge should have paged him herself or the nursing supervisor or unit director should have become involved.

You didn't do anything wrong that I can see - don't let your charge or director berate you because the doctor wasn't doing his job. Contrary to the propaganda that nurses and hospitals like to broadcast, it's really more his ass on the line, not yours.

Up Vote Up Vote ×
Specializes in Neuro ICU and Med Surg.

I am a rapid response nurse so if your facility has triggers for rapid calls I would follow them. You can call me anytime for a question or to eyeball your patient.

Each facility has triggers for rapid responses, so at our facility we would have had you call for HR >130. The house physician would have managed for the time being. You can suggest to the attending a cardiology consult, but that doesn't mean that they will consult.

I think you did all you could. On our general med floors they aren't allowed to give IVP lopressor. OP what kind of floor do you work on?

Up Vote Up Vote ×
I am a rapid response nurse so if your facility has triggers for rapid calls I would follow them. You can call me anytime for a question or to eyeball your patient.

Each facility has triggers for rapid responses, so at our facility we would have had you call for HR >130.

That's a good point. However, the OP's charge nurse should be aware of all of these things as well.

I believe the OP works on a step-down unit.

Up Vote Up Vote ×
Specializes in Palliative, Onc, Med-Surg, Home Hospice.
The patient has no significant health history but is a DNR status? Dosn't his family love him, or is thier a BIG will? Anyone discuss with the patient the fact that if he codes we are just gonna watch him die even though ther may be an eaqsily treatable problem that we can manade.? I'm not sure I get this post.

This is off topic but I want to point out: I am a DNR, and so is my husband. I don't want my ribs cracked if my heart stops. It DOES not mean no treatment. I see DNRs all the time. And it isn't because of a "big will" or because the family doesn't love them. It's because they don't like the idea of having a tube in their throat and cracked ribs. What kind of like if is that?

Like a previous poster said, I am not sure I get Your post.

Up Vote Up Vote ×

Another learning point would have been to identify under which parameter the MD would've liked you to call back (or not)

My conversations generally go like, "So I'll give the 5 cardizem IVP, I'll call you back if the hr sustains ____"

OR

"Okay so the patient is 130s, asymptomatic with a BP of XX/XX, Im going to give the 5mg cardizem ivp.What parameter should I call you back for? (insert suggestion here).

This is commonplace when we have patients that have frequent PVC's, NSVT, etc (I'm talking to you CHF'ers!)

Up Vote Up Vote ×
+ Add a Comment