I think I made a mistake

jadelpn, LPN, EMT-B · Nov 10, 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.

Again, a good reason to ask for an alternate level of care until the patient is stabilized. Most likely pneumonia or confirmed with an x-ray? There are lots of stuff going on with this patient--bottom line is that you did not do the wrong thing, but shame on your charge for letting you figure all of this out on your own. This is LTAC not the ICU, and I am not trying to knock your clinical knowledge at all, but when you are in the weeds, best if the charge RN or a response team come and assist.

DSkelton711 · Nov 10, 2012

Sounds like you were trying to save your patient's life and did what was ordered. Giving both meds may have made his B/P drop, but you monitored his vitals very closely and were able to get interventions started. I also agree with PP who said to involve your charge nurse in these situations to help you in making a plan. I am the nurse manager and involve other nurses in care of my patients so I can have feedback in difficult situations.

PMFB-RN, RN · Nov 11, 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.

Several things I don't get. If his HR was in the 130's why didn't you get an EKG to make sure he wasn't in a-fib or something else? Your patient had dangerously high BP of 200/115 and you didn't immediatly call the physician or RRT to report? In my hospital such a BP would get you a STAT IV antihypertensive order. Giving the hydralazine PO on top of the Lopressor PO seems like a bad idea. Your CNA reported a BP of 62/58 and you didn't check it yourself? That is a very narrow pulse pressure, I would want to make sure that was an accurate BP. Why did you place patient in trendelenberg when it has been shows to contribute to hypotension? With how rapidly your patients BP "improved" (10 min) I question if that 62/58 was accurate to begin with.

My constructive critizem is to use the nursing process. When a CNA reports a dangerous vital sign you should assess your patient yourself. I am guessing the 120-130 HR you reported was new for that patient since you reported it to the physician. I would be uncomfortable just "waching" such a HR and would have advocated the physician either deal with it more definitivly or come and assess his/her patient. If you are not allowed to get an EKG without a physicians order in your hospital you could have suggested it to the physician when you called to report the elivated HR. A 12 lead EKG would be appropiate for newly elivated HR in 120-130's.

Does your hospital not have a rapid response team for this exact situation?

echoRNC711, BSN · Nov 11, 2012

lopressor ,a beta blocker affects HR predominantly with secondary benefits of decreasing BP it peaks in about 1 hr.

Hydralazine is a dilator and in doing so can decrease BP markedly however it generally takes 2 hrs to peak (plus dose was small / max dose can be up to 300mg QD.

So as they are different actions it is appropriate that both were ordered I am surprised given how high BP was that 5mg IVP lopressor wasn't a first option. Fast heart rate was maybe more shock though.

Main thing:Although it is possible the hydralazine kicked in I wouldn't expect to see the results so quickly given it takes 2hrs to peak .IVP here again would have been better 1st option if CVA potential an issue.

I can't comment on the GSW or brain injury as it's no longer in my scope. The pt survived. Read up on it learn. It will make you better.Every nurse goes through where you are at now (or will in the future ) so be gentle with yourself. If the attending is a decent human being just ask they will guide you. If they thought the error was truly yours they would have screamed at you on the spot.

RNikkiF · Nov 11, 2012

Several things I don't get. If his HR was in the 130's why didn't you get an EKG to make sure he wasn't in a-fib or something else? Your patient had dangerously high BP of 200/115 and you didn't immediatly call the physician or RRT to report? In my hospital such a BP would get you a STAT IV antihypertensive order. Giving the hydralazine PO on top of the Lopressor PO seems like a bad idea. Your CNA reported a BP of 62/58 and you didn't check it yourself? That is a very narrow pulse pressure, I would want to make sure that was an accurate BP. Why did you place patient in trendelenberg when it has been shows to contribute to hypotension? With how rapidly your patients BP "improved" (10 min) I question if that 62/58 was accurate to begin with. My constructive critizem is to use the nursing process. When a CNA reports a dangerous vital sign you should assess your patient yourself. I am guessing the 120-130 HR you reported was new for that patient since you reported it to the physician. I would be uncomfortable just "waching" such a HR and would have advocated the physician either deal with it more definitivly or come and assess his/her patient. If you are not allowed to get an EKG without a physicians order in your hospital you could have suggested it to the physician when you called to report the elivated HR. A 12 lead EKG would be appropiate for newly elivated HR in 120-130's. Does your hospital not have a rapid response team for this exact situation?

You assume quite a bit. I didn't include every minute detail of the situation simply because there's a limited amount of space here. I don't think you read my post as thoroughly as you seem to think. Adding the word "constructive" doesnt make it so. I'm not going to dignify your attack on me with anymore of a response. To all of you who too my post at face value and didn't assume that I didn't verify the BP or contact the doctor, etc., thank you. I appreciate your well thought out advice.

kanzi monkey · Nov 11, 2012

Any reason to consider autonomic dysreflexia for this pt? That is quite a response to his beta blocker (a dose that he has presumably tolerated before) and hydral. I had a similar thing happen once with a paraplegic--gave hydral for SBP > 200; only to discover the foley wasn't draining properly. Fixed that problem, now the BP is in the 60s. Kept pt in trendelenberg and no further intervention as the pt was asymptomatic and the pressure was resolving.

For those vitals I probably would have given both meds as well. The on call md should have come to the bedside.

RNikkiF · Nov 11, 2012

No. I don't think AD is likely. GSW was to the face (!) and no spinal cord injury present. HR and BP are always outside of normal parameters (high). Md wrote new order to keep BP above 120/80. I didn't have the pt when this order was written but RN who did said the md explained order was d/t the fact that sustained BP below 120/80 could cause more brain damage. Still trying to figure out how. Md apparently didn't explain that. Pt is back in his normal range and was shortly after this situation. Hr still high though. Confused.

PMFB-RN, RN · Nov 11, 2012

You assume quite a bit. I didn't include every minute detail of the situation simply because there's a limited amount of space here. I don't think you read my post as thoroughly as you seem to think. Adding the word "constructive" doesnt make it so. I'm not going to dignify your attack on me with anymore of a response. To all of you who too my post at face value and didn't assume that I didn't verify the BP or contact the doctor, etc., thank you. I appreciate your well thought out advice.

*** OK! I wsa under the impression we had gotten a blow by blow. You take care to specify it was a CNA who took the questionable BP but did not specify you checked. Seem an odd way to decribe the situation if you want the reader to make aumptions about your action. It would have been helpful had you indicated you left out some details. Also the OP did not specify this was in an LTC. I assumed it was a hospital. I undertand why you didn't call RRT if you work in an LTC. Still wondering about the trendelenberg postion for hypotension???

Sun0408, ASN, RN · Nov 11, 2012

No. I don't think AD is likely. GSW was to the face (!) and no spinal cord injury present. HR and BP are always outside of normal parameters (high). Md wrote new order to keep BP above 120/80. I didn't have the pt when this order was written but RN who did said the md explained order was d/t the fact that sustained BP below 120/80 could cause more brain damage. Still trying to figure out how. Md apparently didn't explain that. Pt is back in his normal range and was shortly after this situation. Hr still high though. Confused.

Keeping the BP higher will help the brain tissue that is damaged. More pressure more blood flow to the area as well as the much needed O2. With TBI we like to keep the pressure higher. CVA with a clot, we keep the BP higher, for a bleed we like to keep it lower to prevent re-bleeding.

As for the two meds, no, I would not have given them both. I would give the lopressor first as ordered, continue to monitor and then if it was still too high I would have give the other.

With brain injuries, agitation can increase BP, pain can also cause increase in BP. Without knowing all the details I might have went with pain medication also.

psu_213, BSN, RN · Nov 11, 2012

Your patient had dangerously high BP of 200/115 and you didn't immediatly call the physician or RRT to report?

There are several parts of your post that stand, out, but this one the most. On the 2 inpatient units on which I have worked, we never would have called an RRT for this BP. Probably would not have called the doctor if their was a PRN order for BP. While I may have handled the situation a bit differently from the OP, going immediately to an RRT is not necessarily the answer.

PMFB-RN, RN · Nov 11, 2012

There are several parts of your post that stand, out, but this one the most. On the 2 inpatient units on which I have worked, we never would have called an RRT for this BP. Probably would not have called the doctor if their was a PRN order for BP. While I may have handled the situation a bit differently from the OP, going immediately to an RRT is not necessarily the answer.

*** I see. In both hospital where I work DBP >100 is a trigger for RRT. The OP's PRN for hypertension was for a PO med when the standard of care would call for an IV antihypertenive thus my questioning for no call the MD or RRT. Certainly the reported BP of 62/58 would have triggered an RRT call. We have a full time RRT and the standards for calling may be lower than for those hospital where the RRT RN may have to leave their own patient to come and see the RRT like in hospitals where they use ICU RNs for their RRT.

Anna Flaxis, BSN, RN · Nov 11, 2012

My rationale was to prevent CVA or clot and A-Fib.

Can you elaborate on this? I get that you might be concerned about hemhorragic CVA with a sustained high BP, but I'm not connecting the dots as to what any of this would have to do with a clot or A-Fib?

Given the information you've supplied, I probably would have given the scheduled medications, then rechecked vitals in an hour.