Need RN's opinion- BIG clinical mistake

[CrazyheadSN]

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....

[PeepnBiscuitsRN]

No...you are right to think about the implications of your actions on your patients- however, also being someone who can easily start to let my anxiety spiral out of control, you need to be able to know how to nip it in the bud. The best way I learned how to do this is to prevent any situation that could cause me to start to panic. A story: about 3-4 months ago, I had a patient who was confused as confused could be at baseline. He was 84, 85 and diabetic. He was admitted with hypoglycemia, and very shortly after admission they discovered he was septic, and he had a cascade of other stuff happen. So a week or so later when he was MY patient, we weren't even reporting that he was admitted with low blood sugar, we were more concerned about the sepsis. Even in the MD notes they didn't seem to do much delving into WHY he was hypo to begin with- probably it was because he had something else going on (sepsis). So, I have this guy, he's on a 1:1, and has the PCA in the room all night with him. I can hear him, he's blabbing on about one random topic after another. Doesn't say a THING about any discomfort- denies it when asked, in fact. At one point around maybe... I want to say 0530-0600 he happened to say he was kind of hungry, and then continued to talk to the PCA about baseball. I'm sitting outside the room, checking in every hour or so, and he appears to be good. He fell asleep about 0630.

Imagine my horror when lab calls me with a critical glucose of 34 on this guy. WHAAAAT?!!? So after I went bananas and checked it again on our accu check, while shoving an OJ or 4 in his face I went to the charge nurse who said "oh, wasn't he admitted with low blood sugar?" Of course this is the one charge who intimidated me so... so she and I went ahead and I learned how to push D50. After that incident, I could. not. let. go. of it. I almost went to my nurse manager and told her what happened. I mean...the guy didn't show ANY clinical symptoms I could see at that time. He was confused at baseline, he was never sweaty, nauseated, shaky. But in hindsight- he said he was hungry. That's it. He said he was hungry and that was the only warning besides him falling asleep. I ran this past several seasoned nurses, and even the charge who said that people present differently. It won't always be classic textbook symptoms and that I've learned now. I learned that to prevent my ever feeling that awful about something like that- if I have a patient who was admitted for anything diabetic related, even if they haven't been doing it on other nights...that person is getting a fingerstick at 0400. Especially if they got Lantus at nighttime. An ounce of prevention is worth a pound of clean conscience going home!

I hope this makes sense. Don't worry, be happy. It's fun, remember you've got people's lives in your hands, don't let anyone hassle you into hurrying up (unless you're like...3 hours behind) and whenever you have an out of whack reading, just stop. think. proceed conservatively unless they're symptomatic or looking to become that way.

[netglow, ASN, RN]

OP, I hope you have calmed down. That kind of stress is hard!

Good you realized what could have gone wrong. I do think that your instructor was MIA. The advice given here is so good. Just always start by finding the right size cuff and and just try telling the patient that yes, lots of people don't like this, BUT, you and I will get it done. Then, just do the BP and don't hesitate or discuss further unless the patient pitches a fit (I always do manual). If you cannot find a XL cuff that is functional, then you have to improvise. Some hospitals will spend every last cent on fancy new rooms and cut quality patient care basics. Narcs and heart meds -- never, never, push alone as a student. If you have a crappy teacher (you do) get your patient's RN and hook your arm around hers and drag her in with ya. I bet ya she'll take a manual before she lets ya push. After all, it's her rear if the patient bottoms out.

[lockheart678]

When I was in nursing school, we weren't allowed to give any kind of medication by ourselves, even if our instructors knew that we knew how to give them. Your instructor is irresponsible by leaving you alone to do things that she should be in there for, and that's not your fault.

Don't let your anxiety get the best of you. You're not even out of school yet, so it's expected to be pretty stressful. As you gain more experience and build your confidence, things should get better for you. Being stressed out doesn't necessarily mean that nursing isn't for you. Stick it out and hopefully things will start getting better for you.