Priorities

14 Jun

So I work in PCU. Part of the care delivered in PCU is blood pressures/complete vital signs and assessements every four hours.

12 noon assessments come quickly, almost as soon as you are done rounding your first assessment it is time to do it all over again. This frequent assessment is pertinent to progressive care, it seems that the acuity of these patients can often change that quickly.

This one particular shift I get to one of my patients on a few blood pressure medications but not anything out of the ordinary. I had just medicated him maybe 2 hours prior. He is in for chest pain: ECG normal sinus, no ectopy on the monitor, cardiac enzymes negative times 3, 2dECHO normal. No chest pain since admission to the floor 3 days prior. The patient has a history of hypertension and dementia.

I find the patient resting comfortably in the bed, no chest pain, pleasantly confused as usual, but severely hypotensive especially compared to his baseline of Systolic blood pressures in the 130s. His blood pressure now is 78/43. I check the other arm, 74/43, I get a manual blood pressure of Systolic 80. The patient is sinus rhythm- no tachycardia. The patient has no signs of infection, no white count, normal electrolytes. I was perplexed: It could be cardiogenic with the admission of chest pain, it could be a far fetched sepsis situation. I do everything. I get a more experienced nurse with me. While she is starting normal saline solution, getting all the labs including: coags, troponin, blood cultures, lactate, CBC, chemistry, inserting foley catheter, urine samples , inserting an 18 gauge IV catheter into the antecubital, all while I am on the phone with the attending basically obtaining all the orders for what we are already doing. We end up getting a fluid bolus of Normal Saline 500ml- then 125 ml per hour, and call the cardiologist to come see the patient.

We also find the patient soaked in his own urine (prior to inserting the foley) and diaphoretic. Blood sugar is normal.

Approximately 30 minutes go by during all these interventions that started with the fluid bolus. The patient is still hypotensive with a systolic blood pressure in the high 70s.

Stat ECG= normal.

The experienced nurse tells me to write all the verbal orders.

The experienced nurse tells the nurses aide: ” Get all the clean linens, we will clean him up and then call a rapid response.”

I was all laughing inside because she has got her priorities straight, right?

Everything was fine. The patient was basically asymptomatic, all the labs were normal and the patients blood pressure improved into the 90s and then low 100s. He remained on NSS at 125 ml per hour, and everyone was happy.

Except the patient of course pissedoff about the foley catheter. I felt his pain but refused to take it out so that we could monitor the output with all these fluids.

And of course all the medications were discontinued.

This was a good outcome! A rapid response was not called, the patient was stable, and became normotensive! How many times do we find a patient with a low blood pressure that ends up with severe sepsis, or some other ICU requiring transfer?

Yaay! One up for the immediate good outcomes. I am still unclear of the etiology? Maybe the medications, or maybe the patient was just volume depleted.

I was so amused by the experienced nurses calm demeanor. “Let’s clean him up then call a rapid response.”

Of course the patient presented stable clinically in no apparent distress.

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2 Responses to “Priorities”

  1. David in Houston June 16, 2009 at 00:51 #

    Severe dehydration? What was his HCT? Any sign of skin turgor? Just curious.

    • seejanenurse June 18, 2009 at 22:22 #

      The HCT was not elevated and the skin turgor was resilient!

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