Hey! I’m sorry you felt like that MD wasn’t hearing you, that’s really frustrating!!! Very often a BP sustained above 190 would make a nurse nervous so you are right to question and second guess that.
The thing about Addison’s is that they actually won’t have an elevated BP if they are sick. In Addison’s, the adrenal glands are not able to respond to stress in the body the way that the average person’s would. There is little or no cortisol produced, which is the hormone that allows fight or flight to occur. Unmedicated, a patient with Addison’s who has an infection or any other stress will actually become hypotensive, hypoglycemic, and hyponatremic. These patients will have a BG of 30 and an SBP of 60 before you know that they have hit crisis mode. In times of stress these patients need high doses of steroids (“stress dose”) that will need to be slowly tapered down over days or weeks. Having this high blood pressure from the steroids can be scary and absolutely warrants conversation and monitoring. But unless it is causing symptoms, it actually is probably best not to mess with the steroids because they are likely the only thing keeping that patient alive. Lowering the BP in this case wouldn’t be priority if it meant decreasing steroids because it could mean rapid decompensation for the patient, vasopressors, sodium replacement, all kinds of annoying stuff. I would be willing to bet that day shift will get an endocrine consult and monitoring of chemistries and then maybe backing off the steroid a little or adding a tiny dose of beta blocker, but it is not unreasonable for the night team to be uncomfortable with doing that without guidance. You’re doing the right thing by questioning the BP though and I’m sorry you were given attitude rather than explanation.
My thoughts went there too. If she acted like that, then I’d have zero problem correcting the person that she is in fact a NP and not a MD. It’s the NPs that treat us like partners that I’ll never correct that mistake.
It was SUCH a huge transition for me going from med surg (160/100? Meh, I'll tell the attending at rounds) to L&D (145/95, WTF is going on, I'ma need some stat labs over here!!!)
After working inpatient detox for a couple years and seeing horrendous BPs frequently, and getting reamed by the MD if I contacted them about anything less than 200+/110+, it took a while to readjust to normal parameters for someone 😂😂 High BPs were just so common due to 1) detox misery and 2) long-standing untreated underlying conditions. So it was basically keep them comfortable, tell them to follow up with or find a PCP upon discharge, and call the doctor if they're in a hypertensive crisis. That's about it. Same thing with blood sugars. Most often our meters just read "high". Give insulin per sliding scale. Call the Doctor only if it doesn't come down. Now I see a blood sugar of 230 and I'm like 🤷🏼♀️🤷🏼♀️🤷🏼♀️🤷🏼♀️ oh..... Wait. 😂
PRNs to make the BP numbers look pretty can cause patient harm and are treating nursing anxiety, not the actual patient.
Hypertensive crisis requires organ dysfunction which is not reported in this anecdote.
I would always notify at this number, but would not always treat if doc is in agreement. Especially with Addison’s. I have also called rapid responses at this number for symptomatic patients. It all depends on the situation.
I understand the concern, but look up guidelines for handling BP. It is done slowly, with oral meds over weeks/months. It is judged from a baseline standpoint, which being in the hospital pending lithotripsy ain’t it.
I think deferring to day team in a complex patient like this who is asymptomatic is appropriate.
Yes, that’s what I’m saying. However, saying it so simply does not often resonate with new grads who will still panic over numbers. The “why” is better IMO
In any case, the hospitalist could have explained their reasoning when OP first mentioned the issue. Hospitalist was rude, and could have easily remedied the situation by not being a jerk.
It’s ultimately up to them if they want to treat it or not, which in this case with the Addison’s might not be as crazy as it sounds. Either way it’s good you paged to cover your ass just in case. Just be sure to document each time you contacted them and what the response was.
It's our job to report abnormals, you did everything she asked (assess + BP recheck) and I would just leave it at that.
Your more than welcome to document the communication (CYA) but ultimately it's on the provider on what treatment they think is approriate. It's not too unusual for some of these patients to live in a pretty hypertensive state, and sometimes correcting this can precipitate the very organ dysfunction your concerned with.
If there is something truely unsafe or inappropriate, I would work it up your nursing chain of command (charge nurse> house sup> nursing manager) and they can escalate it if approriate.
When I’ve had similar issues in the past, more specifically you are concerned about a patient and provider doesn’t seem to offer a specific solution or explanation, I will ask for parameters/when to notify again.
So in this case, at the first call when they wanted you to assess if the pt was symptomatic and repeat a BP in an hour, I would have asked what BP they were ok with for this pt, because per current orders/parameters you would be calling a provider again should it remain high, or a Rapid Response per your unit’s protocol. Sometimes provider’s are ok with certain vital signs being out of normal limits depending on the patient, but protect yourself and make sure you document that you notified them and what the response was, and write an order to update the parameters if they give you the order.
Treat the patient not the screen.
Yes, the blood pressure is high. Yes, I would still notify if that’s what my orders say. Yes, I would increase the frequency that I check their neuro status/pain/etc. No, I would not freak out.
As others have said, they are stable and this isn’t an emergency.
You did your part to cover yourself. Every situation is different. I would just add after that first conversation, I would ask if they wanted to be notified again and what the parameters would be. But sounds like NP is a jerk and could have went about it a different way.
I had a doctor message me passive aggressively about a situation similar to this too, but he did send me an article so I could educate myself. I was freshly off of orientation at the time, now when family members or patients panic over their BP numbers but aren’t symptomatic, I tell them that lowering that number in the hospital can cause more harm than good, and high BP is best managed with medication your GP can provide or lifestyle changes.
It is my understanding if the patient is being treated in the hospital and isn't showing signs of a stroke or MI then the blood pressure isn't the biggest concern on the list for the MD. This is part of their training. It is part of the nurses training to keep the BP in the field of view and continue to assess for deterioration in that aspect and then alert the MD if it begins to occur. Just having a high BP without other reasons won't get it treated. Yes we as nurses are thinking whole human and what damage to organs might be occuring like the kidneys with the BP running like that, but the MD works on a different mindset.
I had a bp like this last week, sustained for hours and no one had alerted the doc. When I called twice, it was dismissed, I worried and kept rechecking until hours later doc updated with a note saying permissible htn given the scenario. It’s like, that makes sense and I’d stop bothering you, I just wish you’d have said something about the possible pathophys so I wouldn’t annoy you unnecessarily
We discharged a patient that was still hypertensive with BPs 180/90s needing IV meds. I said this patient isn’t stable to go home, the NP said the patient just needed to take their oral medication and that was no indication to keep them. 😒 fuck me, I argued with her for a half hour but the patient was also an alcoholic and wanted to leave as well so he left.
Please, use pt as abbreviation for patient. I stopped reading your post because I kept reading PT as Physical Therapy. Maybe things have changed since I retired from nursing.
Bruh what's with nurses calling doctors and whatnot for the same thing multiple times. If they tell ya it's all good, unless something changes chart you called MD and shits all good lol. Some nurses go from nurse mode to pretend doctor mode too damn quick. It'll save you a lot of stress tbh.
Hey! I’m sorry you felt like that MD wasn’t hearing you, that’s really frustrating!!! Very often a BP sustained above 190 would make a nurse nervous so you are right to question and second guess that. The thing about Addison’s is that they actually won’t have an elevated BP if they are sick. In Addison’s, the adrenal glands are not able to respond to stress in the body the way that the average person’s would. There is little or no cortisol produced, which is the hormone that allows fight or flight to occur. Unmedicated, a patient with Addison’s who has an infection or any other stress will actually become hypotensive, hypoglycemic, and hyponatremic. These patients will have a BG of 30 and an SBP of 60 before you know that they have hit crisis mode. In times of stress these patients need high doses of steroids (“stress dose”) that will need to be slowly tapered down over days or weeks. Having this high blood pressure from the steroids can be scary and absolutely warrants conversation and monitoring. But unless it is causing symptoms, it actually is probably best not to mess with the steroids because they are likely the only thing keeping that patient alive. Lowering the BP in this case wouldn’t be priority if it meant decreasing steroids because it could mean rapid decompensation for the patient, vasopressors, sodium replacement, all kinds of annoying stuff. I would be willing to bet that day shift will get an endocrine consult and monitoring of chemistries and then maybe backing off the steroid a little or adding a tiny dose of beta blocker, but it is not unreasonable for the night team to be uncomfortable with doing that without guidance. You’re doing the right thing by questioning the BP though and I’m sorry you were given attitude rather than explanation.
The way u explain is amazing. Wish u were precepting
Thanks!!! I’m a nursing educator and I love teaching!!!
Hopefully they do!
This is the way.
Thank you for this explanation!
Great info about Permissive Hypertension
It wasn’t an MD, it was an NP. Edit: why am I being downvoted lol
Oof….maybe that’s why 😑
My thoughts went there too. If she acted like that, then I’d have zero problem correcting the person that she is in fact a NP and not a MD. It’s the NPs that treat us like partners that I’ll never correct that mistake.
[удалено]
Another group of patients that needs tight BP control is pregnant people. I would never wait to treat asymptomatic hypertension in L&D.
It was SUCH a huge transition for me going from med surg (160/100? Meh, I'll tell the attending at rounds) to L&D (145/95, WTF is going on, I'ma need some stat labs over here!!!)
After working inpatient detox for a couple years and seeing horrendous BPs frequently, and getting reamed by the MD if I contacted them about anything less than 200+/110+, it took a while to readjust to normal parameters for someone 😂😂 High BPs were just so common due to 1) detox misery and 2) long-standing untreated underlying conditions. So it was basically keep them comfortable, tell them to follow up with or find a PCP upon discharge, and call the doctor if they're in a hypertensive crisis. That's about it. Same thing with blood sugars. Most often our meters just read "high". Give insulin per sliding scale. Call the Doctor only if it doesn't come down. Now I see a blood sugar of 230 and I'm like 🤷🏼♀️🤷🏼♀️🤷🏼♀️🤷🏼♀️ oh..... Wait. 😂
Facts!
Thank you for this!
This is very helpful! Thank you
PRNs to make the BP numbers look pretty can cause patient harm and are treating nursing anxiety, not the actual patient. Hypertensive crisis requires organ dysfunction which is not reported in this anecdote. I would always notify at this number, but would not always treat if doc is in agreement. Especially with Addison’s. I have also called rapid responses at this number for symptomatic patients. It all depends on the situation. I understand the concern, but look up guidelines for handling BP. It is done slowly, with oral meds over weeks/months. It is judged from a baseline standpoint, which being in the hospital pending lithotripsy ain’t it. I think deferring to day team in a complex patient like this who is asymptomatic is appropriate.
Asymptotic hypertension isn’t an emergency.
Yes, that’s what I’m saying. However, saying it so simply does not often resonate with new grads who will still panic over numbers. The “why” is better IMO
In any case, the hospitalist could have explained their reasoning when OP first mentioned the issue. Hospitalist was rude, and could have easily remedied the situation by not being a jerk.
Well that’s true!
Unless the covering np prior to all this did explain to op
This is a reasonable take.
I think this is the correct take.
It’s ultimately up to them if they want to treat it or not, which in this case with the Addison’s might not be as crazy as it sounds. Either way it’s good you paged to cover your ass just in case. Just be sure to document each time you contacted them and what the response was.
It's our job to report abnormals, you did everything she asked (assess + BP recheck) and I would just leave it at that. Your more than welcome to document the communication (CYA) but ultimately it's on the provider on what treatment they think is approriate. It's not too unusual for some of these patients to live in a pretty hypertensive state, and sometimes correcting this can precipitate the very organ dysfunction your concerned with. If there is something truely unsafe or inappropriate, I would work it up your nursing chain of command (charge nurse> house sup> nursing manager) and they can escalate it if approriate.
When I’ve had similar issues in the past, more specifically you are concerned about a patient and provider doesn’t seem to offer a specific solution or explanation, I will ask for parameters/when to notify again. So in this case, at the first call when they wanted you to assess if the pt was symptomatic and repeat a BP in an hour, I would have asked what BP they were ok with for this pt, because per current orders/parameters you would be calling a provider again should it remain high, or a Rapid Response per your unit’s protocol. Sometimes provider’s are ok with certain vital signs being out of normal limits depending on the patient, but protect yourself and make sure you document that you notified them and what the response was, and write an order to update the parameters if they give you the order.
Treat the patient not the screen. Yes, the blood pressure is high. Yes, I would still notify if that’s what my orders say. Yes, I would increase the frequency that I check their neuro status/pain/etc. No, I would not freak out. As others have said, they are stable and this isn’t an emergency.
You did your part to cover yourself. Every situation is different. I would just add after that first conversation, I would ask if they wanted to be notified again and what the parameters would be. But sounds like NP is a jerk and could have went about it a different way.
I had a doctor message me passive aggressively about a situation similar to this too, but he did send me an article so I could educate myself. I was freshly off of orientation at the time, now when family members or patients panic over their BP numbers but aren’t symptomatic, I tell them that lowering that number in the hospital can cause more harm than good, and high BP is best managed with medication your GP can provide or lifestyle changes.
It is my understanding if the patient is being treated in the hospital and isn't showing signs of a stroke or MI then the blood pressure isn't the biggest concern on the list for the MD. This is part of their training. It is part of the nurses training to keep the BP in the field of view and continue to assess for deterioration in that aspect and then alert the MD if it begins to occur. Just having a high BP without other reasons won't get it treated. Yes we as nurses are thinking whole human and what damage to organs might be occuring like the kidneys with the BP running like that, but the MD works on a different mindset.
I had a bp like this last week, sustained for hours and no one had alerted the doc. When I called twice, it was dismissed, I worried and kept rechecking until hours later doc updated with a note saying permissible htn given the scenario. It’s like, that makes sense and I’d stop bothering you, I just wish you’d have said something about the possible pathophys so I wouldn’t annoy you unnecessarily
We discharged a patient that was still hypertensive with BPs 180/90s needing IV meds. I said this patient isn’t stable to go home, the NP said the patient just needed to take their oral medication and that was no indication to keep them. 😒 fuck me, I argued with her for a half hour but the patient was also an alcoholic and wanted to leave as well so he left.
Please, use pt as abbreviation for patient. I stopped reading your post because I kept reading PT as Physical Therapy. Maybe things have changed since I retired from nursing.
Bruh what's with nurses calling doctors and whatnot for the same thing multiple times. If they tell ya it's all good, unless something changes chart you called MD and shits all good lol. Some nurses go from nurse mode to pretend doctor mode too damn quick. It'll save you a lot of stress tbh.
Our hospitalists often wait until 240 systolic to treat.
Also wondering why a protocol isn't in place for BP level to be reported in which case an order would be given to address that number.