What the heck is this doctor thinking? Actually not thinking!

[DutchgirlRN]

I have a new home health patient who is elderly he/she was admitted post hospital stay for syncope and resulting fall. He/she has a orthostatic BP's to the tune of Lying: 220/116 Sit: 240/120 Stand: 178/112. I noted that the patient was eating a diet high in sodium, canned soups, salted peanuts, bacon, etc...Naturally I called the doctor. He did not order any meds. Said "no this pt doesn't need to come in for a visit" and he/she can have all the salt he/she wants. The only order was to decrease the pt's dose of Flornef and continue to keep him informed of the orthostatic readings.

What the heck? I documented, documented and documented some more. I also put all this in a fax and have the fax confirmation in the patients chart.

BP was WNL in hospital. Orthostatic BP's at admit visit and visits x 2 following were also very very elevated and doctor was notified. No orders.

I can't force this doctor to do anything and I can't tell the patient to get a new doctor. I can't do anymore than I have. I did tell the patient to limit his/her salt intake even though the doctor said it was ok.

Do you have any suggestions?

[stsdoc]

Please allow me to explain. The pt you are taking care of suffers from orthostatic hypOtension, ie a severe drop in blood pressure upon standing, which is no doubt what caused the syncope/fall which caused the pt to be admitted in the first place. Now this can be caused by any number of things: medications, autonomic insufficiency d/t diabetes/stroke, adrenal insufficiency, but the common factor is decreased intravascular volume (ie low bp).

The treatment of choice for this condition is florinef, which increases blood pressure by acting like aldosterone, a hormone made by the adrenals which increases the reabsorption of sodium by the kidneys, thus raising intravascular volume. This is often used in combination with a high sodium diet to treat this condition.

The physician acted appropriately in telling you to reduce the dose of florinef, as this (and this alone) is probably what caused the spike in bp in this patient with orthostatic hypOtension. He also acted appropriately in not ordering any meds which would acutely lower the blood pressure, as this would just again increase the chances of another orthostatic episode/fall. If the pt was not symptomatic from the HTN with headache, visual changes, etc, then continued monitoring of bp is all the treatment needed. The bp should come down with decreased florinef.

Sorry for the long post, but I just wanted to show that there is a method to our madness

[tridil2000, MSN, RN]

Please allow me to explain. The pt you are taking care of suffers from orthostatic hypOtension, ie a severe drop in blood pressure upon standing, which is no doubt what caused the syncope/fall which caused the pt to be admitted in the first place. Now this can be caused by any number of things: medications, autonomic insufficiency d/t diabetes/stroke, adrenal insufficiency, but the common factor is decreased intravascular volume (ie low bp).

The treatment of choice for this condition is florinef, which increases blood pressure by acting like aldosterone, a hormone made by the adrenals which increases the reabsorption of sodium by the kidneys, thus raising intravascular volume. This is often used in combination with a high sodium diet to treat this condition.

The physician acted appropriately in telling you to reduce the dose of florinef, as this (and this alone) is probably what caused the spike in bp in this patient with orthostatic hypOtension. He also acted appropriately in not ordering any meds which would acutely lower the blood pressure, as this would just again increase the chances of another orthostatic episode/fall. If the pt was not symptomatic from the HTN with headache, visual changes, etc, then continued monitoring of bp is all the treatment needed. The bp should come down with decreased florinef.

Sorry for the long post, but I just wanted to show that there is a method to our madness

i agree.

the florinef was a red flag. this pt must have a hx of LOW bp. maybe she has an adrenal issue that you don't know about. giving her a beta blocker could cause her to pass out an hour after you left. it sounds like reducing her florinef first was the best thing to do for this pt.

it would be great to have her do her own bps qday and record them for you.

[PANurseRN1]

It's one thing to have a genuine question as to why a doctor is pursuing a particular treatment course, and quite another to paint the doc as stupid, particularly when there may indeed be excellent reasons for what he/she is doing.

Yes, you really do need to know more than just the pt having an elevated BP. I would tread very carefully in the future.

[fuegorama]

Dutchgirl.

Thank you for your attentiveness and concern for your pt.

Without a full H&P it is impossible to deduce the logic here. However, allow me to hypothesize that this pt. is actually benefitting from his/her HTN.

The numbers you give are alarming in the standard white, middle-aged normotensive population.

This may not be the situation in your pt's case. There is a minority of people who actually require these pressures to perfuse the vasculature you eloquently described in you earlier post.

African americans and other minorities can actually suffer "watershed ischemia" from a seemingly mild drop in systolic perfusion.

There is substantial documentation of CVAs occuring in situations of a mere 30mm Hg following reduction via antiehypertensives e.g. clonidine 0.1mg.

Yes, some of these people live in the mid-200s. I wouldn't recommend it for the majority of us, but these folks do exist.

These examples are not limited to blacks, but anecdotally that is the majority.

This is just a blind guess, but it may explain "what this doc was thinking".

[fuegorama]

Great explanations above.

Thanks.

[PANurseRN1]

i agree.

the florinef was a red flag. this pt must have a hx of LOW bp. maybe she has an adrenal issue that you don't know about. giving her a beta blocker could cause her to pass out an hour after you left. it sounds like reducing her florinef first was the best thing to do for this pt.

it would be great to have her do her own bps qday and record them for you.

Agreed. You can almost hear your mental tires squealing when you read "Florinef." It should make most nurses stop and think, "Whoa, there's more to this than meets the eye."

Said "no this pt doesn't need to come in for a visit" and he/she can have all the salt he/she wants. The only order was to decrease the pt's dose of Flornef and continue to keep him informed of the orthostatic readings.

I did tell the patient to limit his/her salt intake even though the doctor said it was ok.

Do you have any suggestions?

So, in spite of what the doc told you, you instructed the pt contrary to what the doc said? That was unwise in this situation. If you were unclear as to why he didn't want to restrict the diet, you should have point blank asked him to explain it to you. Without that understanding, you were out of line to contradict him to the pt.

[leslie :-D]

perhaps your pt would benefit from a pt handout of florinef.

it's a med that has remarkable se's and implications.

i know i'd appreciate a printout of what this particular med does.

leslie

[Myxel67]

Sometimes we are too quick to be outraged by what we don't understand. Just looking up Florinef and its unlabeled uses would lead to understanding and keep our own BP from going through the roof. It's so vital to understand the meds you give and why they're being given to a particular pt.

[elizabeth321]

Please allow me to explain. The pt you are taking care of suffers from orthostatic hypOtension, ie a severe drop in blood pressure upon standing, which is no doubt what caused the syncope/fall which caused the pt to be admitted in the first place. Now this can be caused by any number of things: medications, autonomic insufficiency d/t diabetes/stroke, adrenal insufficiency, but the common factor is decreased intravascular volume (ie low bp).

The treatment of choice for this condition is florinef, which increases blood pressure by acting like aldosterone, a hormone made by the adrenals which increases the reabsorption of sodium by the kidneys, thus raising intravascular volume. This is often used in combination with a high sodium diet to treat this condition.

The physician acted appropriately in telling you to reduce the dose of florinef, as this (and this alone) is probably what caused the spike in bp in this patient with orthostatic hypOtension. He also acted appropriately in not ordering any meds which would acutely lower the blood pressure, as this would just again increase the chances of another orthostatic episode/fall. If the pt was not symptomatic from the HTN with headache, visual changes, etc, then continued monitoring of bp is all the treatment needed. The bp should come down with decreased florinef.

Sorry for the long post, but I just wanted to show that there is a method to our madness

I am in total agreement to this quote..I couldn't for the life of me understand why you wanted to add Lopressor based on the info you gave .

Dutchgirl I can't help but notice at least two threads you have started where you have been appalled by the actions of others....sometimes you need to take a deep breath and try to understand the issues at hand without getting emotionally/personally involved. These issues are rarely black and white....you have to look at the whole complete comphrehensive picture. I do like your enthusiasm and with more experience I can see you doing some great things in nursing....I also like the fact that you are a strong patient advocate.

Good luck

Liz

[Cattitude]

even if only 30% of the general population are salt sensitive, it would be prudent to eliminate it as the source wouldn't it? and say if this person were a minority such as african american or native american, doesn't that percentage go up for those populations?

but on the other hand was he showing other symptoms? dizzyness, spots before the eyes, headache? perhaps the dr. was worried about adding a new med and having the pt plumet too much?

just wanted to advocate for both sides here.

that's what i was doing too. now reading further, i just received a wonderful education on florinef. a med i was unfamiliar with! thank you everyone.

[color=#483d8b]

[Cattitude]

ido you have any suggestions?

dg,

[color=#483d8b]one more question. i know that your agency is good from what you've shared. doesn't your supvr. get involved with trying to figure out some of this with you?

[color=#483d8b]i was just sitting here thinking that my boss is kind of nuts about stuff like this. she either would have known about that med. already and told me about it or investigated further. then again, my boss is also an attourney. .

[burn out]

What other medications was the patient taking? I had a patient not long ago but the first time ever that remained 250/140 and was on 100 mcg/hr nitroglycerin, lopressor iv, norvasc, lobatelol and nothing ever brought his pressure down for any length of time. His physicians said that we had to maintain his systolic at least 160 or else he would stroke out. I can't remember the reasoning for that but at the time it made sense.