any experience with telemetry patients

Ditto what Gwen said

Especially the always check the patient part.

Are you ACLS certified? If not, I'd recommend looking into it. It gives you a good feel for what to do in emergent situations and is a good selling point for you.

The scariest rhythms as far as I'm concerned is when we're babysitting someone waiting for a pacer who has sick sinus syndrome or is going in and out of a 3rd degree block. Those patients make me afraid to leave the floor. There is nothing more unnerving than watching a patient's HR go from 29 to 179 and everything in between; it feels like you're just waiting for their heart to give out on you all night long. And the 3rd degree blocks make me want to just throw a hands-free on them just in case...personally I don't think they should be anywhere besides step down at the least, but some of the docs will keep them on our floor.

I'd like to add on that in addition to looking at the electrolytes, be sure to check and see what meds your patient is on. I can't tell you the number of times I've had a patient get started on Lopressor only to bottom out to the 40's all night long. Oh, and if they're on digoxin and they're doing funky stuff, check to see if they've had a dig level recently. And I've never had a physician get upset if I had to get an EKG to verify a rhythm. I've had patients before where even the EP couldn't figure out exactly what they were doing, and patients where we took strips from floor to floor to get input from multiple nurses b/c noone was quite sure.

Make sure to communicate with those who have more experience with you until you get the hang of it; the more common rhythms that you'll come across (afib, aflutter, sinus brady, first degree block, PACs and PVCs) you'll get the hang of right away.

I've worked on a med/surg telemetry floor for a while, and you will get used to when to call/when to worry, etc- until then, rely on the nursing judgement you already have and the more experienced nurses around you.

Here's a general cheat sheet, though:
the FIRST thing you do- AlWAYS- is check the patient

Afib- does your patient have any prior history of AF? Some people have been in AF for years- hardly an emergency, just worth noting. What is the rate? (I'm always more concerned about a rapid AF than a rate controlled one) Are there any symptoms? A new onset rapid AF gets a call to the MD to come up and assess ASAP. A new onset rate-controlled gets an FYI to the MD who may or may not have further orders at that time. An ongoing chronic AF gets charted.

V-tach (runs of PVC's) as someone who sits at the monitors on PCU, I can tell you this is the most frequent reason I have to call a doc at night. Many, many, many patients have 3-6 beat runs that break on their own and by the time you get to the room, it's over. If they're sympomatic, first thing I get is a set of vitals. Obviously, if the run is long, the patient "just doesn't feel right" etc, I'd think about a rapid response. Even more obvious- sustained, pulseless VT is time to call a code. But 95% of the time I walk down to find a patient asleep and wondering why the heck I'm asking how they are. This brings me to frequent ectopy...

PVC's- we all have em- but when someone is having TONS of em, runs of 3 beats, bigeminy, trigeminy, the second thing to look at (remember, the first is always the patient) is the electrolytes. The most common causes I see are K and Mag imbalances... so if they haven't been checked, they need to be. Now some of our docs don't mind an 0630 phone call... "Hey, I added a mag and phos to Pt Smith's labs", some would rather we called first. That comes with time.

Just remember your monitor is simply ONE tool- look at the patient, and the whole picture, and whenever you're not sure, ASK!

From your post, I'm getting that you want to know what to do for a new-onset A-fib---that is, someone who was in SR going into A-fib.

If you see a lot of PAC's, keep checking the monitor, because they could flip into A-fib.

If they go suddenly into A-fib: You need a 12-lead EKG to prove it. Have your tech get the machine while you assess the patient. You need vitals: get a manual BP, and call the doc if A-fib is confirmed by a 12-lead. Put on O2 at 2L. Explain to the patient that the heart is showing irritability, and that usually means that the heart needs a little more oxygen. While you're waiting for a callback, make sure that the patient is comfortable and note any symptoms--dizziness, chest discomfort (sometimes patients describe "fluttery" or "jumpy" chest feelings).

You need to find out if they're having any other s/s: any nausea, dizziness, pain. Check the skin--clammy, dry or sweaty? Sometimes if the heart rate is less than 120 and the patient has no symptoms, the doc will want to have you "watch" the patient. I hate that. Ask him for parameters ---such as "If the Heart rate sustains >140 for more than ten minutes, then give N mgs of X. Hold for a BP of Y." You'll need something to slow the heart rate and make the heart work better.

You'll also need some type of anticoagulant like Lovenox. Do not delay with this medication; A-fibbers are at great risk of clotting, and you know what that means --stroke, heart attack, etc.

The doc will also most likely ask for some blood tests to pin down the cause of the sudden change. (Sometimes the elderly will pop into Afib if their electrolytes get out of whack. ) If the patient's Heart rate goes way high or way low, he may ask you to transfer to Intensive care for more monitoring and medication titration.

Oh, and the drugs we most often used for A-fib: digoxin, Lopressor, Cardizem, and an anticoagulant like Lovenox. So know your Calcium channel blockers, beta blockers, and antiarrhythmics. An ACLS course is really valuable to help you know how to deal with different types of critical problems, as someone else suggested.

Just remember, you will most likely have help to deal with all this. (Till you're old and jaded like me... )

That's certainly not everything, but it's the basics. I hope that helps.