rhythm question

  1. I'm relatively new nurse with critical care training and a new job on a tele floor. I had a patient who came in for syncope with collapse who bradied to 36 while in my care. I went to check on him, got vitals (all stable) and he had no symptoms. The monitor reader said he was already back up to 85 in the time it took to walk back to his room. My preceptor checked the strip and came to tell me it was a run of about 10 non-conducted PAC's in a row. I didn't even question that, I just wrote it down. When I gave this info to a more experienced nurse during report, she scoffed and huffed and puffed at me, saying, "That doesn't make any sense! PAC's are harmless!" I told her they were non-conducted, and that I thought maybe the pauses that can be associated with each PAC with no subsequent QRS complex might have accounted for it (I should have looked at the strip myself, in retrospect, instead of letting my preceptor make up my mind for me), but she was still huffing and rolling her eyes, telling me that just can't be and it made no sense. I wasn't in the mood, at the end of 12 hours, to argue with her, and don't feel I would have a strong argument anyway. I said, "Okay, you'll have to take a look at it yourself, that's the information I have." The patient had no repeat episodes and the doctor had been called regarding the issue. The patient received an AICD three days later. Heart cath (after the episode) revealed a partial blockage of LAD (they said this was not "tight" enough to open), and an EF of 20%.

    Anyone out there with more experience in reading strips know if a 10 beat run of non-conducted PAC's can result in bradycardia? It's just bugging me.


    Thanks.
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    About Hoosiernurse, RN

    Joined: Apr '05; Posts: 164; Likes: 81
    Registered Nurse; from US
    Specialty: 10 year(s) of experience in telemetry, cardiopulmonary stepdown, LTC

    13 Comments

  3. by   Blee O'Myacin
    It is my understanding that a p wave without a QRS is considered a third degree heart block and is a medical emergency. That's why s/he had an AICD implanted. I think that the bradycardia afterwards was the heart resetting itself.

    A bit of advice from another preceptor here, always have all the information that you are going to give report with as firsthand. So in other words, this is the patient you are responsible for, look at their strips. The oncoming nurse was annoyed because you were giving her second hand info without looking into it. I don't know how far along you are with orientation, but it really doesn't matter since your preceptor should be listening to you give report. These patients are still technically the preceptor's until you are counted in the census.

    Good luck. This is a huge amount of information to process in a relatively short amount of time.

    Blee
  4. by   GilaRRT
    A "P" without a "QRS" is not always a complete heart block. A regular rhythm that consists of narrow complexes without an associated "P" wave may be a junctional rhythm. A run of 10 non conducted PAC's in a row sounds rather funny; however, we would need to see this strip to make any definitive statements.
  5. by   RNKPCE
    A run of p waves without any QRS that takes the heart rate down to 36 is a block. The atria are working but the impulse can't be conducted through to the ventricles at that particular time possibly due to ischemia or just an electrical malfunction. This is a very serious situation and luckily he got an AICD.

    One of those P waves alone occurring early hence "premature atrial contraction", is usually nothing to worry about but calling it a run of non conducted PAC's is not really appropriate as you can't tell if the pacs after the initial one are early and most importantly it minimizes the seriousness of the rhythm.
  6. by   Teresag_CNS
    Maybe the oncoming nurse was confused by the use of the term PAC because, technically, the non-conducted p waves were not "premature." Premature usually refers to a p waves that comes sooner after the last QRS than expected, & the QRS was missing in this case. The person could be said to have had a temporary complete (3rd degree, as said above) AV block.

    Technicalities aside, I think the oncoming nurse was relying upon a "rule", not a deep understanding of the conduction system and its many abnormalities. Kudos to you for thinking it through!
  7. by   Hoosiernurse
    I think you are right. Calling it a run of PAC's does imply it's much less serious than it actually was. And in response to another poster, yes, I should have looked at the strip on my own rather than taking my preceptor's word for it. I have had perhaps 7 preceptors while orienting on this floor, many of whom have difficulty "letting go" of some of the details of caring for the patients. I was a nurse for six months on a solid organ transplant floor prior to this job, and I have been in the critical care classes since February at this new hospital and in orientation on the tele floor for 12 weeks, so I'm not "new" new, but still learning.

    The nurse I gave report to was not annoyed because I was giving her second hand info, she was annoyed because she is rude and nasty to many people, even much more experienced nurses. She delights in pointing out and nitpicking things that don't sound right to her or attacking when she thinks it makes her look like a big shot. I'm sure many of you have met the type that loves to point out something they think is wrong with your report, state it LOUDLY so other nurses will look and listen, and then the nurse will huff and puff and roll her eyes a lot while you are trying to explain things. Fun. It's easier to do with me because I am still learning some of the processes on the floor, so I am easier to trip up. She was certainly correct for questioning what I was saying and wondering if it was the right deduction, and we could intelligently discuss that, I have no issue with doing that...but there are ways and there are ways, you see what I mean?

    At any rate, I'm 40 years old, not "supernew", and will always be learning and sometimes getting things wrong as we all do. As I'm out of orientation next week, I will never be taking anyone else's word about anymore strips on any of my patients. I think what confused the nurse I gave report to was terming the rhythm "a run" of non-conducted PAC's. It does give the idea that it's a more benign rhythm than it was.

    I'm just glad my patient got his AICD...in the meantime, I'll just keep learning and improving. Thanks for the help!


    Hoosiernurse
  8. by   oramar
    Quote from Blee O'Myacin
    It is my understanding that a p wave without a QRS is considered a third degree heart block and is a medical emergency. That's why s/he had an AICD implanted. I think that the bradycardia afterwards was the heart resetting itself.

    A bit of advice from another preceptor here, always have all the information that you are going to give report with as firsthand. So in other words, this is the patient you are responsible for, look at their strips. The oncoming nurse was annoyed because you were giving her second hand info without looking into it. I don't know how far along you are with orientation, but it really doesn't matter since your preceptor should be listening to you give report. These patients are still technically the preceptor's until you are counted in the census.

    Good luck. This is a huge amount of information to process in a relatively short amount of time.

    Blee
    Even so, is that eye rolling necessary? What does it accomplish? If it were me I would merely indicate I was not comfortable with something in report. I would engage the person in a discussion about the issue. I would not huff and puff, I would not roll my eyes. These behaviors are a passive aggressive type of bullying.
  9. by   Virgo_RN
    Quote from Blee O'Myacin
    It is my understanding that a p wave without a QRS is considered a third degree heart block and is a medical emergency.
    A third degree block is a complete dissociation between the sinus node and the ventricles. A single nonconducted P is not a third degree block. You can tell a third degree block because the P to P and R to R intervals remain constant, but are simply unrelated to one another.

    Without seeing the strip, what the OP describes sounds more like a transient second degree type II. The reason the tele monitor would call it "bradycardia" is because machines are stupid. The tele monitor is simply tracking the ventricular rate, so when there are no ventricular beats, the telemon will either call it "bradycardia" or a "pause".
  10. by   Teresag_CNS
    Quote from Hoosiernurse
    I think you are right. Calling it a run of PAC's does imply it's much less serious than it actually was. And in response to another poster, yes, I should have looked at the strip on my own rather than taking my preceptor's word for it. I have had perhaps 7 preceptors while orienting on this floor, many of whom have difficulty "letting go" of some of the details of caring for the patients. I was a nurse for six months on a solid organ transplant floor prior to this job, and I have been in the critical care classes since February at this new hospital and in orientation on the tele floor for 12 weeks, so I'm not "new" new, but still learning.

    The nurse I gave report to was not annoyed because I was giving her second hand info, she was annoyed because she is rude and nasty to many people, even much more experienced nurses. She delights in pointing out and nitpicking things that don't sound right to her or attacking when she thinks it makes her look like a big shot. I'm sure many of you have met the type that loves to point out something they think is wrong with your report, state it LOUDLY so other nurses will look and listen, and then the nurse will huff and puff and roll her eyes a lot while you are trying to explain things. Fun. It's easier to do with me because I am still learning some of the processes on the floor, so I am easier to trip up. She was certainly correct for questioning what I was saying and wondering if it was the right deduction, and we could intelligently discuss that, I have no issue with doing that...but there are ways and there are ways, you see what I mean?

    At any rate, I'm 40 years old, not "supernew", and will always be learning and sometimes getting things wrong as we all do. As I'm out of orientation next week, I will never be taking anyone else's word about anymore strips on any of my patients. I think what confused the nurse I gave report to was terming the rhythm "a run" of non-conducted PAC's. It does give the idea that it's a more benign rhythm than it was.

    I'm just glad my patient got his AICD...in the meantime, I'll just keep learning and improving. Thanks for the help!


    Hoosiernurse
    A good retort to these people is to ask sincerely, "Is there something you don't understand?" Don't be sarcastic; act as if the problem is theirs, not yours. Because it is.
  11. by   Keysnurse2008
    With an ef of 20...nothing would suprise me. But....basically...keep in mind HOW you monitor registers a rate. It registers that rate of 36..of 85 or whatever by reading the R waves. It only looks at R waves to read a rate. So....if you had a run of PACS.....in a 6 second strip it can read as a rate of 36. Why???? BC it only reads the R waves when checking for a rate thats why. Hope this helps. Also....if you have someone hyperkalemic and they have tall T waves....the monitor can be fooled into thinking they are R waves and instead of your rate being 75 it will read 150...thinking that tall T is a R.
  12. by   Keysnurse2008
    Quote from blee o'myacin
    it is my understanding that a p wave without a qrs is considered a third degree heart block and is a medical emergency. that's why s/he had an aicd implanted. i think that the bradycardia afterwards was the heart resetting itself.

    .

    blee
    actually it can be a second degree 1 or 2 type block...or it could just be pac's....atrial tach, a fib or a flutter. gotta look at the rhythm......
  13. by   Blee O'Myacin
    Quote from oramar
    Even so, is that eye rolling necessary? What does it accomplish? If it were me I would merely indicate I was not comfortable with something in report. I would engage the person in a discussion about the issue. I would not huff and puff, I would not roll my eyes. These behaviors are a passive aggressive type of bullying.
    I agree. The oncoming nurse should have taken the time to go over the strip with the new (to the unit) employee. Especially since so much time was spent with 'clarification', I apologize if my response was unclear.

    Blee
  14. by   highlandlass1592
    Quote from Virgo_RN
    A third degree block is a complete dissociation between the sinus node and the ventricles. A single nonconducted P is not a third degree block. You can tell a third degree block because the P to P and R to R intervals remain constant, but are simply unrelated to one another.

    Without seeing the strip, what the OP describes sounds more like a transient second degree type II. The reason the tele monitor would call it "bradycardia" is because machines are stupid. The tele monitor is simply tracking the ventricular rate, so when there are no ventricular beats, the telemon will either call it "bradycardia" or a "pause".
    I loved that! Machines are definitely stupid, that's for sure!!!!

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