Should I have pushed Doc for more?

[lovin]

Hello,

I am a new nurse - 3 months out on my own - and I just had my first experience with a patient changing condition rapidly while on my shift. It was the first time that I did not want to leave after my shift because I wanted to stay with that patient. Now, I am looking back and wondering what I could/should have done.

Here is the story:

Pt is transferred from a step down unit to me on the tele floor around MN. I get in report that she has high blood pressures (190s/80s) but is asymptomatic. Her first BP for me is 205/90s, she denies HA and dizziness, and I give her Hydralazine. 3 hours later her pressure is 228/90s and she is complaining of throbbing in her head.

I call MD, he tells me he is aware she has high BP and that I should have gotten that information from step down. I tell him I am calling because the BP is higher than it has been since she was admitted and because she is symptomatic. He says to give hydralazine.

I give hydrazine and when I come back to recheck BP, pt is at 205/90s. Pt is lethargic and unable to open eyes on command. Blood sugar is 110. Sats are over 95%. I tried to do a quick stroke assessment - smile, push pull etc. But cannot because pt is unable to participate. As I am preparing to call the MD we hear the pt screaming from the nurses station. WHen I walk into room, pt is sleeping and clearly having a vivid dream. I am able to awaken her, but she goes right back to sleep.

MD is called. He comes to floor to assess pt. Determines that pt is anxious and asks me to give her Xanax and her am BP meds early (this is now 4am). My inner voice is screaming -- "there is something wrong with this pt!" So, I tell the MD again that this patient was alert and conversing with me less than an hour ago. He is able to get minimal pt cooperation for a quick neuro and tells me that pt was just having a bad dream and is, in his opinion, just fine.

So, I give meds and and get help from other nurses so that I can observe pt more closely. Bp comes down to 170's. Pt still lethargic and having difficulty answering questions.

Day doc arrives at 6:30am. Assess pt and determines she is sleepy since she was transferred at MN. Doc had to manually hold pt eyes open to assess responsiveness. I again state that the patient was alert and oriented and able to ambulate at 2am - 4 hours ago. Doc decides to order a CT scan, just in case.

At shift change (7:30), pt is still in room waiting for CT when I give report to oncoming nurse. Pt is still very lethargic, knows name and date but is minimally responsive. Asks us to call her son but cannot remember son's phone number and has to think about what his name is. Nurse and I recheck BP - 205/90 and now she has a noticeable facial droop on one side.

Oncoming nurse was very kind, but in report I gave her the "well the doc says she is fine, so she is probably fine" line and when we went into the room that pt was CLEARLY not fine. I feel like I should have done more for this pt.

WHat would you do in this situiation? WHat can I do differently next time?

[Here.I.Stand, BSN, RN]

I haven't had to do this myself, but I've heard of other nurses tell the MD, "I'm going to call a RR" when the MD was aware but not doing enough. Sometimes the "threat" is enough to light a fire under them.

[canoehead, BSN, RN]

If you think the patient needs more than they are getting, ask the doctor to come and reevaluate for themselves, even at frequent intervals. Document " requested physician respond to pt bedside." The ball is completely in their court at that point. You must kick it up the chain of command as well, and make the same request to each person you call. Serial in person evaluations are going to be the most accurate assessment, and you can push harder by saying she is becoming less and less (or more and more) whatever over time. I think you did everything you could, but those are the phrases that have worked for me.

[Biffbradford]

The RN said that at 0430 the MD came to the bedside and assessed the patient. i don't understand, is the rapid response team going to override the MD because he's not doing enough in your view? I would have had that head CT ordered stat. so the pt doesn't sit waiting, but I don't understand what the stroke team is going to do in addition to having the MD at the bedside. Like mentioned already, cover your butt and chart everything. Ain't nursing grand?

[nrsang97, BSN, RN]

Sometimes the MD will listen to the rapid nurses and do as we suggest and not the floor nurses. Sometimes we even ask for the same thing. They give me what I need no problem. I don't get it but sometimes that happens.

[Cal-Neva]

How could a patient be anxious when they are barely responsive??? MD attitudes like this really tan my hide. You did the right thing, and hopefully documented all of this. The only thing that might have helped is a rapid response like others have said only because you would get a bunch of sets of experienced eyes and minds on the case who might know tricks to motivate the MD a little better.

How the information was conveyed may have mattered too. Telling a doctor that you think the patient is having a stroke vs has high blood pressure and is lethargic may get the MD to act differently. I am in no way telling you that you didn't communicate the problem well, because you did, just something I learned with dealing with Docs at night.

[NurseKatie08, MSN]

Would have definitely called a brain attack at my facility...have called them for much less than what you describe.

[Here.I.Stand, BSN, RN]

Sometimes the MD will listen to the rapid nurses and do as we suggest and not the floor nurses. Sometimes we even ask for the same thing. They give me what I need no problem. I don't get it but sometimes that happens.

Unfortunately that's how it works sometimes. Some of our float pool RNs who work in our ICUs *and* on our floors have contrasted the type of response they get from the same MDs regarding the same population of pts, when on the floor vs. the ICU. It's not right, but according to them it's true.

I haven't had to call a stroke code at my hospital or been involved with one--yet--(come to think about it, I don't think I even suggested a stroke code in my previous reply...where is my brain??), but I'm pretty sure when one is called, neurology becomes involved until a stroke is ruled out. So that's an option if your hospital has them, if this pt is on say the cardiac service but having stroke sx. If not, I also think it's a good idea to discuss protocols w/ your manager.

[Nurse SMS, MSN, RN]

I haven't had to do this myself, but I've heard of other nurses tell the MD, "I'm going to call a RR" when the MD was aware but not doing enough. Sometimes the "threat" is enough to light a fire under them.

Yup. It works. I have had to do this a time or two.

"No Dr. Soandso....I didn't recheck their blood pressure in 15 minutes. It was xx/xx and the patient is unresponsive. We are in a Rapid Response situation and we wish to transfer to ICU. May I have that order please."