Case study - Atrial fibrillation (Afib): Nursing

Nurse Derek works on an inpatient cardiac unit and is caring for Mrs. Alvarez, a 76-year-old female with a history of hypertension, who was admitted with new-onset atrial fibrillation, or a-fib, with rapid ventricular rate, or RVR. She was given an IV bolus of diltiazem in the emergency department then started on a continuous diltiazem drip. After settling Mrs. Alvarez in the room, Nurse Derek goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about her care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Derek recognizes important cues, including Mrs. Alvarez’s vital signs, which are blood pressure 100/74 mmHg, heart rate 112 beats per minute, and respirations 22 breaths per minute. After placing Mrs. Alvarez on continuous cardiac monitoring, he evaluates her ECG, noting the QRS complexes are normal, but the rhythm is irregular and there are no P waves.

She denies pain but reports mild shortness of breath, diaphoresis, and feeling dizzy and tired with movement.

Next, Nurse Derek analyzes these cues. He determines that Mrs. Alvarez is still in a-fib. He then reviews the electronic health record, or EHR, and notes that her diltiazem drip is ordered to be titrated as needed to maintain a heart rate of less than 100 beats per minute; and the drip was last titrated in the emergency department one hour ago.

Nurse Derek also realizes that rapid and irregular atrial contractions can lead to decreased cardiac output and tissue perfusion, causing Mrs. Alvarez’s symptoms, therefore, she needs more effective heart rate control.

Now, using the information he's gathered, Nurse Derek chooses a priority hypothesis of decreased cardiac output.

Then, he generates solutions to promote heart rate control that will include pharmacologic interventions. He establishes the expected outcome that after intervening, Mrs. Alvarez will maintain a heart rate of less than 100 beats per minute within two hours.

Nurse Derek then takes action to implement these solutions. He knows that the diltiazem drip was adjusted one hour ago in the emergency department, so he can titrate it again since Mrs. Alvarez’s heart rate remains above 100 beats per minute. However, he has only cared for one other patient on a diltiazem drip and is concerned about his inexperience with the medication, so he calls the charge nurse to help him titrate the drip.

Once the charge nurse arrives at the bedside, they review the medication order together.

Charge Nurse: Hi Derek, how can I help you?

Nurse Derek: Thank you for coming, could you verify my titration of Mrs. Alvarez’s drip?

Charge Nurse: I sure can!