BP: how high is too high (at 2am)? i.e., when will Pt stroke out?

1. There was an elderly Pt running 190's/90's (manual BP), pulse WNL (SR c some PVC's), asymptomatic, no acute distress, neurologic check fine, at 2am. I called the MD about the BP, and he was a little perturbed, asking if this was a new development or chronic (possibly he was asking if the BP could have just waited until morning).
   
   The answer to to that question was that she'd been at the hospital a few days for a bone fracture after a fall; the first day or so, BP's had been high but not crazy high (systolic BP's 150's - 170's, diastolic's < 90 or 100); over the past couple of days, her BP's had gone up (180's - 190's, systolic, with diastolics mid-80's to low-100's); in fact, her BP's had been a little higher than the 2am one; I hadn't called up for the 8pm BP because it wasn't too bad (170's/70's). Pulse on telemetry was always WNL, btw, although c some PVC's.
   
   She was on BP meds at the hospital, but a couple of her home diuretics had fallen through the cracks...the way the MD wrote it, it looked like the Pt should actually have been getting those diuretics for a day or so now, but no one had done it, and I was a little timid about starting her back on without a clarification (MD had written to hold those meds while the Pt was NPO, but then the Pt got taken off NPO, and no one rewrote for or restarted the meds).
   
   However, she did seem stable, neuro's fine; my question is, how high is too high? I get antsy about high BP's, thinking the Pt's going to stroke out...but what BP is really stroke range? Comoribidities on the Pt, btw, were DM and "borderline HTN," also hx ETOH abuse, cirrhosis, possible CHF, probable PVD, and risk for DVT.
   
   For me, it was kind of one of those situations where I'm looking at it, thinking, "Err, the Pt will PROBABLY be ok in this situation...but what if she isn't?? I'll look back and beat myself up for not having done something."
   
   (side note: darn you, allnurses.com, for keeping me up to 10:30 am!! i have to work tonight! I was just going to get on and post this one thing, and I got sidelined by the posts! growl)

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2. 12 Comments

   Comment
3. 
   Jun 26, '11

   ehhh, i would have called the doc too on that BP. I mean, If her BP's had been high prior to this one she would maybe have a PRN medication ordered. I would have given the PRN medication, checked again in a bit and notify MD if it was still high.
   If it went down after that it could have waited till morning.
   
   but if you didnt have anything ordered, you did the right thing i think. That is a really high BP. imagine if the patient did stroke out, then you'd have that same doctor "WHY DIDNT YOU CALL ME WHEN YOU SAW THAT BLOOD PRESSURE?"
   You just can't win with the docs.
4. 
   Jun 26, '11

   There isn't a specific bp that would cause a stroke.
5. 
   Jun 26, '11

   The thing that jumped out at me was the hx of ETOH. Usually, the patient will tell you they have a "couple drinks" and that generally means many more! I would be concerned that the b/p is going up day by day because the patient is NOT drinking. This is usually a sign of DT's. Withdrawing from ETOH is the only substance that can cause a life-threatening condition. ETOH patients who DT can have arhythmias that can cause an MI. You did the right thing by calling the MD regardless of the time of day. Every patient is different so it is impossible to say that a specific number could cause a stroke. One never knows. Calling the MD to clarify meds and treatment for this patient was correct. MD's need to get over themselves and just address the issue without making nurses feel bad for calling them. Honestly, if he were asked which he'd prefer, answering the phone at 2 AM or sitting on a stand answering to a prosecutor, I am sure he'd prefer the phone call that woke him up. I think you did the right thing.
6. 
   Jun 26, '11

   as for an actual number in danger zone, she was well into danger zone. I don't think there is an actual number on it, but i'd say anything in the 160's and above is danger zone. 140-160 is maybe "warning" thing.
   Who knows?? just an estimate. Like i don't flip if i see a BP of 150 or 155, but i will address it.
7. 
   Jun 26, '11

   I work in Neuro ICU and we let ischemic strokes be "permissively hypertensive" for perfusion purposes. Generally our goal is < 180/80... I've seen it all the way to < 210/110. As with most medicine, there is no cut off (i.e. At x SBP, person will stroke)
   
   You did the right thing in at least needing a PRN to give, maybe some hydralazine or labetolol if there HR is ok.
8. 
   Jun 26, '11

   At my hospital they always order captopril PRN for SPB over 180. So that seems to be the cutoff - but I guess if it's repeated 170s - I would still call to inform them even if they don't give an order.
   
   You also have to look at the pt - is he/she in great pain? having urinary retention? Symptomatic? etc.
9. 
   Jun 26, '11

   Determining when a patient will have a stroke is difficult, since it varies. It depends, too, on what the patient's personal usual BP is. For someone whose BP is usually 90/60, a reading of 130/80 could be dangerous.
10. 
    Jun 26, '11

    I agree with the mention of the ETOH withdrawal comments, but what about the possibility of pain also causing an elevation of BP. Inadequate pain control could also be the culprit, you did say the patient was post bone fracture and make no mention what so ever of how this is being treated so on is left to guess.
11. 
    Jun 26, '11

    Thanks for replies.
12. 
    Jun 26, '11

    I'll be the odd duck and risk the flames by saying I honestly don't know whether I would have called the MD. If the patient has had a BP in that range, and even higher than that, previous to this particular set of VS....I might not have (and I say might because I wasn't there and in that situation, so I can't say for sure). If the MD has been aware of the pt's trend in BP up to this point, it maybe could have waited until the morning (I would have done more frequent checks after that, if I didn't call initially). It also would depend on the specific doc I would have been calling...you get a feel for who would want to know at that time, and who would have wanted to know in the morning (again, since the pt's trend hadn't changed). I have dealt with numerous patients over the years who ran quite high numbers, ones that I would have considered alarming, where the response was "we're watching it, it's ok." Guess that's why I'm not the doctor.
    
    There is no specific, magic number that would equal the patient having a stroke. If they normally run quite high, you'd be surprised.
    
    As for the comments re: uncontrolled pain or DT's. The pain question can be pretty simple...if the patient can tell you, how do they feel? If the patient is non-verbal or unresponsive (and this is not new, of course), are there ANY other signs of uncontrolled pain? When the cues are reflexive (facial grimacing, etc), they would generally be there. For DT's, there are a myriad of symptoms that indicate DT's, and BP alone would not be indicative. If the BP is elevated, giving them a higher score, if everything else is zero, it's not enough to suggest it. That WOULD put me on alert to make sure I'm watching for other symptoms of it, though (HR, agitation, sweating, fever, etc etc).
    
    Do I think it's wrong that you called? No. If you're concerned, by all means, call! The doc will get over it; you didn't call to *bother* them, you called out of concern for the patient. I just wanted to offer another perspective.
13. 
    Jun 26, '11

    I'd have called for BP meds/Ativan to ward off DTs, and that's how I would have phrased it. What most of our docs look for is change -- if a person's been 160/94 for 3 days and hops to 170/100, and they're figitty or something, I'm not going to freak. If they've been 140/90 and then they're 210/90, I'm on the phone -- same if goes the other way. I also look at HR -- You get someone who's BP drops down in 80's SBP(unless they're on beta blockers) and the HR doesn't change, that can be a sign of a major hissy about to occur in that mean old widowmaker. I've had pt's with phenochromocytoma (that's probably spelled wrong) that live with a BP of 210/110, and you have to watch it like a hawk because if you get it to drop, they go into cerebral edema and then you got a whole new set of problems....
14. 
    Jun 26, '11

    Like everything else, it's relative. I agree with pretty much all the other good thoughts. And if it makes you feel better, I'd have also called, and I'm VERY conservative in my calls at night. (Not because I'm afraid to call the doctor, but because I don't think all that many things warrant a call in the middle of the night.) She was trending up, and this was a middle of the night, supposedly at a "relaxed/sleeping" time, so it concerns me more than a BP above their trend mid-afternoon. Throw in risk of DTs, I'd call.

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