Hi. I was hoping to get other's perspectives on this clinical scenario. I assumed care of a pt from 3:30-7:30. During this time, I did a routine EKG on a pt. Pertinent background, the pt has a dx of A-fibb and is on Digoxin and Plavix. I initially conduct the EKG while the pt is sitting in her wheelchair as I thought it would be accurate as long as the leads had good contact w/ the skin. I do seperate EKG's which say the pt's heart rate is between 140 and 150 BPM. I take her pulse manually and it's 56 BPM and I wonder whether the EKG is accurate. Pt has no c/o at this time. I know A-fibb can be asymptomatic, but didnt expect a change in heart rate that quickly. I immediately take her vital signs w/ an automatic vitals sign machine and again her pulse is around 56. I repeat the EKG laying down and again her pulse is reading between 120 and 130 BPM. I decide the machine must be giving a faulty readout and ask night shift to retake her pulse in an hr. I did not hear anything from night shift, but today a nurse on day shift called to ask about the EKG in question.
Now I'm wondering if I should have notified the dr? I'm also thinking that the machine may have been correct and she was having paroxysmal episodes of A-fibb? Conidering she has already been diagnosed w/ A-fibb and being treated for it, should I have noticed the on-call dr anyway?
Thank you for taking the time to read and respond to my question.
Pulse and Heart Rate by EKG are two different things, typically the two match up but particularly with tachyarrhythmias they may be completely different.
'Pulse' is the number of detectable perfusing beats, the EKG HR is number of electrical impulses to the ventricles. This can often be seen in variations between the EKG HR and a pleth pulse or A-line pulse.
With a markedly elevated HR the ventricles may not have time to fill sufficiently to empty enough with a contraction to produce a perfusing beat, so some beats may not perfuse if the ventricle remains underfilled.
As a psychiatric nurse, it is very interesting to have the expertise of a CC RN. Thank you for explaining the difference between HR and pulse; I did not know the two could vary dramatically, but, anatomically speaking, your explanation makes sense
Pulse and Heart Rate by EKG are two different things, typically the two match up but particularly with tachyarrhythmias they may be completely different.
Have seen more than one person learn this the hard way.
If it was a.fib the vital signs machine will not pick up accurate heart rate because a.fib is irregular. The purpose of the ekg is to get an accurate rate and rhythm, so go with the ekg.
The EKG was ordered routinely and it showed a fib, with which the pt was already diagnosed. However, a fib is still abnormal, as is a pulse of 56. That's enough to notify the doc.
Just wondering - what was the exact order? Could you have waited til she was in bed? Or was it ordered for an exact time, a time before HS?
Glad your boss and doc weren't upset with you.
It's likely the machine was not picking up all the fibrillating, thus making the pulse register only 56 effective beats per minute. You know the fibrillating isn't so good at circulating blood. See Muno above.
6 yr ER nurse . 1 yr cath lab nurse . I seen this before . If you palpated 56 and got that on the pulse ox chances are theyre probably right . The Ekg was probably picking up the electrical activity of atria depending on the ekg or she might of been moving or lead not on all the way or she was trembling / nervous you just couldnt see that she was. Heck even a crappy ekg machine all factors . I think it would be best to notify the doc incase she had a freak thing going on and documented that and rational if no further orders .
Specializes in Geriatric, Med-Surg, Critical Care.
Just because a person’s telemetry readout shows a certain rate doesn’t mean their palpable HR will correspond.
The EKG strip is going to show you information about how the heart’s conduction system is working.
In conditions like A-fib the heart conducts and even contracts, but not always effectively enough to perfuse tissues. In A-fib with RVR especially. You lose the atrial kick, which accounts for about 25% of cardiac output. And you lose a lot of your preload because diastole is shortened.
In this case I would have auscultated the heart for 30-60 seconds, and obtained a radial pulse at the same time to see if what was auscultated matched what was palpated. I then would have compared radial pulses bilaterally.
If there was a significant difference in radial pulses I would obtain a BP in both arms.
I then would have called the doctor to inform them of any discrepancies. A radial pulse of 50s and EKG and/or apical HR of 140-150 with a readout of a-fib could be a sign of decreased cardiac output (not every heart beat is perfusing). A discrepancy between radial pulses could be a more ominous sign and typical means you have an arterial problem of sorts.
...... I had my charge nurse review the EKG as well, and he saw no outstanding abnormalities. No significant findings from pt assessment. O2 sat above 95% on RA, no c/o of fatigue, dizziness, SOB, chest pain, or palpitations. LOC x4. No abnormal breathing pattern or other signs of distress noted. Pt conversational throughout exam.
My thinking is that the charge nurse reviewed it and gave the okay just a s you had initially believed it to be.
My only concern is that the pt was talking during the exam. Perhaps I was taught wrong but it is my understanding talking can affect the outcome because people breath differently while in conversation so the pt should lie quietly still during the testing.
You should have listened to her apical for a minute, which would have given you more information.
Then you'd call the doc, because either a) shes in active afib or some other type of cardiac crisis or b) you need to find out whether or not to repeat the EKG and when.
One thing worth mentioning is that if you have a very abnormal finding or a discrepancy in your findings, right then is the time to clarify it. I've seen other posts here (or real life examples) along the lines where, for example, someone's blood pressure reading via machine was 50-70 systolic and the nurse just said to themselves "well that can't be right so I'm not going to worry about it." Or, as in this case, the HR reported by this machine or that machine must not be right.
Rechecking it later isn't going to change a broken machine...but it could mean that your patient has continued to deteriorate in that amount of time, if in fact their decompensation is already underway. So it behooves you/us to find out which is which and what is what right at the time that an abnormality is discovered.
I've always found this decision-making odd so figured I'd point it out because it isn't that uncommon.
It sounds like there was just a misunderstanding about what to expect (from machines) in this case....but the decision to make assumptions and not to clarify sometimes leads directly to far worse consequences. When faced with puzzling or conflicting data from machines, try not to make assumptions about it. Get a new machine if you have to, take a manual (apical) pulse, blood pressure, whatever. Try to figure it out (especially if your patient is looking or feeling different in any way - - which did not seem to be the case this time but it will be the case many other times!)
MunoRN, RN
8,058 Posts
Pulse and Heart Rate by EKG are two different things, typically the two match up but particularly with tachyarrhythmias they may be completely different.
'Pulse' is the number of detectable perfusing beats, the EKG HR is number of electrical impulses to the ventricles. This can often be seen in variations between the EKG HR and a pleth pulse or A-line pulse.
With a markedly elevated HR the ventricles may not have time to fill sufficiently to empty enough with a contraction to produce a perfusing beat, so some beats may not perfuse if the ventricle remains underfilled.