Afib: A question of nursing judgment

Nurses General Nursing

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I am seeking your input and advice on an issue related to nursing judgment.

A patient with a history of heart disease treated with digoxin presents with chest pain (of one week duration), intermittent n/v (felt over the course of the week), fatigue, and feeling cold. Temp, B/P, and HR are within normal range. Pulse is irregular. Paramedics are called and ECG reflects patient is experiencing afib.

As a nurse, you know that digoxin (with anti-coagulants) is a common treatment for chronic afib.

Would you as a nurse working within a community setting recommend that the patient be taken by the paramedics to the hospital ER for further evaluation?

Thank you in advance for your thoughtful response.

Yes, the coworker is a nurse.

Yes, the coworker is a nurse.
Then you should be questioning THEIR judgement, instead of yours. I would now be watching him/her like a hawk.
Specializes in SICU, trauma, neuro.

I agree. Symptomatic afib needs to be treated. It could be that he had a hx of rate controlled afib but now is in RVR, or it could be new. Dig is typically prescribed for its inotropic properties, right? Afib is an arrhythmia, not pump failure. (ETA: I mean, the fact that he is already on dig doesn't mean he's good to stay home and see his provider next month.)

In any case, hr had chest pain. That needs to be treated as an emergent situation until proven otherwise. And again, afib with RVR is a serious situation. I mean when it happens in the hospital, we use things like amiodarone drips and cardioversion. Afib is a fairly common condition, but think about it -- if the rate is sustained in the 140s, 150s, 160s... what is that going to do to an already stressed heart?

Yes, Nurse, you did the right thing!

I am seeking your input and advice on an issue related to nursing judgment.

A patient with a history of heart disease treated with digoxin presents with chest pain (of one week duration), intermittent n/v (felt over the course of the week), fatigue, and feeling cold. Temp, B/P, and HR are within normal range. Pulse is irregular. Paramedics are called and ECG reflects patient is experiencing afib.

As a nurse, you know that digoxin (with anti-coagulants) is a common treatment for chronic afib.

Would you as a nurse working within a community setting recommend that the patient be taken by the paramedics to the hospital ER for further evaluation?

Thank you in advance for your thoughtful response.

If the patient is newly symptomatic, then they need evaluation in the hospital. Their current regimen is obviously not working and a new regime should be trialed - which is clearly much safer to do on a monitored unit.

I agree. Symptomatic afib needs to be treated. It could be that he had a hx of rate controlled afib but now is in RVR, or it could be new. Dig is typically prescribed for its inotropic properties, right? Afib is an arrhythmia, not pump failure. (ETA: I mean, the fact that he is already on dig doesn't mean he's good to stay home and see his provider next month.)

In any case, hr had chest pain. That needs to be treated as an emergent situation until proven otherwise. And again, afib with RVR is a serious situation. I mean when it happens in the hospital, we use things like amiodarone drips and cardioversion. Afib is a fairly common condition, but think about it -- if the rate is sustained in the 140s, 150s, 160s... what is that going to do to an already stressed heart?

Yes, Nurse, you did the right thing!

Digoxin is a negative chronotrope and can be used for rate control - but that's an outdated/old school way of doing things - as is prescribing digoxin in the first place.

Specializes in Critical Care.

The A-fib is largely unrelated, the OP already stated the BP and HR were normal. Unexplained chest pain in a patient with a history of CAD and active signs of impaired cardiac function is always worthy of ER evaluation.

Specializes in ICU, LTACH, Internal Medicine.

Here.I.Stand.,

Afib steals up to 30% of left ventricular filling volume, or so-called "atrial kick". By the Frank-Starling law, this negatively impacts pump function. To which degree, it is a question in every single case but even patients with afib and normal LVEF of 65% tend to decompensate much quicker than expected.

Just to clarify things:yes:

Specializes in Med/Surg, Telemetry.

Absolutely. Symptoms x 1 week, plus pain and n/v tell me this person could be ready to throw an embolus.

Specializes in Cardiac, Home Health, Primary Care.

I'd want them evaluated more than I can do in my clinic. If they are a fib and no anticoagulant could have developed a clot. If their rate is bouncing around its only a matter of time before their BP won't keep up. Perhaps it is straight up angina and he's missed his window (unfortunately) but he still needs treatment.

When there are so many very possible scenarios that could be life threatening then it needs emergent evaluation by a place that can treat the possible issues or stabilize the patient.

Specializes in NICU, PICU, Transport, L&D, Hospice.

I also am curious what the plan of the other RN was that required ridiculing a perfectly sound decision to activate EMS and get the patient to ED safely and quickly.

Did that nurse think that he/she was advocating for the patient by suggesting that they get a bus or cab to the ED for their chest pain?

Specializes in ICU + Infection Prevention.

You and the paramedics are right... your coworker is dangerous

Specializes in Acute Care.

Good discussion...

There is NO way that this is not homework though... Just the way the OP phrased their initial questions...

"As a nurse, you know that digoxin (with anti-coagulants) is a common treatment for chronic afib."

Seriously...

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