Should I worry???

  1. Ok, here's the situation......2 days ago I took care of a 54 y.o male patient who had a lap chole POD #2, except for history of prostate enlargement and depression, this patient is otherwise healthy and stable. During my morning assesment his vital signs are stable, bowel sounds active, soft abdomen, passing gas, 4 abdominal puncture wounds CDI, not in any distress. Then on my noon vitals, his BP got elevated to 202/103 (right arm) 198/101 (left arm) (patient did not have any complain of any pain, headache, neck pain, chest pain, palpitations, SOB..in other words he's stable and assymptomatic) rechecked his BP after 15 minutes, BP still elevated at 186/98 and 178/72 (patient still assymptomatic)...I told my Charge Nurse who then placed a call to the surgeon...1/2 hour later Surgeon called back and I made him aware of the patients status...MD ordered 1 time dose of 10 mg Norvasc PO and stated he will come and evaluate the patient will discharge him home and pt to follow up with his PCP about his BP (per patient did not have any history of HTN)...Norvasc was given to the patient, instructed patient to relax and elevated HOB. 1 hour later, I rechecked his BP, BP still elevated 182/78, this time the surgeon came and evaluated the patient and discharged patient (he talked to him about his BP). All this time patient remained stable and assymptomatic, no complain of any distress. Prior to discharge, I took his BP again ( aprroximately 3 hours since Norvasc was given), BP still elevated this time 198/103, I did not feel safe sending this patient home with how his BP reading were, so I placed another call to the MD and made him once again aware...MD stated "It's ok, send the patient home. I really can't do anything with the patient's BP..anyways gave him some BP meds to go home with and he will need to follow up with his PCP. It's okey he can go home". I asked my CN who then said "well, if the MD said send him home, then send him home..just make sure you write good documentation on that". So, I then preceded to discharge the patient even if I felt I should not. I stressed to the patient to follow up with his PCP and to take his meds as prescribed and if he feels something is wrong once he gets home to go to the nearest ER stat. Patient agreed. He left the hospital stable and assymptomatic. To this day, I'm still doubting my judgement...of sending this patient home with that kind of BP....Feedback please.....I'm really concern....I felt like I was not a good advocate for this patient.
    •  
  2. 14 Comments

  3. by   Liddle Noodnik
    Quote from KulRN
    I asked my CN who then said "well, if the MD said send him home, then send him home..just make sure you write good documentation on that". So, I then preceded to discharge the patient even if I felt I should not. I stressed to the patient to follow up with his PCP and to take his meds as prescribed and if he feels something is wrong once he gets home to go to the nearest ER stat. Patient agreed. He left the hospital stable and assymptomatic. To this day, I'm still doubting my judgement...of sending this patient home with that kind of BP....Feedback please.....I'm really concern....I felt like I was not a good advocate for this patient.
    I would feel that way too KulRN, but there wouldn't be much else you could do. I think you followed through well especially that last call to the doc and checking with your CN.

    Did he deny anxiety? Not that anxiety should elevate the BP THAT much... Well, I hope he did check in with his PCP (who will probably yell at the surgeon!)
  4. by   KulRN
    thanks zoeboboey for replying...yep , i asked the patient if he was anxiuos quite a few times and he said " i feel fine"... he was vey stable for somebody with a bp like that. yeah, i really hope he followed up with his pcp....my other concern too is that i'm sure my don will come across his chart and sees that this patient's bp was elevated and still was sent home, she will go nuts and pin me down and will make me feel less of a nurse...
  5. by   Liddle Noodnik
    Quote from KulRN
    ....my other concern too is that I'm sure my DON will come across his chart and sees that this patient's BP was elevated and still was sent home, she will go nuts and pin me down and will make me feel less of a nurse...
    Just write down that "patient denied x,y, z ...", what you said to the doc each time you called, and what he said; what you said to the CN and what she said; what your vitals were; and what teaching you did with the patient. You did all you could do and if it's documented the DON will know that too. Make sure your meds are charted on your med sheet too. If the DON has more questions she can "pin down" the CN or the doc, lol.

    Sometimes we feel like we could/should have done more, but sometimes you just can't Stinks, don't it.

    You did a good job!
  6. by   GardenDove
    As long as you documented your discussions with the doc, you DON is FOS if she rags on you. Good idea to also chart "charge nurse aware".
  7. by   meownsmile
    Why wasnt the patient given a consult to a cardiologist or even a GP there at the facility. That is what we would have done is had him seen by someone willing to address the blood pressure prior to discharge and he probly would have been kept at least another day to make sure the BP was stable on any new meds.
    Also,, giving a dose of pain medication even if the patient was denying pain could have brought it down. Sometimes a stowic patient wont admit to pain or will not percieve pain the same way we would like them too.
  8. by   KulRN
    Oh, I forgot to mentioned that I've given him a dose of his pain med (Dilaudid 2 mg IVP) eventhough he was rating his pain to zero, hoping that his BP will go down...And I've also asked the MD to have him consulted by one of the Kaiser Doctors (pt has kaiser insurance), but MD said "he doesn't need it".
  9. by   GardenDove
    Maybe you want to discuss this case with risk management for a chart review?
  10. by   AnnieOaklyRN
    honestly people walk around with that BP everyday. I agree with the surgeon there isn't anything you can do and keeping the patietn in the hospital and repeatidly checking his BP is only going to keep it elevated as it will no doubt stress the patient out. Just my oppinion.

    Swtooth
  11. by   meownsmile
    With that, i too think risk management would be a good place to discuss this patient. I also understand, yes people walk around with BP's that high all the time but people also have strokes all the time. A blood pressure that high should have been addressed. I also understand the surgeon didnt want to keep the patient, he had done what he had the patient there to do and blood pressure isnt something he treats. We have an orthopedic like that too, dont call him for a blood pressure problem or you may get screamed at so loud they will hear it into next week. But that is also when you advocate for your patient and request they order a consult for the blood pressure problem. If they still wont you can document you suggested a consult that was refused and the ball is back in the doctors court if they guy goes home and has a blow out because of his blood pressure.
  12. by   Liddle Noodnik
    Quote from swtooth
    honestly people walk around with that BP everyday.
    Well, this guy never HAD hypertension tho. I think it was worth looking into. But I don't think there was anything else the OP could have done anyway.
  13. by   GardenDove
    Incidentally, this very same scenario happened to me once, the pt was an outpatient sx that I ended up doing the second stage recovery for. All of a sudden he developed high BP, which he had never had before. In this case the surgeon said to contact his primary. I called him and he came over himself and saw the pt before he sent him home.
  14. by   rita359
    The surgeon was not going to do anything else per current standards. From a surgical standpoint the patient was ready for discharge. It would have been a good idea to find out who the patients primary care doc was, give patient copy of bp readings and advise patient to immediately call primary care physician for appointment. Might also educate him regarding normal bp readings. That way you have done all you can do after documenting same and it is up to patient to follow up.

Must Read Topics


close