April 27, 2018

Cardiac Dysrhythmia Nursing Assessment

Regardless of where you work, inpatient or outpatient, a cardiovascular assessment is a crucial component to assessing a patient. I had an excellent nurse ask me about cardiac abnormalities and how I would go about evaluating a patient who displayed cardiac irregularities. I am by no means a cardiac nurse, but I've had my fair share of cardiac events. Here are a few tips to get your on the right track when it comes to assessing a patient in cardiovascular abnormalities.

#1. IS IT REAL? 
Loose leads, muscle contractions, shivering, tremors, and other patient movement can produce artifactual findings on a monitor, rhythm strip, or 12-lead ECG. Such pseudodysrhythmias mimic and are often mistaken for serious dysrhythmias, including ventricular fibrillation. The critical detail is avoiding decisions based solely on the ECG without incorporating the clinical context. You have no idea how many times I've heard someone scream, "Hit the code blue button. My patient is coding." Only to have everyone run into the room and the patient is eating dinner while watching television. You should never make a judgment call without assessing your patient first. I've had a patient cough a few times, and the monitor tracked ventricular tachycardia (VT) and asystole all within the coughing episode. I get it, computers are awesome and magical and blah blah. But nothing will replace the head-to-toe assessment. Wow, I sounded super old there, but it's true. You can't simply take information and run with it. You must assess first, then act.

You see a dysrhythmia, but is the patient in cardiopulmonary distress? This answer will determine the available interventions and how you proceed. I remember taking an ACLS course, and the instructor told us, "Asymptomatic means medications and symptomatic usually means shock. If you have time, medications are your best friend. When your patient is unstable, shock all day." When your patient is symptomatic, options change, and a quicker, more aggressive response is required. The symptoms displayed can be chest pain, palpitations, dizziness, nausea, or syncope. Every patient exhibits distress differently, so take unusual presentation seriously. Presentation depends on the presenting cardiac rhythm. The next question a provider might ask nursing is whether the patient hemodynamically stable? This is another important question that you will be asked when you call the provider. The blood pressure, heart rate, and oxygen saturation can all be affected by cardiac dysrhythmias. Your patient's clinical picture is the utmost importance, and you must start there. Rule in or rule out symptomatic presentation and hemodynamically stability. An additional question the provider might ask nursing is whether the patient is taking cardiac medications? I try to answer all these questions on this initial call (if the provider allows me). Here is an example...

A 74-year-old male with a medical history of hyperlipidemia and diabetes mellitus type-2 was admitted to the ICU on 04/26/18 with DKA (from the ED). The patient is currently on an insulin drip (4 units per hour), the patient is only taking Crestor, 20 mg, qday and is hemodynamically stable. The reason I'm calling you is because at 21:15, the patient displayed four beats of ventricular tachycardia and converted back to normal sinus rhythm afterward (while in bed). He is currently in normal sinus rhythm and resting comfortably in bed. He reports no symptoms during the event. The episode has ended, and the patient was stable throughout the entire episode. It's hospital protocol to call cardiology (who is on the case) when the rhythm changes or when there are abnormal cardiac beats. Would you like nursing to do anything or simply monitor? (Yeah, it's long but guess what? I get NO follow-questions)

Now, what if the provider says, "No orders at this time, continue to monitor?" Well, if you are going to "monitor," what are the cardiovascular parameters? Are three beats of VT okay? Is asymptomatic VT okay, regardless of the number of beats presented? Does cardiology want to be called if the heart rate reaches 120, sustained? When I'm told to "monitor" a cardiac dysrhythmia or cardiac changes, I'm very detailed, and I make the provider explain what they expect nursing to call them back on. Monitoring can mean 25 different things to 25 different people. I don't like grey zones in cardiology, like troponin grey zones, haha. Did I make a cardiac joke? Haha. The goal is to get concrete parameters regarding when nursing should call the provider. Because I've walked into a room with sinus tachycardia and a heart rate was 170s (sustained) x 4 hours. And the nurse tells me, "Oh, cardiology said monitor only for the sinus tachycardia." Yeah, well monitor up until what point? What is the cut-off? Most providers don't give you, "monitor only" orders without parameters. There is usually a cut-off. Here is an example...

The patient is asymptomatic, nursing to monitor sinus tachycardia at this time. No orders were given. Nursing will continue to monitor and call cardiology if the heart rate is greater than 130 bpm x 15 minutes or the patient becomes symptomatic.

You shouldn't be put in a position where you have to decide when you need to call the provider. The provider needs to let you know when he or she wants to be called. You are not a mind reader. They are the medical professional who creates the plan of care for the patient, not you. They should be able to verbalize their needs and concerns to you without being vague and cryptic.

Now, if you are calling a general provider, you probably won't need to know the PR interval or QRS complex. But usually, you have to call cardiology with cardiac changes (either for a new consultation or existing patient). And if you work on the night shift as I do, you better not be waking someone up without knowing your ECG values and how to locate them. Remember, most conversations are over the phone. The provider will only know what you tell them. You have to describe the clinical presentation in great detail, don't assume anything. When I call cardiology, I have a general statement, something along the lines of...

A 74-year-old male with a medical history of hyperlipidemia and diabetes mellitus type-2 was admitted to the ICU on 04/26/18 with DKA (from the ED). The patient is currently on an insulin drip (4 units per hour), taking Crestor, 20 mg, qday and is hemodynamically stable.

The reason I'm calling you is because at 21:15, the patient started complaining of left-sided chest pain and shortness of breath. 

He is currently in sinus rhythm (PRI normal @ 0.12, QRS wide @ 0.14) with significant ST-elevation in two consecutive leads (V3 & V4, greater the 2mm), a 12-lead ECG was completed at the bedside. The episode is ongoing and increasing in intensity. It's hospital protocol is to initiate the STEMI protocol. Oxygen was applied, and oxygen saturation is 100%. He has received aspirin, along with 3 mg, IVP morphine and a full set of labs have been drawn. His pain has diminished and is under control. 

What else would you like nursing to initiate or perform? 

With each cardiac change or change in clinical condition, a call must be initiated (unless you have orders to monitor that ONE thing). Some nurses go straight crazy with the "monitor orders" and don't call for anything. Monitoring orders are generally for a particular event ONLY, not global. So when I have monitoring orders, I call the provider to confirm the order. He or she might have told dayshift to monitor, but I want to them to reiterate and give me specifics. I don't want to miss a STEMI because the dayshift nurse told me the ST-elevation was old and cardiology already knew about it. Yes, I might get yelled at for calling, but I want verbal confirmation this is known and not a new-onset event. I don't ever accept word-of-mouth monitoring orders. I always call and get confirmation. And if the provider doesn't call me back, I document an attempt was made by nursing to confirm monitoring parameters. With something like this...

Nursing called the cardiology service (existing patient - spoke to Nancy @ 407-000-0000 @ 21:45) about patient John Smith in Room # 4598. A message was left with the service regarding nursing wanting confirmation r/t cardiology parameters (heart rate sustained in 120s, patient asymptomatic - monitoring instructions). Nursing will continue to monitor per information the given during patient handoff. Charge nurse aware of call out and monitoring instructions.

As a nurse who had a husband suffer a heart attack, I know how serious this stuff can get. I don't want someone having a massive heart attack while I'm on lunch or assessing them but ignoring the giant elephant in the room. Sometimes, as a nurse, you have to confirm things five times. Cardiovascular events are one of them. I call and call and call. I don't want someone's loved one falling through the cracks on my watch. And if a cardiologist wants me to monitor, I will document that conversation in great detail. I'm not a provider. I'm a nurse. I work within a scope of practice, and I follow said practice by promptly updating providers with needed information. I'm not the one who makes the decisions to treat or not to treat. I'm the initiator. I initiate appropriate medical treatment based on the provider's judgment and medical plan.

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