What the heck is this doctor thinking? Actually not thinking!

  1. I have a new home health patient who is elderly he/she was admitted post hospital stay for syncope and resulting fall. He/she has a orthostatic BP's to the tune of Lying: 220/116 Sit: 240/120 Stand: 178/112. I noted that the patient was eating a diet high in sodium, canned soups, salted peanuts, bacon, etc...Naturally I called the doctor. He did not order any meds. Said "no this pt doesn't need to come in for a visit" and he/she can have all the salt he/she wants. The only order was to decrease the pt's dose of Flornef and continue to keep him informed of the orthostatic readings.

    What the heck? I documented, documented and documented some more. I also put all this in a fax and have the fax confirmation in the patients chart.
    BP was WNL in hospital. Orthostatic BP's at admit visit and visits x 2 following were also very very elevated and doctor was notified. No orders.

    I can't force this doctor to do anything and I can't tell the patient to get a new doctor. I can't do anymore than I have. I did tell the patient to limit his/her salt intake even though the doctor said it was ok.

    Do you have any suggestions?
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    About DutchgirlRN

    Joined: Aug '04; Posts: 6,708; Likes: 1,448
    Medical Imaging RN~Special Procedures CT
    Specialty: 33 year(s) of experience in OB, M/S, HH, Medical Imaging RN

    30 Comments

  3. by   jnette
    Wow, Dutch, that's outrageous. :stone

    You did the right thing by telling the pt. to SEVERELY limit sodium intake (give him some handouts on hi-sodium foods to avoid!) and by calling the doc, etc.

    I really don't know WHAT this doc is (not) thinking! I imagine he has been following this pt. for some time? Is there sth. he knows about this pt.'s hx. that you all don't?

    I'd be tempted to ask him WHY this is not a concern. What have you got to lose?
  4. by   P_RN
    How old is the patient? Has she been known to be noncompliant before? That's not a good doctor patient situation.
  5. by   muffie
    wowee
  6. by   Cattitude
    you asked this doc to do something. he chose to do nothing. still, you are doing your job and he is not.
    [color=#483d8b]

    [color=#483d8b]i may have called the doc and told him about the bp and that i would either send the pt. to him or to the er, which did he prefer? that would have kind of prodded him into doing something.

    [color=#483d8b]now i know this is tougher for your cases as they have just come home from the hospital, but really, the dr. needs to do something.
    [color=#483d8b]a person with no hx. of htn certainly does not need to not be treated and be told to eat all the salt they want.
    [color=#483d8b]has the pt. ever been treated by a cardiologist before? if so, maybe they could make an appt? it wouldn't have to be the primary following up on this right?
    Last edit by Cattitude on Feb 21, '07 : Reason: changed thoughts
  7. by   caldje
    Without more information I cant honestly say the doc isnt doing what he's supposed to. We have to remember that there are many things we dont know. For example, the vast majority of hypertension is not sensitive to salt intake AND low sodium can actually increase the risk of renal complications when on certain meds. Like I said, a full case presentation of this patient, leaving nothing out, and I think we might find that the doc is not being "bad." Give the guy a break, you wouldnt want someone treating you like you're treating him.
  8. by   Cattitude
    Quote from caldje
    without more information i cant honestly say the doc isnt doing what he's supposed to. we have to remember that there are many things we dont know. for example, the vast majority of hypertension is not sensitive to salt intake and low sodium can actually increase the risk of renal complications when on certain meds. like i said, a full case presentation of this patient, leaving nothing out, and i think we might find that the doc is not being "bad." give the guy a break, you wouldnt want someone treating you like you're treating him.
    isn't is something like only 30% of hypertensive people are salt sensitive? but still that was a high bp and on several occasions. you would think the doc would at least have said, "let's hold off on giving any meds right now because blah blah blah" give the poor nurse something!!!!
    [color=#483d8b]
  9. by   DutchgirlRN
    Quote from jnette
    Wow, Dutch, that's outrageous. :stone

    I'd be tempted to ask him WHY this is not a concern. What have you got to lose?
    Thanks jnette, I think that's a very good idea! I better ask my DON first if that's ok.
  10. by   DutchgirlRN
    Quote from casbeezgirlrn
    [color=#483d8b]i may have called the doc and told him about the bp and that i would either send the pt. to him or to the er, which did he prefer?
    that's what i did and he said no need to come in and certainly no need for the er. :uhoh21:
  11. by   twinmommy+2
    Quote from casbeezgirlrn
    isn't is something like only 30% of hypertensive people are salt sensitive? but still that was a high bp and on several occasions. you would think the doc would at least have said, "let's hold off on giving any meds right now because blah blah blah" give the poor nurse something!!!!
    [color=#483d8b]
    even if only 30% of the general population are salt sensitive, it would be prudent to eliminate it as the source wouldn't it? and say if this person were a minority such as african american or native american, doesn't that percentage go up for those populations?

    but on the other hand was he showing other symptoms? dizzyness, spots before the eyes, headache? perhaps the dr. was worried about adding a new med and having the pt plumet too much?

    just wanted to advocate for both sides here.
  12. by   DutchgirlRN
    Quote from caldje
    Without more information I cant honestly say the doc isnt doing what he's supposed to. We have to remember that there are many things we dont know. For example, the vast majority of hypertension is not sensitive to salt intake AND low sodium can actually increase the risk of renal complications when on certain meds. Like I said, a full case presentation of this patient, leaving nothing out, and I think we might find that the doc is not being "bad."
    Dangerously high BP is all the clinical information I need to know. This has been going on for a week. What more info does this doc need? What if this were your elderly Dad/Mom? I'd be having a fit. I would have already taken them to the ER after the first severely elevated set of orthostatics and fired the doctor.

    Give the guy a break, you wouldnt want someone treating you like you're treating him.
    Just how am I treating him badly? I followed his order to keep him informed of the BP's. I wasn't rude in any way. I asked if the pt needed to come in or go to the ER. My concern was for my patient. I never treated the doctor badly. The fact that I think he's totally incompetent is something he'll never hear from me. I know my limits.

    Lets review the basics of hypertension:

    HTN is the silent killer... high blood pressure left uncontrolled, causes fatal heart attacks, sudden cardiac death and strokes. If you have high blood pressure, the increased pressure of blood flowing through your arteries can cause a variety of problems, including arteriosclerosis, an aneurysm, kidney failure, damage to the heart such as coronary artery disease, heart failure and an enlarged left heart. Just like your heart, your brain depends on a nourishing blood supply to function properly and survive. High blood pressure can cause several problems, including: Brain bleed, transient ischemic attacks, dementia due to the extensive narrowing of the arteries that supply blood to the brain. The kidneys are responsible for filtering and excreting excess fluid and waste from the blood. These processes are highly dependent on blood vessels. HTN compromises both the vessels leading in and out of the kidneys. HTN is the leading cause of kidney failure.
    HTN damages the eyes. The tiny delicate blood vessels that supply blood to the eyes are vulnerable to the damage of high blood pressure.

    In some patients the blood pressure rises so quickly and severely that it constitutes a medical emergency requiring immediate treatment.
    Last edit by DutchgirlRN on Feb 21, '07 : Reason: Spelling
  13. by   DutchgirlRN
    Quote from twinmommy+1
    But on the other hand was he showing other symptoms? Dizzyness, spots before the eyes, headache?
    Dizziness yes, Syncope yes, Falling yes, Headaches yes. He/She has CNA's 24/7 who can take the BP at any time. I doubt a small dose of Lopressor would plummet this patient. Something is obviously causing the sudden severe hypertension and I feel like this pt should be back in the hospital for extensive testing to find the cause. Sorry I totally disagree with this doctor. My documentation is complete so he's not going to blame any of this on me.
  14. by   stsdoc
    Please allow me to explain. The pt you are taking care of suffers from orthostatic hypOtension, ie a severe drop in blood pressure upon standing, which is no doubt what caused the syncope/fall which caused the pt to be admitted in the first place. Now this can be caused by any number of things: medications, autonomic insufficiency d/t diabetes/stroke, adrenal insufficiency, but the common factor is decreased intravascular volume (ie low bp).

    The treatment of choice for this condition is florinef, which increases blood pressure by acting like aldosterone, a hormone made by the adrenals which increases the reabsorption of sodium by the kidneys, thus raising intravascular volume. This is often used in combination with a high sodium diet to treat this condition.

    The physician acted appropriately in telling you to reduce the dose of florinef, as this (and this alone) is probably what caused the spike in bp in this patient with orthostatic hypOtension. He also acted appropriately in not ordering any meds which would acutely lower the blood pressure, as this would just again increase the chances of another orthostatic episode/fall. If the pt was not symptomatic from the HTN with headache, visual changes, etc, then continued monitoring of bp is all the treatment needed. The bp should come down with decreased florinef.

    Sorry for the long post, but I just wanted to show that there is a method to our madness

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