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When to react to an abnormal reading

Specializes in Critical care and home health. Has 5 years experience.

I am a new grad on step down/cardiac unit. Most of our pts are in for AMI, Angina, Stroke, Chest pains, etc. I know basics, but I finding when it comes to blood pressure, heart rate and rhythms I do not know when I need to call the doctor or observe. One night I had a pt's b/p bounce up and down all night and charge not concerned. I have b/p's in 190s systolic and 100's diastolic[ Pt's who converted to AFib; Heart rates in the 120-140's and charge nurse look me like whats the problem? What am I missing? I need some general guidelines to go by.

Me Too! I'm in a "Chest pain Center", basically Cardiac Obs for ED pts with Chest Pain.... I'm nervous - I start in a week!

Do you have any tips for organization - do you use a binder, brain-sheet, etc? How did you study up on drugs etc?

Would love to keep in touch!

alabamagrad

Specializes in Critical care and home health. Has 5 years experience.

Most of the nurses on my floor keep clip boards. I notice that all the ones that are less than a year use the clip board/folder combo so we can keep notes with us. I am trying different brain sheets. I will probably just take one and modify it to fit my floor. I am still working on my basic assessment. I am trying to do two things from each system. Then I will do a through assessment on the systems that brought them to the floor.

heart27

Specializes in Cardiovascular. Has 9 years experience.

Dont be too hard on yourself if your new to this stuff. Learning your strips comes with time. But you should train your mind to recognize arrythmias that need quick intervention, ie 3rd degree AVB, VT or pt demonstrating symptoms! Look at the WHOLE picture, what meds may be causing tachy arrthymias or bradycardias? What is the admitting Dx? Any history? Most recent labs? Potassium? Magnesium? Consult with your resources and never be afraid to ask for help. I may suggest to review EKG interpretation books and prepare to take your ACLS course. Offer to accompany your charge nurse if a code is called in the hospital (just designate another RN to cover your pt's ahead of time if a code should occur). Do what you can to seek out learning opportunites that will increase your knowledge and provide safe and efficient care to your pt's. Good luck!

To be specific to what you mention in your post..............if the BP was 190/100 I would think the provider covering that patient would order a medication to lower the BP ( I would look to see if this is a dialysis patient or renal patient, or if there is a provoking cause for the elevated BP (ex pt refused previous BP medications...........pt in pain etc) most of my providers would add something to lower the BP at that range...........regarding pt in Afib with heart rates of 120-140..........while the new onset afib who is not anticoagulated is my biggest worry a patient with a sustained rate of 120-140 should be given medication to lower that rate 120-140 sustained is uncontrolled afib ..........rate should be lower.........note if patient is sustaining 70-80 rate only occassionally going up to 120 maybe the doctor will wait to add a medication but if patient sustaining that rate (120-140)they will often give cardizem........IV push to bring it down at least on my unit both in step down and on the Heart progressive unit............so if your provider is ignoring you for these two things maybe you need to ask another nurse how new is that provider........in my experience sometimes new provider (new residents new PA are hesitant to intervene or add a medication) I have learned which providers judgement I trust and whose I dont ........if my covering person is someone whose judgement I dont trust I will monitor my patient very closely and if I find them at risk and nothing being done I will go over that person head ex charge person or I consult with ADN depending how serious is the problem or consult a more experienced nurse on how to approach the situation first before going over the person head.........

I covered a new nurse who let her patient all night at rate of 140-150 she was new to the floor she told new covering PA about her patient rate and covering PA did not intervene she did not do anything about this heart rate....................when I covered that nurse patient I told the PA very confidently she needs to control this patient rate and to tell me what she was going to do cause I couldnt leave patient continue at this rate all night ...........PA called cardiology and they intervened ...........different approach same PA patient rate after treatment 70-80 sustained .............knowing what to do comes with time and talking with nurses on your unit ..........follow your gut .......if something seems wrong and intervention seems to be needed more than likely your right...........observe on your unit who is the most experience nurse working that night/day with you who can be your resource person..........I usually had more than one person and if I told her my situation and she agreed my patient should have an intervention and the doctor /provider was not doing anything I would ask for advise on what to do........I did that my first 2years on my unit and it was a big help ..........and when needed if I dont know something I still will consult those nurses....they have been doing nursing 30yrs some of them and are a great resource to you for specifics of your patient during your shift..........sometimes generalized information from a post cant help you when your patient has specific situation ........but that nurse can review that patient hx with you and tell you if what your thinking is right or wrong........but better to ask and be wrong than to ignore a situation just because the provider not impressed with what you tell them about the patient ..........

I had a cardiologist make a bad call on my patient when I was only a year on my unit...........Had a patient with atypical symptoms stomach discomfort general malaise ......headache ...but VS stable...these are the symptoms that brought her to the ER and she ruled in for MI now she on my unit having same symptoms ( I dont know why but everything about her said she was going to code so she arrived @ 8pm at 830pm I tell PA patient needs to go from step down to CCU or cath lab

trop through the roof CPK through the roof:eek: no hx of renal ( I say that cause on occassion elevated CPK trop with renal patient can occur and not be MI) , PA agrees pt not stable..............(vital signs where stable but pt symptomatic) , Cardiology does not agree, charge pa notified agreed with me pt should go to CCU .............cardiology disagrees it is now 10pm at night pt still symptomatic so now Cardiology goes in alone with patient (pt spanish speaking cardiologist does not speak spanish) he come out says to me "pt says she is fine pt does not need to go to CCU"..............I am shocked cause since 8pm patietn has been telling me of her symptoms............I go in ask patient in spanish if she told doctor that she was fine she says no .........i tell him doc I was in with patient just now pt does not feel fine...........its now 11pm cardiologist still does not want to move my patient to ccu I call ADN, tell her my situation nows it 12 M she says she will talk to cardiology..............all this time I waiting ............. pt then codes at 1am in morning cardiologist does not get me a bed in CCU until 3am in morning meanwhile my pt coded 3 more time on my unit............now I was new nurse I was covered becaue told every body and there mother since 830pm that this patient was going to crash .........

Pt finally was taken to CCU by 330am with a pulse and pressure intubated I find out she died at 4am .........CCU nurses not knowing what I went through with cardiology or that I had requested pt to transfer since 830pm said I brought pt hald dead to them in CCU ..........I was devasted that my patient died:sniff::cry: .............I was upset with cardiologist:angryfire but held my tongue cause it was to late now to change the facts......... at least everything was documented and they couldnt blame the nurse ,........I couldnt stand the sight of that Cardiologist for months .........he was new fellow ............it took a long time for me to forgive him but I finally did realizing he just human and we are all falliable and not perfect I am sure he learned a lot that day and hopefully wont ignore a situation again............I dont know how that patient by passed the cath lab which is where I think she should have went from ER since she ruled in for MI in ER ...............never had a patient like that again..................but I tell the story to new nurses just so they know in the back of there heads that the doctors can be wrong .............second story,.............just today got patient came from having blood drawn and right after she felt sick ..........nausea dizziness, heart rate went up , sudden onset sweating ..... I tell provider(new doctor) the provider says she probably just sick from having blood drawn and probably a vagal response and to make her a regular visit..............I tell doc this is not a vagal response pt got worse on abulation and heart rate is up not down....I insisted she needs EKG because doc was not going to order anything and let her be seen regular visit ( I am triaging in clinic today not on my unit ) I did EKG pt was in afib sustaining a rate of 132-146 .......doctor wanted me to walk her over to her room I told her shouldnt walk this patient her heart was 126 when she was in my room she walked short distance for the EKG went up to 146 ...think you should see her in the room she in .......Doc saw pt had to send her by EMS to hospital and told me later good catch.......... but had I listen to the doc and something happen to patient who fault would you think they will say it was (you got it the nurse)............. she wanted me to sit patient in our waiting area like regular visit and not run any test......I already had marked pt acute cause I triaged her..........the point of the story is that sometimes docs dont know everything and some times they assume things...........and nurse needs to follow her gut and sometimes disagree respectfully ........of course I never go head to head with a doctor but I try within the order of leadership and chain of command address an issue if I think my patient is in danger of a problem being missed I try to advocate for the patient through proper chain of command and seek advise from my senior nurses on the unit or clinic or what ever the setting I am in ............sorry for the long story but hope something I said was of help..................:heartbeat;)

A little off the subject. I saw a post from you regarding RN jobs in Kuwait. Were you ever successful in finding nursing opportunities?

alabamagrad

Specializes in Critical care and home health. Has 5 years experience.

thanks for the advice. it is greatly appreciated.

High bp's tend not to scare me because you can easily call for prn meds to bring it down.

afib 120's-140's probably didnt scare her due to experience. From experience 120's to 140's is hardly ever symptomatic. Symptomatic being the key word.

Some general guidelines I go by. Learn your deadly arrhythmias, those require immediate attention. Everything else that IS NOT SYMPTOMATIC you'll learn to deal with through experience. But since your still learning use you co workers experience as a guide.

NocturneNrse

Specializes in Med/Surg/Tele/SNF-LTC/Supervisory. Has 6 years experience.

Well, I agree with running it by a coworker who is experienced, and also the supervisor. I would call the MD for a switch over to A-Fib, especially one w/a high heart rate - may need to intervene with some medications. The High BP's, if no medications are prescribed for this patient, I would definitely call the MD and see what he/she suggests. It's always nice to alert the MD to changes, b/c he/she probably knows how to handle the situation better than any experienced nurse (sorry), plus - you don't want him/her coming in, and finding this change.. and him/her saying "Why wasn't I alerted to this?" Advocate for your patient - think.. if that were ME, would I want my doctor to know about this? You'll get there my dear.. overkill is better than just plain KILL.. :grn:

Yes, you should definitely call the doctor for A-fib RVR, an antidysrhythmic should probably be initiated, as well as anti-coagulation addressed. But there is a difference between how I would react if a pt's rate is 120-'s versus 190's and symptomatic.

2nd-Did you ever check the blood pressure manually. When a person is in afib, especially rvr, electronic bp machines tend to have a hard problems getting bp's. I've had my tech's come to me all the time and tell me my bp's are 200/100 or higher, and then manually they're 90/40. It's a known rule on my floor with afib. Which leads me to, thats why you check with a more EXPERIENCED nurse, they know these things.

Lastly, I tell all new nurses "The worst thing you can do is not ask questions". Next chance you get ask the nurse what she thought of the situation.

alabamagrad

Specializes in Critical care and home health. Has 5 years experience.

thanks for the feedback, sometimes I feel bad about asking experience nurses questions, but it worse not to do anything. Thanks!!

thanks for the feedback, sometimes I feel bad about asking experience nurses questions, but it worse not to do anything. Thanks!!

Do not feel bad about asking! This scenario is complex and the feedback will help you develop your personal style. This is a safe forum.

More than once, a seasoned nurse has written, "There is no dumb question." The best code is the one that didn't happen.

When you ask a question, we all learn from the answers. Keep on asking.

centex

HeartRN_09, BSN

Specializes in Cardiac step-down, PICC/Midline insertion. Has 10 years experience.

I'm a new nurse too and I have had some issues with the same thing. At first, calling the doctors was scary because I am always worried that they'll think I'm just a dumb nurse and it's silly that I'm calling them. I've got over that pretty quick. If you have a real concern about the patient, call them. You're just doing your job. If I were a doctor, I would rather the nurse call then not call, because then I'd just know even more about what's going on with the patient. Of course most of them do not think like nurses and they can get ugly on the phone. Just take it with a smile. At least you'll know for sure in your mind that the patient is ok. And you chart that you called the doctor and what he said about it. Then if something does happen...it's on him not you.

It takes experience...I am learning as well. If I have a concern, I always ask a charge nurse or more experienced staff nurse what they think and sort of "screen" my potential doctor calls through them first. A BP of 190/100 is too high for anyone. If you get a crazy reading like that...recheck it, preferrably manually. There may have been a problem with the cuff. Machines lie sometimes.

I always call a Dr if the rhythm changes and is sustained. One run or 2 of afib or tachycardia is not a big deal, it's if it stays sustained. If they're in afib and the rate is sustained at a high rate I would call the Dr. Everytime I have called for this they ordered something to control the rate...IV dig or an amio bolus or something. But then again you always have to take in consideration what's going on with the pt...if they're in pain or distress, that could be the cause, so give them pain medicine or some xanax or something first, that way you don't end up hanging a $300 drip like cardizem or something.

Then keep in mind too if they're on anticoagulants or not. If not and they're in a fast afib, calling the Dr. is a must so they don't potentially throw a clot and stroke.

I call the Dr for my own peace of mind more than anything sometimes. I don't care if they get mad. Let them. It's their patient too.

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