Looking for thoughts/opinions of experienced nurses

[FashionablyL8, CNA, LPN]

I love the wisdom and experience that so many of you possess, and wanted your opinions on how I handled a situation. I apologize in advance for the length of this.

I'm an recent LPN grad but haven't taken the NCLEX, so I'm just working as a regular MAP cert staff, not a supervisor. Our supervisors are not nurses either- we have a nurse who oversees the residents and gives advice in medical situations (I don't have her number, the supervisors call her).

The other night I went to admin PO meds to a resident- one of the meds was clozapine- and she was unresponsive to verbal and physical stimuli, including an ice pack to neck and chest, with an automated BP of 83/45, P 49. I contacted the supervisors, elevated the resident's legs and kept talking to her. Within 15 mins she was stirring and BP was up to 120/62. Supervisor arrived with manual cuff (I usually bring my whole nursing bag but of course, that was the day I left it in the car)- manual reading was consistent w/ automated. I said I was OK with monitoring the resident but wanted to hold the clozapine just until BP had been stable for 15 mins (still within the time frame to give it). But after 15 mins, the resident was again out and this time the automated BP read 47/25, P 29. My supervisor walked in right as I got that reading and said she was sure it was an error because I had just gotten a normal manual BP 15 minutes ago and there's were no parameters so I should just give the meds. I said I wanted to call and check to see what to do before giving the clozapine. I was thinking that the doctor would be called and maybe they would want to send her to the hospital. My supervisor told me she was calling the nurse and left the room, then came back and told me the nurse instructed the meds be given. I ended up giving the meds and feeling partly petrified that something was going to happen to the resident and partly foolish for refusing to just obey the rules, like I was trying to act like a know-it-all and that they were probably thinking I was obnoxious and thought I was all that just because I had graduated from nursing school. But my intentions were to protect the resident.

My shift ended shortly after, and I worried all night about the resident but I haven't heard anything so apparently she was OK. I just keep thinking, what if she hadn't been OK, if her BP had tanked after the dose of clozapine? I also know that if something had gone wrong with the resident, I would be forever blaming myself for not just calling an ambulance. What would you nurses have done? Thank you for any advice!

[LibraNurse27, BSN, RN]

BP of 47/25?? And the nurse didn't come to help? What was the pt's mental status? I've only seen BPs that low when pt is about to code. You were right to be concerned, stay with the patient, assess mental status and elevate the legs in attempt to improve BP, and right for re-checking the BP frequently. If the BP says 47/25 I wouldn't be concerned about giving any PO meds.

I would re-check manually, and if confirmed to be that low or close to it, call for help. Pt will most likely need transfer to acute care, but if was a vasovagal response BP may come back up. I think you did everything you could within your scope of practice. The nurse should have come to assess the patient, not just randomly determine it was OK to give meds. It sounds like you are working in long-term care, so I'm sure everyone is busy, but a BP that low would be high priority in my book. From what I know hypotension is not one of the main side effects of clozapine, but that is not in your scope to have to know. In fact, RN can hold meds based on clinical judgement, but eventually MD needs to be notified and make the final decision, unless there are parameters ordered. I'm glad the pt is OK! But seems like your team let you down and left you in a tough position. It never feels good to do things we're uncomfortable with, and doesn't feel good not to have guidance when we need it. 

[NRSKarenRN, BSN, RN]

Clozapine is a psychiatric medication, often to treat schizophrenia.  Low BP is not one of its side effects to my memory. Are you thinking of another med?

I share your concerns regarding this BP.  What was the patients underlying medical diagnosis.?  Was she a full code -- if so, a trip to the ED for low BP and unresponsiveness was warranted in my book. If DNR, then at least call to doctor after full assessment by nurse should have occurred.  Dehydration/ UTI quite common in elderly resulting in ED visit.  When patient alert, able to talk, I would have tried to give some water/fluids to drink and recheck BP after intake.

Keep being concerned --good critical thinking.  Hope you can take NCLEX soon.

[Sour Lemon]

Everything about this is weird and makes no sense. Or maybe I'm just weird and make no sense. There would be no discussion of whether or not to give a PO medication to a patient with a 47/25 blood pressure who is unresponsive. The patient wouldn't be able to take it whether you wanted to give it, or not. And who put an ice pack on her neck and why?!

This sounds like an episode of Scrubs.

[Been there,done that, ASN, RN]

'But after 15 mins, the resident was again out and this time the automated BP read 47/25, P 29." Automated BP and pulse is useless in this situation. Also what was the respiratory rate and effort?  What other meds were due? How would you administer meds to somewhat that was "out"?

Sounds like the facility is just trying to dot their I's and cross there T's with medication administration.

[EDNURSE20, BSN]

This is ridiculous. The pt was unresponsive, and should have gone straight to the hospital!

Personally I would of just call an ambulance and then told the supervisor. Unless they were palliative, Ofcourse.  

[TheMoonisMyLantern, ADN, LPN, RN]

Whenever you get a wonky reading with a machine always obtain the data manually to confirm it's accurate. As others have said, a bp or pulse that low will not sustain life for very long so if those were accurate 911 should be called immediately unless the patient is comfort. I'd much rather be in trouble for not obtaining permission to call 911 than to fail to rescue someone in distress.

[JKL33]

8 hours ago, NRSKarenRN said:

Clozapine is a psychiatric medication, often to treat schizophrenia.  Low BP is not one of its side effects to my memory.

Side note: It is a possible effect as is QT prolongation. Hypotension is listed as a common reaction.

Anyway. A couple of things for you OP:

8 hours ago, FashionablyL8 said:

I said I was OK with monitoring the resident but wanted to hold the clozapine just until BP had been stable for 15 mins (still within the time frame to give it).

If the time frame you are referring to is the idea of giving the med at the "right time" and not having a medication error based on not having given within a certain range of time, understand that is out the window if you are assessing the patient for a concern. It is not an error, there is no rush to give the med within what would have been the normal time frame. If you are assessing the patient for an acute change in condition then meds can be held until the situation is clarified and/or further direction is received. All of that has very little to do with "right time."

8 hours ago, FashionablyL8 said:

My supervisor walked in right as I got that reading and said she was sure it was an error because I had just gotten a normal manual BP 15 minutes ago and there's were no parameters so I should just give the meds.

So your supervisor is not a nurse, but is the quazi-authority on patients' blood pressures and when meds should be given or held?

8 hours ago, FashionablyL8 said:

My supervisor told me she was calling the nurse and left the room, then came back and told me the nurse instructed the meds be given.

Whether licensed or not, you do have the ability (or "right" as the word is commonly used) to invite those above you to perform the action themselves. And that is what I would have done. It can be done collegially and without a tone of conflict.

8 hours ago, FashionablyL8 said:

I ended up giving the meds and feeling partly petrified that something was going to happen to the resident and partly foolish for refusing to just obey the rules, like I was trying to act like a know-it-all and that they were probably thinking I was obnoxious and thought I was all that just because I had graduated from nursing school.

What rules were you refusing to obey? If they can't handle people asking questions or voicing concerns before handing out dangerous medication, that's their problem. Just conduct yourself in a way that isn't aggressive or know-it-all, and let the chips fall where they may.

Right now you still don't have the authority or position to have been the final decision-maker here, but I think you deserve a pat on the back for raising the concern and asking for your superiors' input.

(Beside the point, but I do believe the vitals you obtained may not have been too far off because the patient's mental status correlates with your readings, and the patient's mental status then correlated with the reading's they got at the time they got them. IOW, pt was "out" when you got your readings and had aroused by the time they got theirs.)

Whether you are right or wrong, now or in the future, if you have a serious concern then your duty will be to hold the line and not do something that you are seriously concerned could be very wrong.

??

[Davey Do]

4 hours ago, EDNURSE20 said:

This is ridiculous. The pt was unresponsive, and should have gone straight to the hospital!

Bottom line: yes!

The Clozaril doesn't really even need to be considered in the mix. Yeah, low BP are side effects, as with the vast majority of dopamine antagonists antagonists, and about every other psych med. Geodon can also cause QT prolongation.

Patients on Clozaril typically lean toward the more psychotic, since there are several safer antipsychotics out there, like Zyprexa and Risperdal. Clozaril tends to be one of the last, prescribed, since there are more side effects.

One of the major side effects with Clozaril is agranulocytosis and labs are typically drawn every two weeks. 

Karen noted that maybe the OP was referring to another med. As I was reading the somewhat bizarre scenario, I thought of captopril and clonazepam, antihypertensive and benzodiazepine.

[JKL33]

 

55 minutes ago, Davey Do said:

The Clozaril doesn't really even need to be considered in the mix. Yeah, low BP are side effects, as with the vast majority of dopamine antagonists antagonists, and about every other psych med. Geodon can also cause QT prolongation.

 ?? Yes, a number of medications list similar side effect/adverse effect possibilities and often times they are not likely.

Meanwhile the concern is not completely unreasonable. Besides, even if all the OP knew is that clozaril is a serious medication, then s/he was correct to have been concerned to give it or any other medication at that point, for that matter.

[Davey Do]

1 hour ago, JKL33 said:

Meanwhile the concern is not completely unreasonable. 

The concern that the med may drop the BP is a valid concern, JKL, but like I said, it doesn't need to be considered in the mix.

Wondering whether to give an oral med, that might drop the BP, to a non-responsive hypotensive patient, is akin to making sure there's no celery in that unresponsive hypotensive patient's tuna salad.

The med administration, with all due respect to fashonablyL8, shouldn't even be a point of consideration. The med administration is not important. Clozaril has a relatively long half life span, and missing one dose most assuredly isn't going to send an otherwise psychiatrically stable patient into a psychotic episode.

If there's any concern, the ERP treating the hypotension and unresponsiveness can order a Clozaril level.

[FashionablyL8, CNA, LPN]

Thank you all for your responses! I agree the situation was rather bizarre- I actually thought as I was writing it that it seemed like a troll post. 

To answer a few questions, the resident is a full code. Her physical health is usually stable, baseline LOC is confused, often agitated (she has dementia, schizophrenia and tardive dyskinesia). Her RR was 14, shallow with no increased effort, lung sounds clear. I just applied the ice pack for a couple seconds to see if I could get her to respond, as this resident is often somnolent (but can normally be wakened). The med was definitely clozapine. We give it often at my place for schizophrenia. I've seen parameters to hold it for systolic BP <90 and to check BP 15 after admin to assess for hypotension. That's why I wanted to the BP to be in range for a while before giving it. The resident did begin moving and was able to sip water with assistance after both hypotensive episodes so she was able to swallow meds then (meds are crushed and liquid given in applesauce). 

Your replies have helped me work through what I did right, and mistakes I made. I think the supervisor was task focused and maybe didn't understand how serious the situation could be. I should have stayed focused on the actual problem- the condition of the resident- instead of letting myself get into a discussion on whether or not meds should be given, because that really pwasn't the issue. Automated readings aren't as reliable as manual, but as JKL pointed out, the resident's LOC correlated with the BP readings. There was definitely something going on. It was also crazy not to have a manual BP cuff and pulse ox- I'll be certain to ALWAYS bring my own equipment from now on.  

5 hours ago, JKL33 said:

 

Whether licensed or not, you do have the ability (or "right" as the word is commonly used) to invite those above you to perform the action themselves. And that is what I would have done. It can be done collegially and without a tone of conflict.

 

??

I wish I had thought of that at the time!  For the future, I'll remember that advice. That prevents me from possibly causing harm by following out an order from someone else, without having to get into a power struggle. 

Thanks again, everyone.