New Onset Afib

[donotenter]

I admitted a patient for observation because he fell and couldn’t get up. Patient was obese (54.1 BMI). I am on a non monitored med/surg floor.

History of congestive heart failure, diabetes 2, hypertension, hyperlipidemia, obstructive sleep apnea.

Patient also developed new onset a-fib in the ER, from what I read in the EKG and ER doctor notes. I did not know this until he showed up to the floor. Heart rate 70s-110s, asymptomatic, for the most part. +2 Bilateral lower extremities edema we’re treating with lasix 20mg iv. Also ordered, aspirin 325 mg tab, and 50 mg of lopressor.

I am not a cardiac nurse. What should I be doing about this new onset afib?

[Crash_Cart]

AF is not a particularly fatal issue, but if left untreated it can cause strokes. That explains the order for aspirin I guess.

Probably should be admitted on a cardiac floor considering his previous hx of hypertension and CHF.

Guess we need to ask ourselves why did he collapse at home in the first place huh?

Hx of CHF and now he's retaining fluid and needs lasix. Hmmm. His cholesterol and triglyceride labs sounds like a code waiting to happen. I don't think he really belongs on your floor. Is he on oxygen and how are his o2 sats and everything? Is he exhibiting any signs of pallor, diaphoresis or anything?

Sounds like you have your hands full.

[donotenter]

3 hours ago, Crash_Cart said:

AF is not a particularly fatal issue, but if left untreated it can cause strokes. That explains the order for aspirin I guess.

Probably should be admitted on a cardiac floor considering his previous hx of hypertension and CHF.

Guess we need to ask ourselves why did he collapse at home in the first place huh?

Hx of CHF and now he's retaining fluid and needs lasix. Hmmm. His cholesterol and triglyceride labs sounds like a code waiting to happen. I don't think he really belongs on your floor. Is he on oxygen and how are his o2 sats and everything? Is he exhibiting any signs of pallor, diaphoresis or anything?

Sounds like you have your hands full.

we've had afib patients on our floor before, but controlled with whatever medication they were prescribed. the admitting MD (not ER) wrote RRR on the CV assessment which makes me think he missed it?

i called the pharmacy to see if the aspirin was enough as a "thinner" (anti platelet/coagulant) and and what medication is usually prescribed for afib. i didn't get a clear answer, except i should be asking the doctor.

he probably slipped, is what i heard.

he didn't display any signs of anything. my charge nurse said nothing is wrong with him. and we will call the doctor if the heart rate goes higher. so i sat outside of his room with a vitals monitor with the pulse ox attached my entire shift. bp was ok at 140s/90s

[CalicoKitty, BSN, MSN, RN]

Sometimes, people with new afib get a treatment like cardioversion (usually if their heart rate is high - like the 130s) or perhaps an ablation (interventional radiology where they essentially burn off the bad "timer" cells in the heart). For people with chronic afib, sometimes medications like amiodarone to treat the irregularity and usually anticoagulants like warfarin.

The other medications like metoprolol (beta blocker) and lasix (diuretic) are usually treating the heart failure - also usually lisinopril (ACE inhibitor) and a cholesterol medication like atorvastatin. If the blood pressure is still elevated, other BP meds may be used like hydralazine.

Regardless, if the afib is new, he should be on telemetry. Sometimes with afib, the patients can go into RVR (rapid ventricular response/rate) with high heart rates ~130+. Those can be the cause of the fall since the heart output would not get enough oxygenated blood to the brain, so they faint.

[JKL33]

52 minutes ago, donotenter said:

the admitting MD (not ER) wrote RRR on the CV assessment which makes me think he missed it?

It is your responsibility and duty to call the admitting service to report your findings which appear to be a change in condition compared to the admitting service's previously documented assessment.

52 minutes ago, donotenter said:

i called the pharmacy to see if the aspirin was enough as a "thinner" (anti platelet/coagulant) and and what medication is usually prescribed for afib. i didn't get a clear answer, except i should be asking the doctor. 

That is correct.

52 minutes ago, donotenter said:

he probably slipped, is what i heard.

?

Maybe. Maybe not.

52 minutes ago, donotenter said:

he didn't display any signs of anything. my charge nurse said nothing is wrong with him.

Well, that doesn't sound completely true. He might not be experiencing any hair-on-fire emergencies at the moment but that doesn't mean we don't report our findings when they may have bearing on the situation, or that we don't seek to clarify when we have concerns.

This issue is very bothersome to me, I'm trying not to be short. But can we talk about why it is easier to gather various opinions while worrying about your patient all shift than it is to just communicate your findings with the physician or provider?

[Corey Narry, MSN, RN, NP]

Definitely call the provider or physician if you have concerns about what you think is a new onset a fib. Typically, what providers want to know is whether that patient is hemodynamically stable and what the heart rate is. If the patient is stable from a hemodynamic standpoint, let the provider figure out whether this is new onset or not because that would determine the next steps which would be rate control vs attempt to chemically convert.

That also goes along with the decision to anticoagulate which is typically guided by the patients CHA2DS2-VAsc Score which the provider will figure out. The score gives an idea of the patient's risk of stroke from the a fib which must be balanced with the safety of blood thinner for this patient all other factors considered. It's best to communicate with the responsible provider so you both could be on the same page about what the plan is.

[Swellz]

I wonder what your reasoning was for not calling the doctor? I know it shouldn't matter, but are you a new nurse on night shift or something? Sometimes you think there's a barrier to calling, but if you really think the doc missed something like a new arrhythmia, it is your responsibility to communicate this. This is not your charge nurse's patient, it is your patient.

If it doesn't acknowledge anywhere in the H&P and plan of care that this patient has new onset afib, I would call. If it acknowledged it but didn't specifically say "no tele needed due to stable HR" or something, I would call. The patient should be on telemetry for monitoring. This is all after talking to my patient - do you see a cardiologist? Have you ever been told you have an irregular rhythm or afib? Are these all the meds you're taking? How did you fall? You mentioned you weren't sure how he fell, and if he's AOx3 there's no reason why you can't ask him. If he doesn't know how/why he fell, he is probably going to get a syncope workup, which would get him tele anyway.

[donotenter]

i work night-shift and we have 1 provider for the entire hospital. however that isn't an excuse because the charge nurse tells me make phone calls for suppositories and medication to sedate confused loud patients or bed jumpers. sometimes, i wonder if it causes the charge nurses more work if i do my job properly.

i am not a new nurse (7 years). just somewhat new at this location. my charge doesn't like to be challenged and i believe her ego (med surg 20+ years) gets the best of her. i think i rub her the wrong way when i ask questions. thing is, i am just trying to due diligence for my patients.

this isn't the first time something like this has happened. ironically, she admitted a new onset seizures for observation. the md came up to the floor 15 minutes later and said the patient probably was syncopic and didn't seize. we need to send him to tele. i was the nurse, again. i swear she is trying to set me up to kill somebody. and i probably might if this keeps up.

i am just trying to do my job and not create any animosity with anybody.

[BSN-to-MSN, ADN, BSN, RN]

New onset of afib should be on telemetry floor.

If you look thru his meds, if he is already on a blood thinner such as warfarin or xarelto, then afib most likely is not new, and you can keep the patient on medsurg as long as he continues to take his bloodthinners and betablockers.In some cases, due to bleeding risk, patients are only on aspirin and plavix, no heavy duty anticoagulant. Age, fall risk, previous GI bleeds.

Call the doctor, and communicate safety concern. Make sure to use the word "safety", that gets people listening.

Afib rvr needs cardizem drip, new afib 5needs heparin drip, if rvr, also a cardizem drip.

[donotenter]

that's why i called the pharmacy. to see if there was any medication on his profile for the afib. i didn't see anything "hear rate" or "blood" related. he was aox4 and says i don't know what afib is. i told my charge and she said "just watch him. wait until his heart rate goes above 120."

anyway. thanks for all the replies.

[OUxPhys, BSN, RN]

Meh, its not a big deal as long as it's controlled. If gets real high then he'll have to be transferred to a tele floor that can start a drip or push meds.

[workinmomRN2012, BSN]

At the very least the patient should have a monitor on and ideally be on a cardia floor.