Can you continually give SL Nitro tabs on floor while monitoring BP? A long post.

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I recently had a patient admitted for CP r/o ACS and this pt was stable otherwise. Relatively young, good health, non-smoker, no cardiac history. History of high anxiety due to losing house and everything in fire, then Hurricane Sandy took it all away again, now trying to restart a 3rd time.

Stated he had some tightness "not real bad, but noticeable". I asked this pt is they'd like something for the pain, declined it. Stated it was only a 4/10 rating. This pt was on tele and reading NSR at the time.

MD visited pt and pt was just about to call for me when MD entered room. I was told about 10-15 minutes later that pt was complaining of CP and MD wanted Nitro SL immediately for pt. Note: I was currently on the phone with the ED at the time getting report on a new admit. Upon being told this situation, I went to pt's room with the Nitro and he gave pt dose #1. BP was great (120's/70's). MD started quizzing me on how many Nitro can you give and why monitoring BP while giving it, etc..I told him 3 tabs max 5 minutes apart. MD stated "wrong, that's the common sense info we give to pt's who don't know better"). Mind you, he's saying this right in front of the pt.! So...he keeps up with the dosing, meanwhile the BP reading between each dose bumps maybe....2-3 points on both SBP & DBP, still great. Pt stating pain decreasing but still there. Is sitting up in bed talking and comfortable. MD gives total of 4 tabs and when pt states his pain is now a 1/10 and most discomfort is gone, MD orders him to be on a Nitro drip!

So, I go out to nurses station to start getting things ready to transfer pt to CCU since Nitro drips cannot be done on MS floor (will be able to soon, but not yet) and MD comes out and says he needs to get pt into Cath lab right away. Plus get an EKG and get him to the unit (CCU). By this time, I don't know what I supposed to do first.

After all is said and done (pt transferred to unit) MD talked to me about how when a pt has CP, it means there is ischemia and that as a nurse I "need to be astute and stay on top of it because time is muscle". Let me interject here, he was speaking to the pt for 10 minutes before pt even reported CP to him and I was at the nurses desk when this occurred so I wasn't even aware he was having CP!! My question through all this is:

How many Nitro SL tabs can you give on a MS floor? Everything I've read and been taught is 3 tabs MAX! MD states that as long as you are monitoring BP, you can keep giving it because it is a vasodilator and by dilating the arteries, you are letting more blood into the heart, "decreasing the ischemia" and allowing it to function better resulting in an increase in BP.

Does this make sense to anyone? It does but it doesn't. (If that makes any sense to you). I felt like a stupid incompetent nurse when he was done talking to me. He didn't berate me but made me feel completely idiotic.

(Sorry for the really long post but in order to get a good reply I needed to give an accurate description of the situation).

nowim clean

296 Posts

This is why C/P should be admitted to a tele floor and med/surg admitted to med/surg. I am a tele nurse and sometimes not often we use nitro sl, most times it is paste q6hrs. Also with a pt admitted for CP I always get a 2nd IV started since if they go to the cath lab a 2nd IV site is required. With all that said I would say yes you could continue the SL if needed, but paste or drips make it easier.

Specializes in Critical care.

The MD was correct in the lack of true max sl dose and that in ideal circumstances, ntg can be dosed quite high. However, outside of critical care areas monitored by experienced staff, I'd continue to operate under the common q 5 min x 3 as I bet you'll find your hospital policy or protocol on m/s reflects.

Know that we critical care types are quick to switch to IV ntg and titrate it, each sl ntg dose is actually a pretty good hit.

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

He was being a dweeb....yes you can give more than 3 tabs watching the patient B/P but the 3 doses and call MD means that the patient need to go to a higher level of care. YOu did fine.

He was being a dweeb....yes you can give more than 3 tabs watching the patient B/P but the 3 doses and call MD means that the patient need to go to a higher level of care. YOu did fine.

Dweeb was not my first choice.

Welcome back.

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

The physician is correct, the thinking that you can only given patient's 3 NTG tabs is false! PATIENT'S are told this so that they don't keep popping them when they could be either having an MI or having non-cardiac chest pain, the instructions on only taking up to three tabs is for them so they will call 911 or otherwise seek medical attention. NTG can and will drop BP, just lay them flat if they can tolerate that and wait about 5 minutes, it is usually self limiting unless that took the little blue pill and didn't tell you or they are having a right sided MI.

NTG SL only lasts about 5 minutes, so you can give them 10 tabs 5 minutes apart if you like, it does not have a cumulative effect. I work pre-hospital and nurses look at me funny when I tell them the patient has had more than 3 NTG, I have to explain the above to them, although I am lucky I work in an EMS system that allows for IV NTG so I don't have to keep spraying them. I will be honest, if they are still having CP after 3 NTG, even if it is improving, I will usually try a low dose of Morphine.

Another thing I noticed is you did not mention doing any 12 lead on this patient? Was one done when he started complaining of chest pain? And what about cardiac enzymes? I think NTG is the most overused drug we have...

I think you did great!!! Having a MD bark orders at you and question you in front of a patient does not look good for him. You did the best you could under those circumstances. Funny how things start to fall apart when one is getting report!! If you had the second IV line in then the next would have been to get the 12 Lead and call the cath lab to let them know you have an urgent case and the MD who wanted it to be done. I am not sure if he was the Cardiologist or the attending MD. Who knows if cath lab is booked solid and if they have to push another case to take this one. It does sound like the pt should have some cardiac enzymes drawn as well. Do you have a protocol in place for pts exhibiting uncontrolled chest pain?? And yes, why is it that patients do not tell us about their pain until the MD is present??

canoehead, BSN, RN

6,890 Posts

Specializes in ER.

If the doc is standing there I would be OK with giving more than one at a time, with BP monitoring, and IV access. If the doc was on the way I'd continue the Q5min NTG, with a verbal order. I wouldn't do either one beyond an initial crisis. Get the NTG drip primed and going, and transfer the patient out.

Specializes in Emergency Department.

There truly isn't a max dose of NTG... as long as you're giving SL q 5 min. However giving SL NTG that often means you're not leaving the patient's side. Just remember that when you're giving it, you need to take vitals (primarily BP) right before you give it every time to ensure that you're not bottoming out the BP. Morphine works too, but the BP drop is mostly due to the histamine release that occurs with it's administration.

NTG paste also does work, but it's effects aren't as predictable as SL or IV routes are.

In any event, make sure you know the chest pain protocol for your floor/hospital because that can allow you to get going quickly on treating the patient's pain/discomfort.

Patients are often taught to reduce their activity and take their NTG every 5 min x3 and then call EMS if the discomfort isn't completely relieved by then. As an EMS provider, I'm going to give NTG q 3-5 min with vitals prior to each administration so that I don't bottom the patient's BP out. After the 3rd round, I'm going to start giving an opiate q 5 min (with vitals done prior to each dose) or as ordered in my system's Cardiac Chest pain protocol and if the protocol doesn't specify a maximum number of NTG to give, then I'm going to continue giving it. Once the patient is pain-free, then I'm going to simply continue to monitor closely.

While I disagree with the MD's doing what he did in front of the patient, he did give you a set of orders that should allow the patient to be put on a track to getting treated definitively right away and on to recovery. I don't think you did half bad at all!

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