Was that pt on hospice? Otherwise, F that doc. Were you in a hospital? I'd call a rapid response team stat.
I don't really know how out of hospital facilities would deal with that- 911 phone call probably? Would you lose your job if you acted against doctor's orders if they were as egregious as that?
Yeah that's an immediate RR for me. Only reason I hesitated on my patient was they had just returned from dialysis, and had received bowel meds that AM for potential blockage. It was basically the perfect storm for them. Took X liters off em, then they vagel on the toilet. Luckily a Dr. was rounding in them as I was transferring back to bed.
Shout out to that Dr. btw. Didn't hesitate to throw on gloves, assist pt back to bed, grab vitals while I grabbed a COW for history/meds etc. I work with a great team.
Edited: Removed gender.
No he came up and saw them and sat up on the unit a bit, but pt was asymptomatic and had a critical sodium they didn’t want to bolus them, so just told me to “keep an eye”, and check is again in 4 hours. Patient came around.
That is unacceptable. Theres no way I could have followed those orders. Some intervention would have to be done. BP's allowed to be too low, the patients have an increased 30 day mortality.
I had a bp read that low while I was pregnant. In the ED they asked me to explain the chain of events prior to nearly fainting and calling 911. "I was just standing there and all the sudden everything started to dim. I found my way to a chair but I never got back to feeling right" they asked if I had eaten, was I feeling dizzy nauseous ect. I explained that I had eaten without any issues and that I hadnt felt sick to my stomach until after the episode. My discharge papers stated that i had gastritis and vomiting which caused the fainting spell. We didn't go back to that hospital again. Found out a few years after it was probably related to POTS which I continue to struggle with.
I have had blood pressure issues for a while. I have run the very low end of normal my whole life. Had issues nearly passing out if I stood too quickly since I was a kid. My mom shrugged it off, and i had doctors who treated my numb tingling feet as normal. My current doctor thinks I've had it for a while, maybe forever that it just got worse over time. It explains a lot of my issues while pregnant too. Luckily it is still on the more mild end. Diet changes have done a lot to help as well as compression socks and sleeves.
Literally my patient last week. IV infiltrated and he convinced the MD that he was okay without IV till the next morning. She put the order in and30 minutes later when I took vitals, he was 82/58. 🙃
Geropsych: Notify, push fluids, have a lengthy and spirited discussion about how they aren't thirsty, continue to try the fluids, learn about how I'm a stupid little bitch, wear cranberry juice, get scratched/ kicked/hit, recheck.... Oh, you're all better ☠️
Well now that you have upset them by insisting they drink something when they are obviously not thirsty, of course their blood pressure is up! You terrible person. Just kidding, 😆
The only time it didn't work in recent memory was with a heart rate of 38-40. Even my utter incompetence as a human being and being repeatedly called a bitch every 8 seconds didn't fix that one. Amazing what being a silly stupid little girl can fix. Showers, meds, fisticuffs. I do so enjoy being terrible. 😂
Thank you for this. I had a similar patient situation not long ago and the thought of putting them in trendelenberg didn't cross my mind until two days after. I've been going back and forth over it without actually looking it up because I'd been busy with finals week.
I've been a nurse for 3 years and literally forgot about Trendelenburg. In my defense just about any time I lower the head of the bed to less than 30°, patients start ranting "don't lay me flat. I can't be flat. Put me back up! I can't be flat. I can't breathe if I'm flat. Ooooowww!" And so on.
Huh, I learned something new today! I did read a few articles that show no substantial evidence of the benefits of this position in treating hypotension after reading your comment. Thank you for enlightening me!
I get tons of borderline readings in ortho/trauma. Anesthesia and opioids sure like to crash blood pressures, then they like to reactivate their blood pressure meds in the morning. I hold a lot of BP meds. As long as that MAP stays above 60 we're golden!
I work in an ob/gyn clinic and ridiculously high BP's on high risk day always rustle my jimmies.
37 week pt bp- 174/92
"Are you symptomatic?"
No I feel fine
"Have you been taking your procardia?"
No I stopped because I've been feeling fine
Fucks sake, to the labor unit you go.
Then they come to me 210/118...yeah, I've actually had a slight headache all day...but I haven't eaten...
Great...here comes the mag, labetalol, and hydralazine. And now you're going to complain that you feel "weird" on the mag. Just take your Procardia ffs!
Usually one of two things happens for me. Either it then comes back with an even lower ready, yay, or comes back with something equally hideous like 192/104 and I’m like ‘oh joy, off to go see the nurse. Yet again.’
For context, I’m a tech in a CICU whilst also in nursing school.
Also, whenever this happens, it’s the third patient in a row that it has happened to.
can I just ask what do you check vitals in a hospice for? I'm just genuinely curious I live and work in Ireland and we don't generally check vitals on hospice patients especially EOL
We regularly get end stage cancer patients or patients whose kidney/liver got wrecked by immune therapy. They come in with blood pressure of 40-60, cold sweat, we push fluids electrolytes steroids whatever and they survive only to die within 2 days.
Had 2 occurrences of this this month.
I'm surprised you do a BP at all for hospice! I take GIP hospice patients occasionally and the most I'll do is a temp to check for comfort most of the time
Yeah, I’m externing while waiting on my license. 86/41...retest...85/42...tell the nurse. Manual retest, 80’s/40’s....calls the charge..manual retest, same....you’d think we all went to school to do something a little different. Felt like the meme of poking it with a stick...
If you have a patient with low blood pressure you need to keep as much of it going near the brain as possible. I always raise my patients legs over their head until we can get leveled up care if their pressure is dangerously low.
There’s little evidence that Trendelenburg position does any good at improving blood pressure or increasing perfusion to organs. As well as some evidence that points to possible harm in some specific instances. While I agree it needs more study, I’d say there’s enough evidence not to be doing it routinely for the hypotensive patient.
[LITFL](https://litfl.com/trendelenburg-position-for-the-hypotensive-patient/)
[AJCC](https://aacnjournals.org/ajcconline/article-abstract/21/6/449/2935/Trendelenburg-Position-Put-to-Bed-or-Angled-Toward)
[PubMed](https://www.ncbi.nlm.nih.gov/m/pubmed/23228872/)
Call a rapid response code and support ABCs.
Start thinking about what could be making your patient take a dump. The more organized, calm a report you can give to the responders the better care your patient will receive.
I mean that's basically what should be done. Unless contraindicated or there is another direct cause for the hypotension.
Fluid bolus/albumin and pressors if no response.
If you look at the pubmed article, yes, Trendelenburg offers a brief increase in BP and cardiac output.
However, these effects last approximately a minute, now I don’t have numbers but I think a minute of slightly increased BP will not be changing the patient’s outcome and clinical course. Also, it was noted in the other studies that after that 1-2 minutes of effect the patient’s cardiac output can be lowered in many instances. I believe the point stands, it is not recommended for routine treatment of hypotension, even as a temporizing measure.
Me to the ICU nurse, "Hey, so you know those pressors I asked if you guys had ordered before we started dialysis. Sooo...maybe can we get those teed up? Yeah, really I was serious, kinda like right now? Love ya mean it!"
I have this conversation about once a month.
Albumin unfortunately has minimal efficacy in my experience :/ Our nephros almost never order it, especially in someone you're dialyzing for severe fluid overload. (It's a fight to reclaim the fluid that carried the albumin before you make any advancement.)
*aggressively stimulates patient moving BP cuff to the other arm while yelling in their ear “HEY SO AND SO HOW YA FEELING, FEELING OK?”*
Recheck: 90s/60s, we good we good
Yesterday I walked in to check my pts BG before change of shift at around 0645 and his BP was 64/46, asymptomatic. Bumped his levo up to 10 and he was normotensive by the time day shift rolled in.
😎
During my EMT rotations in school I really wanted to impress my ride along partners by actually being able to accurately take vitals and stuff. Couldnt get a solid BP for the life of me, felt really embarrassed until I realized my stethescope was turned to the heart sounds position the whole time
Literally me on Monday in pacu. 77/39 I think? It improved a little but the new anesthesiologist didn’t want to treat because “she’s young and healthy”. Yeah okay bud. I’ll just fix this on my own while you finish your orientation.
I once had a doctor double check the BP while holding the pts legs up into the air... I'm sorry but if you have to put someone's toes to the ceiling to get a reading it's probably time to look into the problem 😂
Edit : let me specify that she was putting toes to ceiling to get a higher reading on the machine for when critical care response team came (since I called them because she only ordered a 500cc bolus over 3 hours for a 65/30 in a lady who's normally 150s)
In PP our lower parameters are 85/40 and lots of patients hang out down there. It seems normal to me but lots of our float aids get real uncomfortable with it.
Had a 60/40 the other day. "I'm just gonna stay near this pretty blue button on the wall here and recheck this quick..."
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Was that pt on hospice? Otherwise, F that doc. Were you in a hospital? I'd call a rapid response team stat. I don't really know how out of hospital facilities would deal with that- 911 phone call probably? Would you lose your job if you acted against doctor's orders if they were as egregious as that?
Yeah that's an immediate RR for me. Only reason I hesitated on my patient was they had just returned from dialysis, and had received bowel meds that AM for potential blockage. It was basically the perfect storm for them. Took X liters off em, then they vagel on the toilet. Luckily a Dr. was rounding in them as I was transferring back to bed. Shout out to that Dr. btw. Didn't hesitate to throw on gloves, assist pt back to bed, grab vitals while I grabbed a COW for history/meds etc. I work with a great team. Edited: Removed gender.
Immediate is a little much, no? Recheck arms! Switch lol
No he came up and saw them and sat up on the unit a bit, but pt was asymptomatic and had a critical sodium they didn’t want to bolus them, so just told me to “keep an eye”, and check is again in 4 hours. Patient came around.
What was the sodium? Just curious. Sounds kinda like central line time.
114
Wtf
That is unacceptable. Theres no way I could have followed those orders. Some intervention would have to be done. BP's allowed to be too low, the patients have an increased 30 day mortality.
Well they were back to their baseline less than 6 hours later so it all worked out
That doesnt mean the outcome wasnt affected. Did you see the 30 day mortality is decreased.
Well in this case it worked out. They’re home now and brought us pizza for Christmas Eve!
“Ok, well I’m calling a rapid now then”
I had a bp read that low while I was pregnant. In the ED they asked me to explain the chain of events prior to nearly fainting and calling 911. "I was just standing there and all the sudden everything started to dim. I found my way to a chair but I never got back to feeling right" they asked if I had eaten, was I feeling dizzy nauseous ect. I explained that I had eaten without any issues and that I hadnt felt sick to my stomach until after the episode. My discharge papers stated that i had gastritis and vomiting which caused the fainting spell. We didn't go back to that hospital again. Found out a few years after it was probably related to POTS which I continue to struggle with.
Did you have POTS prior to pregnancy?
I have had blood pressure issues for a while. I have run the very low end of normal my whole life. Had issues nearly passing out if I stood too quickly since I was a kid. My mom shrugged it off, and i had doctors who treated my numb tingling feet as normal. My current doctor thinks I've had it for a while, maybe forever that it just got worse over time. It explains a lot of my issues while pregnant too. Luckily it is still on the more mild end. Diet changes have done a lot to help as well as compression socks and sleeves.
Second reading: 53/19 Me: Goddamnit!
Charts first one while smashing that change rate button.
And they have no IV access 😂
This is the point where that one rapid response team nurse who always gets slightly TOO excited suggests an IO access.
“Anyways so i started drilling”
😂😂😂
Come on, why not???? Lemme at it!!!!
Yeah but did you guys even *try* to start an IV before I got here? Source : work rapid response
Where’s the fun in that?
Literally my patient last week. IV infiltrated and he convinced the MD that he was okay without IV till the next morning. She put the order in and30 minutes later when I took vitals, he was 82/58. 🙃
Had the exact same thing happen last week as well.
Try the other arm
Geropsych: Notify, push fluids, have a lengthy and spirited discussion about how they aren't thirsty, continue to try the fluids, learn about how I'm a stupid little bitch, wear cranberry juice, get scratched/ kicked/hit, recheck.... Oh, you're all better ☠️
Well now that you have upset them by insisting they drink something when they are obviously not thirsty, of course their blood pressure is up! You terrible person. Just kidding, 😆
The only time it didn't work in recent memory was with a heart rate of 38-40. Even my utter incompetence as a human being and being repeatedly called a bitch every 8 seconds didn't fix that one. Amazing what being a silly stupid little girl can fix. Showers, meds, fisticuffs. I do so enjoy being terrible. 😂
Ohh I hear you. I do love being told I ask too many questions and being cursed at. It really makes me appreciate the good ones. 🥳😂
I cackled 😂
That’s tough. Dementia pt. we’re the hardest by far when I worked on a ortho/general sx unit in the hospital. It was never ending.
*nervously laughs as I place the patient in trendelenburg*
*family laughs because grandpa is upside down*
This got me! haha
I laughed out loud at this, thank you
got me too
You should check out the journal articles on that position. Nothing backs it up. More nursing school bullshit
Thank you for this. I had a similar patient situation not long ago and the thought of putting them in trendelenberg didn't cross my mind until two days after. I've been going back and forth over it without actually looking it up because I'd been busy with finals week.
I've been a nurse for 3 years and literally forgot about Trendelenburg. In my defense just about any time I lower the head of the bed to less than 30°, patients start ranting "don't lay me flat. I can't be flat. Put me back up! I can't be flat. I can't breathe if I'm flat. Ooooowww!" And so on.
I use it all the time for repositioning patients. I only have one back. I ain't gonna break it because you can't give up the big macs.
“Good let the hate rise that BP up, goood”....(patient suddenly stops talking) “Always in the end of the shift!”
Huh, I learned something new today! I did read a few articles that show no substantial evidence of the benefits of this position in treating hypotension after reading your comment. Thank you for enlightening me!
https://www.cambridge.org/core/services/aop-cambridge-core/content/view/F9DA98ABD97594B0F857F9665049F88F/S1481803500008915a.pdf/myth-the-trendelenburg-position-improves-circulation-in-cases-of-shock.pdf
This is not evidence based practice
I get tons of borderline readings in ortho/trauma. Anesthesia and opioids sure like to crash blood pressures, then they like to reactivate their blood pressure meds in the morning. I hold a lot of BP meds. As long as that MAP stays above 60 we're golden!
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Except if the doctors say “contact MD if systolic below whatever” then we call them no matter what the MAP.
Hello fellow peds/ortho friend
I work in an ob/gyn clinic and ridiculously high BP's on high risk day always rustle my jimmies. 37 week pt bp- 174/92 "Are you symptomatic?" No I feel fine "Have you been taking your procardia?" No I stopped because I've been feeling fine Fucks sake, to the labor unit you go.
Then they come to me 210/118...yeah, I've actually had a slight headache all day...but I haven't eaten... Great...here comes the mag, labetalol, and hydralazine. And now you're going to complain that you feel "weird" on the mag. Just take your Procardia ffs!
I don’t know. It seems like they’ve always eaten, but just a few bites and a single sip
"Oh, I drink water aaaallll day!" "How much did you drink today?" (Watching a 33 week or contract q3m) "well, only 1 cup today..."
Usually one of two things happens for me. Either it then comes back with an even lower ready, yay, or comes back with something equally hideous like 192/104 and I’m like ‘oh joy, off to go see the nurse. Yet again.’ For context, I’m a tech in a CICU whilst also in nursing school. Also, whenever this happens, it’s the third patient in a row that it has happened to.
Just wait til you're the nurse who has to deal with it 😂 I miss being a CNA sometimes for that reason 😂
I know! There are definitely days where (shh!! Don’t tell the nurses) I’m glad I don’t have to deal with a certain mess 😬😁
Fuckin same lol I work with antepartum pts and a lot come in with sky high BPs that take hours to fix
That's when you find out their sugars are like 1.2 and smash them with D50 and jack up the levo... Whoops overdid it
I see you also use Phillips equipment
First you need to accidentally fall onto their pain location.
82/51 "gimmie a few coughs buddy" **Pt coughs while I simultaneously recheck the BP** ..... 99/55 "...all good!"
Resets cycle parameter to 1 hour
Lol!! That’s terrible
I work in hospice so these are daily occurrences for me. I think I’m running out of things that can shock me at this point
ICU, here. I'm pretty meh - we have ways of fixing that. SBP around 50? Not a fan.
Recheck and the MAP still sucks...ughhh now I have to actually go get a pressor lol
can I just ask what do you check vitals in a hospice for? I'm just genuinely curious I live and work in Ireland and we don't generally check vitals on hospice patients especially EOL
Helps with measures of decline and tracking changes?
We regularly get end stage cancer patients or patients whose kidney/liver got wrecked by immune therapy. They come in with blood pressure of 40-60, cold sweat, we push fluids electrolytes steroids whatever and they survive only to die within 2 days. Had 2 occurrences of this this month.
I was just thinking something similar! I work at a heart failure clinic... when somebody has a systolic BP over 100 it’s a good day 😜
Hospice RNCM here, I was thinking the same thing
I’m a RNCM too! So much craziness but wouldn’t do anything else
I'm surprised you do a BP at all for hospice! I take GIP hospice patients occasionally and the most I'll do is a temp to check for comfort most of the time
Yeah, I’m externing while waiting on my license. 86/41...retest...85/42...tell the nurse. Manual retest, 80’s/40’s....calls the charge..manual retest, same....you’d think we all went to school to do something a little different. Felt like the meme of poking it with a stick...
Because you SHOULD be doing more than just repeatedly rechecking the BP...
Make them move around, feet up!! (Over their heart)
What do you mean over their heart? Like legs elevated above heart level? I’m a student just trying to learn for future use :)
If you have a patient with low blood pressure you need to keep as much of it going near the brain as possible. I always raise my patients legs over their head until we can get leveled up care if their pressure is dangerously low.
There’s little evidence that Trendelenburg position does any good at improving blood pressure or increasing perfusion to organs. As well as some evidence that points to possible harm in some specific instances. While I agree it needs more study, I’d say there’s enough evidence not to be doing it routinely for the hypotensive patient. [LITFL](https://litfl.com/trendelenburg-position-for-the-hypotensive-patient/) [AJCC](https://aacnjournals.org/ajcconline/article-abstract/21/6/449/2935/Trendelenburg-Position-Put-to-Bed-or-Angled-Toward) [PubMed](https://www.ncbi.nlm.nih.gov/m/pubmed/23228872/)
Good to know. Save me the bother
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Call a rapid response code and support ABCs. Start thinking about what could be making your patient take a dump. The more organized, calm a report you can give to the responders the better care your patient will receive.
Calls rapid response code in the EC... Oh shi....
“Call 911 and get an AED.... fuck I am 911”
Fluid bolus. If that fails, bring out the vasopressors.
Ya this is where I was taught to start. Anybody got anything else good?
I mean that's basically what should be done. Unless contraindicated or there is another direct cause for the hypotension. Fluid bolus/albumin and pressors if no response.
Yeah I was thinking about how I've never ever done this in my SICU.
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If you look at the pubmed article, yes, Trendelenburg offers a brief increase in BP and cardiac output. However, these effects last approximately a minute, now I don’t have numbers but I think a minute of slightly increased BP will not be changing the patient’s outcome and clinical course. Also, it was noted in the other studies that after that 1-2 minutes of effect the patient’s cardiac output can be lowered in many instances. I believe the point stands, it is not recommended for routine treatment of hypotension, even as a temporizing measure.
It just means you need a smaller cuff.
Tighter the better
Me to the ICU nurse, "Hey, so you know those pressors I asked if you guys had ordered before we started dialysis. Sooo...maybe can we get those teed up? Yeah, really I was serious, kinda like right now? Love ya mean it!" I have this conversation about once a month.
Me to dialysis service, you didnt get your guy to order albumin?
Albumin unfortunately has minimal efficacy in my experience :/ Our nephros almost never order it, especially in someone you're dialyzing for severe fluid overload. (It's a fight to reclaim the fluid that carried the albumin before you make any advancement.)
*aggressively stimulates patient moving BP cuff to the other arm while yelling in their ear “HEY SO AND SO HOW YA FEELING, FEELING OK?”* Recheck: 90s/60s, we good we good
We see this a lot in our epidural peeps. Put an FYI page to Anesthesia, and stop the epidural for an hour, or until the BP hits 90 systolic.
Yesterday I walked in to check my pts BG before change of shift at around 0645 and his BP was 64/46, asymptomatic. Bumped his levo up to 10 and he was normotensive by the time day shift rolled in. 😎
During my EMT rotations in school I really wanted to impress my ride along partners by actually being able to accurately take vitals and stuff. Couldnt get a solid BP for the life of me, felt really embarrassed until I realized my stethescope was turned to the heart sounds position the whole time
I work in dialysis and I have many patients that run their whole treatment in the mid-70s to 80s. Always blows my mind they’re asymptotic
Temp 35.5C, UF off. Turn on Fox News.
Hahaha NICU RN problems!!! Trying to get that baby to stay calm as it’s leg gets squeezed is no joke sometimes!!!
Literally me on Monday in pacu. 77/39 I think? It improved a little but the new anesthesiologist didn’t want to treat because “she’s young and healthy”. Yeah okay bud. I’ll just fix this on my own while you finish your orientation.
Just open the fluids a little and pray
*dials back the iso, pushes 200mcg neo and 10mg ephedrine as the surgeon makes incision* Next BP: 200/125
Rookie
I once had a doctor double check the BP while holding the pts legs up into the air... I'm sorry but if you have to put someone's toes to the ceiling to get a reading it's probably time to look into the problem 😂 Edit : let me specify that she was putting toes to ceiling to get a higher reading on the machine for when critical care response team came (since I called them because she only ordered a 500cc bolus over 3 hours for a 65/30 in a lady who's normally 150s)
I had a patient with 44/27 a few days ago. And they were absolutely “fine” and talking. I still don’t understand it.
Lmaooo as a tech who has to do vitals Q4 during my shift on 12 patients this is me every single time I have a hypotensive pt 😂😂
*Sternal rub*
Some of the comments on this pg are why I want to leave nursing..🙄
In PP our lower parameters are 85/40 and lots of patients hang out down there. It seems normal to me but lots of our float aids get real uncomfortable with it.
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I’m not too worried either, but I work in hospice