Do you call the doctor at night for low B/P's on night shift? - page 2

by Blackcat99

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B/P was 90/60. What would the B/P have to be before you would call the doctor on night shift? I work in the "skilled side" at the LTC. The doctor does not have orders or parameters in regards to calling him in regards to the... Read More


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    Quote from Blackcat99
    B/P was 90/60. What would the B/P have to be before you would call the doctor on night shift? I work in the "skilled side" at the LTC. The doctor does not have orders or parameters in regards to calling him in regards to the low B/P's. The first thing this doctor does when you call him at night is that he calls the DON at her home at night and reports you for calling him at night. However, the nurse from the 3-11 shift says you are suppose to call the doctor each time you get a low B/P on nights. In other words, I would be calling the doctor every night at 1am to report these low BP's. The DON would then be awakened every night at 1am when the doctor calls and reports me to the DON. Is it not normal to have a lower B/P when you are asleep at night?
    First, why doesn't this doctor write some parameters???

    Then, what does your DON have to say about this ridiculous situation?

    Lastly, what do the other nurses do?

    Oh, is the pt in distress? Are you doing routine VS at night? It's not unheard of for old people, thin people, sleeping people, people on BP meds, LOL to have lower BP? There's good advice earlier in this thread about MAP and about not fearing doctors.

    What time are you doing these VS? Usually, long-term VS are done monthly, but if you're on the skilled, presumably shorter stay, side, well, you will have to use good judgment. You can always RECHECK the BP after you get the pt moving, like flexing the hand and arm muscles.

    Even when VS are ordered around the clock, a prudent nurse might determine that sleep is more important at that particular moment.

    But your bosses need to protect you from this rude, unreasonable doctor. There's no reason, except to cover himself, that he isn't writing parameters for when to call at night re: sort of unusual VS. Obviously bad VS, pt in distress must be reported.

    It's your license. Protect it. But be reasonable. You will learn what "reasonable" is with time.
    Last edit by Kooky Korky on Dec 9, '12
    Mandylpn, gypsyd8, LoveToHike, and 2 others like this.
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    Depends:

    Is this BP normal for the patient? Is it part of a trend?

    Any adverse signs/symptoms accompanying it?

    What are the other VS, particularly the pulse?

    What's the blood pressure and pulse when rechecked manually?

    Is the patient on known antihypertensives?

    Does the patient have known or suspected bleeding problems? Or known/suspected dehydration? Or other issues that may result in low BPs?

    Did the provider specify parameters for when they want to be notified (e.g., "call if below 90/60")?

    Assess the patient, find out what's going on, and take all of that into account when deciding whether to call. Sometimes a low BP doesn't necessarily signal a problem. Sometimes it does. You can't just consider a BP by itself when deciding to call...unless of course, it's critically low or parameters were written.

    Though to be honest...if you are ever uncertain, IMO it's better to call and risk the wrath of an irate doctor to protect both the patient and your license.
    LoveToHike, Blackcat99, and loriangel14 like this.
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    In addition to assessing the resident and checking whether the low blood pressure is normal or part of a trend, I also check with the CNA to see which arm was used for the blood pressure and have the blood pressure checked on the other arm. There are a couple residents at the facility I work at who have blood pressures around 90/60 in one arm. But if you check the blood pressure on the other arm, it's normal. And this is normal for those residents, which is why for those residents I make sure to chart which arm we got the blood pressure on.

    I've only worked for a year and a half, but I have not had to call the doctor about a low blood pressure during the night as the majority of the time it's normal for the resident. The rest of the time, there's something else going on, and fortunately the nurses there for days or PMs have had the doctor address it already.
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    Quote from mappers
    Why are you taking a BP at 1:00 am?
    DON says all vitals on nights are to be done at 12 midnight so they usually turn in the v/s list between 12:30am and 1:00am
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    We didnt do a BP on nights unless there was a reason even our medicare pts they did temp pulse an O2
    Blackcat99 likes this.
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    If you are uncertain, call the doc. Tell him why - Then ask for an order for parameters so you don't have to call him again - and say it in just that way.
    Mandylpn and Blackcat99 like this.
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    Equation: MAP = [(2 x diastolic)+systolic] / 3

    Diastole counts twice as much as systole because 2/3 of the cardiac cycle is spent in diastole. An MAP of about 60 is necessary to perfuse coronary arteries, brain, kidneys.
    Usual range: 70-110
    Don't have time, how hard is this. If you have a tool that is useful and takes all of 10-20 seconds (depending on your math skills) to do , why not use it. Takes way to much time is a euphemism for "i can't be bothered"
    gypsyd8 and Blackcat99 like this.
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    No - the sad thing in LTC is you have very little time to actually think. Over time you'll know when to call the doctor just by looking at the numbers AND your patient. The MAP will confirm what you'll already know. Whether you need to intervene immediately or whether this can wait. I don't think it's super necessary honestly. 15 years of nursing - don't use it even though I know how and can 'be bothered' myself. But that's just my 2 cents.
    Blackcat99 and annlewis like this.
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    A BP of 90/60 is not usually considered a critical low BP unless there are other symptoms at play. If your patient is consistently 90/60 at night, chart the BP and leave it on report for morning. Perhaps the meds need to be adjusted, and the MD needs to know that. Does he need to know it in the middle of the night? Not really. He just needs to know before the next dose of HTN meds is due. Nursing is 24 hours. If the BP is lower than 90/60, you really need to assess the patient further. Is their usual BP on the low side? Is 80/50 their normal? Are they symptomatic? How is their pulse? Is it 72 and regular? Or are they tachycardic because their heart is trying compensate for a low BP? Anyway, you get the idea. And never be afraid to call the doc. So he calls the DON... it's still your license on the line and your assessment of your patient. I agree with those who said, give it right back to him. That's what he's there for.
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    First of all, I am quite surprised at everyone here for what is almost a complete lack of support for an RN in a nursing forum.

    Second of all, the MD needs to be writing some parameters. They should be a standard on the order set for every patient that comes through the door. It can even be a standardized check off and sign at the bottom sheet that tells how frequently to do certain things and gives parameters.

    Third, why doesn't the DON have a standard protocol binder with things like that in it, especially if this happens every time someone calls the MD at night?

    I see several breakdowns in the system here. If I were you, I would want to recheck it myself on both arms and make sure the correct size cuff was being used. Calculating the MAP as someone else suggested is a great idea and can be done for single patients like this on an as needed basis. A quick assessment can also be very helpful in determining if you need to call the MD.

    My last thought here is that the MD sounds a bit abusive to the nursing staff and that is not right. I would say that needs to be addressed at your facility. And he/she needs to write parameters if the MD doesn't want to be woken up at night.
    Mandylpn, LTCangel, and Blackcat99 like this.


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