What should I have done differently? Did I endanger my patient?

[misha]

Hi! I am a nurse with 5 months experience working in stepdown icu. I was wondering if someone could give me some insight into a recent situation. I had a patient who was there for a fungal infection. Pretty healthy patient only in stepdown because he had a reaction to the anti fungal med the day before. History of hypertension. I gave him a scheduled dose of clonidine at 9 pm. This brought him from around 175/90 ish to 140/80 ish.

As the night continues, his bp creeps back up. At 4 am, bp is around 175/90 again. I page the house officer about the bp, he calls back and tells me he isn’t concerned about it as his blood pressure has been on the higher side and they are trying to adjust his clonidine. I thought this made sense.

By shift change (6 am) bp reads 188/95. During bedside report I explain to the oncoming rn why it is high and my conversation with the house officer. He is very upset with me and saying this bp is dangerous, why didn’t I call the house officer again, why wasn’t this addressed. Now the patient is upset and I feel terrible that I could have harmed them.

Would you have paged again? What would you guys have done instead?

I’m thinking now that I should have asked the house officer what bp I should call him for.

[Rose_Queen, BSN, MSN, RN]

Did the patient have any other symptoms beyond the hypertension? Are there protocols that lay out when a provider needs notified of a blood pressure?

[misha]

No symptoms. We don’t have a general BP protocol, but sometimes patients will have a nursing order to notify MD for BP over/under ___. This patient didn’t though.

[NewOncNurseRN, BSN, RN]

We have a protocol for calling a rapid response for that high of a blood pressure- I think it’s >160/100. While you did call the doctor, you could have advocated for something to be given right then, especially something IV. Also, document in a note that you contacted the physician, what they stated if appropriate, and “no new orders at this time”. Was this an known side effect of the anti fungal?

[JKL33]

1 hour ago, NewOncNurseRN said:

While you did call the doctor, you could have advocated for something to be given right then, especially something IV.

What evidence supports this?

[beekee]

Nah, I wouldn’t worry about it. The only thing I would have done differently is ask at what point he’d like to be notified. I also might have given the patient his morning BP meds early.

If I had to call a rapid on everyone with a SBP greater than 160, I’d be calling a rapid several times a shift. I don’t really bat an eye until the SBP is over 180 in most patients.

[LovingLife123]

2 hours ago, NewOncNurseRN said:

We have a protocol for calling a rapid response for that high of a blood pressure- I think it’s >160/100. While you did call the doctor, you could have advocated for something to be given right then, especially something IV. Also, document in a note that you contacted the physician, what they stated if appropriate, and “no new orders at this time”. Was this an known side effect of the anti fungal?

You guys call a rapid for a BP of over 160?

[MunoRN, RN]

While there is a common misconception that an SBP over 180 is "dangerous" as a general rule in acutely ill/hospitalized patients, it's actually not and it's unnecessarily treating hypertension in hospitalized patients that is more likely to result in harm.

Practice guidelines for 'hypertensive urgency' (SBP>180) is to assess for acute signs of end organ dysfunction, TIA symptoms for instance, in which case it becomes 'hypertensive emergency' and only then is acute intervention indicated.

[Lunah, MSN, RN]

I have discharged people from the ER with blood pressures like that. Treat the patient, not the number. I was also surprised by the other post about rapid responses at 160/110. Really? Is it specific to a particular population for some reason?

[brownbook]

How the day shift nurse handled the situation, making you feel you did something wrong and managing to get the patient upset, is completely inappropriate.

I've seen patients with consistent BP's of 200 ++ over 110 ++ for over several hours. The patient doesn't stroke out or drop dead. Depending on A LOT of other factors the MD will treat this in many different ways.

Good reason why bedside reports are a bad idea!!!!!

[Emergent, RN]

What is inappropriate here is the fact that the nurse attacked your actions in front of the patient, embarrassing you and making the patient insecure about his care. He was totally out of line, and was basically bullying a new grad in front of a patient. What a total jerk!

[Rose_Queen, BSN, MSN, RN]

6 hours ago, NewOncNurseRN said:

We have a protocol for calling a rapid response for that high of a blood pressure- I think it’s >160/100.

Interesting. I had a blood pressure just over 200 when I was getting an echo. The tech said they'd have to take it again after and if it was still over 200 then notify the doc. (It came down- I blame anxiety over having that probe shoved into my ribs.) 160 seems rather low- what if that's the patient's norm and there are no other symptoms? I can't imagine the number of calls a provider would get in just one shift.