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.

[misha]

8 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?

I asked for hydralazine, but lately I've noticed docs are less likely to order it, not sure why. Anyway he said he'd prefer to adjust his clonidine in the morning over giving a PRN. Wow we don't usually notify a physician for a BP of 160/100 at my hospital unless it's a big jump from their norm...I think we'd be constantly having rapid responses if we had this protocol! but I did write a note. Not sure if it is a side effect. Patient wasn't receiving the anti fungal, I heard they were going to try and give it to him again possibly the next day which is why they wanted him on the monitors but it wasn't ordered for my shift.

[misha]

On 11/10/2019 at 8:36 PM, Emergent said:

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!

Yeah I wish he would have stepped out of the room before mentioning that too ? what made me kind of upset is that other nurses on night shift gossip about this nurse a lot and nitpick at his charting etc. and it always gets on my nerves and I try to say nice things about him instead. but then he did this to me, oh well.

[misha]

5 hours ago, MunoRN said:

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.

That's really good to know! It's strange because sometimes patients will have standing orders to give a PRN for a BP as low as 150/something. Then other times they've waited until the systolic was in the 200s before ordering something. Last time I had a patient with a BP this high the nurse didn't blink an eye. this time the nurse was upset. Very confusing!

[JKL33]

On 11/10/2019 at 10:23 PM, Alex W said:

I asked for hydralazine, but lately I've noticed docs are less likely to order it, not sure why

Because much of the time it simply isn't indicated and it may cause problems when used in situations where it isn't indicated (such as episodes of hypotension, the need to hold the patient's regular antihypertensive medications, etc.).

On 11/10/2019 at 11:09 PM, Alex W said:

That's really good to know! It's strange because sometimes patients will have standing orders to give a PRN for a BP as low as 150/something. Then other times they've waited until the systolic was in the 200s before ordering something.

Because (depending upon the situation) other approaches are preferred, such as optimizing the existing medication regimen--which is the approach that the on-call told you was underway in this case. ?

This isn't strange at all; it is individualized patient care. It is declining to treat a number when a patient is asymptomatic and not having signs of end organ damage, knowing that aggressive treatment in those scenarios may lead to harm (or at least more risk of harm than benefit).

[caffeinatednurse, BSN, RN]

At my hospital, we have such parameters on hydralazine that it's not even appropriate to give it unless the BP is greater than 170/110.

Was your patient prescribed IV solumedrol? Just wondering, since you mentioned they had a drug reaction that landed them there. I've seen solumedrol send my patient's BP sky high, especially in people who have some mild HTN issues at baseline. Sometimes our MDs will prescribe something for it, but most of the time when we start tapering down their steroids, their BP comes down, too.

Tbh, the nurse you were reporting to shouldn't have done that. The only thing I would have done differently is ask the MD at what point should we be concerned about a BP. Always document your interactions with MDs. If she/he wants to do something differently, they have 12 hours to approach a new doc. You can't make everyone happy, unfortunately.

[misha]

On 11/10/2019 at 11:51 PM, JKL33 said:

Because much of the time it simply isn't indicated and it may cause problems when used in situations where it isn't indicated (such as episodes of hypotension, the need to hold the patient's regular antihypertensive medications, etc.).

Because (depending upon the situation) other approaches are preferred, such as optimizing the existing medication regimen--which is the approach that the on-call told you was underway in this case. ?

This isn't strange at all; it is individualized patient care. It is declining to treat a number when a patient is asymptomatic and not having signs of end organ damage, knowing that aggressive treatment in those scenarios may lead to harm (or at least more risk of harm than benefit).

You're right maybe I should say interesting instead of strange! And confusing to me because I don't always know the reasons determining one pt treatment from another. I don't really like giving IV hydralazine, I once gave it to a patient as ordered and they dropped much lower than I expected and made them slightly tachy as well kinda scared me even though they were ok ? but i suggested it since that's usually what is given for htn at my hospital.

I hadn't thought about the consequence of having to hold the home BP meds! That's very true, it could through off someones regime. I've also noticed that sometimes pt's who require hydralazine PRN in the hospital may not have any changes made to their home regime by discharge, i'm curious if then their BP continues to rise when they leave the hospital.. anyways thank you for your insight!

[JKL33]

@Alex W it all sounds like a good learning experience. Don't feel bad about the other nurse's behavior--that's his problem.

Do you have access to your institution's library (or maybe your school's library)? That would be one good way to get good, up-to-date information about the numerous things like this that you will run across. ??

[lifeatthebluffs, BSN, RN]

The only thing I would have asked for is for the provider to give you clear parameters on when to call again, which could be a number or signs/symptoms, then document it!

[adventure_rn, MSN, NP]

It sucks that the oncoming nurse handled the issue in that manner.

Honestly, I do think that report is a great learning opportunity for newer nurses; it can be helpful for someone coming behind you to mention if they see something that you could do to improve (whether it's related to following a policy or a nursing judgment call). If I'm doing something wrong (or even if my action wasn't 'wrong,' but could be done better), I'd rather have the on-coming nurse mention it than not know at all.

Unfortunately, some nurses who do this are entirely tactless, and make the off-going nurse feel like an idiot. That sucks because a) it's rude, b) it affects the confidence of newer nurses, and c) it undermines the learning experience.

What I mean to say is this: even though the nurse was a jerk, try to re-frame this as a learning opportunity. It's possible that you didn't do anything wrong. However, there are a handful of things that you could do differently in case you experience this again.

First: investigate whether or not you have a policy or standard of care about this issue. As you've seen from the responses so far, some units might call this a rapid response situation, while others think nothing of it.

Second: as @lifeatthebluffs said, if you're ever in a similar situation again, always always always try to remember to ask the provider at what point they want you to notify them again (i.e. systolic > 200? a change in symptoms?) This covers you in several ways. First, if something goes wrong with the patient, you'll cover your butt. Second, if your jerky coworker gives you a hard time, you can respond that the provider only wanted to be notified for certain parameters. Third: you don't have to waffle back and forth about bugging the provider again in the middle of the night. In a perfect world, it's best to get this ordered in writing, but in a pinch you can just note the parameters discussed when you chart that you notified the provider.

Third: if you're second-guessing something like this again, your charge nurse is a great resource. They have been around long enough to have a sixth sense about what's worth escalating and what can wait. That way, if your coworker gives you a hard time, your charge nurse can back you up (and they'll probably have a bit more clout with your grumpy colleague).

Again, I know it's hard, but try to think of this as an opportunity for improvement and learning rather than some personal failing. I don't think that you did anything wrong, but you can still turn this unpleasant experience into an opportunity to grow as a nurse.

[ruby_jane, BSN, RN]

23 hours ago, brownbook said:

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!!!!!

I guess my question is - what did the pt look like? Because, as Brownbook said...if someone lives high (really high) then that's their new homeostasis. Was this guy well-appearing? Complaining of worst headache ever?

You *could* have rechecked. But the doc wasn't worried about it. So you didn't. Maybe you'll change practice but maybe not. Hang in there.

[TooManyCats, ASN, BSN]

The oncoming nurse was inappropriate in handling that. You notified the provider, they declined to treat. Some people hang out higher, not everyone needs to be treated at 180. You could have asked for call parameters, maybe could have pushed for a PRN. But you didn’t do anything incorrectly.

Hydralazine does seem to be falling out of favor, perhaps due to its need for frequent dosing or the risk for reflex tachycardia (or SVT).

[Katie82, RN]

In the absence of policy on B/P, the house officer should have given you the parameters for follow-up. In the absence of his doing so, it would have been a good idea to ask. The thing that makes me so angry is your co-worker chastising you in front of a patient, an action that caused the patient anxiety. At the very least, I would have asked him to step into the hall and read him the riot act. Watch your back with this guy.