Did I need to call the Doc?

[ChiSmile6]

I was caring for a pt the other day who had a baseline BP of 120-130/80s. The midnight BP was 94/60. I re-took it at 0100, it was 84/43. I called the surgical resident and he said it's fine, the pt is sleeping, no worries. This pt was transferred from the ICU the previous day and I saw that they had bolused him for a BP of 80/40 previously so I was a little concerned about the low BP, even though he was sleeping. I re-took the BP again an hour later it was 117/60 after the pt walked to the bathroom. I called the hospitalist a little after just to let her know bc she was medically managing, I said the pt's BP dropped last night he is only on KVO fluids b/c his oral intake is good. I told her I re-took it and the BP looked OK. She said ok, so, 117/60 is a normal BP. I said yes, she said nothing, paused, said OK, and hung up. I could tell I had woken her up, but the question is, is what I did idiotic? I felt so stupid after, really really stupid and incompetent. She made me feel as though what I did was so completely out there. I reassessed and yes the BP was ok, but does that mean everything is fine then? That it's just something I endorse to the next nurse? I have only been on my own for about a month and I work nights. I know it will take practice and experience but I just feel unsure about what can wait till morning and what needs to be reported to the doc with a phone call...does anyone have advice? I mean obviously I understand emergent situations can never wait but I seem to be having troubles with other issues a lot like BPs, elevated temps, and what not... Anyone's honest opinions are welcome, I just really want to learn.

Thank you

[proudnurseRN]

It comes with experience abd sometimes just depends. A few months ago I had a newer nurse ask about whether she should call a BP of 180/90 to the dr. Mu questions were is he symptomatic (no), has he been running high (yes, his 0400 Bps had been high the last 5+ days, had even been higher), and does he have morning BP meds (yes), and who was the doctor (a surgeon). I told her no, I wouldn't call about it based on those, I would leave a note on the chart for the dr to address in the am and pass it on in report.

She asks the charge nurse and the charge nurse said to call.

The surgeon said that he didn't handle blood pressure issues, that the family doctor or hospitalist can address that and they didn't need to be contacted that early. He said just leave a note in the chart.

You have to get a feel for the doctors and the patients history. You also have to follow orders. I remember I had a doctor jump down my throat at 1am because I called. He said, are you aware of the time? I said I was, it's 1am, but I had specific orders to call under X circumstances, and x circumstances has occurred, so there you go.

One thing I try very hard to do is think about what I might need from a doctor before 10pm. Is there a home med that needs addressed? No nausea meds and the patients been feeling quesy? 2000 temp of 99.6 with no antipyretics ordered? When I do call I ask at what point they want me to call back. If I'm calling a low B/P, give a bolus, at what B/P do you want me to call back? Do you really want abnormal labs called, or do you want grossly abnormal labs called?

Just some things I've learned along the way.

[qt2168]

What I do when I have a low bp like that is wake the patient up. No joke, I mean like flip on the bright lights and get them moving a bit. I then take the bp and if its normal I let them go back to sleep, no call to the dr. I NEVER call a dr for a good thing to tell you the truth, unless they ask me to. I think I would have probably got yelled at if I called a dr to tell him about a good bp. Its ok though because your still new. I hope you have a good resource nurse where you work because that can make all the difference.

[kanzi monkey]

Thank you MagSulfate for sharing such an important story. You did everything you could within your scope of practice, and a vague complaint that's not supported by anything in the patient's history, other complaints, or physical evidence is a nursing issue until proven otherwise. You consulted a colleague because these kinds of complaints make you paranoid, make you wonder "is there something I'm missing". But this kind of thing happens all the time. The point is that your decision to NOT call the doc was sound. Good judgement does not always equal good patient outcome. I think we forget that.

Nurses don't have a special "nursing sense". They are trained to notice things. You can't notice something that's not there. I don't think we talk about this enough. We talk a lot about those moments where nurses have a "gut feeling" that something is wrong. That "gut feeling" is based on your assessment, which MAY include very subtle signs that only a bedside nurse who knows the patient will pick up on. But the feeling is based on SOMETHING. It's not paranoia. If you can't tell if you're paranoid or actually noticing something, talk to a colleague. Or call the doc if you just feel like you have to. But in MagSulfate's story, the decision was made not to. Maybe the outcome would have been different if a call had been made. But hindsight is not always a friend to people who rely on critical thinking skills. If you make hindsight a friend, you will be crying wolf a lot, and no one will listen to you.

In response to the OP--you didn't do anything wrong. With more experience you will feel more comfortable interpreting a situation that may or may not require a page to the doc. Start by asking yourself "why am I worried about this?"--think about why the patient is in the hospital, what treatments they're getting, what the side effects might be. What's the patient's history? (ie, you interpret the significance of a low O2 sat on a young healthy pt vs. a chronic COPD pt). Has the pt had this happen before? (You noticed the pt had been bolused previously--though they do tend to bolus more in the unit than on a floor). And like other posters have said--gather your data and ask a colleague.

When I first started I paged on a patient's sodium of 132 at 2am. The patient's sodium had been between 130 and 134 for over a week. And looking back through years of previous admissions, the sodium had never been normal. It was a long time ago and I don't remember why the pt was chronically hyponatremic, but the point is it was OBVIOUSLY stable. Chronic conditions don't need urgent attention at 2am. *doh* The doc was nice about it--he knew I was new.

You will be fine.

[kanzi monkey]

I am not putting you down but I would know. You asked how would anyone know the pt was headed south. I would and I'll tell you why.

His face was shiny and he was sort of hyper alert, if anyone understands that description.

With all due respect, MagSulfate was talking about another patient.

[kimmie518]

I would have called. The patient had a pretty variable BP change from baseline and I would have about the drop just to cover my butt. She wasn't able to check urine output since the patient didn't have a foley.

The only thing I wouldn't have done was to call back to let them know it was back to baseline.....

[ChiSmile6]

thank you all-your comments make a lot of sense and are helping me see the situation from a different light-great input :)