HYPOTENSION AT NOON

Isabelle is a 84--old female with a history of dementia with agitation, atrial fibrillation, hypertension, depression, coronary artery disease to name a few. I walked onto the unit to sit down and see some patients.

“Hi there. Good morning,” I told the nurse standing at the medication cart.

“Oh hi,” she said (I will call her Mary).

“How is everything going?” I asked her as I was putting down my briefcase getting ready to dive into a chart.

“Oh. I am glad you are here. I just took Isabelle’s blood pressure and it was 80/50,” said Mary holding up a small piece of paper. It was almost lunch time.

“Let me look at the meds she is on,” I said as I walked towards the medication cart. I flipped through the pages until getting to Isabelle’s room number. I noticed she was on quite a few meds for her hypertension.

“Wow. She is on a lot of meds for her blood pressure,” I told Mary still turning pages of all of the meds Isabelle was on.

“I know. We had to split them up because there was too many to take in the morning,” said Mary.

“What does she get at noon?” I asked.

“She gets two of her blood pressure medications and her diuretic,” said Mary.

“We are going to have to hold them today because how low her BP is,” I told Mary grabbing an order sheet to write the hold order. I sat down to write the order.

“What does her pressure normally run?” I asked Mary. She started to flip to the page where her blood pressure readings were.

“Well she was 126/74 this morning before I gave her meds,” said Mary as she used her finger to see the BP’s.

“It looks like that is about where she usually is in the morning,” she said.

“Ok. We will hold her noon meds and re-evaluate it again tomorrow,” I told her and put the chart on the desk with the hold order.

“Sounds good,” said Mary as she was preparing noon medications for her patients. I gathered my things and walked off the unit to get into my car to go to another facility.

The following day at 1100 I saw Mary standing at the medication cart ready to give noon meds.

“How has Isabelle’s BP been?” I asked.

“It was 122/70 this morning,” she said. I saw a CNA walking down the hall towards the nurse’s station.

“Hi there. Can you please get a BP on Isabelle?” I asked in a nice voice with a smile.

“Sure,” she said as she grabbed the cuff out of the drawer and walked towards the room. Several minutes later she came out.

“It was 90/60,” she said.

“Ok. Thank you,” I said. The CNA then proceeded to walk down the hall doing whatever she started to do before my interruption.

“Sounds like she is bottoming out at lunchtime,” I told Mary. “We are going to have to hold her noon meds again. I need to look at her meds to see what she is taking in the morning.” I grabbed the medication sheets and sat at the desk. I started to flip through the pages. Then I started to count meds that could affect blood pressures. I counted six.

“Oh yeah some of these need to be adjusted or stopped,” I said to myself. I saw Isabelle was on two nitrate medications, along with a beta blocker, a calcium channel blocker, and her meds for depression. I noticed that her Diovan had been increased two months before to 160mg. My thought process was to put back whatever was recently changed to where it was before. I am still stumbling through this new role as an NP. I wrote an order to hold the noon meds and to decrease the dose of Diovan. I also wanted BP’s taken three times a day to determine if noon was the only time her pressure was bottoming out. I wrote it as TID. Bad idea. Lesson number one: be more specific.

I came back two days later to check on the BP’s. I looked on the medication record and saw the blood pressures have been taken but only in the morning.

“Well this is not going to help,” I though loudly to myself. I saw Judy walking down the hallway.

“Do you know why the BP’s have not been taken three times a day?” I asked. She looked at the medication record and starred. I knew she didn’t have an answer. Or maybe she did.

“Maybe the aids were too busy,” said Judy. I looked at her.

“Isabelle’s BP was getting low about lunchtime. I want to see if her BP is about the same morning, noon, and at dinnertime,” I told her trying to be as nice as I could. Judy continued to stare at the medication record.

“I will write a new order. Please make sure the BP’s get taken at breakfast, lunch, and at dinnertime,” I said.

“Ok,” said Judy.

I specifically wrote the order for breakfast, lunch, and dinner and left the facility. I wondered what I would find when I came back in a couple of days.

I returned a couple of days later and went right to the medication record to see if the BP’s had been taken. They were and Isabelle’s blood pressure was about the same during the day. Decreasing the Diovan made a difference. I knew I needed to go through the meds more to do more finagling but thought this was a good start. I learned I needed to be more specific even though TID meant the same thing. Who knew?