Blood pressure drastic variation

[oceanblue52]

As evidenced by this posting, I'm a new nurse currently working in home health. I had a patient a few days ago that has some early dementia, high anxiety, and also drinks occasionally (living relatively independently at the moment). When I took her reading at the beginning of my visit, I got about 196/100 and obviously started panicking. I then took her blood pressure in her other arm and got 170/90. Before calling her PCP I decided to wait 20 minutes after she took her cardiac meds (an ACE inhibitor) and her benzodiazapine. I rechecked it 20 minutes later in both arms and it had gone down to 160/90. I rechecked it a third time in both arms 10 minutes later and got 150/88. Then by the time I left it was 138/86 in one arm only.

My questions:

1. Is it normal to have that much variation between arms? I have been in healthcare awhile and feel confident in my manual BP readings. The cuff was an appropriate size. I also know that one of my PCPs always checks BP in both arms. Can someone explain this reasoning?

2. Can anxiety produce readings that high?? She was pretty panicky when I started my visit and still anxious when I left. Could a hangover be contributing to these vital signs? It is pretty hard to judge how much she drinks, although I don't think she is binging.

3. Can blood pressure really be reduced that much from just 2 medications in that short a time span? Or do I have reason to doubt my vital sign assessment skills?

I really appreciate any advice people can offer! Would like to get a better handle on how to handle abnormal vitals in the home. I did assess for chest pain, headache, blurry vision, all of which were negative. Anything else I can screen for in future scenarios? All her other vitals were WNL.

[MaxAttack, BSN, RN]

Anxiety can definitely make someone's BP skyrocket. Not only does anxiety raise BP (fight-or-flight sympathetic activation), but usually they're tense or moving which will skew the reading even higher. That could be the reason for the difference between the arms. If I remember right, they should be within 15 mm Hg of each other - a difference greater than that could indicate peripheral artery disease. But again, anxiety and accuracy don't go together.

Quick onset could be the meds, could be the patient calming down, or could be a placebo-like effect where just the act of taking the pills starts relaxing her (especially for benzos and if this is something she takes frequently).

You handled it perfectly.