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pvcs bigemy medsurg

Nurses   (556 Views | 11 Replies)
by pvcsbig pvcsbig (New) New Nurse

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Morning.

 

Question:  I am a brand new graduate on a medical/surgical unit.  My coworker did an EKG/ECG on a patient with a heart rate that fluctuated from 40 BPM to 160 BPM.  The results were sometime along the lines of “PVCs and bigemy”   charge nurse said it was OK, since the doctor knows about it and it is patients’ history.  I am not a cardiac nurse, so educate me please.  What should be done at this point?  Interventions?

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Pixie.RN has 12 years experience as a MSN, RN, EMT-P and specializes in EMS, ED, Trauma, CNE, CEN, CPEN, TCRN.

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Was the patient symptomatic? And what was the radial or apical pulse? I am not talking about what the monitor showed, but actual conducted beats. 

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CCU BSN RN has 7 years experience and specializes in CICU, Telemetry.

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Basically the patient is probably going back and forth between a sinus rhythm with a lot of ventricular ectopy and a rapid atrial fibrillation (hopefully not VT unless they already have an AICD). Happens postop sometimes. I'd want them on telemetry and I'd want them to get an EKG when their rate is 160. Basically if they're asymptomatic with a stable blood pressure there's not a whole lot to do but monitor them and check their extended lytes to r/o reversible causes.

I'd want to know what exactly their history is (AF, SSS, CHF, VT/VF) and how it was/is being managed (PPM/AICD, Ablation, etc.). I'd also want to know what their EF is because surgerh involves a lot of IV fluids and I'd like to know if I should be watching closely for the inevitable flash pulmonary edema. 

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7 hours ago, pvcsbig said:

The results were sometime along the lines of “PVCs and bigemy”   charge nurse said it was OK, since the doctor knows about it and it is patients’ history. 

1. Results meaning the machine read?

2. Why was the patient having an EKG?

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Been there,done that has 33 years experience as a ASN, RN.

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Can't  tell what the patient's rhythm was, or what needs to be done.  But with any rhythm change , you would do an assessment. You are looking for chest pain, palpitations, or shortness of breath, diaphoresis or pallor. Always get a set of vital signs and check labs for electrolytes.

Assessing a rhythm change is a learned skill. Request a telemetry/ EKG interpretation class.  

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On 12/28/2019 at 12:26 PM, pvcsbig said:

Morning.

 

Question:  I am a brand new graduate on a medical/surgical unit.  My coworker did an EKG/ECG on a patient with a heart rate that fluctuated from 40 BPM to 160 BPM.  The results were sometime along the lines of “PVCs and bigemy”   charge nurse said it was OK, since the doctor knows about it and it is patients’ history.  I am not a cardiac nurse, so educate me please.  What should be done at this point?  Interventions?

Generally when somebody says rate between 40-160, it means that the monitor alarmed and flashed those numbers.  A heart rate that truly wanders between those extremes would be a problem.  Since the charge RN didn't see the rate as a problem, I am guessing it wasn't.  Emphasis on "guessing".

Let's say a person has a heart rate of 60, and misses a beat.  If the monitor choses to measure right there, it might read 40, despite the fact that the PTs heart beat 59 times in one minute.  The monitor is a tool- the more you use it critically, the more effective the tool will become.

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CCU BSN RN has 7 years experience and specializes in CICU, Telemetry.

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It sounds like you have the abilities for telemetry on your unit but not in your patient room. It's true that NSR at 80 with bigeminy could read as 160bpm, or atrial flutter where your flutter waves have a high amplitude so they're all triggering the count. Either way it sounds like this person was a cardiac patient of some kind pre-op, and may need a higher level of care postop due to this kind of issue. I'd want the tele tech to compare this patients ectopy/rhythm now to the last 12-24h and see if any of it is an acute change.

 

Again, if your patient feels fine and his vitals are stable, it means you still have time to figure it out.

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CCU BSN RN has 7 years experience and specializes in CICU, Telemetry.

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Basically the take home here is that all cardiac patients should have telemetry while they are ill enough to require a hospital level of care. For everyone's safety.

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FWIW I had a 48-hour Holter recently with low of 32, runs of SVT to 130, bigimeny and trigimeny consistently and PCP said Cards said it was normal.

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10 hours ago, harvestmoon said:

FWIW I had a 48-hour Holter recently with low of 32, runs of SVT to 130, bigimeny and trigimeny consistently and PCP said Cards said it was normal.

Well, if those were what was actually indicated that is not normal. We could infer that Cards either didn't agree that those things were actually represented, or else they meant that they didn't consider the findings problematic in your scenario. And the "in your scenario" part is important.

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AHENY specializes in Nursing Education, Critical Care, NCLEX, CPR.

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If you truly feel uncomfortable for any patient condition you should speak directly with the physician.  You also should get a print out of whatever is going on so that the rhythm can be properly identified.  I always check the chart to see what has already been documented (12 lead EKG etc.), as well as the physician's notes about the rhythm and treatment plan.

 

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Assuming patient is tolerating irregular rhythm/ectopy (no shortness of breath or chest pain, and has acceptable blood pressures), don’t expect to do anything urgently just based on abnormal rhythm and ectopy. Especially since patient has history of this and since MD is aware.

 

What you should do in this situation is:

-ensure the patient is tolerating rhythm, and monitor for signs that he is no longer tolerating: BPs trending downward, physical discomfort, or decreased level of consciousness. Monitor for further overall changes in rhythm/rate patterns.

-Ensure electrolytes are of normal values and don’t need correcting. Even if patient lives in a funky rhythm, optimizing potassium/magnesium will decrease myocardial irritability and possibly decrease ectopy. 

-Make sure patient is receiving regularly taken antiarrhythmics (and probably anticoagulants) if history of atrial fibrillation. 

-Rule out any other major acute medical issues that could be causing increased irritability. Such as respiratory issues, fluid volume imbalances, infections, etc

-Know whether your patient has a permanent pacemaker/ICD and what the settings are. They will usually have a pacemaker interrogation upon each admission, which noninvasively assesses the device’s function, any detected arrhythmias, and any response to the arrhythmia. Patients with atrial fibrillation have higher likelihood of pacemaker implantation due to common management of atrial fibrillation being rate control with medications (beta-blockers). Sometimes the result is great prevention of tachycardias, but such a low heart rate that a backup pacemaker is needed. 


 

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