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?

[GSDlvrRN, MSN]

On 8/9/2019 at 11:58 PM, 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.

Totally agree. If the AF continues, consider an anticoagulant to further prevent clots. I also do not think he should be on your floor. Tele units can do metoprolol IVP, cardizem IVP, also drips like amiodarone and cardizem. Also considering that he fell, it could’ve been caused by a conversion pause. How do you know he hasn’t been going in and out of a.fib. at home? For how long?

[KeepinitrealCCRN]

new onset fib + CHF history = Telemetry admit

[beekindRN, ASN, RN]

If you sat outside his room monitoring him all night, that's continuous monitoring. I would call the MD and say he is not currently Afib with RVR but with his extensive cardiac history, I'm afraid he will convert without us knowing on a non-telemetry floor.

I work in ICU and have had two different patients convert into Afib with RVR in the 140s to 190s...completely asymptomatic. That's great that they don't feel it, but that's a HUGE risk for stroke. I called the MD, who is very laissez faire, incessantly. It took many hours, but I got my patient back on a Cardizem drip.

Don't be afraid to vocalize your concern. If your charge is not reacting appropriately, and it seems as though she isn't, contact your house supervisor if you have one. Call the MD available at nights. I hate calling people at night, but they're on call for this reason.

Best of luck to you!

[NurseBlaq]

I was on a step down unit with tele monitoring and a cardizem drip as a new afib patient until I converted back to SR. Now I take aspirin as my blood thinner with my cardiac meds. But my age may also be a factor, I'm under 50.

[donotenter]

2 hours ago, NurseBlaq said:

I was on a step down unit with tele monitoring and a cardizem drip as a new afib patient until I converted back to SR. Now I take aspirin as my blood thinner with my cardiac meds. But my age may also be a factor, I'm under 50.

what was your heart rate? my patient was bouncing around between 70-110

[LibraSunCNM, BSN, MSN, CNM]

On 8/10/2019 at 6:58 PM, donotenter said:

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

Your job is to take care of patients though, not be anyone's friend. I understand it's uncomfortable to work in an environment with tension between coworkers---that's sucky. But if your desire not to ruffle feathers comes at the detriment of the patient, that's not cool either. I think a call to the physician was in order.

[NurseBlaq]

1 hour ago, donotenter said:

what was your heart rate? my patient was bouncing around between 70-110

It was ridiculous, 120s-180s. 70-110 is a good day for me. ?

[MunoRN, RN]

Rate controlled A-fib is not actually an indication for continuous cardiac monitoring, and anticoagulation isn't indicated in the first 24 hours of new-onset A-fib, so there's not really anything that needs to be urgently addressed. If the patient becomes hemodynamically unstable, and the cause is found to be significant tachycardia, then that would justify transfer to a monitored floor for acute rate control interventions.

[Kooky Korky, BSN, RN]

On 8/10/2019 at 6:58 PM, donotenter said:

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.

If you think the Charge is wrong and is endangering the pt and/or you, don't you think you had better go to the House Sup or just call the doc? And let the chips fall where they may. You are not expected to do what she says if you really think she is wrong and you think the pt is endangered or your license is in jeopardy. If the pt suffers harm because you did what the Charge said and she was wrong, you will still be liable. Doing what your Charge says when it causes harm does not relieve you of liability.

Can you and your Charge have a little heart-to-heart talk about this? Understand each other? Get it all clarified? You might need to talk to her/your hiring boss/Manager.

The seizure pt who was later re-diagnosed as having syncope - who said he had seizures? The ER Doc?

[Kooky Korky, BSN, RN]

On 8/13/2019 at 8:44 AM, LibraSunCNM said:

Your job is to take care of patients though, not be anyone's friend. I understand it's uncomfortable to work in an environment with tension between coworkers---that's sucky. But if your desire not to ruffle feathers comes at the detriment of the patient, that's not cool either. I think a call to the physician was in order.

Furthermore, if your pt goes bad, you will be on the hook. Even if your Charge gave you the wrong advice, even if you were trying to be at peace with her/him.

That is your patient. You will be answerable for what goes on with him. It 's hard to have a crabapple for a Charge, but you have to leather up. The devil with whether or not he/she likes you. Stay out of court.

[kaylee.]

On 8/13/2019 at 2:45 PM, MunoRN said:

Rate controlled A-fib is not actually an indication for continuous cardiac monitoring, and anticoagulation isn't indicated in the first 24 hours of new-onset A-fib, so there's not really anything that needs to be urgently addressed. If the patient becomes hemodynamically unstable, and the cause is found to be significant tachycardia, then that would justify transfer to a monitored floor for acute rate control interventions.

Telemetry is initially warranted on ALL new onset a fib until treatment plan can be made.

https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000527

[babychickens]

Never forget- Patient advocate is part of our job. Period. No RN should fault a fellow for doing their job. When I keep that in mind the rest of the drama like "this charge is trying to have me kill someone" falls away.