Need RN's opinion- BIG clinical mistake

applewhitern, BSN, RN · Feb 25, 2012

I'm with KelRN215 on this one. Your instructor should have been with you, and should have told you to check the B/P again, and preferably, manually. That is why you are a STUDENT~to learn! Stop beating yourself up over this, and next time, make sure your instructor earns her pay.

NoviceRN10 · Feb 25, 2012

Personally I don't think you made a big mistake. Stop beating yourself up :). The object was to get the pt's bp lower than it was, and you succeeded and definately didn't bottom the pt out or harm her. It isn't always possible to get an accurate reading on an obese person if you are trying to use the upper arm (I don't care what size cuff you use, the darn thing will slide or it's dificult to get it tight around the arm), we use the wrist often where I work. We use manual readings if the bp is ugly high or low, so the reading you got wasn't something that I would have used a manual to double check.

bjaeram · Feb 25, 2012

I don't think you made a mistake at all. It is perfectly fine to take a forearm bp. If someone has a fat short upper arm it's almost impossible to get a good reading there and it does hurt like crazy. If the cuff is sized properly you will get the best result. I often find people grab a large cuff for a fat arm but the cuff covers the entire upper arm. That is also incorrect and will give an inaccurate reading. I often grab a long cuff not a large cuff!

tangerinetea · Feb 25, 2012

Don't worry about it. I honestly commend you for being so onto it about knowing your anti hypertensives, reviewing PRN medicines, making a conscientious decision to treat the problem - that to me all shows critical thinking which can take some people a long time to grasp in the field of health care. Well done. You know the mistakes you made, and I really feel that they weren't yours alone. You're a student because you are LEARNING to be a nurse. Therefore to learn, you need a teacher - and yours wasn't there to advise you. Learn from it, let it go... you will make a great nurse.

A good habit to get into is providing rationale to the nurse who is CHECKING the IV medication with you. Where I work (in a PICU), if I was to replace potassium, I would tell the nurse what my K+ was. If I didn't tell, I know she/he would ask! Same with hydralazine, isradipine - they would want to know the BP and the parameters we are wanting before signing for it.

(p.s. if your patient asked to have it on her forearm as if that was her usual method, chances are other nurses have given her that option!)

All the best.

bethisonline · Feb 25, 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....

First of all the BP of 139/93 is NOT a low blood pressure, so you cannot say that you

did anything unsafe. AND alot of women who are larger or who have fibromyalgia do experience pain from BP cuffs on their upper arms regardless of the size. I work with pain management patients and on occasion have taken their BP on the radial artery on the lower arm, just like we take the BP on the leg for breast cancer pts. AND by the time the larger cuff was put on the upper arm the hydrazaline could have started working. The other thing that needs to be realized is that patients who have high BP that goes untreated will probably not respond very quickly to medications for BP. Chronic high blood pressure is a viscious cycle and it just takes time for meds to kick in and probably repeated doses.

It would behoove us all to do some research and comparison of radial artery BP and Brachial artery BP, because I guarantee that another patient you will come across will complain the same as your pt did and you will want to place the BP cuff elsewhere so you do not cause pain in the upper arm.

Esme12, ASN, BSN, RN · Feb 25, 2012

I don't know where you are in your education. You have learned a few things here.....first, the appropriate sized cuff is imperative to an accurate B/P reading.....even with an automatic cuff. Second, never treat medically a result of physical with out double checking. Many times over the years, MANY TIMES, I have asked another nurse to listen to a patient's heart tones, doppler pedal pulse repeat a blood pressure to verify my findings. When treating a patient with meds a good habit to develop is to verify the B/P in the other arm by a different means to ensure accuracy to prevent these types of errors from happening.

I too, question where is you instructor or the nurse leaving you to be giving IV push meds without someone with you. It is not the first mistake and it won't be the last. The key is to keep them with the minimal impact on the patient. Kudos for knowing the med and it's peak effect

Good Luck in school!

cardiacrocks, BSN, RN · Feb 25, 2012

I work on a tele floor I'm curious about something. What was the HR, was she in A-Fib or SR, or ST. Also, we were never allowed to take automatic BP's in clinical, ALWAYS on a tele floor as the RN we take manual BP's. Also, did you know that if the pt is in A-Fib an automatic cuff usually is not accurate, because the rate is so irregular. Sounds like you did think through the situation well enough, no harm no fowl. However, where was the RN and the Instructor when you were doing an IV push? Students at our hospital are not allowed to do IV pushes, especially a cardiac med, I'm blown away by that. When do you graduate? I'm wondering why nobody called a doctor? I will compliment you on the fact that you did think through the situation and for that you need to give yourself some credit :)

delilas · Feb 25, 2012

Maybe my school was strict, but until independent preceptorships, we gave no medications (especially IVP) without a nurse or instructor present. Not that that would've completely corrected the issue here.

Just take a deep breath - you learned a good lesson here, and no one was hurt.

CapeCodMermaid, RN · Feb 25, 2012

I haven't read all the responses so forgive me if I am repeating something already said. But, IVP as a student with no instructor present?? I'm not thinking that is a good idea.

I'm glad your patient was okay.

CrazyheadSN · Feb 25, 2012

Thank you all for the replies. I have definetly learned a valuable lesson. I did hear back from my instructor and she feels that my mistake is OK. Though, she still wants to talk to me about my worries bc I have worried about other things in the past such as- causing hypoglycemia in a pt., etc. I get really worried about my patients.

My instructor is there to check off the IVP med (we go into the pt.'s room together) but she is usually not there when I actually give it. She might be there for the first flush, and MAYBE when I start the med IVP, but the instructor does not stay for the entire push. She usually leaves to go to another student. I think a lot of my worries has to do with not being supervised more. I am debating if nursing is for me. My instructor feels that I may not be able to enjoy the profession if I feel this way often....Ughhh...I feel like I really don't want to work in a hospital! Mainly bc I don't want to make a mistake. So I think I strive for perfection and no one is perfect... :uhoh21:

nursingj · Feb 25, 2012

#1 Your instructor should have been with you if you were pushing any kind of medication. #2 If in the future you need to push any kind of a med because of what a machine says, check it again with the skills you have learned. #3 I don't believe you can be kicked out of nursing school. It is the instructor who is responsible for what the students are giving. Whether it is a po, rectal, IV and especially an IV push. She should have checked herself, after all you are still in the learning process. Sorry you had to learn this the hard way.

RN/Mom · Feb 25, 2012

Thank you all for the replies. I have definetly learned a valuable lesson. I did hear back from my instructor and she feels that my mistake is OK. Though, she still wants to talk to me about my worries bc I have worried about other things in the past such as- causing hypoglycemia in a pt., etc. I get really worried about my patients.
My instructor is there to check off the IVP med (we go into the pt.'s room together) but she is usually not there when I actually give it. She might be there for the first flush, and MAYBE when I start the med IVP, but the instructor does not stay for the entire push. She usually leaves to go to another student. I think a lot of my worries has to do with not being supervised more. I am debating if nursing is for me. My instructor feels that I may not be able to enjoy the profession if I feel this way often....Ughhh...I feel like I really don't want to work in a hospital! Mainly bc I don't want to make a mistake. So I think I strive for perfection and no one is perfect... :uhoh21:

Don't beat yourself up too much! Everyone does make mistakes, and you sound like the type of person who really learns from their mistakes. I am also a nursing student and could see the same thing happening where we have clinicals.

We have a big group of students and the instructor does not stay with each of us when we draw up and give IVP meds (once we have passed competency to do so on our own). If we have a PRN that comes up, we just let her know why we are giving it and must answer any questions she has for us about the drug (usually relating to administration, action, s/e).