I'm getting so confused

TopsDrop, RN · May 23, 2013

General rule of thumb if there is a rhythm change, first thing to do is assess your patient. If they are symptomatic with the rhythm change it usually warrants a call to MD after you assess and do what you can for the patient per whatever protocols you have.

LBBB v. RBBB. Doesn't really matter to RN scope of practice, sure its nice to know, but all it means is where in the Bundle of His the delay is occurring, its a "normal" rhythm for in most of patients you see. Same with 1st degree AV block. Just means there is a slight delay from AV node to rest of conduction system, but HR almost always 60-100.

These are both sinus rhythms with a small delay somewhere in the conduction system and very common in a lot of pts. that a lot of doctors don't care about as is the same, so they would probably not be thrilled about a call if the patient is asymptomatic.

As for which leads to look at, I feel its up to the nurse, I always look at lead 2 as its oriented along normal conduction path of heart. IIRC the aVR angled at less of an angle and goes more through the Bundle of His.

Any significant change in rhythm should show up on all leads.

turnforthenurse, MSN, NP · May 23, 2013

TopsDrop pretty much nailed it. Always assess your patient, not just the monitor. Is your patient hemodynamically stable or not? A 1st degree block is pretty insignificant, in my opinion, and all of the docs and cardiologists I have worked with would be pretty ticked if you called them at 0300 just to notify them of that, unless your patient was experiencing symptoms, which is very rare. Many of the cardiac medications (beta blockers, calcium channel blockers, cardiac glycosides) will cause a 1st degree block due to the slowing of AV conduction. Treatment generally isn't warranted unless the block is associated with an MI.

As TopsDrop mentioned, BBBs isn't really within the scope of an RN's practice...but the easiest way to differentiate between them is the "turn signal theory." Imagine a turn signal lever and look at V1. If it's going down (left), it's a LBBB. If it's going up (right), it's a RBBB. Very easy and simple trick.

Now, about the 5-lead monitoring system. That 5h lead (V) lead can be placed in any of the V lead positions (V1-V6):

V1-V2 = septal

V3-V4 = anterior

V5-V6 = lateral

I've seen so many people (whether it be nurses, CNAs, EMTs...) just slap that V lead smack dab in the middle of the chest. That's incorrect. That lead placement is the same as if you were doing a 12-lead EKG. So for example, if you wanted to monitor V6, that electrode would go on the 5th ICS, mid-axillary line.

As for which lead to monitor, there was a practice alert put out by the AACN about the "ST segment fingerprint." This is the pattern of ST segment elevation and/or depression unique to a particular patient based on the anatomic site of coronary occlusion. This can be obtained during a STEMI or PCI. If the fingerprint is not known, AACN recommends monitoring leads III and V3 (inferior, anterior), which corresponds with the LAD and RCA. Here is a link to the practice alert powerpoint: http://www.readinghealth.org/doc/Page.asp?PageID=DOC015798

Most places have lead II as the standard because it is a bipolar lead and supposedly the most useful for detecting cardiac dysrhythmias as it lies close to the cardiac axis (the overall direction of cardiac movement) and allows the best view of P and R waves.

Hope this helps.

raindrop · May 29, 2013

A big, fat THANK You to you both, TopsDrop & Turnforthenurse!!! Everything you wrote makes sense to me.

Now if I may pick your brains on a few other things:

Some of these patients are getting soooo many cardiac meds. I had a patient the other day who was supposed to get a BB, CCB, ACE +IV Lasix - all at the same time. We had parameters for the BB, and we ended up holding the BB because his b/p was below the parameter. My preceptor went ahead and gave the rest of the meds. I thought we should have notified the MD about the rest of the meds since his bp was already low. But preceptor administered anyhow. And when the MD came in a couple hours later, he didn't question why she gave them when his b/p was 90/60! I understand that CCB, ACE and BB all work differently to lower the B/P, but I don't understand why the MD would order a patient to have so much and at the same time. And I don't understand why the CCB and ACE don't have parameters, and I don't understand why the preceptor wasn't concerned abiout his b/p lowering even more! Her only explanation (we were busy) was that ACE + CCB don't lower the b/p per se, but they inhibit the b/p from getting higher.

And when talking about 5 lead monitoring. I know the Brown Lead is the V lead. But what are the White, Red, green, etc?

And there have been times where patients have had a run of Vtach, but are fine. And the nurses do nothing since they are asymptomatic. But I always thought the MD should be notified! Just because they are fine this time, doesn't mean that the next run will be fine. My preceptor said she only notified the MD if it happens alot. Uggh. Well, I tend to err on the side of caution. If a patient had a 4 beat run of Vtach on you, but were asymptomatic. What would you do???

psu_213, BSN, RN · May 29, 2013

And when the MD came in a couple hours later, he didn't question why she gave them when his b/p was 90/60! I understand that CCB, ACE and BB all work differently to lower the B/P, but I don't understand why the MD would order a patient to have so much and at the same time.
And there have been times where patients have had a run of Vtach, but are fine. And the nurses do nothing since they are asymptomatic. But I always thought the MD should be notified! Just because they are fine this time, doesn't mean that the next run will be fine. My preceptor said she only notified the MD if it happens alot. Uggh. Well, I tend to err on the side of caution. If a patient had a 4 beat run of Vtach on you, but were asymptomatic. What would you do???

As for the BP and the BP meds: the doc may have wanted the BP that low. In addition, the ACEI may have been for preload reduction if the pt has any degree of CHF...not just BP control. Also, was the CCB just for BP or because they had a history of a fib? Were these home meds for the pt or were they started on this admission? How many doses have they gotten? If these are home meds, I doubt the pt takes their BP before every single dose at home. The point is, a lot of information is taken into account when deciding to give or hold a particular med.

On a related note, I have seen cases where the cardiologist wanted a patient beta blocked to a HR in the 40s. Both this HR and the BP you described are outside the traditional normals, but the normals are just normals for a percentage of the population, not for everyone. Plus, there are times when a lower than normal BP (or HR) might be called for. When you have a doubt, you should call the doc...it seems like your preceptor did not have such a doubt. Ask your preceptor (in a non-accusatory way of course) why she chose to give the meds rather than call the doc. Make sure it does not sound like you are calling her out on it, and make sure it is clear that you are asking since it is a learning opportunity for you.

Now the V tach. I worked on a PCU. Our written policy was to call the doc for any run of V tach 6 beats or longer (unless there were other factors...hemodynamic instability, it was happening frequently, etc.). I would have never been off the phone some nights if I called a doc each and every time I had a patient with even a short run. There is nothing wrong with erring on the side of caution, however, some docs are not going to appreciate getting 5 calls in a particular night. As for your direct question...all else being equal, would I call the doc for an asymptomatic 4 beat run of V tach? No.

Esme12, ASN, BSN, RN · Jun 1, 2013

A big, fat THANK You to you both, TopsDrop & Turnforthenurse!!! Everything you wrote makes sense to me.
Now if I may pick your brains on a few other things:
And when talking about 5 lead monitoring. I know the Brown Lead is the V lead. But what are the White, Red, green, etc?
And there have been times where patients have had a run of Vtach, but are fine. And the nurses do nothing since they are asymptomatic. But I always thought the MD should be notified! Just because they are fine this time, doesn't mean that the next run will be fine. My preceptor said she only notified the MD if it happens alot. Uggh. Well, I tend to err on the side of caution. If a patient had a 4 beat run of Vtach on you, but were asymptomatic. What would you do???

Are you on orientation? Are you a new grad? Have you had any EKG courses yet?

EKG leads.....White is right (shoulder/side), Black is the opposite of white so that is left(shoulder/side).......green is ground on the right lower abdomen and brown is ground so left lower abdomen. http://www.aacn.org/WD/Practice/Docs/REV4_02_pocket_card.pdf

Using a 5 lead system.....many cardiologists like MCL1 or V1 to monitor heart patients.....it is a diagnostic lead for VT/SVT and it is the lead where you can see the development of a BBB R or L which when a new finding is an indication of an extension of a MI of a new MI has occurred. The development of a New RBBB is an ominous sign and carries a less positive prognosis.

An Introduction to MCL1

Electrode Placement

The best leads to monitor BBB is V1 MCL1.....I haven't heard of using AVR....that is a diagnostic lead but not significant to standard monitoring.

When to give meds and why is a multifunctional problem....it depends on the patient and what the ejection fraction is......some patients need the meds given outside the "normal parameters" as their cardiac function is so poor and so fragile that they need the preload, after load reduction, vasodilitation properties to stay out of failure. It is best to always ask the MD and get parameters AND know what your policy and procedures are for your facility for these meds....for standards of care.

4 beats of VT is 4 beats of VT...I would rather get yelled at for calling instead of sued because I didn't.....however if this is a common arrhythmia for this patient and they have a history of this AND the MD notes it in his progress notes...no I wouldn't call.

1 degree AV block I probably would not call especially if they are on meds and have a history of this....however if this patient has been in for a few days and develops a 1 degree.....I would notify the MD...if on nights I would call in the morning before I went home.

http://www.usfca.edu/fac-staff/ritter/ekg.htm

turnforthenurse, MSN, NP · Jun 2, 2013

My hospital's policy was to notify the doctor of runs of v tach that were greater than or equal to 6 beats in length. Always assess your patient, too! I've had patients "go into" v tach from things like brushing their teeth, CPT or tapping the lead wires. Check their electrolytes.

psu_213, BSN, RN · Jun 2, 2013

Always assess your patient, too! I've had patients "go into" v tach from things like brushing their teeth, CPT or tapping the lead wires.

Very true....treat the pt, not the monitor. I have even seen a patient intentionally make the monitor show v tach just to screw with the nurses. :madface:

NewbieNurse4U · Jul 7, 2013

This post has been extremely helpful for me thanks for all the input

LifesAJourney · Jul 7, 2013

Whenever I have monitor duties, the preferred lead they want patients in is V1. Unless, the patient has an inferior MI or atrial dysrhytmias. Then, they want us to put the patient in lead II. To be honest, we put them in whichever lead we can BEST see the rhythm.

LifesAJourney · Jul 7, 2013

Per protocol, anytime we have a rhythm change, I alert the nurse and print a strip. An ekg usually follows to dependent on the order. Occassional PACs or PVCs are nothing to call the physician about. However, if it becomes more frequent, then I would be concerned. If a patient was sinus then became junctional, I call the nurse. If a patient had a run of PAT, I call the nurse. The list goes on and on. I would say if the rhythm changes and it is something new, seek the advice of your change and call the physician. At least you can document physician notified, no new orders given, continue to monitor or something along those lines. Always remember to assess the patient to see if they are symptomatic.