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!
Specializes in Preop/PACU, IM, Orthopaedics, Med Surg.
"BP read 47/25, P 29."
Hi new grad,
I was concerned reading your post for several reasons. You said the resident is normally not like this which is concerning. She has had some kind of change or event with those vital signs you got, BP 47/25, P29, R14 and shallow. Regardless, this sounds like a 911 call to me. Better to error on the side of caution. You were right to call your supervisor, but she sounds like she couldn't be bothered.
On 2/25/2021 at 10:42 PM, FashionablyL8 said:
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).
This statement concerns me, too. What if she didn't really call her? You are getting second hand orders, especially ones that are potentially life threatening. If something would have happened to the resident, it's your word against hers. Isn't there a licensed nurse on your shift? If there is, I would have called her in to assess the resident. In any case, one of the side effects of that particular medication is hypotension. I would have held it. If the supervisor was dead set on giving it to her, than I would have passed that job on to her. All in all, you have to do what you feel in your gut and with your nursing training. Know that when you do get your license, you have to protect it like you would your child. You worked hard for it! I feel bad this is your first job right after graduation. You may want to consider other nursing options, if there are any. Good luck with your career! It is a wonderful profession, but follow your instincts and your training. God bless!
P.S. Make sure you have clear and concise charting of this incident. CYA as they say! ???
Thank you for your encouragement and advice ?. That's exactly what I thought, something must have been going on; people don't just not wake up for no reason, even if the BP monitor wasn't accurate. Also I could barely palpate her radial pulse, which indicated low BP to me. I thought it strange that my supervisor was so nonchalant but maybe, not having a nursing education, she really didn't understand how much can go wrong. Which is also concerning if she's making decisions on whether or not to send residents to the hospital or not!
I thought of the same thing, that the supervisor might not have even called the nurse. That's a huge chance for the nurse to take with her license, isn't it? Advising someone to give meds to a PT she hasn't even assessed, doesn't seem like a safe idea.
I am really torn on whether I should stay there once I get my license. I love my residents and it feels like my second home. However, I would really love to work in a place where I have experienced, smart nurses like you all working by my side so I can ask for advice or watch and learn the best way to do things. I'll keep thinking on that.
The things I've learned from this are:
1) Next time I find a resident displaying really abnormal VS or otherwise deviating from their baseline in an alarming way, I'm going to call 911. This situation turned out OK, but if that resident had died or suffered lasting harm, I don't think I would forgive myself AND I'm pretty sure I would have faced repercussions. The lowest person on the ladder is usually easiest to step on.
2) ALWAYS have my own supplies- manual BP, stethoscope, penlight and pulse ox at the very least. I usually have bandage scissors, Kelly clamps, tape measure, etc. even though I don't really need them.
3) When I am actually working as a nurse, be sure that I have the numbers to contact the RN and the MDs on call so I can talk to them directly (I would love to have those numbers now but I'm sure I won't get them!).
4) From now on, if someone higher up asks me to do something that I feel isn't safe, I can decline and they can do the task if they are so certain it should be done.
Her heart rate was only 29? Holy smokes. She needed to go to the ED and get checked out. I can't believe places like this don't have an RN overseeing things to make decisions on when to send a patient to the ED. I would look for another place to work as an LPN so that you and your patients are safe and you can progress properly in your career. Good luck to you. That sounds very stressful and frustrating.
C.Love, thank you for your good luck wishes ?. Although I love many things about my job, I would really benefit from having more experienced nurses to work alongside. I also don't want to inadvertently make any mistakes that could affect my license.
FolksBtrippin (one of my favorite user names!), the nurse/nurses are usually off duty after hours but available for phone calls. I'm not sure if they are truly on call, as in coming to assess residents.
In light of what you said, it makes sense that the clozapine be held. That's what I said to the supervisor- that even though there were no written parameters, I'm sure that the HCP writes the order with the expectation that the person administering the meds will have the critical thing skills to hold the med in unusual circumstances.
In the future, I plan to be more proactive about sending residents to the ER. I would rather do that and find that they didn't really have to go than discover later that they could have been helped had I sent them out.
I can think of a lot of different conditions that could drop a BP that low in less than 15 minutes and most are life threatening. It's scary thinking someone so medically unaware is managing care of patients AKA your supervisor. Your gut is one of your best resources. Keep trusting yours and it will prevent recklessness like this in the future (not on you but woof...)
Thank you, Eeks! I'm so grateful that this resident turned out OK although I still wonder what happened. I've always found that my gut reactions served me well before, in life and work, but I tend to question myself with medical things that I'm not very experienced with. I think the bottom line is that I'm better off getting help for someone in my care if my instincts tell me something is wrong, rather than second guessing myself, saying nothing and the resident having a bad outcome. I'd rather be embarrassed about making a big deal of something that turned out to be nothing, than feeling responsible for someone else's suffering or demise because I was too insecure to speak up.
I've learned a lot from your answers to this post- thank you all!
These are just thoughts. Several things come into my mind reading this. Safety first. So verify BP. Using a manual BP is a good idea for sure. Even with manual aneroid BP machine though at this low, we may not be able to appreciate a BP. While using a manual BP, instead of using your stethoscope use your finger to check for palpatory BP. The first pulse you get is the SBP as you deflate...This low, you won't get a DBP for sure...Manually check for pulse or rather auscultate for the HR as well...Maybe this pt has arrhythmia...so sometimes PR will be read as normal, or high or low, will be read by machine but when you manually count, you'll get a better picture and be able to tell whether it is regular or irregular.
Next, mental status...at this low, patient will most likely be stuporous as this not enough to perfuse the brain to keep them awake...keep stimulating to wake them up...If they are awake and responsive...it's a good sign at least and that proves BP is really wrong.
Next, Clozapine sounds like Clonidine...I definitely hope it is not the latter...this doesn't need further explanation..Clozapine on the other hand can cause arrythmia..particularly prolonged QT is a risk which can initially slow conduction and can further lead to lethal arrythmias. These in mind...whether patient has been stabilized or not, needs further evaluation for EKG monitoring and electrolytes....BP and PR are just point of care evaluations which just tells you whether pt is stable or not at that point of time. So safety wise...hold meds until verified patient is stable...and physiologically stable to continue to receive the meds...send to ER...we cannot just assume what occurred at that point in time since there was indeed a change of clinical status if there was indeed a change of mentation of the patient...he could have been found to be stable back in 30 mins...but then crash again because whatever caused it was not evaluated and addressed.
I agree with the other suggestion, that if another person wants to continue to administer the medicine, then let them administer it, and have them realize the responsibility with their license on the line.
But at the end of the day. If they did not take the safe route, and patient lived with no problems...your superiors will just say, I told you so...you did gain insight from this experience at least. So consider it still a win. Thanks for sharing the experience!
That's a good trick with palpating the BP- I'll have to try that. The med was definitely clozapine- clonidine would have been scarier since that is actually used as an antihypertensive. Good point about the possible SE of QT prolongation. Anything really could have been happening since the resident was not sent out. Since then she has had other hypotensive episodes (not as extreme), but apparently the MAP cert staff have just recorded the BP and gone about their day. Apparently the resident has survived... but still, there must be a reason for this. That's the problem with staff without a medical education being in charge of monitoring the health status of a fragile population like this. I know I was one of those staff until I graduated nursing school, but it always concerned me and I always made sure to be as aware as possible of signs of emergent situations and to ask for advice from a nurse if needed. Ah well.
I'm glad I posted about the experience, because I feel much more prepared and confident now. I have also made sure to bring my own equipment so I can assess residents without depending on others.
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PREOP PACU LVN, LVN
12 Posts
"BP read 47/25, P 29."
Hi new grad,
I was concerned reading your post for several reasons. You said the resident is normally not like this which is concerning. She has had some kind of change or event with those vital signs you got, BP 47/25, P29, R14 and shallow. Regardless, this sounds like a 911 call to me. Better to error on the side of caution. You were right to call your supervisor, but she sounds like she couldn't be bothered.
This statement concerns me, too. What if she didn't really call her? You are getting second hand orders, especially ones that are potentially life threatening. If something would have happened to the resident, it's your word against hers. Isn't there a licensed nurse on your shift? If there is, I would have called her in to assess the resident. In any case, one of the side effects of that particular medication is hypotension. I would have held it. If the supervisor was dead set on giving it to her, than I would have passed that job on to her. All in all, you have to do what you feel in your gut and with your nursing training. Know that when you do get your license, you have to protect it like you would your child. You worked hard for it! I feel bad this is your first job right after graduation. You may want to consider other nursing options, if there are any. Good luck with your career! It is a wonderful profession, but follow your instincts and your training. God bless!
P.S. Make sure you have clear and concise charting of this incident. CYA as they say! ???