Heart Rate Bouncing Up and Down

[halsey]

When a heart rate bounces up and down within seconds on a pulse oximeter monitor say from 90 to 120 is this a sign it’s irregular and patient may have atrial fibrillation?

[RNNPICU, BSN, RN]

Not really, movement, poor connection, lots of other reasons.  One way to test for afib is an official EKG,

[DavidFR, BSN, MSN, RN]

Take the pulse manually in such cases. If it's irregular, rapid or both, do an ECG.

[Been there,done that, ASN, RN]

Atrial fibrillation is a possibility.  Is the patient stable? Why was the pulse ox ordered?

 

[halsey]

The patient is stable, pulse oximeter was used for post procedure vital signs monitoring. The patient had a history of strokes (no diagnosis of AF) and had ceased anticoagulant for procedure. Could this be why? Sorry I’m a student it’s the first time I’ve seen this.

So if I notice the heart rate up and down on monitor, the pulse needs to be checked manually and do ecg?

[Rose_Queen, BSN, MSN, RN]

One of the phrases often repeated in nursing school was “Treat the patient, not the monitor.” So yes, you would want to verify that what you’re seeing on the pulse ox is actually what’s going on with the patient- that the heart rate really is jumping around like that and it isn’t just artifact. If it’s artifact on the monitor because of the things mentioned above like movement or a cold finger, and the patient assessment says the patient is fine, then you wouldn’t need further immediate intervention. 

Think of this scenario: you’re at the nursing station with a patient on a tele monitor. The monitor shows V tach or V fib. Do you go running in the room and just shock your patient or do you go in to look at them, see that they’re brushing their teeth, and realize the only reason the monitor looks like an arrhythmia is artifact from their movement?

[Guest219794]

8 hours ago, Marie27 said:

The patient is stable, pulse oximeter was used for post procedure vital signs monitoring. The patient had a history of strokes (no diagnosis of AF) and had ceased anticoagulant for procedure. Could this be why? Sorry I’m a student it’s the first time I’ve seen this.

So if I notice the heart rate up and down on monitor, the pulse needs to be checked manually and do ecg?

Good thought process.

A few things.

Stopped anti coagulation?  The most common indication for that classification drug is Afib.  Possible you missed it in the chart?  If not, there is also a chance that these strokes are caused by paroxysmal Afib, never caught with a 12 lead.  I have a family member in this situation.  At her age, I don't want her anti-coagulated, so I don't push the issue.  

And remember.  Stopping the anti coagulation increases the risks from afib, but does not make an occurrence more likely.

Also- it is good to understand how how electronic heart rate monitoring reports a rate. In order to respond rapidly to changes in rate, it spits out a number with a very small sample.  Not sure how short. Lets say it checks for three seconds.  If there are 3 beats in that period, it will display a reading of 60.  If one beat is missed, it will read 40.  If there is one extra beat, it will read 80.  That's not accurate.  Taking the first example, if you were to measure the pulse for a full minute, it would be 59.  If you measured for 15 seconds, it would either be 56 or 60, depending on whether you caught the missed beat in your 15 second sample or not.  Get in the habit of taking manual pulses on every patient.  You will learn a lot about what is normal and not, and may learn something about the patient.  You would be surprised at how often a patient has only electronic vitals taken during an encounter, and a dysrhythmia is missed.

And- your thought process is excellent.  That pulse oximeter gave you a clue to look for something else.  The gold standard for diagnosis is a 12 lead ekg.  But, that can take time while catching it with a regular cardiac monitor- and printing a copy- will also do.

[Tegridy]

Most common causes probably sinus arrhythmia (I have this myself) or just the patient moving around.

Need EKG for a fib but if you feel an irregular pulse not related to respiration and not a set pattern to the irregularly it always could be afib or aflutter with variable block or even just PVCs.

I wouldn't get to hung up on watching the vitals all the time they are normal ranges for a reason and noones numbers stay exactly the same all the time.

[Been there,done that, ASN, RN]

On 12/24/2021 at 12:47 AM, Marie27 said:

The patient is stable, pulse oximeter was used for post procedure vital signs monitoring. The patient had a history of strokes (no diagnosis of AF) and had ceased anticoagulant for procedure. Could this be why? Sorry I’m a student it’s the first time I’ve seen this.

So if I notice the heart rate up and down on monitor, the pulse needs to be checked manually and do ecg?

That is the core of nursing. You observe a change... you get more data to evaluate. Always do manual vital signs if you have a concern.  Did you check the EKG's on record for comparison? Going off an anticoagulant would not cause an irregular heart rate. An anti coagulant is not an antiarrhythmic.

As a student, you have many resources. Take any concerns to your instructor or the patient's nurse. You are there to learn. You have some pretty good critical thinking skills. Keep up the good work.