Did I Do Something Wrong?

I came home and cried feeling like a truly incompetent nurse. I work on a very busy SDU/Tele unit taking overflow from med surg. I had a patient who was being diuresed r/t chronic bladder retention and mild pleural effusion and was prescribed Lasix IV 40 mg q12h for the past 2 days. His BPs were stable with SBP in the mid to low 90s. At 0600, looked at his last VS (0400) and saw a BP of 98/60 (his usual trend) and his HR was 64 on the tele monitor. I did not take his BP and administered the Lasix. At 0650, a nursing assistant told me that the patients BP was 65/45. He took it twice. I went to check on the patient and checked his BP manually. I did not doubt the nursing assistant, but from experience I have seen that machines can be inaccurate. The machine was right. My patients other VS were stable and he was otherwise asymptomatic. Called the doc for a bolus and other orders. To make a long story short, I routinely take VS such as BP and HR before administering BP and cardiac meds, but have never done that for diuretics (even though I realize these meds can decrease BP). Do any of my fellow nurses take a pt's BP before administering diuretics?
Though I am sure best practice would dictate to check. The fact that this patient had stable BP's through other doses, as well as a baseline previous BP WNL, I can't say I would have rechecked before giving the am dose.I don't consider myself a bad nurse, but perhaps this would be a learning opportunity for this patient and others under similar conditions.:uhoh21:

If I am giving it IV, yes.

I usually do not take my patient's BP before giving diuretics. The only reason I would is if there was a reason too. You did nothing wrong as far as I could tell. It was just one of those things that happen.

I don't usually unless the order has parameters.

Depends. If the pt is eating, drinking and the lasix is PO, then no, probably not. If it's IV and the previous BP's have been low, like the 0400, then yes, I would have.

Quote from rnccf2007I came home and cried feeling like a truly incompetent nurse.

Quote from rnccf2007I came home and cried feeling like a truly incompetent nurse. I work on a very busy SDU/Tele unit taking overflow from med surg. I had a patient who was being diuresed r/t chronic bladder retention and mild pleural effusion and was prescribed Lasix IV 40 mg q12h for the past 2 days. His BPs were stable with SBP in the mid to low 90s. At 0600, looked at his last VS (0400) and saw a BP of 98/60 (his usual trend) and his HR was 64 on the tele monitor. I did not take his BP and administered the Lasix. At 0650, a nursing assistant told me that the patients BP was 65/45. He took it twice. I went to check on the patient and checked his BP manually. I did not doubt the nursing assistant, but from experience I have seen that machines can be inaccurate. The machine was right. My patients other VS were stable and he was otherwise asymptomatic. Called the doc for a bolus and other orders. To make a long story short, I routinely take VS such as BP and HR before administering BP and cardiac meds, but have never done that for diuretics (even though I realize these meds can decrease BP). Do any of my fellow nurses take a pt's BP before administering diuretics?

It would be one thing if baseline was above 100's systolic. becuase baseline was under 100 there's not much wiggle room. I would have checked to make sure, then hold medication if SBP <90. Don't worry about it though, lesson learned. just think about it this way though, what if the pt was in moderate to severe CHF also and you couldn't just bolus them. Then more invasive measures would be required like a presser drip and trip to ICU for close monitoring.

Sounds like in the end the MD needed to put a parameter on this medication. Also how aggressive was the diuresing? 20mg, 40mg, Q6, Q8, Q12?

Sounds like in the end the MD needed to put a parameter on this medication. Also how aggressive was the diuresing? 20mg, 40mg, Q6, Q8, Q12?The dose was 40 mg q12. The patient had been given this dose for two days prior and his SBP was trending in the 90s which was WNL for the patient. However, lesson learned. I thank everyone for their comments.

if he'd been getting it q12h for two days, he might have diuresed out the chf he came with, and so the last dose pushed him too far back on his starling curve-- insufficient diastolic fill to generate a good cardiac output. before you give any meds, it's sometimes worth it to give a quick look at not just the bp (which can, after all, have some component of compensation in it) but the hct (going up?), hr (going up?), i&o (net losses? making much urine since the last dose wore off?) and weight (how real were those losses?). (ideally all these data points are easy for a clinician like you to access in a quick moment. if not-- well, maybe you can get them to do something about that. a better flow sheet?) if all those together tell you he's getting to the dry side, think twice about the iv diuretic.i agree, though, it's not intuition that tells a nurse these things, it's education and experience. you'll never make this mistake again. and btw, good on ya for checking the bp after the tech did it c a machine. you're right, often those are inaccurate due to user error/poor technique.

I do re-check blood pressures before I give IV diuretics and IV/PO antihypertensives. Remember, too, that if you are giving a medication at 0600 and the last BP was from 0400 then it is 2 or more hours old...and BPs can definitely change in that length of time for a lot of reasons. I will say though that it was very good that you looked at the BPs as a trend and not just as a single occurrence. In general, if the SBP is trending under 100 then I look back at the last time the medication was given and what their BP was then. I also use my coworkers as resources and look at their reactions and get an idea of what they would do. Lasix 40mg IV Q12 is a standard dose for diuresing, I am glad it was not 80mg! I think MN-Nurse said it very well, everyone who is a good nurse was at some point in their life clueless, no one is born a fully competent nurse! Everyone has had to learn and make mistakes! Do not beat yourself up over this. The good news is that the blood pressure was re-checked within 50 minutes and you were able to intervene appropriately. I think any nurse who will tell you they have never made a mistake would be lying to you. As far as I am concerned, its only a tragedy if you take nothing from the experience and let it repeat itself, which I am sure you won't =)