Nsg care of hypotensive pt

Blee O'Myacin, BSN, RN · Dec 24, 2007

I'm a new nurse, about 1/2 year experience and... I had a hypotensive pt the other day BP dropped very low, I called rapid response. My charge nurse told me today that there are certain things I could have done in the moment. She gave a few suggestions but I was so preoccupied and nervous they just went in one ear and out the other. I got home today & started looking through my nursing books but couldn't find a clear answer. Should i have lowered the bed, other than calling rapid response, what could I have done?

Better that you called a rapid response early than a code later in the shift.

Talk to your charge nurse again - tell her that when you last talked you were preoccupied with caring for that patient and you want to know what you should do the next time this happens so that you are on the same page with unit policy. You are a new nurse. Bad things happening are still going to throw you through a loop - it just means that you need more time to learn and experience things. Your charge nurse trying to teach you is a good thing - but it was just poor timing. No one's fault, but do follow up. Check your unit policy about what you can and can't do. Protocols exist in the ICU and ERs that won't fly on the floors. I got floated to tele one day (bless all of you, by the way), and started a fluid bolus without an order. I got one after the fact, but I was told "YOU CAN'T DO THAT HERE!!!" by a very flustered, yet understanding nurse manager. We wound up sending that patient to the unit from where I was re-pulled and stayed with the patient for the rest of my shift. So it all worked out - but my point is this - find out what you are *supposed* to do, within what's acceptable on your unit.

On another note all together, does anyone else find it odd that we all accept the machine reading when the patient seems "fine", but as soon as it isn't, we all run for the manual cuff! I understand that we are ruling out a machine malfunction, but it still seems funny. (not "ha-ha" funny, just weird funny) - just me? Nevermind then...:trout:

Blee

EmmaG, RN · Dec 24, 2007

I was told "YOU CAN'T DO THAT HERE!!!" by a very flustered yet understanding nurse manager. We wound up sending that patient to the unit from where I was re-pulled and stayed with the patient for the rest of my shift. So it all worked out - but my point is this - find out what you are *supposed* to do, within what's acceptable on your unit.[/quote']I was pulled to a med/surg unit and found one of my patients with a BS of 16. Not a typo--- sixteen. He had no IV access, and as the charge nurse stat paged the doc (no standing orders for low glucose either), I started a large gauge heplock. She hollered at me because 'WE DON'T HAVE AN ORDER TO STICK THAT PATIENT!' I told her I could pretty much guarantee we'd have one once the doc returned the page

GrumpyRN63, ADN, RN · Dec 24, 2007

I was pulled to a med/surg unit and found one of my patients with a BS of 16. Not a typo--- sixteen. He had no IV access, and as the charge nurse stat paged the doc (no standing orders for low glucose either), I started a large gauge heplock. She hollered at me because 'WE DON'T HAVE AN ORDER TO STICK THAT PATIENT!' I told her I could pretty much guarantee we'd have one once the doc returned the page

She must also want you to get an order before calling a :trout:code

GrumpyRN63, ADN, RN · Dec 24, 2007

I think it all depends on the whole picture, pt's age, dx, med hx etc. First and foremost recheck the BP, how does the pt look, tachycardic?,bradycardic? febrile? asymptomatic? dizzy? fluid status? Sometimes you need a cardiac intervention, sometimes position, lay flat, Have IVF running, openthe line, sometimes nothing, some pt;s will be perfectly healthy at 80/50 or even lower,you really need a better picture of what was going on w/this particular pt scenario

Even if you 'jumped the gun',(and I don't know if you did or not) It was still much safer for the patient to go that route, than to have someone who ignored the hypotension in a sick pt leading to a bad outcome. As you gain experience, you'll get more comfortable with these types of issues. You may want to aska more experienced nurse (If available), or call a resident ( if available) first,

If your gut tells you call rapid response, than call--better to have 10 men on death row than execute one innocent man... as in nursing--better to call 10 codes then send one pt to the morgue

pagandeva2000, LPN · Dec 24, 2007

I remember reading to lay them flat and to raise their legs.

Crocuta, RN · Dec 24, 2007

The latest literature does not support the use of trendelenburg or modified trendelenburg to treat hypotension and low cardiac output.

Do you have some citations at hand?

Thanks!

gwenith, BSN, RN · Dec 24, 2007

I agree with those that say do not use trendelenberg positioning. Although the old saying "Head pale raise the tail, head red raise the head" is still OK - it simply means raise the legs but do not put the patient head down.

http://209.85.173.104/search?q=cache:9qk65Y-M8rQJ:www.caccn.ca/Abstracts_2005/33)%2520Trendelenburg,It%27s%2520Time%2520To%2520Change%2520Our%2520Position.doc+trendelenburg+hypotension&hl=en&ct=clnk&cd=1&gl=au&client=firefox-a

http://ajcc.aacnjournals.org/cgi/content/abstract/6/3/172

not now, RN · Dec 24, 2007

I recently had a patient with a BP of 70/40 manual. Couldn't take it on the other arm, he had a fresh faciotomy (sp?) from about mid forearm up most of his upper arm. I took his BP at 2100 for maintenance meds and it was 110 systolic so I gave them. When the CNA did midnight vitals was when the BP was 70/40 (not tachycardic, HR in the 60's). He felt fine but looked like crap. This was the first time I'd ever had him. Apparently his wound had been bleeding for three days, the AM nurse changed his dressing and when I came on he had a big puddle of blood under his arm (Yes, I showed it to the team lead). He said he felt fine.

There was no IV. He was not only a very difficult stick but the two working IV's were pulled for being five days old. He got compartment syndrome from IV starts and the MD was worried about further problems. Rather than put in a central line the MD said he'd be fine without one and wanted the old IV's pulled.

Anyway, I called rapid response after I put him flat. The ICU and house supervisor looked at me crazy because he wasn't in trendelenberg. (I wasn't gonna say anything about that since I'm new and that was not the place for debate. It helped while he was in it but about 30 minutes after the team left he was back at 68 systolic) Someone finally started an IV we got labs, bolused him and I ended up giving two units for a Hbg of 6.2.

I'm still confused why he wasn't tachycardic.

Valerie Salva, BSN, RN · Dec 26, 2007

I was pulled to a med/surg unit and found one of my patients with a BS of 16. Not a typo--- sixteen. He had no IV access, and as the charge nurse stat paged the doc (no standing orders for low glucose either), I started a large gauge heplock. She hollered at me because 'WE DON'T HAVE AN ORDER TO STICK THAT PATIENT!' I told her I could pretty much guarantee we'd have one once the doc returned the page

Man, what is a pt doing in the hospital without IV access, especially a diabetic pt?

I agree with your actions- save the pt now and get an order later.

CritterLover, BSN, RN · Dec 26, 2007

i recently had a patient with a bp of 70/40 manual. couldn't take it on the other arm, he had a fresh faciotomy (sp?) from about mid forearm up most of his upper arm. i took his bp at 2100 for maintenance meds and it was 110 systolic so i gave them.
i'm still confused why he wasn't tachycardic.

what meds did you give him?

since you were checking the bp before giving them, i'm guessing that you might have given him a bp med?

many bp meds will lower hr as well. beta blockers, clonidine, and norvasc are three common ones.

beta blockers, especially, will prevent reflex tacycardia when bp drops.

gwenith, BSN, RN · Dec 26, 2007

I recently had a patient with a BP of 70/40 manual. Couldn't take it on the other arm, he had a fresh faciotomy (sp?) from about mid forearm up most of his upper arm. I took his BP at 2100 for maintenance meds and it was 110 systolic so I gave them. When the CNA did midnight vitals was when the BP was 70/40 (not tachycardic, HR in the 60's). He felt fine but looked like crap. This was the first time I'd ever had him. Apparently his wound had been bleeding for three days, the AM nurse changed his dressing and when I came on he had a big puddle of blood under his arm (Yes, I showed it to the team lead). He said he felt fine.
There was no IV. He was not only a very difficult stick but the two working IV's were pulled for being five days old. He got compartment syndrome from IV starts and the MD was worried about further problems. Rather than put in a central line the MD said he'd be fine without one and wanted the old IV's pulled.
Anyway, I called rapid response after I put him flat. The ICU and house supervisor looked at me crazy because he wasn't in trendelenberg. (I wasn't gonna say anything about that since I'm new and that was not the place for debate. It helped while he was in it but about 30 minutes after the team left he was back at 68 systolic) Someone finally started an IV we got labs, bolused him and I ended up giving two units for a Hbg of 6.2.
I'm still confused why he wasn't tachycardic.

If he was on Beta Blockers he may not have been. Beta Blockes sometimes "mask" the symptoms of shock by preventing tachycardia.

martymoose, BSN, RN · Dec 28, 2007

The latest literature does not support the use of trendelenburg or modified trendelenburg to treat hypotension and low cardiac output.

i guess i should have specified we only use mod. trendelenburg in a vagal response, and when we know the pt is not having neuro issues.