Help! I think I'm going to accidently hurt or kill someone

[HollySue061566]

Help,

I'm a new graduate nurse who has been training for five weeks on a busy med-surg floor. I think that it is just a matter of time before my ignorance hurts or kills someone. Last night I had a new surgical patient who came back with a blood pressure of 188/85....his previous one an hour before was 153/70 (he tended to run high and most of his blood pressure meds were held that morning for the surgery....his pressures were in the 160's/80's in the OR and recovery). His pain level had also increased from a "5" to a 10 during that time frame. Stupid me....I gave him pain medication and his beta blocker....I didn't know that there was a hypertensive emergency protocol at my workplace. I feel so bad....I recognized the pressure was high and took action, but I didn't take the right one. I didn't know that a call to the care provider was also required for any blood pressure over 160/80. I am so scared and need advice. I feel nursing school taught me how to recognize a problem, but not the proper steps to take to address it....

Can anyone suggest a book...or a website that describes the steps one should take? Even a few shared "tricks of the trade" would be greatly appreciated.

I am making myself sick with fear and worry.

Thanks,

Holly

[calivianya, BSN, RN]

I don't think you did anything wrong, and I think that nurse who got after you made an error in judgment. You can't just start a hypertensive emergency protocol on ONE elevated blood pressure, and that when the patient is in pain. If the patient's pain was controlled, and his systolic was still over 180, that would warrant investigation. A 180 in a fresh post op who is in a lot of pain is not.

I would not have called the physician for one pressure over 180 either.

[nurseprnRN, BSN, RN]

You realize that if you run up two or three flights of stairs, your BP will probably be in the 180 systolic range, too? True. BP is not a static thing. And you will not die, assuming you don't have a very fragile leetle berry aneurysm in your posterior fossa. :) Neither will your patient. One data point is not usually worth spit, because it's trends that are important. Although there are some individual data points that should make you sit up and say boy-howdy, this is not one of them. :) You'll learn that with more experience, really, you will.

People are tougher than you think. Including you. You are having a hard time with limits, expectations, and consequences because you are new and you have so little data to work with.

Of COURSE you aren't an expert nurse yet.

Of COURSE you're feeling your way.

Of COURSE you're nervous.

We're actually a lot more nervous about a new grad who isn't nervous, because they are blithely unaware of just about everything.

Breathe. Do NOT make yourself crazy by being surprised that you are not perfect, or that you are a special case because of it. There isn't a nurse you can see that hasn't been in exactly your shoes. Chill. This will get better. When you've been a nurse for a year and you're welcoming next year's crop of new grads, you'll have more empathy for their twittiness because yours will still be in recent memory, and perhaps you'll be able to reassure them the way we're trying to reassure you.

{{hugs}}

[BrnEyedGirl, BSN, MSN, RN, APRN]

Holy cow girl,..breathe!! That BP wouldn't even get me excited and I would not have thought hypertensive emergency with that BP in a post op pt who hadn't taken his meds,...or not in anyone really,....you are on the right track,..learn your units protocols,...you wlll get there!

[sweetmuffin48]

Now you know, and you will never make the same mistake again. Every place has it's own policies and it takes a while to learn them. The patient is ok and you medicated them for pain which was the right thing to do because that is probably what made the blood pressure go up. When I was new I had a little flip book of index cards of ranges in which it is appropriate to notify the doctor whether it be lab values or vitals. If I learned something new or gave a med that I have not given before...I would go home and look it up.

[babilidose]

Try and stay calm. First of all, talk to your preceptor. I always remind my orientees that just because our time is over, it doesn't mean I stop being a resource. Utilize your resources. Ask questions. You're not going to know all the policies. You learn as you go. Everyone has duhhh moments. Take them as learning opportunities and don't be so hard on yourself. If you act how you're sounding on your post, you'll worry your patients. You're a new grad. We all made mistakes. Sounds like you might not have gotten a good orientation.

[kanzi monkey]

Hypertensive emergency suggests end organ damage with SBPs over 180 (ie, heart or kidney failure, focal neuro exam, etc)

Your patient had post op pain which was likely contributing to the htn (though i wasnt there, so can't be certain, obviously). Managing with the patient's own home BP controlling meds and pain medication is completely appropriate as a second step (the first being quickly assessing your patient for other frank cause of acute distress, which you probably did)

If your institution's policy is to page a provider with lower parameters, well, now you've learned them. ;-)

No harm done.

[Been there,done that, ASN, RN]

You took two very good actions, well thought out. Is the 160/ 80 parameter standard to the unit... or post op orders?

You state you have been in training for 5 weeks? Please elaborate.

[nurseprnRN, BSN, RN]

Another thing that will increase BP is ... Opioid withdrawal. He was taking Norco regularly, eh? And c being NPO for surgery, what would he likely do? And how effective would the usual doses of pain meds be for him? And then what?

[eukaryote]

I think you did the right thing. You assessed the pt's vital signs and found he had a high blood pressure and increased pain. You gave the blood pressure medication that was scheduled *at that time* and gave appropriate pain medication per the order. His blood pressure could have been elevated because of pain, or because he was due for a blood pressure med, or some other reason. I would have done the same thing, and then rechecked the blood pressure in 30 minutes, and then an hour. If it was still elevated, then I would have initiated the protocol.

If I had called the doctor right away, the conversation would go something like this.

"Hi doc, my pt's blood pressure is 188 systolic. They are in pain and have a blood pressure med scheduled."

Doc: "Did you give the med?"

"No, not yet, I'm instituting the hypertensive protocol."

Doc: "Well give the med and call me if it's still high in an hour if it's still elevated. Click."

[canoehead, BSN, RN]

Medscape: Medscape Access

By common definition this was NOT a hypertensive emergency, and you did exactly what I would have done. OF course if your policy is different you have to abide by it. Still, it's a stupid policy.