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.
"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?"
I worked overnights the majority of my 7 year RN career and have learned to "prompt" the providers to provide parameters to call the provider back. I usually say, " would you like to give parameters when you'd like to be contacted so I don't have yo keep bugging you throughout the night?" Then document the heck out of it and be sure to pass it on to the the next shift.
Additionally, I would have asked the oncoming RN to give you their practice... and why. Of course not while at the bedside. You will be able learn something and have a chance at relationship building with your co-worker.
Specializes in Critical Care and Community Health. Dabbled in Cor.
I think one thing that is illustrated here is that different institutions have different policies on how to handle things. I don’t think it’s appropriate that the oncoming nurse jumped all over you. I might’ve said thank you for the information. Then again I might’ve called the house officer more than once. It’s always appropriate to ask them what they wanted to be called on. I wouldn’t advise traveling to anyone. This is the kind of problems you run into. And I’m not saying this was a travel assignment. But with traveling I did learn how many varied opinions they were. And how many different policies and protocols for something so common they were.
Bottom line, chart what the doctor told you. Chart what questions you asked and what you reported. If possible ask them to put in their own orders instead of you doing it for them. With house officers, it isn’t uncommon for them to pass the buck on to you and the supervising doctor questions what they ordered. It’s also not unusual for nurses with different opinions to be very vocal with their criticism. When your new one starting out, chart everything. Check for standing orders from the medical managers. Know your hospitals protocols. If you have a rapid response team you can always call and ask who is assigned to it for that night what they would suggest for you to do. There’s usually a house supervisor you can call also and ask the same thing.
I agree with many here that the oncoming nurses response was inappropriate, and also could have made the BP higher.
I don't think I saw anyone else mentioyn that if the patient was on IV fluids you should also think about decreasing or discontinuing this too. Sometimes I will hold these for 1hr and retake the BP to see if that is the cause, but I don't think that is technically allowed.
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?
Obstetric patients (both pregnant and postpartum) absolutely trigger intervention at this range. We have protocols for provider notification and IV hypertensives for 160/110, they are at risk of severe morbidity, with a recommendation to treat within 1hr (CMQCC toolkit supports this). Just a heads up, as we see a bit of a lack of recognition that this is a severe range BP in our population outside of our OB departments, for example when they present to ED where this is not always a severe range BP (absent symptoms) in the rest of the adult population.
To the original question, I do not agree that the approach the oncoming nurse used to give critical feedback was very collegial. Having said that, increasing pressures to the range described should warrant a provider call to update about patient condition, and clarification with notification parameters. If the patient had experienced a complication of a sustained high BP, the nurse’s judgement could be called into question. Take as a learning opportunity, but certainly provide feedback in a professional manner to the nurse who berated you in front of a patient.
Obstetric patients (both pregnant and postpartum) absolutely trigger intervention at this range. We have protocols for provider notification and IV hypertensives for 160/110, they are at risk of severe morbidity, with a recommendation to treat within 1hr (CMQCC toolkit supports this). Just a heads up, as we see a bit of a lack of recognition that this is a severe range BP in our population outside of our OB departments, for example when they present to ED where this is not always a severe range BP (absent symptoms) in the rest of the adult population.
As someone who developed PPCM, I appreciate you spreading this word! ? A lot of peripartum issues are dismissed as something else, or blown off. But I don't think the OP works in OB or L&D, and the patient was male IIRC.
With a history of hypertension, I wouldn't worry. Even without a history because hospitals are stressful places and stress causes increased blood pressure. If I was concerned I would have asked the doc for some lisinopril because clonidine only works for a small amount of time.
Oh! And also always involve your charge nurse. If you're concerned enough to contact the doctor and the doctor blows you off, tell the charge nurse. A simple "hey, I'm worried over the patients blood pressure. Its _____ with (these) symptoms. I called dr ___ and they said ____. Is there anything else I should do or is this ok?" Then chart a note "pt bp ____. Notified dr ____, no new orders. Charge nurse also aware." It will be an easy 2+ years of nursing before you should be confident enough to not bounce thoughts off your charge nurse. I've been in nursing for 6 years and I still ask my charge nurse something at least once a shift. It's why they're there and sometimes they have ideas that you didnt think about.
Document-document document--He was aware --you continued your observation--what did your charge nurse say or the supervisor--those are also your avenues
I've been in nursing for 6 years and I still ask my charge nurse something at least once a shift.
This is good to hear because I probably call the charge nurse at least 2 times a shift...sometimes over really small things. I sometimes feel like i'm supposed to be more independent by now. I wish I had called them this time though ?.
Jory, MSN, APRN, CNM
1,486 Posts
Forgive the question, but is the house officer the in-house hospitalist? (We don't use that term at all where I live).
You did nothing wrong if you documented it. That is their call. But by house officer you mean house supervisor....you should have called the MD.