Need RN's opinion- BIG clinical mistake

Nurses General Nursing

Published

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....

Specializes in Trauma, Emergency.

Anytime you come across a crazy reading, you should redo it manually. And don't let a pt bully you- unless it says in her chart that BP should not be taken on upper arm (for PICC line or DVT for instance), it should be upper arm. Tough noogies if it's uncomfortable to pt for a minute, you can tell her it's that or a potentially dangerously inaccurate reading, period. Good luck!

Specializes in Telemetry, Med-Surg.

This was probably your first mistake, but it will not be your last. Take this opportunity to learn from it and use what you learn in your future practice. Nursing is a job in which you will learn something new everyday. Just be happy that the patient is safe and no harm done. Any nurse that tells you she never makes a mistake is not being completely honest, as no one is perfect. Admitting your mistakes, taking ownership, and making sure it doesn't happen again is the best you can do. However, I would also encourage you to ask questions from experienced nurses if you are unsure about something. Once you are a practicing nurse, don't be afraid to ask questions before you perform a treatment if you are unsure about it. It's best to ask questions before rather than afterwards. Don't beat yourself up over this.

On most floors I have done clinicals on, I have not for the life of me found any manual cuffs. Sadly, I can't find the one I bought in my first semester of nursing school, and how in the world can I carry it around in my pocket anyway. When I find it, I will carry it in my bag and bring it out when the occasion comes.

As for getting an inaccurate reading and giving a push med based on that reading, you've certainly learned a lot from this. If your instructor found out about this, you could have been failed. I made a serious mistake in my junior year by giving a medication I shouldn't have. The patient was thinking of surgery, it wasn't a done deal yet. I gave an anti platelet medication along with the rest of her 9:00 AM medications, and in retrospect, I shouldn't have. I could have been failed for that. We all make mistakes. The key is to not make those mistakes again.

Specializes in PICU, Sedation/Radiology, PACU.

You gave the hydralazine IV at 1245 and 45 minutes later her BP was 132/93. Did you look up the onset of IV hydralazine in your medication reference? This will tell you that the onset is 10-20 minutes. It will also tell you that in a hypertensive crisis you can give 10 mg of hydralazine q 15 minutes if you need to.

Always check manually when you get an abnormal reading on the dynamap. Use the appropriate sized cuff and check on the upper arm unless contraindicated. Learn from this, and then let it go. Your patient is fine and there's no point in continuing to stress yourself out over it.

Specializes in LTC Rehab Med/Surg.

I always check a questionable pressure with a manual cuff. Always.

It's too bad we're expected to make the customer happy at any cost. I'll bet that pt would have complained, if the nurse didn't take her B/P where she expected it to be taken.

It is only partly a matter of where a BP is taken - - if it is always taken in the forearm then that is okay. And the size of cuff is still important. I am very heavy and my ulnar nerve gets compressed if it takes too long to get my BP in my upper arm, causing my ring and pinky fingers to become numb. I prefer my BP in my forearm, and have found that there is little difference when it is done correctly.

The issue here is knowing more about the meds that are being given, as others have mentioned.

And stop making yourself totally crazy.

Best wishes.

Specializes in Trauma SICU.

I'm a PCT in nursing school, and the patient population I work with is a mixed bag of body types. If you need to take a forearm BP, put the index over the radial artery. For a calf BP (great for very confused/combative pts!) put the index over the posterial tibial. Always document where and it was taken.

I always, always, recheck an abnormal reading manually before reporting a BP to a nurse. Dynamaps, even if correctly applied and sized right, have an error of margin. It's best just to use your own senses when the moeny is on the line.

Specializes in Pedi.

OK, I'm confused about something. The OP is a student per his/her own statement. When is a student EVER supposed to be assessing/giving medications independently? A student does not have a license and is working either under the clinical instructor's license or the assigned RN's. I precepted a student last semester and I would never not be in the room if she were administering any IV meds, PRN or not and I always double-checked any abnormal values, pump settings and completed my own assessments. I'm the one with the license who is ultimately responsible for the patient.

OP, what happens in your clinical? If I were the RN taking care of this patient and a student took a BP that warranted intervention, I would expect the student to come find me and tell me "Joey's BP is 180/100, I want to give him PRN hydralazine" so I could investigate the situation more. If Joey is a screaming baby who was kicking while his BP was being taken on his leg, his BP is not 180/100 and he doesn't need any intervention. Same for if the patient is an obese adult and the cuff is the wrong size. Students would never give a PRN medication on my unit without first discussing it with their instructor and the RN responsible for the patient.

I am not trying to make you feel worse, I am just genuinely not understanding what goes on in your clinicals if you're doing all these things without your clinical instructor or the RN caring for the patient. The patient's BP was 130s/90s after hydralazine so you didn't kill her and you certainly didn't bottom out her BP... that's a relatively high BP still.

Size of cuff can really alter the BP result. It should always snug the patient's arm properly. Taking BP manually when results are doubtful is the next option.

Yes, the patient could have been harmed if her BP happened to be low..

Like what others said, there was no harm done, so you should be fine. You might get some words from your instructor, but really he/she should have been there to check the patient too.

Did you tell your instructor that you took the BP from your pt's forearm???

Specializes in PACU.

Umm, even the lowest reading (which was when the hydralazine was really doing its thing) was still high. You did nothing wrong per se, and you certainly did not harm the patient. Take the opportunity to learn that taking the BP on the forearm is often less accurate (I tend to see it be lower than it should be vs. high) and that ideally you should use a properly fitted cuff on the upper arm. That said, sometimes you gotta make do with what you've got.

You might only be able to get a BP on the lower extremity of your patient with injuries to both arms. I'm not sure I agree that a manual reading is necessarily the way to go. My goal when assessing BP is to make sure the patient is compatible with life and to monitor for significant changes from patient baseline. As mentioned in another post, consistency in how a particular patient's BP is monitored so you can see trends is the most important thing. And if you see a really weird reading get the patient to hold still and cycle the cuff again.

Oftentimes movement (even just shivering) will give you a totally bogus reading. I had a reading of 210/120 on a fella today who was shivering severely. I gave him some Demerol and he stopped shivering a couple of minutes later and the reading was much better. With any type of patient monitoring it's important to look at the patient and consider the context.

Forearm BPs are generally not accurate, and should only be used in an absolute pinch. If you MUST take BP on a forearm, make sure the forearm is at the level of the heart. If lower, you will get a falsely elevated reading.

Specializes in OB (with a history of cardiac).

I can echo what is being said. I work on a tele floor and so this sounds like a typical patient. The things you should be asking yourself are:

What have her BP's been running? (because I guess the initial 163/87 doesn't stun me too much, sounds right for someone who gets their BP meds in the am, especially if they're poorly controlled). So look back and see if this figure you got agrees with what has been charted.

Have they always been taking her BP on her forearm? We will take BP's on forearms and thighs if the patient has restricted limbs or is very obese. We don't tend to make it a habit, but we will do it.

Is she in pain? What is her HR doing? What else is going on with her?

Did she recently get a PRN BP med? When? What?

ALWAYS do a manual if you get something high. If the PCA reports to me that someone has a really high BP I ask them if they would (pretty) please (with a cherry on top) do it on the opposite arm. If it is still out of the range they've been running, then I'll do a manual. If that agrees with the automatic, then I'll start considering my PRN options.

In our hospital, our patients get their own disposable BP cuff, and it stays right in their room. That way we can ensure that nobody uses the wrong sized cuff. A too tight cuff will indeed give you an inaccurate reading.

That said...yes, pushing an IV BP med when the parameters are too low could bottom your patient out. So yes, keep it in mind the next time. It sounds like no harm was done to this patient, so it's a learning experience. Also, I'm going to assume that your instructor or a staff nurse would be with you when you're pushing said medication (at least I would HOPE they would be, with all due respect to you, the OP). So I'm thinking they're not just going to be like "duhhh ok! lets do it! Wooo!" Without double checking everything.

I hope you don't get kicked out. Your patient sounds like they needed some kind of intervention if after hydralazine IVP their BP was still 139/93. That's by no means sky high, but it's bordering on the high side.

+ Add a Comment