Should I have pushed Doc for more?

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Hello,

I am a new nurse - 3 months out on my own - and I just had my first experience with a patient changing condition rapidly while on my shift. It was the first time that I did not want to leave after my shift because I wanted to stay with that patient. Now, I am looking back and wondering what I could/should have done.

Here is the story:

Pt is transferred from a step down unit to me on the tele floor around MN. I get in report that she has high blood pressures (190s/80s) but is asymptomatic. Her first BP for me is 205/90s, she denies HA and dizziness, and I give her Hydralazine. 3 hours later her pressure is 228/90s and she is complaining of throbbing in her head.

I call MD, he tells me he is aware she has high BP and that I should have gotten that information from step down. I tell him I am calling because the BP is higher than it has been since she was admitted and because she is symptomatic. He says to give hydralazine.

I give hydrazine and when I come back to recheck BP, pt is at 205/90s. Pt is lethargic and unable to open eyes on command. Blood sugar is 110. Sats are over 95%. I tried to do a quick stroke assessment - smile, push pull etc. But cannot because pt is unable to participate. As I am preparing to call the MD we hear the pt screaming from the nurses station. WHen I walk into room, pt is sleeping and clearly having a vivid dream. I am able to awaken her, but she goes right back to sleep.

MD is called. He comes to floor to assess pt. Determines that pt is anxious and asks me to give her Xanax and her am BP meds early (this is now 4am). My inner voice is screaming -- "there is something wrong with this pt!" So, I tell the MD again that this patient was alert and conversing with me less than an hour ago. He is able to get minimal pt cooperation for a quick neuro and tells me that pt was just having a bad dream and is, in his opinion, just fine.

So, I give meds and and get help from other nurses so that I can observe pt more closely. Bp comes down to 170's. Pt still lethargic and having difficulty answering questions.

Day doc arrives at 6:30am. Assess pt and determines she is sleepy since she was transferred at MN. Doc had to manually hold pt eyes open to assess responsiveness. I again state that the patient was alert and oriented and able to ambulate at 2am - 4 hours ago. Doc decides to order a CT scan, just in case.

At shift change (7:30), pt is still in room waiting for CT when I give report to oncoming nurse. Pt is still very lethargic, knows name and date but is minimally responsive. Asks us to call her son but cannot remember son's phone number and has to think about what his name is. Nurse and I recheck BP - 205/90 and now she has a noticeable facial droop on one side.

Oncoming nurse was very kind, but in report I gave her the "well the doc says she is fine, so she is probably fine" line and when we went into the room that pt was CLEARLY not fine. I feel like I should have done more for this pt.

WHat would you do in this situiation? WHat can I do differently next time?

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Do you have a rapid response team in your facility? I would have used them.

That being said, you called the doctor several times, with appropriate updates.

You can't always get appropriate treatment ordered. Lousy doctors are every where.

It was prudent to have senior nurses assess the situation. Next time call supervision. They can take it to the chief of staff.

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Specializes in MICU - CCRN, IR, Vascular Surgery.

I agree with calling rapid response. And make sure that you documented every single time you called the doctor and what was ordered and done because of these calls!

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Specializes in SICU, trauma, neuro.

Hugs!! Sometimes with these people who have been hypertensive forever, you're not going to get a textbook normal BP--nor should you, since they can get sx of hypotension and not perfuse their brains well. Of course, 220s/90s is too high and you were right to give the hydralazine and call back when it was ineffective.

Next time, I would reassess her BP sooner after giving a prn (esp. if it was an IV med). Did they have a call parameter, such as call MD if SBP >190? If it was ineffective, call back with her VS pre- and post. Depending on what her HR was, he could have ordered prn labetalol also. Get your charge nurse involved. And call RRT when they become symptomatic, esp. if the MD drags his/her heels.

I know it's hard when the MD isn't concerned, because you are desperately hoping that he's right and she IS okay. It is commendable that you're putting yourself out there now, asking what you should do differently next time. Learning what to do in these situations comes with time, but you're going to get it faster by being so proactive! More hugs!!

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
WHat would you do in this situiation? WHat can I do differently next time?
You notified the doctor of the patient's various changes in condition and high BPs multiple times during the course of your shift. As long as you document you've been making the physician aware, there's not a whole lot else you can do.

If your facility has a rapid response team, I do agree with the others regarding calling them. Her sky high BPs, change in mental status, and your concern that something isn't quite right are three legitimate reasons to activate the RRT.

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Specializes in Pedi.

If the MD was a Resident, climb the chain of command. Chief Resident==> Fellow==> Attending if necessary. I've had to do that before.

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Specializes in ED; Med Surg.

This is why I am glad we have a "Code Stroke" Team. It is non-punitive as well, so if you call it and it is not a stroke, no worries. If you think for an instant that your patient is having a stroke, one call and you get more than the Rapid Response Team. It's great and I know it is saving lives -- from just the situation that you relate.

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Her first BP for me is 205/90s, she denies HA and dizziness, and I give her Hydralazine. 3 hours later her pressure is 228/90s and she is complaining of throbbing in her head.

WHY OH WHY would you wait 3 hours before checking her blood pressure again after giving Hydralazine? You didn't really paint a complete picture, but I've seen sun downers behave like that. One minute they are complete angels, and in the blink of an eye they turn into something completely different and it last until they get several hours of sleep.

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Specializes in CWON - Certified Wound and Ostomy Nurse.

A rapid response team would've been ideal in this situation. If you are able to do so I would file an incident report. Clearly ignoring a hypertensive crisis (knowing the medications were ineffective) is negligence. The report is important to help prevent similar occurrences. It might also lead to the development of a rapid response team if your hospital doesn't have one.

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THank you for all your responses. To utadahikaru, I did check the BP at 15 and 30 min after pushing the hydrazine. It went down to the 150's then back up again. Sorry for the incomplete picture. This pt had been at the hospital for several nights and there are no reports of her screaming in her sleep. Per the patient, this sort of thing had never happened to her before.

To others, I did not think to use the rapid team since I had already had the MD evaluate her. Great suggestion!

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Specializes in Neuro ICU and Med Surg.

Your patient met triggers to call rapid response. SBP >180 ( or whatever your facility has determined is their number), change in condition or mentation, and you were concerned about the patient. As the rapid response nurse I would have called the physician and requested a CT of the head stat for rule out stroke. I would have also called our stroke team as well. (ours is not in house 24/7)

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Specializes in Critical Care; Cardiac; Professional Development.

That would have been a Code Stroke in my facility.

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