I think I made a mistake

[RNikkiF]

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.

[turnforthenurse, MSN, NP]

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.

Exactly. and let me add that if a patient is dehydrated, that can worsen the hypertension.

I would have asked the MD for hydralazine or Lopressor IV which would have worked a lot faster than PO. For a BP that high you should't have to wait around for an hour or two for it to come down...at my facility a BP that high automatically gets a STAT IV BP med order.

[Anna Flaxis, BSN, RN]

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???

In a patient with hypertension r/t TBI, I'm guessing that finding the right medication at the right dose is a time consuming process. I'm guessing that this is part of why this patient is in an LTACH.

You don't want to aggressively lower BP. You want to lower blood pressure gradually over the course of hours. You tanked your patient's pressure in less than an hour. That's why the physician wasn't too thrilled.

Also keep in mind that someone with chronic hypertension, like your patient, may not be able to tolerate "normal" blood pressures.

[RNikkiF]

Update. Was assigned to this same patient again this weekend. He neurostormed all day Saturday and despite administering Tylenol and Oxycodone per orders throughout the day, he did it all day (he does this frequently).

I tried to minimize stimulation, which is difficult in this case. Because of his religious practices, it is standard for family to be present at all times. They are constantly talking (not loudly, but still, with his TBI, even quiet conversation could be too much and trigger a storm). Anyway, tried to decrease stimulation (turn lights off, cluster care, encourage keeping noise to a minimum, etc.) with no effect.

Sunday morning, I come in and his VS are running low (98/70s), HR in the 90s, O2 98 c 2L NC, T 98.6 RR 16. BP meds held per parameters. This patient's BP has always been volatile, but usually runs high, but he does dip to this range. CNAs got patient up to broda chair without consulting me (GRRRR!!!!)... at least they took bp immediately after getting him in chair and notified me immediately. Rechecked BP manually and dynamap (always do, but going to spell it out this time ;0) )... 61/50!!! Told CNA get him back in bed NOW, elevate feet and Q15 VS. Don't leave his side.

Got order for NS Bolus 500 ml @ 250/hr (asked MD if that is fast enough, he reiterated his order). Monitored patient and BP increased to 120/80 over about an hour and continued to gradually increase.

TF bolus was due with 200 ml h20 before and after, so, slowly elevated pt's hob over several min checking bp for orthostatic hypotension, bp remained stable. Administered TF and flushes per orders. VS remained stable rest of shift and all night.

Monday morning, come in and once again, pt. neurostorming. Thinking to myself "Got to try something different today and find a way to stop this!". Pt. family left (rare for that to happen). Turned down volume on religious meditation volume to a "background music" level, dimmed all lights. Gave Tylenol and Oxy together. 4 hrs later (per MAR), still storming but bp had decreased some but had remained steady. Administered oxy (no prn tylenol, only sched. to prevent acet. toxicity 3g/day restriction). 1 hr later, no effect... administered Loraz. IV 1 mg (this was a new order written late Sunday night)... 30 min later... NEUROSTORM OVER!!! Yay!! BP 135/80, HR 80, RR 16, T 98.6, no diaphoresis or agitation!!!

MD arrived, updated him on events of weekend (he wasn't on call and hadn't seen weekend doc yet), updated him on interventions that day... MD looked at me, smiled and said "Now, THAT is how you stop a neurostorm! Good job!" :) I guess the loraz was just the little extra that he needed... along with a quiet environment. Glad I finally figured out the magic combo for him...

Spoke to the MD about adding inderal or bromocriptine for long term control of neurostorms... understandably didn't want inderal (volatile BPs) but said will look into bromocriptine, said it might be a good option. MD also said he spoke with family re: DNR and EOL/comfort cares... they're not ready for that just yet. Am so praying this pt. does not code... otherwise we would be doing cpr just to break his ribs and force him to continue "living" being in a near vegetative state with probable further brain damage and definitely more pain.

Several nurses have spoken to MD about the this but were mainly focused on BPs (I was too until I did some more in depth research and the patho of neurostorms "clicked" (this is the first pt I've ever had who neurostormed and I'm a relatively new nurse))... anyway... the increased bp, hr, temp, rr and bs are all symptoms of neurostorms and we (nurses) were so concerned with possibility of cva from bps or clot, etc. that I think that's all we could look at...

So glad that I had a day in which I feel I made a difference for my patient... so often I feel like a pill pusher that I've started to ??? nursing career! Not saying the situation played out exactly as it should have, but bps are stable and in a safe range, and I made that happen.

Lots of nurses might think it is simple and something that should have come to all of us who have cared for him, but as I said, I'm a relatively new nurse and this was my first patient with neurostorms, so no matter what anyone says, I learned and grew and most importantly, may have even saved my patient!

[RNikkiF]

BTW... before anyone says bp was d/t getting up to chair, which I'm sure didn't help, it was low before (had a talk with cnas about checking bps prior to getting up to chair if AM bp already low, and about not getting pts up without giving me heads up first!) and bp remained low even after getting back in bed.

[SionainnRN]

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.

That defeats the purpose of PRN meds. What you can do when this situation arises again is look at your PRNs right off the bat when you're having issues. If you had given the hydralazine first and given it time to work before it was time for his scheduled meds you may not have had such issues. The biggest issue was giving two meds at the same time. Or you could have just given the scheduled meds waited about an hour and a half to kick in then look at your prns. Glad you learned a hard lesson, but don't ignore your PRNs they are very very important.