Treatment of the DNR patients and the supravenricular arrhythmia

SorenDrake · Jun 13, 2006

DNR means no life saving measures, such as code stuff. We still continue to treat the other things. My unit will notifiy the doctor of changes such as the electrolyte imbalances or changes in rhythm, and follow orders accordingly. Typically we'll treat until it would be considered extreme (ie, we'll hang neo for b/p, but not neo+levofed+dopamine+...). A-fib with rvr can easily be treated, but if the basic measures don't work, we don't push it. Of course, each case is individual.

RoxanRN · Jun 13, 2006

DNR does not mean Do Not Treat. We continue doing what we've been doing - maintaining BP, normal heart rhythm, decubidus prevention, assist respirations (if already vented), eye care protocols, electrolyte replacements, bowel protocols, etc. If the family doesn't want any of this, then we make the patient 'Comfort Care.' The patient is extubated, all IVFs are stopped, and they are make as comfortable as possible, which includes using pain medications PRN.

We usually have to do a lot of family education when a family is debating DNR. Most out there think we then stop what we are doing and that's not quite what they want. They just don't want us to do anything in the event of arrest. So we have to explain the difference.

steelydanfan · Jun 21, 2006

In our unit, DNR means many and varied things, and there's the rub. The doctors have a checklist that they go over with the family, and "Limited Code" could entail everything short of a ventilator.

What you wind up with is often dependant on the beliefs and mindset of the primary physician who talks to the family...

rninme · Jun 21, 2006

DNR status is not a Do Not Treat status at my facility. If the patient codes, we do not resucitate. If the family requests, we do stop all other forms of treatment and make the patient a Comfort Care/Hospice Care.

papawjohn · Jun 22, 2006

Hey Mish!!!

1. DNR doesn't mean stopping treatment any place I've worked (and thats a lot). Of course, there might be an added "Comfort Measures Only" which would change everything--but would get them a transfer out of ICU, yes?

2. SVT has lots of causes and treatment is based on the causes but I'll toss in a few thoughts. First, correct the electrolytes. The K+ for instance should be higher than the lowest-normal value. Try to keep it 3.8 or better. Check Mg+ and Ca++ and get them right.

Second, do your best to 'unload' the Atria. Based on ABGs and the general respiratory status, try to lower any PEEP and PS. You might have to 'un-wet' those lungs with diuretics--which will of course involve those electrolytes. (With acute Atrial Fib--generally think of excess 'stretch' of the Atrial tissue. That's why it's so common in COPDers.) There might be a bit too much Neo, speaking of cardiac issues. If the order is to keep MAP > 60, the dose needed for getting it to ~70 might be too much.

To feel confident you're doing everything you can think of for the rhythm, you'd need to know dig levels and things like that. Has your Pt been on beta-blockers that haven't been continued? Drug issues can surprise you.

You'll need to really really be sure of the rhythm--so get a 12lead. If it is AFib, you'd nomally expect to start treatment with Cardizem which is hard to reconcile with a Pt on Neo.

And you should have sent a set of cardiac enzymes with the first lab draw.

Hope that helps

Papaw John

Critical LPN · Jun 23, 2006

:monkeydance: Hello Mish,

Pardon me if I get the posting a little off , but this my first time at this type of forum. I, although an LPN, have worked for 24 years in ICU/CCU settings as well as post ICU/CCU , LTAC(Long Term Acute Care), and have found that DNR in some

cases means DO NOT RISK not doing everything! You unfortunately have to learn the need to try to read not only the doctor's order but, try to be the best patient advocate you can be in trying to adhere to the patient's wishes , the family

interpretation of DNR order and your employer's policies. It is much like dancing

like the monkey on here to try to do right by all concerned. I believe that our jobs as nurses should be to consider the patient's intended consent. It all bases on education of all concerned to make sure everyone is on the same page. And always consider people do change their mind in a crisis, like when they are in resp.

distress. Do we treat by sedating to prevent as much discomfort as possible or do we go all the way to the vent? Is the irregular heartbeat causing distress? It truly can be a challange but I've found too many times we wait till the time of crisis to be stuck in a situation that perhaps if we spent a few minutes longer finding out the patient's /families(if patient wants) educational base on what a DNR in your particular institution really means. Perhaps the old Comfort Measures Only should possibly be the standard. I still here charge nurses as well as doctors use the old adage "walk slowly" or "trip over the code cart" on the way to the room. Just remember the other adage, "CYA". We all know that one and one day it will be all of us possibly in that position, and would it not be nice for the nurse to simply ask, "What do you want done?, Comfort or everything possible , knowing that the results may be the same. The loss of any control of their wishes is probably the worse thing we can do to dehumanize our patient's .