hypertensive emergency?

Nurses General Nursing

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">Today I had a student I was teaching who had a BP of 188/124. What would you have done in this situation? She says she recently saw the doctor and had a normal B.P., but is having problems with anxiety and has been prescribed med for anxiety, which she hasn't started yet and doesn't have with her. Also that she's being treated now for UTI. She said she had no symptoms with her B.P. except for feeling anxious and flushed. I was alarmed, and suggested she go home and either go to urgent care or call her doctor, but she wanted to stay till the end of the day. She didn't want to get her B.P. taken again at all, because it made her more anxious to do that. At the end of the day, I told her if it were me I'd either go some place that could take my B.P. or call my doctor. And I hinted that it could lead to a stroke. Every time I brought up the subject, though, she said I was making the anxiety worse. What approach would you have used, and do you think it's something a phone call to the M.D. or a trip to urgent care could've taken care of?

One thing to learn is that by reading all the posts here on AN, there are probably many situational (at first) hypertensives on this board. Nursing can do that to you. If you were to take yours during a bad day in nursing you'd find that your BP probably goes somewhat higher even.

Sometimes I come across a post knocking nurses who are on antianxiety meds. Now maybe the ignorant will understand that by doing something to counter that anxiety (meds or whatever) you are doing something to reduce the tork on your CV system! Those of you who refuse to help yourselves will pay for it later...

Remember those who SAY that they don't get anxious, but are explosive anger types, or just bullys... you guys need a script too - time to stop denying you have an anxiety problem and get some help before your head blows off your body.

Specializes in Clinical Research, Outpt Women's Health.

I would have insisted she call and report it to her MD right then and it is up to the MD to decide if she can remain or needs treatment.

Specializes in Surgery, Tele, OB, Peds,ED-True Float RN.

She is a grown woman. You're not a junior high teacher. You give her your opinion, the info about consequences and the option to leave without penalty, and the rest is up to her. Even if she was in her GP's office and he suggested she go to Urgent Care, he can't MAKE her do anything she doesn't want to!

Specializes in Pedi.

I agree with miss81 and was going to say the exact same thing. If you are teaching nursing students, you are teaching adults. You offered your advice and that's all you can do. What she does with that information is up to her. I'd probably have done the same thing this student did... I definitely wouldn't go to an ER and would prefer to call my own doctor on my own time. My BP is probably this high on some days when I'm working... I'm pretty sure I'm going to develop hypertension from my job... and then my insurance provided by said job won't want to pay for the antihypertensives I would then be prescribed. ;)

She is a grown woman. You're not a junior high teacher. You give her your opinion, the info about consequences and the option to leave without penalty, and the rest is up to her. Even if she was in her GP's office and he suggested she go to Urgent Care, he can't MAKE her do anything she doesn't want to!

I agree with the just of this post, and to be honest this does work with a patient-practitioner relationship in most cases. The only thing that might make this particular situation different is the fact that the instructor is, at that point, acting as an agent of the school, and in certain states and situations, such as Florida which has comparative liability, the action of the individual instructor can be legally considered to be the action of the school. In short, while the student (patient) can refuse to go to the doctor the instructor, while acting as an agent of the school, must uphold the policy of the school. If the school's policy is that a student who is deemed to be too unhealthy to remain in class must leave class then the instructor can not allow that student to remain in the class. True, he/she can not require that the student go see a doctor, but the school CAN require that a student who is asked to leave for a health reason must return with a note from a health care provider stating that the student is well enough to return to class prior to being allowed to resume classes. That is why I suggested that this particular instructor should check with the school to see what specific policies, if any, the school has in place. Keep in mind also that in many of these cases the patient, in a patient-practitioner relationship, who refuses to accept the additional medical care must sign a legal document stating that they refused against medical advice and that when doing so they completely understand the possible consequences of doing so. In many EMS systems for example this would require the paramedic or EMT to notify medical control and get their approval to accept a refusal even if the paramedic or EMT believes the patient is competent to refuse. The school might require something similar (i.e. that the instructor must contact the medical director of the program and get their permission to allow the student to remain in class, or the student might have to be sent to the Student Health Clinic, if one exists on campus, and be cleared to return to class, etc.).

Just something to consider.

Specializes in Emergency & Trauma/Adult ICU.

I'm curious what the situation was that caused the student to have her BP taken in the first place, and what made the OP conclude that s/he was the appropriate person to obtain it?

If the student reported feeling ill, would it have been more appropriate to direct him/her to the ED or his/her own PCP?

Specializes in Clinical Research, Outpt Women's Health.

I think they were probably learning how to take BP's on each other.....

True. I teach nursing assistants, and we were at clinical in a nursing home. I was checking off another student on B.P. skill, and I was shocked when I heard the reading. I will talk to my school about the situation, although I'm not sure if we even have such a policy in place in such a small private school. We definitely have no medical director or health room.

Specializes in School Nursing.

I run into a similar situation as a school nurse when one of the teachers or staff asks me to check their BP and it is high. I recommend either a call to their MD, or whatever I think is appropriate, but they are grownups and I cannot force anything. On one occasion a teacher had concerning s/s (that I don't recall exactly) but I told her either she was calling her MD in front of me or I was calling 911 and she could deal with the paramedics, but that was an extreme case. Generally, I just advise them appropriately and document, document, document.

That would be a good trick, to call the paramedics. But I'm not sure if that would violate the students' rights to call 911 without her permission? Another thing I could've done, since I was in the nursing home, would have been to talk it over with one of the other R.N.s there and see if the student would give permission for that R.N. to give her professional advice (maybe with a scary story thrown in about how a resident had a stroke with a high B.P. like that?), if my advice was being taken lightly and if I couldn't require her to go home. I'm still wondering, though, whether anyone could answer whether an urgent care center can handle such problems, or would they just send such a person straight to the E.R.?

I was just reading something about this subject, and it made me think. It says that acute renal failure can be a cause or effect of elevated blood pressure. She says she has a UTI now which has been hard to treat. Hmm...could it be that something wrong with her kidneys now is causing her body to be unable to regulate B.P. and react so strongly to anxiety?

I also still wonder whether it's appropriate in this case to send her to urgent care, or would they immediately send her to E.R.?

With regards to the Urgent Care issue, my wife (who has hypertension and family history of renal failure) was sent immediately to the ER by the physician at an urgent care clinic she stopped in once when she was feeling bad. But I think that decision might factor, for the urgent care physician, more with the history of the patient and what they discover on initial workup more so than any one set policy. I could be wrong about this.

On the issue of calling 911, I have worked for several years in 911 Centers (and while I am currently unemployed I am still a certified emergency medical dispatcher), and can say that it is NOT an invasion of patient privacy for you to call 911 and request an ambulance for anyone you feel needs one. The paramedics can not treat a patient that is competent to refuse, but they will access the patient when they arrive on the scene. It is possible that they might be able to convince this student that they need to go to the hospital.

My father-in-law who had to undergo a kidney transplant due to renal failure caused by untreated hypertension was completely asymptomatic until his kidney's shut down. It might be rare for that to be the case, but it is how it happened with him.

I think there is a innate danger with assuming that a rise in blood pressure in a student is ONLY being caused by stress from school or work obligations. Not saying anyone has taken that approach on here, but thought I would throw that out there anyway.

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