Need RN's opinion- BIG clinical mistake

MJB2010 · Feb 24, 2012

I would not call that a BIG mistake. And think of it this way, no harm was caused to the patient, and you will never make that mistake again. Looks like the bp was still pretty high. Do you not have to tell your instructor before giving a prn like that? Anyway, I think you'll be more careful next time. Lesson learned.

CrazyheadSN · Feb 24, 2012

Thanks for the reply MJB2010, I do have to tell my instructor before giving a PRN med. I told my instructor the pt.'s bp was 166/93 and she had a PRN of hydralazine for SBP >160. Though, my instructor did not know I was taking the BP on the forearm. I didnt even think twice when I was taking it on the forearm....

tokmom, BSN, RN · Feb 24, 2012

Any bp medication can kill the patient. I would have done a manual after that much bp meds and not used the forearm. Yeah, the pt would have complained, but safety over comfort IMO for these bp's.

If the cuff you were using was too small for her forearm, it makes me wonder what her prior bp's were with the cuff that was too small to begin with even for her forearm. Maybe with a larger cuff, she would have been able to tolerate bp's taken on her upper arm

This was not a big deal, but next time question the equipment after giving that much bp meds.

MJB2010 · Feb 24, 2012

And honestly for a prn like that, your instructor should have wanted to be present. Or double checked. But these things happen.

loriangel14, RN · Feb 24, 2012

I wouldn't have used the forearm just because the pt found it uncomfortable.Often the cuff is uncomfortable when it tightens.The pt will just have to bear it for a minute.Sometimes as a nurse you have to be assertive.

Been there,done that, ASN, RN · Feb 24, 2012

No harm done.You are over thinking the episode.

But you have learned..

always use the proper sized cuff and a manual blood pressure is necessary when you will be giving IV meds.

CrazyheadSN · Feb 24, 2012

Being that it was 45min after the IVP do you think that her BP would drop anymore than 139/93? I looked up the peak of hydralazine and I believe it was 30-45min...I feel really sick to my stomach over this. I could have done some serious harm...And I'm now wondering how the pt. is doing....... :sniff:

nurseprnRN, BSN, RN · Feb 24, 2012

the mistake you made was related to the facts that 1) you don't know how an automatic bp cuff works and 2) that you have to use a large-size cuff on an obese arm. when the autocuff is properly applied over the upper arm (you know that little white line that says "index"? it has to lie over the path of the brachial artery), its sound sensor rests over the brachial artery. put it on wrong/twisted, it doesn't give you an accurate read. if you wrap it randomly around a lower arm, where's that little artery it's looking for? right, it's somewhere else.

yyou can take a bp on a lower arm, but you have to do it with a manual cuff, a real stethoscope, and ears that know what they're listening for (listen over the radial artery).

i hate the automatic cuffs, because i rarely, if ever, see the cnas, mas, and even nurses using them properly, so the measurements they record are worthless. yes, it does matter how you put it on. take the time to do it right, or you risk acting on worthless data. like this.

cindyloowho · Feb 24, 2012

You should really always take a manual BP if you are having to medically intervene based on what the machine says.

OCNRN63, RN · Feb 24, 2012

I'm a student. I was in my last Med/surg rotation (telemetry floor). I went to get pt. vital signs in the morning and she wanted her BP taken on her forearm. So, I did. She said it was due to her very large arms and it pinched when you take it on her upper arm. I got a BP of 163/87 (dynamap). BP was slightly high so I wanted to give her 9AM meds which included some BP meds before any other intervention. I administered her medication and I went back at about 1130 and did her VS again and her BP(forearm-dynamap) was 166/91 this time.
I checked her PRN and she had an order of hydralazine 10mg (0.5ml) IVP. So, I administered the hydralazine @1245 IVP. I went back around 130PM and took her BP on her forearm. It was 198/100. I was thinking OMG how the heck is it that high after administered her hydralazine. At the time the nurse was coming into the room so I showed the nurse the vitals on the dynamap. The nurse questioned it and thought "that's not right." I told the nurse I was taking her BP on her forearm because the pt. felt like it was more comfortable. The nurse found a larger BP cuff and took the BP on the upper arm. BP this time was 139/93. Nurse said, "that's better." and that was it....and I went home.
Soooo, basically, 3 days later I'm freaking out because I could have caused my patient's BP to drop. I was probably getting the wrong BP reading the entire day by taking it on the forearm, and then I go and push hydralazine!! I feel so bad about doing that. Here I thought, I'm doing great in clinical, and I go and do this.......I emailed my instructor b/c she doesn't know what happened and I didn't really worry about it or even THINK about taking the BP on the forearm as a big deal, until now. Could 10mg (0.5ml) of hydralazine really cause my patient's bp to drop to the point that she could die? I feel so bad......I think I might get kicked out of school b/c of this mistake......I'm waiting to hear back from my instructor....

OK, well you didn't kill anyone.

Forearm BPs can be erratic. There are very few times I've used them. Try to remember that it isn't always in the patient's best interest for you to accommodate their every request.

The thing that scares me is that your instructors never taught you that BP cuffs come in different sizes. You may need to use a pediatric cuff on some of the really skinny LOLs you'll take care of.

Live and learn. Class dismissed.

OCNRN63, RN · Feb 25, 2012

Being that it was 45min after the IVP do you think that her BP would drop anymore than 139/93? I looked up the peak of hydralazine and I believe it was 30-45min...I feel really sick to my stomach over this. I could have done some serious harm...And I'm now wondering how the pt. is doing.......

Stop torturing yourself. You need to learn from this, but then you need to let it go or you are going to paralyze yourself with fear. No one died.