Did I do the right thing? *long*

[nursesaideBen]

This past weekend I had an oncology patient who was a full code. In the early morning hours about 0500 I was getting qshift VS and this patient's heartrate was 41. I looked at his chart and he was typically running in the 50's. B/P was normal. Patient denied, SOB, dyspnea, dizziness, palpitations, and CP. I spoke with my charge nurse and we decided to put him on tele to keep an eye on him. Well, it wasn't long until he started dipping down into the 30's and staying there. I called the attending which was his Oncologist and he ordered 1mg Atropine IV, I administered the drug and his heart rate came up into the 60's but by the time I was giving report to the dayshift nurse he was starting to dip down into the low 40's again. That day he had a cardiology consult, the cardiologist ordered a BNP and cardiac enzymes. That night I recieved report, labs hadn't come in yet and he was maintaining a HR of about 40. A couple hours into the shift his heart rate was averaging 25, labs came back his BNP was 970, suggesting CHF, and his enzymes were normal. Patient again was asymtomatic, B/p WNL etc. I paged his attending and notified him of the situation, he was going to order Atropine again, I told him it had been minimally effective last time so he told me to page the cardiologist. I did so, and he became very agitated with me stating, "He's asymptomatic, so I don't know what you want me to do." I stressed to him once again what his HR was, what his BNP was, that he was a Full code, etc. Finally he told me to call the oncologist to see if we could transfer him to PCU and the oncologist agreed. We immedidately transferred him he had a scheduled 2100 of Oxycodone which I did NOT administer because my charge nurse and I both felt it could cause his HR to drop even more. Once he was transferred I get a call from the PCU nurse, chewing me out for not giving this 2100, stating "He has cancer and is in pain he NEEDS his pain medicine, I don't understand why you didn't give it to him." I explained to her why, she continued to rant, until I cut her off and told her he was her patient now she could do what she wanted. Of course I didn't want him to be in pain but at the same time I didn't want to kill him either, was I in the right?

[SICU Queen]

You assessed a situation and made a judgement call. You weren't wrong for doing that. It sounds like the receiving nurse was either a) lazy and wanted everything done for her already, or b) being an advocate for the patient, albeit in poor form. In either scenario there was no need for her to "chew you out". She should've simply administered the med or not, as she saw fit.

Now, let me say that, while I do understand the patient's HR was low, I also am a huge advocate of pain control, especially in post-op and/or cancer patients, and I would've administered the med. His pain control needs to be a priority, and if there are systemic problems (BP, HR, etc) those need to be dealt with outside of the realm of his pain meds. In other words, in this particular case, the patient was asymptomatic, so pain meds should not be withheld to attempt to solve the problem of a low HR. This is my own professional opinion. Some will disagree, and that's okay - as long as each decision we make is made with the patient's best interest at heart, but also with the correct theory and patho and nursing knowledge behind us.

You sound like a great nurse. Good job.

[TachyBrady]

What I would have done in this situation is to inform the receiving nurse during my report to him/her that the pt was not given the oxycodone. I would ask their opinion as to whether it should be given and offer to give it before signing off on the pt's care if that nurse so requested.

It sounds like the receiving nurse was on an ego rant and that is sad. How is one to know what is best? You did a good job in monitoring the pt and reporting abnormals. In the future, don't hesitate to ask the receiving unit how care should be handled... two heads are better than one and that is their specialty. When you offer respect for their experience and knowledge, they should return respect to you for doing the best you could under the circumstances.

[EmmaG, RN]

That'd be nice except

Understood. Check your pm's please :)

[gonzo1, ASN, RN]

I would have held the medication too. Probably would have gone ahead with the atropine, thinking it couldn't have hurt. Sounds like you did a good job to me.

[RN1121]

This cardiologist is about to retire, some of the nurses have told me that he's adopted an "I don't want to be bothered" type of attitude.

let's see....when he gets sued............how about if he takes that "I don't care attitude" straight to court represented by a lawyer who is about ready to retire who doesn't give a rat's a$$$ either???

[steelcityrn, RN]

I would have asked the patient if he needed this pain med also. I am assuming he must have been in pain for the next nurse to go off like that. Your intentions were good, but next time I would involve the patient and or m.d. who ordered this to CYA.

[leslie :-D]

that's a somewhat tough call in the absence of a supportive cardiologist.

i would have given the atropine, then the oxycodone at the scheduled time.

detailed report to onc nurse, with emphasis on need for cardiologist input.

even though elevated bnp is indicative of heart failure, further tests need to be done to confirm dx (echo, cxr).

i've seen docs think heart failure when it ended up being lung disease (where is this pt's ca?).

you made a good call, ben.

your interest was clearly for the benefit of your pt.

leslie

[suanna]

I sounds to me like you aggressively managed a pretty sick patient with minimal support form you medical staff. I've got 20+years in critical care and couldn't have done more for your patient. I hope the cardiology residents have more luck getting approp. intervention from the attending. By the way a BNP in the 900s isn't too bad considering the patients bradycardia. Aggressive medical management could have included dopamine, epi, dobutamine (IVs) all which have +chronotropic properties. Getting this pt to cardiac critical care and finding the source of his bradycardia is the only way he was going to get better- even if you had to bug him docs into moving him in order to stop the phone calls. GOOD JOB. ps: I would have skipped the pain meds too unless he was in significant pain. It's not like you skipped a dose of MS contin. or a 24hr analygesic patch. If he c/o pain the nurse in pcu/ccu can give him his meds just as easily but if his BP dropped it's tough to "ungive" it.

[Nightcrawler, BSN, RN]

While I understand that in this case the cardiologist probably didn't want to be bothered, I have had many cases of asymptomatic bradycardia that the cardiologists weren't too concerned with. I work in a cardiac pcu, and agree that a move to a higher level of care where ionotropes could be started if he started to decompensate and become symptomatic. Was the patient sustaining his rate in the 25-30 range, or was he having periodic dips? If he was sustaining in the 20's it wouldn't be long until he started to decompensate.

With the information that you have given I would have given the atropine, then the oxy and placed pacer pads on his chest with the code cart outside the room just in case he started to go down before you could get him to the pcu where they could start a drip to maintain his rate.

I feel for you. These can be very scary situations. I have seen patients convert to a bradycardic rhythm and go from being asymptomatic and unaware of any change to flash pulmonary edema on the verge of death in the span of 10 minutes. On the other hand I have seen people with rates in the 30's and sbp's in the 60's walking around the unit in complete heart block completely asymptomatic because it was their norm.

You did an excellent job of advocating for your patient, and getting him the care that he needed. Don't beat yourself up about the pain med, I may have given it, but you were more concerned with his overall condition. The nurse that called you was probably just upset that she had to deal with the patient's pain on top of starting whatever interventions that were ordered to manage his hr, oh well, she can deal with it.

Just move on and continue to give the care that you are giving to your patients

[CRNI-ICU20]

I would NOT have given the pain med....

22 years experience here...

A DEAD PATIENT ISN'T GOING TO NEED PAIN MEDICATION.

Breathing and having a heartbeat that perfuses IS the priority in this situation. Pain control in this situation is the secondary issue...

This man needed a pacemaker....some vaso-supportive drugs/drips and some diuresis....not to mention an 2Decho and other cardiac testing to determine what the source of the brady problem is....

You did the absolute RIGHT thing....you advocated for your patient....if he was painful in the next nurse's hands, she should have just given the drug and stopped raggin' on you about it....Don't let a battle-axe with poor communication skills rattle your cage...she's just one little speck of dust in the universe...remember that the next time you look up at a sky full of stars. And then, remind yourself, that you, too, are just one of those stars....who does all he can to help another heal....

crni