Giving Nitro Spray

Published

Hello everyone! I just have a quick question regarding a patient I was caring for who was admitted to the hospital with CHF and rule out ACS. When I first came on to my shift to assess this patient, she had denied any chest pain or SOB; however, when doing her last set of vitals before shift change, she indicated that she was having 5/10 midsternal chest pain that she described as both a pressure type pain and a feeling of indigestion. When assessing this pain further, the patient said she has had this same pain constantly for the last week, but she had come to the ER yesterday due to the chest pain worsening to 8/10. When going through her chart, she had nitro spray ordered as a prn for chest pain as well as a daily lasix iv order. No one had given this patient nitro before, and this patients systolic bp was only 105. I asked another more experienced nurse what she would do, and she said she was a little worried about giving this patient nitro if she hadnt had any in the past, and her BP was a bit on the low side. I repeated her 12-lead ECG and I didnt see any changes from the other three. The patient also had three negative trops from when she first came in.

so, my question is whether I should have tried giving Nitro to this patient or not? Is nitro meant for a more acute onset of chest pain as opposed to chest pain that has remained unchanged for the last week? I have read other things about nitro and how it is good for CHF because it helps to reduce the workload of the heart, but im not 100% sure what should have been done for this patient, and I cant stop thinking about it...please help!!!

Up Vote Up Vote ×
Specializes in LTC.

I'm glad you posted this! We had a similar experience on midnights in the nursing home recently and I was curious about BP parameters with nitro as we have a standing order for it.

Up Vote Up Vote ×

Seems like a couple of things don't add up. Her chest pain is not constant. Also find it hard to believe she came through ED as a chest pain work-up and didn't receive any nitro - I could understand if it were contraindicated but apparently it's not in her case since they then wrote an order for it. Where were you caring for this patient? Was she an ED boarder or up on the floor?

I agree her blood pressure is at or near what I would be comfortable giving a first nitro (Ours usually hold if = 100 mmHg systolic). Given all these questions, I would've communicated with the physician about what the next step should be and about how they wish to have this lady's chest pain controlled in the future. If this was a floor order and not a protocol, IMO they should have been a little more specific with the indications and parameters of the order.

Up Vote Up Vote ×
Specializes in ER, Trauma.

Flawless thinking on your part, and I wont second gues what you should or shouldn't have done. You were the nurse, and in my opinion you were right. One bit of information I wish you'd included; did the patient have a good sized IV in place? I know of no way to predict if a patient will drop their systolic 10 points or 30 points the first time they get NTG, but I learned the hard way to always have a good sized iv access in place before giving NTG. A fluid bolus can be such a lovely thing sometimes.

Up Vote Up Vote ×
Specializes in Adult and Pediatric Vascular Access, Paramedic.

Give the NTG! People forget that NTG SL is self limiting and if the patient drops there pressure lie them flat and in about 5 minutes they will probabbly be back to normal again!

Happy

Up Vote Up Vote ×
Specializes in ER.

The beauty of nitro is that the half life is 1-4 mins!

Usually, positioning and a few mins can correct any pressure problem. (Even if you have to give a little fluid- evaluate the extent that CHF is a problem.)

It will tell you a lot, evaluating the effect of nitro on their CP. (Cardiac or not)

Up Vote Up Vote ×
Specializes in ER.
Give the NTG! People forget that NTG SL is self limiting and if the patient drops there pressure lie them flat and in about 5 minutes they will probabbly be back to normal again!

Happy

But put the IV in first.

If it's a right sided MI, and her pressure drops, you'll need the extra fluid. You'll look so efficient if you've prepared for the worst and it happens.

Up Vote Up Vote ×
Specializes in Cardiology, Emergency.

Agree with the other posters, just curious if the BP had been consistently above the 100 mark or teetering? I would have had the IV ready and given 1 to 2 squirts. Then reassessed BP and monitor Chest pain scores. It's tough with any new med in the first instance, but just monitor and observe. Good assessment and remember you made the decision and it was right at the time therefore no one else has the right or ability to poke and say you didn't do the "right thing".

Scotty

Up Vote Up Vote ×
Specializes in Trauma, Teaching.

I'm leaning toward giving the nitro: you had a prn order for CP, and didn't give it. If she had gone downhill, you would have had a hard time explaining not giving it; and as others have said, it is self limiting. Good thinking on asking a more experienced nurse, and the BP was borderline, but rather than just not giving it I'd've called the doc next. Who would likely have said, "how did she respond the NTG?". Our standing orders are nitro AND EKG, (as in don't wait for the EKG, start treatment).

Just my opinion, and hind sight is a whole lot easier when there's no pressure. And I'm in the ER with lots of back up immediately available.

Up Vote Up Vote ×
Specializes in icu/er.

if a pt walks into our er that is showing actual signs of angina its gonna take a sys b/p

Up Vote Up Vote ×
+ Join the Discussion