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Pacemakers and Nitropaste

Posted

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

Pacer is for a tachy arrhythmia and is set at 50 and basically her heartrate is in the 50s or 50. I've noticed nurses holding her ordered NTP because the heartrate is too low.

Should we question the MD's order. Her chief complaint was chest pain upon admission. Or should the nurses give the med as the heart rate is set at 50 regardless of the meds.

Thanks.

I would not hold Nitro paste for pulse. I would hold it for a systolic less than 100. Nitropaste has more effect on B/P than pulse. I would give it. Always clarify with the doc on what they want. But I still say give it.

First let me clarify a few things for you

1-The function of the pacer is to maintain a heart rate that will perfuse the body when the underlying arrthymia fails to do this. This should maintain a good BP.

2- The nitro past is for prevention of angina, it can cause a drop in in the BP.

You should not remove the nitro past because of the HR thats not what it is for.

So what should if you do. I t depends on a few things.

IF the SBP is ok > 100

Do not remove the Past

IF the SBP

As long as the patient remains stable, NO S/S angina, MI, or CHF, Leave on and notify the DR.

If unsable with S/S angina, MI, or CHF. Remove the past and Stat page the Doctor for orders.

You did not mention what the BP is or the condition of the patient in question.

I hope this helps

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

Thanks for your input. I would not have held the ntp either, but wanted validation from others. Again, I can use this opportunity to educate.

Perhaps I am missing the point here (it's early and I haven't finished my first Diet Coke) , but the first thing that confuses me is your statement that the pacer is for a "tachy arrhythmia" yet it is set at 50; If the patient is tachy the intrinsic rate would easily override the setting on the pacer so all I would expect to see is rapid native beats during such episodes.

Then you go on to say that the patient's rate is essentially 50 with the pacer rate set at fifty. So basically assuming good pacer function, your patient's heart should beat at least 50/min..... I don't see why your coworkers are holding any meds for low rate only.

Now maybe that rate of 50 is not adequate to sustain acceptable blood pressures/hemodynamics. Inadequate rate is not the only reason one can have hypotension or other symptoms, of course, but it is one possiblity. And certainly NTG could exacerbate contribute to further blood pressure decreases. So maybe they held it on that basis and you misunderstood their reasoning?

In any event, I would not routinely hold the NTG and certainly not for a low heart rate per se (I have been known to interrupt NTG to intervene during a hypotensive episode etc.). Rather I would contact the physician if the patient is hypotensive or otherwise symptomatic; at that time we could review the patient's medications including the NTG, fluid balance, current pacer settings, other hemodynamics if available etc. in order to decide appropriate modifications to their current treatment regimen.

Chaya, ASN, RN

Specializes in Rehab, Med Surg, Home Care. Has 15 years experience.

For the pt's safety and your peace of mind (and your butt) ask the doc for clear written AP and BP parameters. Don't depend on everyone to make the same decisions- this patient will be cared for by a number of practitioners over the course of his/her stay.

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Has 28 years experience.

Originally posted by rstewart

Perhaps I am missing the point here (it's early and I haven't finished my first Diet Coke) , but the first thing that confuses me is your statement that the pacer is for a "tachy arrhythmia" yet it is set at 50; If the patient is tachy the intrinsic rate would easily override the setting on the pacer so all I would expect to see is rapid native beats during such episodes.

I'm a little confused as to the history of this patient myself. She was 90 and wasn't the best of historians, but this is what she said, that she had a pacemaker for her rapid heartrate. My assumption was that she had some sort of ablation or other procedure that busted up the tachy and then a pacer to regulate a rate. She did have the pacer checked while she was there because a well-meaning nurse was upset her heartrate would drop to 49 (which it would right before the pacer was activated).

My point was her heartrate rarely, if ever, during my time would ever go higher than 50, so why hold the ntp?

Originally posted by 3rdShiftGuy

I'm a little confused as to the history of this patient myself. She was 90 and wasn't the best of historians, but this is what she said, that she had a pacemaker for her rapid heartrate. My assumption was that she had some sort of ablation or other procedure that busted up the tachy and then a pacer to regulate a rate. She did have the pacer checked while she was there because a well-meaning nurse was upset her heartrate would drop to 49 (which it would right before the pacer was activated).

My point was her heartrate rarely, if ever, during my time would ever go higher than 50, so why hold the ntp?

Possibly A-Fib with RVR which they did cardioversion on then placed Pacer to keep things tight. Possibly converted back to A-Fib

Did not read entire thread so I am just sort of jumping in here

If I knew the exact history of this patient, 9 times out of 10 I would tell you to go ahead and give the medication. With a pacer, heartrate is a poor indicator of... ANYTHING :)

Dave

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