HR drop/rhythm change during sleep..Would you call Doc?

Esme12, ASN, BSN, RN · Mar 23, 2012

If this was the first night admitted....... yes. The MD might not be too happy but who cares! It my license and my job. Sinus arrhythmia can be perfectly normal during the night especially the young or athletic. You did not mention this patients age or other comorbidities. But If it was the first night and she has been having "dizzy" spells this may be a sign of a more ominous cardiac arrhythmia that can lead to these "small" ischemic areas from long pauses or the heart rate dropping lower.

I would call.:)

dudette10, MSN, RN · Mar 23, 2012

When in deep sleep, her heart rate dropped and became irregular, stayed SR but brady into the 40s-50s. The monitor was constantly going off because the episodes of brady would cause it to read in the 40s for a few minutes. But when I went in to assess her, as soon as she woke up it went back into 60s and regular. Completely asymptomatic. NO CP/light headed/dizzy.
My question is: Would you have called the doctor in the middle of the night to let him know this? Doc placed standard parameters for this pt: HR 110.

You need to clarify. You said it dropped and was irregular, but it was SR, but it was bradying down. So, which was it? Irregular (which to me means that the R to R measurement was not consistent between beats like in a-fib), SR, or SB?

If it was asymptomatic SB, I would not have called. SB isn't treated unless it is symptomatic, e.g. hypotension, CP, etc. If it won't be treated, I wouldn't make an 0300 FYI call! I would have kept a close eye on her though.

ETA: Just emphasizing that she was admitted d/t dizziness, without a cardiac history, and CT of the head showed small ischemic changes, correct? What cardiac tests did they do in the ER, if any? EKG? CEs? Did you take her VS when you went to check on her?

These are all the things I would have looked at prior to making the decision to call or not call the doc. I assumed that you did, too, but I just want to make sure.

Oh, just one more thing: I'm not experienced...been at this less than a year. Don't want to mislead you.

DixieRedHead, ASN, RN · Mar 23, 2012

doc placed standard parameters for this pt: hr 110.

his parameters, he gets a call. especially with the "irregular" part.

a heart rate is not just "irregular". even an irregular rhythm has a name.

if it's changing to a fib, or one of the blocks that can be a big thing if it's new. maybe the cause of the cva if it goes far enough.

the change on the monitor is a change in the electrical conductivity in the heart.

think beyond the monitor.

BelgianRN · Mar 23, 2012

Doc placed standard parameters for this pt: HR 110.

I probably would have discussed these limits when they were first set. A patient coming in with a HR 60 - 70 will probably drop below 60 when sleeping so perhaps 50 - 110 or 45 - 110 would have been a better choice for the night.

If the heart rate is irregular it can't be a normal sinus rhythm or sinus bradycardia. Since the RR variance can be no more than 10% when speaking in turns of sinusrhythm. Was the variance coupled to the respiratory movements of the patients. Because respiratory sinusarrhytmias are generally benign. If it varies more than 10% something else is going on like sinusarrests, SA-blocks, Afib, or ectopic rhythms, etc...

It all depends on the culture of the facility I guess if a call is warranted. In my facility (both ICU and wards) nurses are allowed to change the alarm limits as we see fit and we generally make a print or note of the rhythm and document we changed the limits and leave the print for the MD that rounds in the morning (providing there are no S/S). Very rarely will we get active orders for HR parameters and they trust on our nursing judgment to call or not.

If they are very anal about absolutely sticking to the set limits I probably would have called. If an MD doesn't think beyond standard limits I don't feel the need to use my nursing judgment too extensively and he gets a call at 3 am.

So HR drop alone I wouldn't call but rhythm abnormalities would get a call excepted only by sinusbrady and respiratory sinusarrhythmia.

jelly221,RN · Mar 23, 2012

Yeah, I'm with everyone else- since it was the first time I'd call, especially since he left those parameters. Maybe would've waited until 6 or a bit more tolerable hour, since the doc isn't going to rush in for a pt dropping into SB during sleep, if it is SB.

Make sure you're clear about the rhythm- SB is not "irregular". It could have been afib, or a heart block, which can be either benign or a warning sign of progression into complete block necessitating a pacemaker. Ask a charge nurse or more experienced nurse to help you decipher that if you're not sure how to tell.

However, most of our cardiologist will yell at us if we call for anything asymptomatic, like VT, stable tachy, etc. Only exception is a first conversion to afib, or a conversion back to afib after a cardioversion or MAZE.

CCL RN, RN · Mar 24, 2012

do you see this often and, would you have called??

Yes and no.

Yes, I've seen this often.

No, I would not have called.

nursej22, MSN, RN · Mar 24, 2012

I would probably not call, esp. if the patient was on a beta blocker or dig.

Am also concerned about the irregular HR. Was there an increase in PACs? Would double check what the 'lytes were and get an order to recheck in the am.

Irregular because of a high grade heart block? That gets a call pronto.

Merlyn · Mar 24, 2012

OK experienced Cardiac nurses..Quick question for you...
A pt came to hospital complaining of "feeling dizzy" normal BP, HR around 60s-70s NSR. No cardiac history. She was being admitted under dx of CVA b/c CT showed " very minor ischemic changes" although she walked into hospital and had no deficits or other suggestions of CVA.
When in deep sleep, her heart rate dropped and became irregular, stayed SR but brady into the 40s-50s. The monitor was constantly going off because the episodes of brady would cause it to read in the 40s for a few minutes. But when I went in to assess her, as soon as she woke up it went back into 60s and regular. Completely asymptomatic. NO CP/light headed/dizzy.
My question is: Would you have called the doctor in the middle of the night to let him know this? Doc placed standard parameters for this pt: HR 110.
I believe this needed to be communicated to the doctor, but maybe not at 3am, since the pt was asymptomatic. I understand I would not have been wrong to call, but also trying to think critical about the pts condition
Do you see this often and, would you have called??
Thx for your advice!

Call the guy. It is important. Don't wait till the rate drops to 0. No matter what time it is.

Even if the Doctor yells, at least you can chart MD notified.

Do-over, ASN, RN · Mar 25, 2012

Asymptomatic sinus brady in the 40-50s and nothing else going on (blood levels WDL and VSS)? I would not call.

I would make VERY sure it was not a 2nd or 3rd degree block though. That would get external pacer pads placed and a call to the cardiologist at any time.

BandaidBunny · Mar 25, 2012

You need to clarify. You said it dropped and was irregular, but it was SR, but it was bradying down. So, which was it? Irregular (which to me means that the R to R measurement was not consistent between beats like in a-fib), SR, or SB?

By "brady, irregular SR" I'm trying to best describe the patients sinus ARRYTHMIA.

Yes, vitals were taken the first few times it happened but the pt was completely asymptomatic so after the first few times, I just kept an eye on her. EKG/ CEs normal.

I appreciate everyones advice. I didnt call the doctor and I think I made the right decision. I feel the strongest reason why I would have ever called the doc in this case is for legal reasons. Yes, he set parameter for this pt, but thats because he HAS to set some sort of parameters for every patient. Instead of calling, I documented my assessment, printed rhythm strips and documented my reassessment. I agree its worthy of communicating to him, but not at 0300.

Yes, it may have been the best choice legally, but was it professionally? As a RN, I did not think the doctor needed to be aware of this right now.

At some point we should be "legally" allowed to use our nursing judgement!! I didnt go to school for 4 years to ignore my critical thinking!

psu_213, BSN, RN · Mar 25, 2012

I probably would have discussed these limits when they were first set. A patient coming in with a HR 60 - 70 will probably drop below 60 when sleeping so perhaps 50 - 110 or 45 - 110 would have been a better choice for the night.

Unforutnately that is not always practical. For example, the pt is admitted at 10 am, doctor writes the parameters then. I come on shift at 11 pm, then at 3 am, pt has this episode of brady.

Anyway, since the MD set specific parameters, I would call. Yes, I've seen it happen before. Yes, there have been times I have not called the doctor for it. However, the parameters are there, and at this point you don't know if this is normal/harmless SB with a sinus arrythmia or something more sinister. Most likely, the doctor will not be happy you called and will probably just say something like monitor the pt. He may have you draw electrolytes. Either way, nothing significant will be done in the middle of the night is she is asymptomatic, but more testing (EP consult?) may come from it.