I think I made a mistake

Been there,done that, ASN, RN · Nov 9, 2012

What is the baseline blood pressure and is there any history of cardiac or renal disease?

RNikkiF · Nov 9, 2012

Baseline BP 160s or 170s over 90s. Baseline HR one-teens but varies up to high130s but comes back down. Today HR was steady 128-138.

RNikkiF · Nov 9, 2012

No hx of cardiac issues but hx positive for CVA during surgery. No renal disease.

Been there,done that, ASN, RN · Nov 9, 2012

If the baseline heart rate is in the 110's ... you came into unresolved issues. No patient stays above the norm of 60 to 100.

The baseline BP is also not in normal range.

Your patient has an ongoing issue that has not been addressed. The doctor was treating the numbers, not the patient.

What setting is this? Hospital or home care?

RNikkiF · Nov 9, 2012

His VS are so far out of parameters d/t traumatic brain injury. I work in an LTAC hospital. I guess I'm just trying to figure out if giving the hydralazine was a mistake. In hindsight it is but it seemed like the right thing to do since it starts working so quickly. Md wasn't too happy that I was "so aggressive" in treating the BP and he dc'd the hydralazine after this situation. Can't figure out why it was ordered if he didn't want aggressive tx???

Aurora77 · Nov 9, 2012

I think the mistake was giving both the scheduled and PRN meds at the same time, or so close together. The metoprolol would treat both BP and HR. I'd have given that then rechecked in a couple hours. It's easy for me to say since I wasn't there and I don't work with TBI patients. But, I do have plenty with HTN and cardiac issues and this is generally my approach.

eatmysoxRN, ASN, RN · Nov 9, 2012

I'd have given both as well. Metoprolol doesn't seem to effect bp quickly and is used mostly for hr. Did you check that super high and low bp in both arms?

jadelpn, LPN, EMT-B · Nov 9, 2012

Metropolol comes 2 ways, extended release and not extended release. I would be curious if one can crush extended release metropolol, as I have heard of splitting it, but not crushing it. Anyways, the extended release has a much slower onset when given PO in whole tablet form. If you thought you were giving extended release, and it was not, then it would act more quickly as well. That is why in our setting, MD's have to specify in the order. (XR or Succinate/Tartrate--????---can't recall which is which----too little coffee....). And obviously, if the patient has a tube, whether you are to crush or give whole--which I think (I think) most meds are crushed for the tube, but get an order to specify. However, the hydralazine was a specific PRN if patient fell out of parameters. So no, in my opinion you did not do the wrong thing as far as medicating with a PRN set up for the purpose you describe. That the MD now has d/c'ed the order, should the patient be that all over the place-- I would have probably spoken with MD about assessing patient for higher level of care. This patient seemed to be very medically unstable, and perhaps ICU for monitoring. Additionally, look at the whole picture. Is he propolaxis for A-fib? Lovenox or coumadin? I would be afraid of an additonal bleed, which you were, so you were acting in the best interest of this patient, agressive or no. Especially when the HR is that high. I would also think about should this scenario happen again, there perhaps should be a plan in place for IV medications for rate and BP control. which should perhaps happen in the ED or ICU. If the MD doesn't want you to agressively treat this stuff, then what is it exactly that he wants you to do? Get your charge nurse involved in this case. You can not have too many specific orders for a patient that is this unstable. If the MD is dancing around comfort care, then that needs to be settled. I would not be afraid to call a rapid response the first time you see vitals this far out of range, even for a brain injured patient. And do involve your charge nurse--two sets of eyes and two assessments are better than one, and no one should be left in the weeds to manage this unstable patient alone.

RNikkiF · Nov 9, 2012

I appreciate the feedback. I barely slept last night thinking about this pt. One thing is for sure. This was definitely a learning experience and I will think long and hard about giving a prn BP med in the future without specific instructions to do so from the md's mouth regardless of orders.

edmia, BSN, RN · Nov 9, 2012

I need some feedback here. It was the first time I have ever cared for this patient. He had a GSW that lead to a brain injury. HR was in the high 120s to high 130s consistently. Called the MD three times, got an order to increase free water via g tube from 100 ml before and after TF bolus to 150 ml TF bolus. Administered prn pain meds with no effect on HR. MD just wanted to watch HR and continue to give prn pain meds to see if it helped. HR stayed high and around 1720, I checked pt's BP prior to giving scheduled metoprolol 75 mg. BP was 200/115, HR 138. Administered metoprolol per mar and saw an order for hydralazine 25 mg prn give for SBP > 180 or DBP > 100. Pt fit both parameters, so I gave it. My rationale was to prevent CVA or clot and A-Fib. Checked bp and hr q15. Was gradually coming down. At 1800, had CNA check BP, which was 62/58. Patient opened eyes to verbal, same as all day. Put pt in trendelenberg and paged MD. CNA checked BP again. Increased to 70s/60s. MD ordered 1L NS 250 ml bolus, finish bag at 100ml/hr. Within 10 min of starting IVFs, BP increased to 100/60.
All of this happened at end of shift (of course). In retrospect, I shouldn't have given the hydralazine, but I knew it would be a while before metoprolol kicked in and hydralazine would work faster... I'm asking for constructive criticism, not attacks, please advise as to what I should have done differently. Should I have NOT given the hydralazine?? That's what my gut says.

I don't think you made a mistake. Next time you should give hydralazine IVP first and check bp q 15 mins. If that high bp is not under control within 30 mins, your patient could stroke out. Waiting 2 hours with a high diastolic as someone suggested is not ok.

Maybe the PO metoprolol could have been held, but listen, there are other issues here. That increased hr was not addressed by the md correctly. He added free water? So, he was thinking the guy was low on fluids but took a very conservative approach to treating that. He bottomed out because he needed fluids as he quickly responded to the bolus. The bolus should have been ordered for the tachycardia hours before and maybe his bp would not have become so elevated in the first place. His body was trying to maintain perfusion with little fluid in the tank, so of course his hr and bp were high after hours of trying to compensate.

You prevented a stroke by using hydralazine . Saving brain was the priority here. It wasn't perfect that the PO metoprolol was given as well, but all that did was expose the true underlying problem of untreated hypovolemia. Don't beat yourself up.

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RNikkiF · Nov 9, 2012

Thank you for your opinion! I asked for ivfs early on but b/c pt most likely has pneumonia, the md didn't want to overload him. Other than changing when I administered the meds I don't think I could have done anything differently.