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?

[MedSurgeNewbie]

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.

Might be totally wrong here but I remember being told that if you take a Bp down too quickly it can cause CVA due to increased chance of clotting - the intern described it as sort of pooling that can happen if the pressure got too low - I am a newbie so it might be off base

[withasmilelpn]

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

Thankyou for your informative post! (I just love this site:balloons: !!)

[twinmommy+2, ADN, BSN, MSN]

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]

i was also unfamiliar with florinef before reading this post. you all are a wondreful wealth of information, thanks!

[Altra, BSN, RN]

Thanks for the great explanations, stsdoc & fuegorama.

I've only run across Florinef once, but I agree ... in reading the OP, prescribed Florinef was a red flag that larger issues were in play.

[TachyBrady]

Might be totally wrong here but I remember being told that if you take a Bp down too quickly it can cause CVA due to increased chance of clotting - the intern described it as sort of pooling that can happen if the pressure got too low - I am a newbie so it might be off base

When there is stenosis and narrowing of the carotids and other higher arteries (which can contribute to syncopal episodes) higher pressures are desired for brain perfusion. Not sure if this is the case for the pt in question but it would explain the doctor's desire for sodium intake/water retention, and higher BPs.

[DutchgirlRN, ASN, RN]

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.

hello....this is a nursing form! it's inappropriate for me to vent such issues the way i do here at work. i feel safe here on all nurses. this is my therapy not my slate for spanking the hands of other health professionals who i think are not thinking correctly. my threads have been a great source of information for me as well as others. i don't look at them as being a problem but rather a source of therapy and education.

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.liz

in the past 31 years i have done some great things in nursing. with that said...i'd like to point out, not judging the doctor, that per the doctors history there is no mention of the patient having addison's disease, the patient is on florinef 0.1mg, 7 tablets qd in am. now decreased to 5 tabs per day. here is info i found.

the usual dose is 0.1 mg of florinef acetate daily, although dosage ranging from 0.1 mg three times a week to 0.2 mg daily has been employed. in the event transient hypertension develops as a consequence of therapy, the dose should be reduced to 0.05 mg daily. florinef acetate is preferably administered in conjunction with cortisone (10 mg to 37.5 mg daily in divided doses) or hydrocortisone (10 mg to 30 mg daily in divided doses). salt-losing adrenogenital syndrome

the recommended dosage for treating the salt-losing adrenogenital syndrome is 0.1 mg to 0.2 mg of florinef acetate daily.

http://www.rxlist.com/cgi/generic/fludro_ids.htm

[Lurksalot, BSN, RN]

I also would have called about that high of a pressure, especially considering it was symptomatic. I agree with the ordered treatment of reducing the florinef...the only thing I would have done differently was have the patient moved to a monitored bed(if it wasn't already) and assess for gradual reduction in the pressures. I would also expect some parameters given for what the pressure should remain above. Apparently this patient requires greater perfusion, however it may be a delicate balance between the symptomatic hypertensive state and hypotensive episodes.

And it's always ok to ask, IMO.