Elder's meds might hide these early signs of shock
Don't rely solely on vital signs
Is your elder patient taking multiple cardiac and blood pressure medications, such as beta blockers, calcium channel blockers, and angiotensin-converting enzyme inhibitors? These medications have important implications for your clinical assessment.
"When a person is in shock, an early sign is tachycardia," says Rhyan Weaver, RN, BSN, CEN, clinical supervisor in the ED at St. Joseph's Hospital and Medical Center in Phoenix. "If an elder is on a beta blocker medication such as metoprolol, they may not be tachycardic."
The patient's maximal heart rate response decreases with age, Weaver adds. "If the elder loses this compensatory mechanism due to the medication or age-related changes, the nurse may miss early signs of shock or disease," she says.
Other conditions that might cause tachycardia are pain, anxiety, heart failure, toxicity, fever, or increased tissue demand for oxygen, notes Weaver. "These may be missed if the nurse is not vigilant in his or her assessment and relies solely on vital signs," she warns.
Beta blockers most likely will prevent the increased heart rate normally seen with shock, says Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN. "Secondly, they will prevent vasoconstriction which can cause a blood distribution problem and add to a shock state," Somes says. "This inability to vasoconstrict is the reason patients on beta blockers often end up with orthostatic hypotension."
If your patient is on beta blockers, be aware of these other effects:
Additional doses of beta blockers might drop blood pressure and heart rate dramatically.
"What I have noted over the years is that often the first dose is tolerated, or the drop is gentle, but proceed with caution with each additional dose," warns Somes. "The patient will often suddenly drop dramatically, versus a nice continuous and gentle decrease. I can't tell you the number of new nurses and physicians that have been caught by this sudden crash."
Giving the beta blocker may cause a worsening of symptoms.
"Let the provider know how the patient is tolerating the medication, or the concerns of what could occur if the medication is given, based on the patient's condition prior to administering the beta blocker," says Somes. (See story on special considerations for septic patients taking beta blockers, below.)
Sources
For more information on elder ED patients and medications, contact:
- Joan Somes, PhD, MSN, RN, CEN, FAEN, Staff Nurse/Department Educator, St. Joseph's Hospital, St. Paul, MN. Phone: (651) 232-3000. E-mail: [email protected].
- Rhyan Weaver, RN, BSN, CEN, Clinical Supervisor, Emergency Department, St. Joseph's Hospital and Medical Center, Phoenix. Phone: (602) 406-5052. E-mail: [email protected].
Stop septic patient from rapid deterioration Don't have a false sense of security If your septic patient is on beta blockers, he or she will not compensate well and might deteriorate more rapidly, warns Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN. In this patient, Somes says "normal" blood pressure and heart rate numbers might give you a false sense of security. "Or the patient may simply present in a near arrest state, with a heart rate on the monitor that should lead to adequate perfusion, but does not," she says. The patient might, in fact, be pulseless or so poorly perfusing that distal pulses cannot be felt. "The skin will be cool, clammy, and mottled," says Somes. "Unfortunately, the classic treatment of fluids to 'fill the tank' may cause more problems. The beta blocker will prevent the heart rate to pick up and push that fluid around, thus sending it to the lungs to further exacerbate the problem." Early invasive monitoring is needed, so fluids and vasoactive medications can be administered together for a better outcome, says Somes. Observe closely Some beta blockers can cause bronchospasm, leading to hypoxia, notes Somes. For this reason, she says, listen for wheezing while assessing lung sounds. "Tissue oxygenation may be poor already," says Somes. "Keep in mind the cause of the sepsis may be a lung infection, thus making it difficult to determine which is causing abnormal lung sounds." Somes says to be suspicious if you have a patient on a beta blocker medication who is not doing well. "If the level of consciousness has suddenly become altered from their normal, look at the respirations," she says. "Persistently increased respiratory rate has been identified as a reason to be suspicious of early sepsis and the body's attempt to compensate." By closely monitoring the respiratory rate and even the end tidal carbon dioxide levels, you might be able to identify sepsis prior to the lactate levels rising, or even before lactate levels are ordered, says Somes. "Counting on the heart rate and blood pressure to tell the tale will not be as productive as looking at perfusion status," says Somes. "Look at the patient's level of consciousness, skin perfusion, temperature, and urinary output." Bear in mind that hypotension might become worse. "The septic patient is typically already having blood pressure issues. This will exacerbate the hypotension," says Somes. A common side effect of beta blockers is decreased moving of blood through the circulatory system, leading to congestive heart failure and poor renal perfusion, says Somes. "The septic patient has many of these same issues, so the circulatory problem is compounded," says Somes. "The patient can become beta blocker toxic, leading to an even slower heart rate. The effects and side effects develop a downward spiral." |
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