rhythm questions!

Trauma Columnist · Dec 12, 2014

Hi and welcome to AN, the largest peer to peer nursing network!

While I can't answer your specific questions, this is a busy forum and someone will be along shortly.

anh06005, MSN, APRN, NP · Dec 12, 2014

Usually with a fib and v tach it depends on the situation if you call. For a patient with a fib I would consider: what is the rate? Is the patient symptomatic? Does the patient have a history? And is the patient on anticoagulants? How are vitals?

For v tach: check responsiveness of course and a pulse. Does the patient have a history? Does patient have a defibrillator? How many beats of v tach was it? How are vitals?

For a fib if the patient is running at a good rate (say 80's), other vitals stable and a symptomatic I'd probably wait until a decent hour to call the doc. Maybe make the call at 6-7 am when they're likely getting ready for work. For v tach a lot of floor say if it's under so many beats to monitor for now and let doc know at a decent hour (is it 10 beats maybe??). This rule depends on stability again of course.

It's something you get more comfortable with as you work with the population and get to know the docs.

anh06005, MSN, APRN, NP · Dec 12, 2014

And you won't be the other nurse on the floor. When I was on tele even the experienced nurses would bounce ideas off each other on what is most appropriate. So don't get too stressed about knowing it all now!! It'll come with experience and there is so many grey areas about heart rhythms and what to do

anh06005, MSN, APRN, NP · Dec 12, 2014

Oh forgot another part of your question lol. As far as rapid vs. Calling the doc it depends on how acute the patient is. Are they having new chest pain? Pulse ox suddenly down from 99% to 85%? Patient obviously dyspnic and its new for them? Wouldn't hurt to call a rapid in any of these situations.

But say you have someone in having chest pain but their heart Cath was clean that am. Pulse ox on COPD patient 85% now but his normal is 88% (yes some get that low as a baseline). Patient is dyspnic but just walked from bathroom and is in for pneumonia. Some of these you could call the doc. Some you just watch the patient and know what is coming up for their plan of care (oh chest pain guy has IV Morphine available and is up for a gallbladder US in the AM. And COPD guy has a PRN updraft available. Your pneumonia patient didn't wear her oxygen to the bathroom).

Like I said before it will come. Ask questions. Even when you're off orientation you are not alone.

Good luck! It's good you're already asking questions!

Here.I.Stand, BSN, RN · Dec 12, 2014

If a patient goes into a fib or vtach would I immediately call a code or a rrt?

afib: if the rate is very fast, accompanied by a drop in BP, and/or pt is symptomatic I'd probably call a RR. (Disclaimer: I work in an ICU so we don't use RR. Someone else may tell you different.) If they go into afib but the rate is only in the 90s-100s I would just call the MD.

vtach: I would call a code. If they're conscious and have a pulse, if the vtach is sustained they likely won't have a pulse for long.

If a patient has svt what would I do?

Asymptomatic, I'd call the MD. Symptomatic, probably call a RR.

What if the patient has a high BP that isn't normal for the patient and has a pretty high BP again around 4 am would I call the dr?

Generally the team will order a call parameter, e.g. call for SBP 150. Now if they have been running in the mid 90s, and at midnight are at 145 I'd check it again an hour later and see what it does. Of course you'd always want to assess for causes of high BP, such as pain or anxiety. If it stays under the call parameter but high for the pt I'd monitor it closely and tell the MD when they round in the a.m. If it goes over, of course call.

They should go over this in new RN orientation. If you still have questions, they are excellent ones for your preceptor. But generally, I'd say look at the pt. If they look like they can safely wait for MD orders and for the pharmacy to dispense, you can call the MD. If the pt needs help right away but is not coding, call the RR.

Congrats on the job!

JessicaDanielle · Dec 13, 2014

I would recommend taking ACLS as it covers a variety of rhythms and scenarios and what can be done in these instances.

**NICU Guy, BSN, RN** · Dec 13, 2014

When in doubt call the Rapid Response. I have heard from several nurses that are on the Rapid Response teams that they would rather go to numerous calls that didn't need them than to not get called when they were truly needed. It is far easier to fix something at the beginning stage by calling Rapid Response than to wait too long and end up calling a Code.

LongislandRN23 · Dec 13, 2014

If you find a patient unresponsive, or in acute distress: respiratory depressing, sever sob ect you would know to call a rapid and if the patient needs to be coded it would then turn into a code. Usually a change in rhythm such has vtach or sever bradycardia (down to the low thirties or twenties) or svt or tachycardia on the tele monitor will draw your attention instantly to that patient.

For vtach: how many beats did the patient have? What were their last electrolyte values: K and mag? Did they miss any cardiac meds in the last 24 hours and what are their vitals and were they symptomatic or not and did they have any other beats of VT before? These are all questions to ask yourself and info to gather before calling the doctor. If it's 2am and the patient was asymptotic I would wait until 5 or 6 am to call.

If in doubt or concerned call the house dr/pa/np - that's what they are there for. Be persistent if something does not feel right. I have had to call the nursing supervisor before and explain the situation and literally make them make the house pa come and assess a patient - after I called them and they refused to come (yes some house practitioners can be like this but certainly not all)

Afib- is it rapid? How fast? Are they new onset? When did they last have an ekg done? Are they symptomatic? What are the vital signs? Do they have a temperature? Are they sustaining? - any prn doses for them? I would call the house dr. If it's an unreasonable time to call the cardiologist. Do an ekg and what not. The house dr might give you a one time dose of something and tell you to call the dr if the patient does not improve or to call in the am and make them aware.

With time and experience you will now when to call/who to call and for what. Good thing is you are never alone and can always ask your fellow nurses questions. The worst thing to do is to not ask questions when you're concerned! Good luck!

That Guy, BSN, RN, EMT-B · Dec 13, 2014

When in doubt call the Rapid Response. I have heard from several nurses that are on the Rapid Response teams that they would rather go to numerous calls that didn't need them than to not get called when they were truly needed. It is far easier to fix something at the beginning stage by calling Rapid Response than to wait too long and end up calling a Code.

This. Call early. Don't be a hero especially when you don't know what to do next. Plus rapid will get you order much faster than calling the doc.

psu_213, BSN, RN · Dec 13, 2014

Part of it depends on facility/unit policy. For example, new A fib was one of the changes for which you called a RRT at my previous hospital. I worked on a step-down unit, so unless they were grossly hemodynamically unstable, we would call the doc, get orders for a Dilt or Amio drip and go from there.

The other issue is…assess the patient. Pt goes into V tach on the monitor…or are the just brushing their teeth? Is it a pulseless V tach (call a code, start CPR) or do they have a pulse with minimal symptoms? Is it sustained or just a 5 beat run of V tach? You unit should have a policy for how many beats are required before calling the doc. Is the V tach new or has he had runs of it all day and his cardiologist is aware of it?

Treatment of SVT really depends on if it is symptomatic. If not, go with vagal maneuvers, call the MD, etc. If they are dizzy, poor BP, LOC, chest pain--call the RRT and they will likely cardiovert.

As others have already said: there are other nurses on the unit. Learn who the knowledgeable experienced nurses are and ask them when they think can be done. Have another nurse eyeball the patient (assuming the pt has a pulse!). When in doubt, call the RRT.

michlynn, BSN, RN · Dec 16, 2014

I work on a tele floor where our patients are diagnosed with various arrhythmias all of the time. Anything new that is sustained even if the a fib is a controlled rate I would still call the doc bc they are most likely going to want an anti arrhythmic and probably an anti coag of some sort. If they have 15 beats or less of VT I would wait until morning if the attending doc is cardiology bc they most likely wont be concerned. Now if its sustained and and they are symptomatic I would probably RRT that pt and obviously if they are pulse less you would call a code. Any type of change in condition warrants a RRT but use your best judgement and ask your coworkers what they would do.