BP freak out

[bindikwan]

I've got a question but my background is I work nights as a CNA on a tele/stroke floor and I am also currently in nursing school.

My question is this. I regularly work with a nurse who doesn't like to cover patient's BP meds, if its too high. Often the orders read give X med for SBP >160 etc. It usually goes like this, I'll take the vitals on a patient and if the BP is high, I let the nurse know. They will always have me recheck it. If it's the same or higher they get upset and take it themselves but they lay the patient completely flat on the bed to do it and they always get a slightly lower reading, just under the parameters of where they'd have to cover it. Last time it was 158 SBP when they took it, right under the 162 SBP that I got without lowering the HOB. Now here's my question, is the lower BP the more accurate one? Because most of our patients have orders to have the HOB raised at 30 degrees or more because they are aspiration risks etc. so I don't lay them flat to take their BP. I make sure they are on their backs, with legs uncrossed etc. This is becoming an issue to where I don't want to work on the same shift with this nurse because I'm actually scared to give them their patient's vitals because I get yelled at. The last time I told them about a high BP, they followed me to the room to watch me retake it and it was the same. They got super upset, kicked me out of the room and laid the hob completely flat and retook it themselves and it was slightly lower. What's the deal? Should I be doing that too? I asked my nursing instructor at school and they said the most accurate BP's are done with the person standing up. My thinking is that if the person is going to be spending most of their time with the hob raised then it makes sense that their BP in that position is their most accurate BP but not according to this nurse that I work with. It's very confusing.

[crazin01]

It sounds to me as though this particular nurse does not want to have to give the PRN BP med, sort of being lazy especially because of the attitude given, watching you retake the vitals and going as far as to be rude/yell at you about it. Is it only this one nurse, or a number of them? Do other's CNA's have this same issue, again with only this one nurse, or with various nurses?

Another consideration (I wouldn't call it an issue) is if you're working with primarily stroke patients. (I will always remember this because I fought with a doc practically all night one shift, to aide a newer RN). In a stroke (thrombotic, not hemorragic) the brain is not receiving proper blood flow due to blockage and thus, when the actue event is over, the body compensates to increased blood flow and blood pressure will rise. So, you sort of want an increased in BP for a certain time frame to re-perfuse the brain with blood it was just deprived of. But it is a balancing act of allowing some degree of hypertension but preventing further issues or risk to patient.

I definitely think it's ok to re-check vitals, but constantly and only on those whose current reported BP requires more work from the nurse? Just seems quite convenient to me. Plus, his/her lower BP after lowering the HOB does not quite add up. Usually (and with no hugely abnormal issues occurring) , when you lower the patients' HOB to flat, or even placing the bed into trendelenberg position, with the head below feet, the BP will actually go up, not down. This change in blood pressure is due to increasing blood flow returning to the heart from the legs. You may often see this action taken before a code situation or if a patient is beginning to go south but not yet coding or no orders are in place yet to address the hypotension. I work primarily nights and often utilize this nursing measure while awaiting calls back from doctors for orders.

Thus, I'm confused why your colleague would do this and seemingly get a lower BP to avoid giving the PRN medication. I'm interested to hear about any other colleagues with these issues.

[NOADLS]

This seems pretty clear cut.

The nurse you are working with wants to expend less effort. It is interesting though since it would probably take less time to administer the PRN than it does to go through all of the hassle.

Neither blood pressure is "more accurate," but the blood pressure you are taking is more reflective of where the patient's blood pressure is likely to be since the patient is going to be in that position. The blood pressure the nurse is taking is not reflective of where this patient's blood pressure is going to be at.

I would also add that these aren't blood pressures that I would "freak out" about. If this nurse wasn't administering the PRN for a systolic of over 180, I would take issue, but as it is, it isn't anything to worry about.

[Pangea Reunited, ASN, RN]

I don't always give PRNs for borderline "bad" blood pressures. Sometimes it's because I know the patient is anxious, has been vomiting, tends to drop once they settle in for the night, etc. Very often, it's because I've recently given something that lowers blood pressure- or they will have something due soon that lowers blood pressure.

I do occasionally ask for a recheck, or recheck myself, if any vital sign sounds "off", but I don't understand nurses who get upset about vital signs or tell CNAs not to chart them until they get "good" ones.

As a CNA, I don't think I'd worry too much about it if it's borderline and you're reporting it to the nurse. Remember that you are not the nurse at work, even though you're a nursing student outside of work. If you have something more extreme, like 240/120 and the nurse doesn't response appropriately, by all means move up the chain. Otherwise, chart that the nurse has been notified and move on with your day.

[Libby1987]

You sound intelligent and fully able to understand a clear rationale. The fact that the nurse isn't giving you one speaks to her own lack of knowledge and why she's possibly not wanting to cover for a reason other than a patient focused reason.

[nurseletDZ]

In a stroke (thrombotic, not hemorragic) the brain is not receiving proper blood flow due to blockage and thus, when the actue event is over, the body compensates to increased blood flow and blood pressure will rise. So, you sort of want an increased in BP for a certain time frame to re-perfuse the brain with blood it was just deprived of. But it is a balancing act of allowing some degree of hypertension but preventing further issues or risk to patient.

Good point! I just learned about this in school. According to our guest lecturer who works in an acute stroke unit, the protocol is that the doc will have specific BP parameters ordered for the pt's situation, to keep the RN from having to make such a critical decision.

[bindikwan]

Thank you! All very good points. We do have some patients with much higher parameters for their BP due to thrombotic stroke. I remember the first night I worked there I took a patient's BP and it was 200 hundred something so I ran straight to tell the nurse. She saw the panic on my face and explained it to me. Very nice of her, even though it was crazy busy. I had just started 1st semester at the time I didn't know anything about anything. Also, it's just this one particular nurse and they do yell at the other CNA's about vitals. The other nurses on the floor are awesome men and women who work their butts off for their patients and we get along great. I'm sure there is a reason why this nurse doesn't want the higher BP charted but I'm not brave enough yet to ask. I don't like confrontation and I really don't like getting yelled at. >> Anyway, I'm working with them again tonight so we shall see how it goes. :)

[Horseshoe, BSN, RN]

T It is interesting though since it would probably take less time to administer the PRN than it does to go through all of the hassle.

That's exactly what I thought. Unless she doesn't trust the CNA, it makes little sense that this is laziness, as it would just be quicker to give the med and keep on moving down the road.

[CrunchRN, ADN, RN]

You are right.

[Here.I.Stand, BSN, RN]

Good point! I just learned about this in school. According to our guest lecturer who works in an acute stroke unit, the protocol is that the doc will have specific BP parameters ordered for the pt's situation, to keep the RN from having to make such a critical decision.

I've had ICU stroke pts who were on a pressor to keep their SBP between 180-220! They lived at such high BP that a quick drop to textbook normal would reduce their cerebral perfusion.

[russianbear]

I believe patients who have been hypertensive for a long time will not receive adequate perfusion if their BP drops too low because the arteries are stretched out so to speak from the years of high pressures.