Does anyone have standing orders or a practice guidline for pts with chest pain at thier facility?
It seems to me that pts get faster care for chest pain if they out in the community than if they are already in the hosp. If 911 is called they get O2, S/L Nitro, aspirin and an EKG as soon as the EMTs arrive. In the hosp they have to wait until the MD calls back and the nurse gets orders.
Please let me know what the procedure is at your facility and what literature supports your practice.
Our facility has telemetry protocol orders. Anyone admitted to our unit automatically has PRN orders for SL NTG, tylenol, O2 @2-4L/NC, EKG, and some other goofy stuff like MOM, Mylanta & a couple other things. What we don't have is orders for obtaining cardiac enzymes and for giving morphine. I HATE that. I called a doc this morning about a patient who was having CP and he gave me the order for morphine but didn't give an order for cardiac enzymes. That bothers me.
hey, remember that we are in a position to advocate for our clients so don't be afraid to ask what you think may additionally be appropriate for your pts and you may document the morphine order and also "no cardiac enzymes order given at this time when questioned." So, it would show your interest...
I'm sorry if I missed this, but I didnt notice anybody saying that IV access part is of the standard protocol. In our facility, Its O2, EKG, IV access x2, until doc gives us order for NTG, asprin chew and swallow, morphine, then enzymes. Our docs always get there pretty fast. If pt is coming to hospital via ambulance, the doc is usually there before pt. gets there.
Specializes in ICU, CCU, telemetry, psych, endocrine.
Written protocols in hospitals advocating NTG for CP should rethink their practice. One of our cardiologists said that giving NTG to a patient w/ RV AMI is risky and he would not do it. We don't have standing orders for that very reason (756 bed -teaching hospital) In 9 out of 10 patients C/P NTG is probably beneficial. However, an earlier member said it best--a patient w/ a RV MI died following an administration of "routine" NTG. Oxygen, IV access, EKG w/ CP, and aspirin are fairly benign. Morphine is usually safe although I always go slow and dilute first. (Duh!)
hey, remember that we are in a position to advocate for our clients so don't be afraid to ask what you think may additionally be appropriate for your pts and you may document the morphine order and also "no cardiac enzymes order given at this time when questioned." So, it would show your interest...
KAL
I did ask about enzymes and the doc didn't feel it was necessary, which is unusual for that particular doctor. Our docs are usually good about ordering enzymes, particularly when we request an order for them. I later found out that patient ended up being transferred for intervention later that morning.
Our facility doesn't have a formal protocol unfortunately, which is something I've tried to work on for about 2yrs to no avail as our mngmt and Cardiology groups are too busy bickering most of the time to approve anything. As for what I practice, and teach my nurses to practice, FIRST you must assess the pain, obtain some vital signs, and obtain and EKG before you do anything, except apply O2. From there, the information you have obtained should guide your intervention. For me the cut-off for NTG is usually any INF MI appearance on an EKG, or SBP
Our unit protocol for CP R/O MI pt is O2 one nitro, stat EKG, can repeat the nitro up to 3, call Doc. They usually call back quickly but if pt really crumping we have a rapid response team we can call. The can order lab and meds and will contact doctors. Works very well.
ACLS is intended as a protocol for dealing w/ emergency, resusitation situations. To use those protocols outside of a 'code' would not be appropriate. They aren't designed to replace MD orders; they are there as 'emergency' protocols.
CP, by itself, is not a resusitation emergency. There is an algorithm for 'ischemic CP' but, outside of an emergency situation, that algorithm must be subject to MD approval. If you look at the CP algorithm, it is dealing w/ pre-hospital/ED care. It is not a 'standing order' for admitted pts.
That being said, most cardiac pts I see have standing admit orders that cover EKG and MONA (morphine, O2, ntg, asa) for CP
~faith,
Timothy.
Along those lines, I'd like to ask if ST depression since admission and for the next 2-3 days thereafter. This would be on a Med/Surg tele unit where patient has an extensive cardiac hx.; Some people tell me that ST depression is an acceptable "baseline" for a pt. with CAD, CABG and all other types of funky cardiac stuff. I have always thought that since ST Depression is reflective of myocardial ischemia, that it is a pre-MI alarm and it is seen with stable and unstable angina. Always acutely and not as a chronic baseline (for lack of better words).
mandykal, ADN, RN
343 Posts
hey, remember that we are in a position to advocate for our clients so don't be afraid to ask what you think may additionally be appropriate for your pts and you may document the morphine order and also "no cardiac enzymes order given at this time when questioned." So, it would show your interest...
KAL