Should I worry???

[KulRN]

Ok, here's the situation......2 days ago I took care of a 54 y.o male patient who had a lap chole POD #2, except for history of prostate enlargement and depression, this patient is otherwise healthy and stable. During my morning assesment his vital signs are stable, bowel sounds active, soft abdomen, passing gas, 4 abdominal puncture wounds CDI, not in any distress. Then on my noon vitals, his BP got elevated to 202/103 (right arm) 198/101 (left arm) (patient did not have any complain of any pain, headache, neck pain, chest pain, palpitations, SOB..in other words he's stable and assymptomatic) rechecked his BP after 15 minutes, BP still elevated at 186/98 and 178/72 (patient still assymptomatic)...I told my Charge Nurse who then placed a call to the surgeon...1/2 hour later Surgeon called back and I made him aware of the patients status...MD ordered 1 time dose of 10 mg Norvasc PO and stated he will come and evaluate the patient will discharge him home and pt to follow up with his PCP about his BP (per patient did not have any history of HTN)...Norvasc was given to the patient, instructed patient to relax and elevated HOB. 1 hour later, I rechecked his BP, BP still elevated 182/78, this time the surgeon came and evaluated the patient and discharged patient (he talked to him about his BP). All this time patient remained stable and assymptomatic, no complain of any distress. Prior to discharge, I took his BP again ( aprroximately 3 hours since Norvasc was given), BP still elevated this time 198/103, I did not feel safe sending this patient home with how his BP reading were, so I placed another call to the MD and made him once again aware...MD stated "It's ok, send the patient home. I really can't do anything with the patient's BP..anyways gave him some BP meds to go home with and he will need to follow up with his PCP. It's okey he can go home". I asked my CN who then said "well, if the MD said send him home, then send him home..just make sure you write good documentation on that". So, I then preceded to discharge the patient even if I felt I should not. I stressed to the patient to follow up with his PCP and to take his meds as prescribed and if he feels something is wrong once he gets home to go to the nearest ER stat. Patient agreed. He left the hospital stable and assymptomatic. To this day, I'm still doubting my judgement...of sending this patient home with that kind of BP....Feedback please.....I'm really concern....I felt like I was not a good advocate for this patient.

[rita359]

The surgeon was not going to do anything else per current standards. From a surgical standpoint the patient was ready for discharge. It would have been a good idea to find out who the patients primary care doc was, give patient copy of bp readings and advise patient to immediately call primary care physician for appointment. Might also educate him regarding normal bp readings. That way you have done all you can do after documenting same and it is up to patient to follow up.

[chenoaspirit, ASN, RN]

With that, i too think risk management would be a good place to discuss this patient. I also understand, yes people walk around with BP's that high all the time but people also have strokes all the time. A blood pressure that high should have been addressed. I also understand the surgeon didnt want to keep the patient, he had done what he had the patient there to do and blood pressure isnt something he treats. We have an orthopedic like that too, dont call him for a blood pressure problem or you may get screamed at so loud they will hear it into next week. But that is also when you advocate for your patient and request they order a consult for the blood pressure problem. If they still wont you can document you suggested a consult that was refused and the ball is back in the doctors court if they guy goes home and has a blow out because of his blood pressure.

I totally agree! People do walk around with BP's that high, but they are at risk for multiple problems. And yes you did all you could do. You did advocate for this patient.

[rita359]

In addition to my previous suggestions, if your institution does discharge phone calls this is one patient I would be sure I did the discharge phone call on. That would give you another opportunity to follow up with the patient to make sure he is following up with the primary care physician.