"A BP of 70/30 is normal"

[TigerGalLE]

So I had a patient today that came back from dialysis with a pressure of 70/30 and a temp of 103.1. After calling a rapid response and paging the MD. The MD had the nerve to tell me that a BP of 70/30 was normal for that patient!!! I'm sorry but that BP isn't even enough to keep his access patent!! And the pt told me his BP runs 130/80 normally. The doctor told me to give some Tylenol and give a dose of vanco... No fluid... no transfer to the unit... no nothing!!!!! So after the rapid response that got me NO WHERE.... The MD finally came and saw the pt an hour later and after 2L of NS he was still 70/40.... Then 5 hours after the initial rapid response was called.... OH now he wants to transfer... Well there is no ICU bed now!! There was a bed then.. but not now... Thanks a lot doc... yea b/c i didn't have 5 other patients......... GRRRRR...

This is the same patient that right after the rapid response stood up on the side of the bed and told me to get the hell out of his room or he was going to throw me through the ******* window.... How he could even stand up with that BP i'll never know.... what a jerk... man my day sucked....

Tiger

[leslie :-D]

yep...my very first thought was that he sounded septic.

sounds like you're not the only one whose day sucked...

what the heck was that doctor thinking?

leslie

[suzanne4, RN]

Was the MD actually a renal doc in the first place or the primary care on the patient?

Not sure why they did not use pressors in the first place either, boluses are not usually given in this type of patient; causes more problems later on a few hours later. And then what made the MD decide to transfer the patient to the ICU, or even wish to? Just so that they would not be woken up at night, sounds like.

But as I said, the case will be reviewed in the RRT program and there will be follow ups made with the MD. You can be thiankful for that. And he will have much explaining to do to try and get out of this one.

Low pressure and temp equals sepsis.

[TigerGalLE, BSN, RN]

Yea the MD was the renal doctor.. he was the primary who admitted the pt... Neuro was consulted for pt's c/o weakness and difficulty talking and swallowing with a hx of multiple myeloma, amyloidosis... also consulted oncology b/c of ? bone Cancer... he was ESRD on dialysis... had hemangiomas all over his body... Recently can only get around by motor scooter.... He has so much going on.. Orders for skeletal survey, MRI of spine... couldn't go to either because he wasn't stable.... it was frustrating. Neuro probably ordered 25 labs on him.. Neuro saw him last night... oncology hadn't seen him... and primary was being so stubborn.... cardiology finally got consulted...

I admitted him last night at 1845 before I left... And I thought then he didn't look good.. And he had a Life port... probably the sepsis culprit.....

Ohhh and his Troponin was 0.5 and his myoglobin was probably 3000 and his CK was probably 2000...

Tiger

[Wicked Wahine]

Whoah, that sounds like a bad, bad day! I also can't get over the patient threatening to throw you out the window. I'm still just a student nurse and I can't imagine just letting a threat like that roll off my back.

[woknblues]

I am sure the doc made a huge obvious error and is just defensively covering it up. I would take the patient and his actions out of the equation emotionally and just deal with the doc and the bad call. you did everything right, so leave it at that, and let whatever administrative process happen. it will not be your butt on the line, for sure.

[traumaRUs, MSN, APRN]

Another medication to use is midodrine - we use this in outpt hemo frequently. I always go back to "treat the pt not the numbers." Many of my patients have multiple old accesses in extremities which can adversely affect BP. If a pt can stand and ambulate w/o falling, then they are used to a very low BP and yes it can perfuse. Agree the physician should have given you more guidance. Rarely are my pts admitted to the unit solely because of hypotension. Hypotension in a dialysis pt (especially one that is febrile) is usually sepsis-related. I am always amazed at how quickly they rebound with some vanco and tobra/gent.

Totally agree that MD was in error - if nothing else should have come to assess pt immediately.

Hope today is better.

[aeauooo]

I don't see in your post that you reported that the patient was symptomatic. That's the flip side of "treat the patient, not the number."

In addition to getting the doc's attention, it would give you 'meat' for your documentation.

[TigerGalLE, BSN, RN]

He couldn't hold his head up and could barely hold his eyes open.

Tiger

He was very weak and at times he would become lethargic with us having to continuously talk to him so he wouldn't drift off.

But anyway I am off work today and luckily I don't have to deal with that place for 6 days! I worked 3 days in a row.. now I'm off for 6!! WOO HOO.

Tiger

[KatieRN04]

def sounds like sepsis, should be cultured and given abx. 6l of fluid off is alot despite sepsis and RF. So giving some fluid back seems appropriate since septic pt's need fluid. If he was on pressors and needing fluid, which is typical with sepsis, and he needed his dialysis, sounds like a patient that needs CRRT not HD