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Be the one who first IDs patient's abnormal EKG
If an ED nurse at Christiana Care Health System in Wilmington, DE, suspects a patient could be having a myocardial infarction (MI), he or she does the EKG immediately at the bedside and interprets it on the spot, says Patricia L. Blair, RN, BSN, CEN, patient care coordinator.
"We are the eyes and ears of the physicians," says Blair. "We always see the patient first. The recognition of an abnormal EKG in real time, as it is being done, allows us to have a rapid door-to-balloon time and save cardiac muscle."
At times, the ED nurse initiates the Heart Alert and obtains intravenous access, while the ED physician calls cardiology and the cardiac catheterization lab. "If the EKG is not looked at by the nurse, the chart would wait for a physician," says Blair. "There could be delays in physician evaluation due to overcrowding."
While all Christiana Care's ED nurses are certified in Advanced Cardiac Life Support (ACLS) and can read basic EKG rhythms, triage nurses receive more advanced training in reading a 12-lead EKG in "a very systematic way," says Blair. "If you look at it the same way every time, you don't miss anything."
Blair says to look at these three things: Is there a P wave with every QRS indicating a normal conduction? Is the pattern regular? And, are there are any ST depressions or elevations? "By looking at those three things every time, you are sure you don't miss anything," she says.
All ED nurses are educated to recognize significant changes in the patient's EKG, says Cynthia Van Wyk, RN, MSN, CCRN, patient care manager for emergency services at Scripps Mercy Hospital Chula Vista (CA). This education covers identification of areas of ischemia or injury to the heart, as well as rhythm and pattern changes that require immediate treatment, says Van Wyk.
Van Wyk recalls a patient who complained of vomiting and not feeling well. "The nurse did the EKG as a precaution and recognized subtle changes that indicated the patient may be having a decreased blood flow to his heart," she says. "She immediately called the doctor to the bedside, and the rapid treatment needed began."
An MI patient might complain of indigestion, neck or jaw pain, or even left shoulder or tooth pain, says Van Wyk. "The longer it takes to restore blood flow to the area of the heart affected, the more unrecoverable damage is done," she says. "Every minute counts."
Here are strategies to improve assessment of patients having EKGs:
Compare the current EKG to the patient's previous EKG if possible.
Christiana Care's ED nurses can view the last EKG done at the facility on a bedside computer screen, which often gives important clinical information, says Blair.
"If you don't know the person has a left bundle branch block, you might think they are in ventricular tachycardia," she says. "Or if a left bundle branch block is there that wasn't there during the last admission, that should throw up red flags that something is really wrong here."
Assign a tech to triage.
Blair reports that her ED has a 10-minute door-to-EKG time. "We have a technician assigned just to do EKGs and take them back to the core physician, so the attending looks at the EKG immediately," she says.
While the technician isn't able to interpret the EKG as the triage nurse would, it is "at least a safety net when our nurses are tied up," says Blair.
When in doubt, do the EKG.
"If there is any question, just do the EKG," says Blair. "It's very quick to do, and it's a great screening. It is something we can do quickly that is going to save muscle."
One woman had elbow pain and came in requesting an X-ray, but the pain was gone by the time she arrived at the ED. "She just looked agitated and sweaty," says Blair. "Something told me to do the EKG, and it showed ST elevation."
It's not enough to ask patients whether they have any pain, warns Blair. "They might not perceive pressure or pushing to be pain," she says. "Ask patients if they feel like they could go on a long walk. Ask them, 'Do you feel like you do on a normal day?'" (See story below on patients with normal EKGs.)
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Normal EKG? Go by how the patient looks
Your patient might report no chest pain and have a normal EKG, says Patricia L. Blair, RN, BSN, CEN, patient care coordinator at the ED at Christiana Care Health System in Wilmington, DE, but "the next thing you know, their troponin is coming back a 4, and they are in ventricular tachycardia. We find out a lot of times after the fact, that their left anterior coronary was completely blocked."
Blair says that she has had "plenty of patients who come in with normal EKGs, and their troponin will come back positive. If the patient doesn't look right, treat them as an MI even if their EKG looks marvelous."
If you suspect a myocardial infarction but the patient has a normal EKG and no chest pain, consider whether your patient has diabetes or hypertension, Blair says. "If somebody comes in with pain without any comorbidities, you might chalk it up to their lifting something heavy last night," she says. "But if your patient has comorbidities, it should raise red flags."