Blood pressure in peds patients

JKL33 · Feb 20, 2020

I can only tell you what I've heard:

- Some places have policies for their own reasons that demand blood pressures on all patients, including all peds.

- Because of ^ this, some nurses put blood pressure cuffs on every peds patient, whether squirming, clenching, flailing or screaming bloody murder, and will enter the resulting value into the chart.

- Some nurses assess patients by other means, including those you have mentioned, and make an attempt at blood pressure; if it is clear that an accurate value cannot be obtained in a low-acuity patient at that time, the attempt is abandoned.

There's no arguing that in general children should be screened and monitored for hypertension. I haven't yet read any widespread standards about how a blood pressure on a frightened, crying/screaming, active or resistant patient has anything to do with appropriate screening.

The referenced article was interesting, but due to innumerable observations, I don't think that their definition of calm is sufficient and I also doubt the accuracy of the determination that a child was calm.

Quote
Calming techniques included distraction and parental soothing as deemed appropriate for age, acuity, and behavioral state. Patients were determined to be “calm” if they were cooperative, still, and accepting of BP procedure. Patients were considered to be “not calm” if they were crying, fighting, or moving during the measurement.

My experience is that it's fairly rare for a generally healthy infant/young child at a lower-acuity ED visit to tolerate a blood pressure without the fine movements they usually do in response to it: the fine clenching, twisting and intermittent muscle movements--even when they otherwise could generally be said to be calm (even cooperative).

There are other factors (anecdotally) that would also suggest that a triage b/p is particularly worthless even if a b/p was absolutely mandatory sometime during the visit. They come into the triage area and, whether in pain or particularly fearful or not, they are encountering stranger, they're very curious about their surroundings, they are uncertain about what's going to happen to them or if it's going to be painful or scary.

I would make the argument that in the absence of conditions (whether congenital, chronic/acute, etc) that place them at high risk, this is a very low-value activity in the ED.

adventure_rn, MSN, NP · Jun 26, 2020

Full disclosure, I have absolutely zero ED experience, but I do have some tips as a NICU/peds nurse.

Honestly, if you can get them when the kids are calm (hard to do, I know), cuff pressures can be quite accurate. I'm sure it's hard to believe, but in NICU we have kids who are on vasoactive drips like dopa whose BPs are only monitored by q 15 cuff pressures. Even in the toddler-sized PICU patients who are awake and active, the routine hourly pressures are accurate at least 90% of the time.

Here's my approach:

Your absolute first step should be putting on the cuff, even before getting the history. Try to grab the pressure before you get in and start assessing, poking around, or doing anything else that could scare the kids or piss them off.

Most kids get pretty freaked out by the process of putting the cuff on; wait for at least 30 seconds to let them calm down before you hit the start button. This is the perfect time to get the history from the parents; if you take all of the focus away from the baby, they'll relax and let their guard down. Little kids tend to have pretty bad stranger danger; it will help a lot if you're looking at the parent, the chart, the computer, etc. instead of looking or touching the child prior to getting the pressure.

If at all possible, try to take the pressure while the parent is holding. Bonus points if they've got a pacifier, toys, or an iPad to distract them.

On little kids, it's way easier to get a pressure on a calf than the upper arm. They are the tiniest bit less accurate, but the kids are far less likely to have a panic attack which will screw up the reading. You can still do a calf pressure while a parent is holding; just try to ensure that the calf/cuff is close to the level of the heart (I.e. the baby is laying flat in the parent's arms, not sitting straight up and down).

If at first you get a funky reading but the baby is still calm, wait another 30 seconds and try again (resist the urge to look at/touch/acknowledge the child in between).

However, if the baby is having a total meltdown, put the cuff but don't take the pressure, and just proceed with your assessment as usual. If, during the triage process, you ever have an opportunity where the baby is relatively calm or starting to fall asleep, that is your moment! Just leave the cuff on, so that when that moment comes, you're ready. Again, if the child is calm know you're about to take the pressure, step back and get out of the kid's personal space. Parents should be on active soothing/toy/pacifier duty.

Granted, it would be pretty rare for kids who are otherwise healthy to become hypotensive unless they're literally about to code. Usually by that point, they're so lethargic that they don't care what you do (very ominous).

If I ever do have to chart a BP that I think seems inaccurate, I'll at least annotate "patient agitated/inconsolable," or even "patient screaming, unable to obtain," and just try again later if possible (not sure if that's feasible in ED, though).

Georgia Weasley · Jun 26, 2020

Thank you very much to both of you who’ve replied! Very helpful :)

adventure_rn, MSN, NP · Jun 26, 2020

No problem!

Forgot to mention, if you're getting a calf pressure, always line up the little tubes on the cuff directly over the post-tib artery (just behind the medial malleolus on the ankle).

Also, if the child is able to stay calm during the BP, immediately after is a great time to sneak in with your stethoscope to listen to heart/lung/bowel sounds. It's nearly impossible to do while they're screaming.

Basically, peds is all about strategic sneak attacks.

speedynurse, ADN, BSN, RN, EMT-P · Jun 27, 2020

On 2/19/2020 at 4:01 PM, Georgia Weasley said:
Background- My experience until recently has been 3 years in an adult only ER. I now have a second per diem job in a a busier emergency department that sees a ton of kids, not a population I am familiar or very comfortable with yet. Last night I was in triage, and felt a little overwhelmed by how many kids came through and I realized I'm needing to review somethings and work on new skills! Its fun.
Here's my question to the community of experienced ER nurses!- At what age is it necessary and valuable to check a blood pressure on kids? Is this something you routinely do, or skip in kids with certain high ESI scores under a certain age?
This question occurred to me last night when I was going through my triage process like I would with a large person, and I was so exasperated to realize that IT IS NOT EASY to get a BP on crying squirming babies and toddlers, and furthermore, are the values even reliable when they are not calm? I wonder how useful a blood pressure is under a certain age when, as I know from PALS, children compensate their pressures and sick kids will have other poor perfusion signs first.
I bring this question here because when I asked some nurses I worked with last night, I got inconsistent ideas about practice. One nurse told me she measures BP on all patients, and another said that they don't measure on kids under 3 years.
When I look online for best practice, I found this interesting study ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385663/ ) which in summary, discusses that for kids with an ESI of 3 or 4, blood pressure may not be valuable in kids <5 years old.
I would like to hear what your practice is when triaging and caring for kids in the ED, or maybe be pointed in the direction of pediatric emergency standards of practice. Having a hard time finding definitive info from my Google searches.
THANKS!!

I have always worked in mixed age EDs. These are the guidelines that I basically follow when triaging....

1. Super sick kids.....lethargic, severe respiratory distress, sepsis, pre-existing health issues (congenital heart disease, neuro issues....etc. - get a blood pressure.

2. Attempt to get a blood pressure on the lower acuity kids and talk them through it if they can understand in "kid" terms. (Younger kiddos - "this is going to give your arm a hug"). If you cannot get an accurate reading after one or two attempts and the child is screaming/upset - just abandon it. It is not worth putting the child through something that is not very valuable in a generally healthy, lower acuity child.

PeakRN · Jul 13, 2020

Just for perspective I have found essential hypertension in otherwise healthy 2 and 3 year olds several times in the ED.

While the ED is not the kid's primary care, that may be the only medical provider they see for months or years. These kids could easily end up with long term kidney disease if they weren't completely evaluated during their visit.

HiddencatBSN, BSN · Aug 18, 2020

Are you able to take palpable blood pressures? They’re faster which means less complaint from a child who doesn’t like the squeezing. Also when using the auto bp make sure it’s set to pediatrics- it doesn’t need to squeeze as tight as for adults.

I’ve always worked peds er and iirc the standard with ENA is a BP on all peds patients. If I’m truly unable to obtain a BP I document why (patient screaming and kicking during vitals, multiple attempts) but I can usually at least get a palpable. In epic we document /0 and note it as palpable so for example 86/0 palp.