Me vs. the charge nurse

All_Smiles_RN · May 24, 2007

it's my understanding that most docs want the bp to be a little on the higher side post cva. 180 being the upper limit of where they want it. any thoughts on this?

CritterLover, BSN, RN · May 24, 2007

it's my understanding that most docs want the bp to be a little on the higher side post cva. 180 being the upper limit of where they want it. any thoughts on this?

i believe that is correct for an ischemic stroke (trying to keep the brain perfused). it depends somewhat on how much swelling there was in the brain. the more swelling of the brain, the higer the icps would be, and the higher the bp would need to be to keep the brain perfused.

however, since the doc had noted the bp in the progress notes, and ordered a tx, he wanted it somewhat lower. or, at least no higher. cozaar, if that was indeed the drug, isn't all that powerful, and most likely wouldn't have caused a huge drop in bp (unless a diuretic is on board as well).

cozaar is also used to prevent strokes, so it is possible that the doc wanted it given for that reason.

they certainly don't want the bp going any higher, and it would be appropriate to put her on some kind of bp med to keep the bp controlled. i would have questioned any order that would have caused a huge drop in bp, but not cozaar.

TazziRN, RN · May 24, 2007

The OP states the high BP was addressed in the MD's notes and a med order was written and just given. I'm sorry, but I'm not understanding........why should she have called the doc about this? I could see it if the BP didn't come down after the med was given, but.....?

jen123321 · May 24, 2007

There's no problem with an ischemic CVA pt. being in the 160-180 range...if you just started PO meds, the MD isn't going to do anything else...it's basically unsafe to bring the pt any lower...they need perfusion to the brain etc....

Inquisitive one · May 24, 2007

So. was the doctor called? If so, what was the response? Any new orders?

CritterLover, BSN, RN · May 24, 2007

there's no problem with an ischemic cva pt. being in the 160-180 range...if you just started po meds, the md isn't going to do anything else...it's basically unsafe to bring the pt any lower...they need perfusion to the brain etc....

the op states the high bp was addressed in the md's notes and a med order was written and just given. i'm sorry, but i'm not understanding........why should she have called the doc about this? i could see it if the bp didn't come down after the med was given, but.....?

i can't figure it out, either.

i was wondering if the charge nurse maybe thought the med was going to bring the bp down too much for an ischemic stroke????

unless the doc wrote for the drug to be given stat (and i don't know why he would have), i don't understand what the big deal was.

the only other thing i can think of would be if the patient's baseline was quite a bit lower than 180/80.

op, do you think you can ask? finding out the rationale would be beneficial to you.

rn/writer, RN · May 24, 2007

Was I wrong in what I did? I need some other perspectives. I was working a few days ago and had a conflict with my charge nurse. It was basically about whether to call the doctor about something related to my patient. She saw a blood pressure and freaked (was 180's over 80's), I saw the doctor had noted this in his progress notes just 2 hours prior and ordered some PO meds to be given, which I just had. I tried explaining this, but it was no use and she practically ordered me to call the doc. I was really upset about this because this was MY patient and I thought she had no right to tell me what to do. Or does she? Basically I am wondering that as a staff nurse, do I have to respond and do (within reason of course) what my charge nurse tells me to do regarding my patients? I am really torn about this and could use some feedback. Thanks!

Medically, it's kind of a toss-up about whether a call needed to be made. There are rationales for either decision.

Politically and practically, I would have made the call, done the documentation, and only then, after the fact, would I have approached the charge nurse for further discussion. If you don't make the call and anything happens, you're goose is cooked.

The charge nurse really is in charge. Unless she's telling you to do something that violates Policy and Procedure or basic medical principles, your best bet is to do what she says. Then the responsibility is hers. You can certainly ask questions, but if she's about to blow a gasket and what she is requesting will not put the patient in harm's way, do it her way and work it out later.

This isn't only about patient care. It's also about chain of command. If you refuse to do what she asks (without a compelling reason), you can find yourself accused of insubordination.

DO follow up later when things have settled down. Express your thinking then and you're likely to find a more receptive audience. If you conduct yourself with this combination of discipline and self-respect, you increase your chances of being taken more seriously in the future.

newnurse2t · May 24, 2007

Was this your first time taking care of a CVA patient? Maybe the charge nurse was really trying to be helpful and thought that you wanted or needed her help. How did the charge nurse see your vitals anyway?

qt314nf · May 24, 2007

I agree that the best thing you can do for yourself is speak to your charge nurse and find out why she wanted you to call the doctor and have her walk you through the situation as a learning experience. Your charge nurse should be a resource for you, not some one to yell at you and point out your mistakes.

Dolce, RN · May 24, 2007

I would have called the doc if it had been 30-60 minutes since the patient had received the BP med and the BP was the same. However, if the med was just given there is no new information to relay to the physician. There is no point in calling a doc to tell them what they already know. If the charge nurse was insistent that he be called I would have been curious as to why she didn't call him herself. Maybe there is more to the story that I am missing, but it seems kinda weird to me.

jojotoo, RN · May 24, 2007

Was this your first time taking care of a CVA patient? Maybe the charge nurse was really trying to be helpful and thought that you wanted or needed her help. How did the charge nurse see your vitals anyway?

As the charge nurse in the ER, I know what's going on with the other RNs patients. I know if they have abnormal VS or labs. I know where they are in the evaluation process - awaiting imaging, awaiting results, awaiting callback from PMD, awaiting admission (lots of waiting!).

I talk to the RNs, the patients, the MDs on what the plan is. I look at the charts. I confirm that MD orders have been implemented and that nursing documentation is complete. I try to anticipate problems and correct bad situations before they get out of control.

Is this not what other charge nurses do?

Tweety, BSN, RN · May 24, 2007

it's my understanding that most docs want the bp to be a little on the higher side post cva. 180 being the upper limit of where they want it. any thoughts on this?

Yes. When I worked neuro we would let the BP get as high as 220/110 before intervening per our protocol for non-hemopharrghic ischemic strokes. This assures perfusion.