Hypotension question

nurse678 · Mar 20, 2011

If they have fluids going I usually just set the pump to bolus some in while I run to call the Dr.

sweetER · Mar 20, 2011

Bolus on a pump = 999mL/hr.

resumecpr · Mar 20, 2011

You have to be careful not to just run in a bolus without an order because the rate (if 999ml/hr) may be contraindicated for a patient with CHF or renal failure.

You have to think critically about why this patient is hypotensive. Are they sleeping? Have they recently been given narcotics like Morphine? Anti-hypertensives? Are they bleeding? What's the MAP?

All of these are important to tell the MD if and when you call him/her.

Hope this helps. Welcome to the wonderful world of nursing!

czyja, MSN, RN · Mar 20, 2011

You have to be careful not to just run in a bolus without an order because the rate (if 999ml/hr) may be contraindicated for a patient with CHF or renal failure.
You have to think critically about why this patient is hypotensive. Are they sleeping? Have they recently been given narcotics like Morphine? Anti-hypertensives? Are they bleeding? What's the MAP?
All of these are important to tell the MD if and when you call him/her.
Hope this helps. Welcome to the wonderful world of nursing!

Absolutely.

I would add that the patient's underlying reason for being in the hospital is very important here. Are the s/p laparatomy? Uh oh, they may have bleed. Better act quick.

Are they an elder with CHF? Maybe they were over diuresed.

Are they on a PCA? Did they overdo it bit with the button? In that case, are they arousable? Mental status OK? Respiration? Wake em up a bit and recheck it. Is there a standing order for narcan? Do they need a little bit? Dont push a full vial though and mess up their analgesia.

It all depends on context. I would never adminsiter a fluid bolus a patient absent on order. It is outside of my scope of practice and I want to keep my license. Even if the pt is bleeding. There is mounting evidence that massive amounts of crystalloid can make a bleeding patient much worse.

So, quickly assess, formulate a plan, implement, and follow up. And ask a more experienced nurse or the charge nurse. If your hospital has a rapid response team they might need to be called.

RNextraordinare · Mar 20, 2011

I would not call an RRT for asymptomatic or placed them in t-berg. As mentioned if they are sleeping or getting meds that can drop the BP. You did a good job just assess the patient. As mentioned keep in mind CHF/Renal patients usually docs want to keep them on the dry side. Some healthy individuals function with lower BP's. People with very low EF's 10-15% function SBP 80's-90's. Aslong as they are mentating, Regular rhythm not tachycardic, clear lungs, skin looks good, no fever e.t.c don't get to worried but talk to the doc if you feel fluids would benefit. Remember giving 1 liter of crystalloid (NS, LR) only about 1/3 will remain intravascular after an hour. Heart patients docs around here like colloid particulary albumin, hespan. There are good articles in up to date or just googling that talk about the advantages and disadvantages of different volume replacement strategies.

ObtundedRN, BSN, RN · Mar 20, 2011

As far as the rate, if there are no special considerations where the rate needs to be limited, and the patient is symptomatic/unstable I'd consider running the fluid in on a gravity set, probably even pressure bagged. I get a little upset when someone's pressure is 60 systolic and people are running a liter bolus on the pump at 300. At that rate, it will take over 3 hours to get the bolus in. Even set at 999mL/hr, it would take a full hour to put in a liter.

casi, ASN, RN · Mar 20, 2011

I work in a very different setting so my response is a bit different. First thing I would do is investigate why they are low. Are they dehydrated (look at i/o's, skin turgor)? When did they last get BP meds? Is their pain under control? I work in TCU so we get pretty much all rehab patients. Whether it be due to pain or illness sometimes in the hospital patients end up on new BP meds because their BPs start to climb. They then come to us and as they get better they'll sometimes drop so medications need to be adjusted.

So once I get an idea of why. I want to know are they orthostatic? Sure they feel fine sitting in bed with a SBP of 80, but what happens when they stand up?

In the setting I work I would leave a note for the NP/MD with my assessment and push oral fluids on the patient. If they continued to drop or become symptomatic I would definitly get a call into the MD.

rachelgeorgina · Mar 20, 2011

Use your clinical judgement. Do you think pushing a bolus of fluid on every single patient you come across who is hypotensive is a good idea? It's already been mentioned above several times but you need to look at more than simply the numbers. Look at the patient, look at their history and their medical conditions. Are you really going to push a big fluid bolus on a CHF patient or on a patient who has had fluid boluses after every set of obs that have been done on them for the last eight hours?

I went to an interesting talk the other day on fluid responsiveness in the hypotensive patient. If you're pushing fluid and the blood pressure comes up with no change in CVP then you're patient is fluid responsive and you're doing the right thing. If the blood pressure doesn't come up with a fluid bolus or it goes up and the CVP is jumping up your patient is likely not fluid responsive and the situation needs to be reassessed. You can wear out the welcome of a fluid bolus and tip the Frank Starling curve the wrong way leaving your patient in a worse position than they were to start with.

Use your clinical judgement.

mcleanl · Mar 20, 2011

Hi all! I am a new grad (graduated in December 2010) and I need some clarification on hypotension. I understand that if your pt becomes hypotensive you lie them flat (or trendelenburg, which is somewhat controversial) and administer a fluid bolus (per MD order) but I have a few specific questions about it. I have yet to have this happen, I just want to be prepared in the event it happens to me.
So say I am getting my morning vitals and a pt's systolic BP is in the 80s (we'll say normally he/she is in the 120s) and they are asymptomatic. What would you do? If it were me I would probably recheck it, if it was still in the 80s, then I would call the doctor. Would you still lie the pt flat if they were asymptomatic?
Next, say the pt was symptomatic. What would you do first? Lie them flat then.... Call your Team Lead (or charge nurse)? Call the doctor? Rapid response?
Lastly, when a doctor give you a fluid bolus order, does he/she tell you the rate? What is normal for a fluid bolus to run?
Thanks in advance!

I work in the ICU but if I was on the floor this is how I would handle the situation

In a symptomatic patient.......keeping in mind their admitting diagnosis........how symptomatic are they? Are they a bit light headed when they stand up or are they diaphoretic/tachy and not looking so good?

Look at all their VS including temp, determine how symptomatic you think they are.....keep them in bed (flat if they tolerate it). If they are very symptomatic call rapid response.....they will be a big help.

If they are a bit light headed and you can reason that they just received pain meds, or they are febrile or their bp meds were increased there may be justification for their minor symptoms. In my experience most patients have call parameters....so call the doctor and let them know the patients vs are outside the parameters. I would let the doctor know "Mrs. Smith's bp is 80/40 she is a bit light headed, she just received her first dose of lasix 2 hours ago and has diuresed over 500cc of urine" or whatever the case may be. Make sure before you call the doc you know all the recent meds that have been given, the I and O's and current vs and prior vs.

These patients need to be kept on closer observation and with repeat vs......and make sure to recheck vs with any intervention.

Last thing I would mention......fluid bolus rate depends on the situation and IV access. If it is a true emergency then let it fly in as fast as you can. But don't try and pump IVF's at a rate of 999 through a 22 gauge IV on a 90year old if that is her only access. In non-emergent situations don't be afraid to ask the doctor about the rate.

SNIXRN · Mar 20, 2011

Thanks everyone! I appreciate all of your responses. I feel a bit more confident if this situation were to arise. :specs:

SNIXRN · Mar 20, 2011

last thing i would mention......fluid bolus rate depends on the situation and iv access. if it is a true emergency then let it fly in as fast as you can. but don't try and pump ivf's at a rate of 999 through a 22 gauge iv on a 90year old if that is her only access. in non-emergent situations don't be afraid to ask the doctor about the rate.

great point, depending on the situation, i would probably start another line if the pt had a 22 gauge.

which probes another question, anyone know how fast fluids can run through a picc?

sorry for the million questions, i am just a new grad and will be on my own next month :eek: