Help needed re BP parameters

erin01 · Sep 16, 2009

wow hugs! That sucks that your not getting a clear answer. I have had a similar experience with not getting a clear cut answer. All i can say is cover your butt. Just call all the time till you get a feel for what they want. I would ask for parameters when you call them. Say so and so bp is now 100/70 would you like to write parameters for b/p under a 100? worse case they yell at you for calling with a normal b/p but then u get more of idea of whats going on. Sometimes i think the dr just need to vent frustration and it happens to be at us, its not right but try to let it just roll off! i will call them for everything until i get more of a feel for what they want. At least i covered my ass=) yell at me all you want ..i cant document that you were notified! i am also new 3m so i hope i gave so good info gl and huggs

llg, PhD, RN · Sep 16, 2009

Your problem isn't really BP's -- it's in having a manager that is not supportive of its staff. As you already know, your management should be working with the physicians to establish some guidelines for you to use. It sounds to me as if you DID use decent nursing judgment and practiced within the guidelines you had been given. If the medical staff is not satisfied with that ... they need to provide you with some input as to their preferences.

My response would be to call the doc any time it is not clear cut. When in doubt, call. If they start getting irritated by the phone calls, they will become ready to sit down at the table and work with the staff to develop new guidelines. But they may like the additional phone calls and that's OK, too. Either way, you win.

Dave419 · Sep 16, 2009

I've been working as a nurse for 7 months now (new grad). Different docs have different "hot button" issues: BP, Hct, amount of drainage/shift, foley output, etc. I'm slowly getting a feel for what the different docs want (thank goodness we don't have a large number of them) and the care coordinator gave me the "inside scoop" on which ones to watch out for when I started. I've been yelled at several times. I think it's all about gaining experience with your docs, and until you know all their quirks expect to get reported or yelled at.

I'm very grateful to the docs who have patiently put up with my learning curve.

morte, LPN, LVN · Sep 16, 2009

I'm a fairly new nurse and would like some info about using nursing judgment on when to call the doctor regarding a pts. BP reading. When I was in school, we were to report to our nursing instructor (clinical setting) systolic BPs under 90. At my place of employment, on our 'standing order' guidelines, it says to call the doc if systolic is under 90 or if there is a 40 mm/hg drop within a 24 hour period.
I had a resident the other day whose BP was 100/70. Since I considered it a little low I checked the resident's BPs that were recorded each shift for the past week. She fluctuated quite a bit, from the 100 to 140, all in a weeks time, not in 24 hours. It wasn't a constant drop - it was a fluctuation. So, I just wrote the BP on the 24 hour report.
When I was giving report to the 2nd shift nurse she tore me a new one. She said that that should have been reported to the doctor. She grabbed a book and slammed it down - vital signs book - and started pointing out some low BPs that had been previously recorded, about in the same range as mine. She said the PA threw a fit when she was in that week and saw those and found out that the Dr. hadn't been called. So, I asked what the parameters were that we should call. She said "normal blood pressure is 120 over 80!" And I said, "so, we're supposed to call if it's under 120?!" and she said "No, used nursing judgment!"
So, a couple of days later we were in our unit meeting and the manager brought up the BPs and how angry the doc and PA were and they actually reported us... so she said to watch the BPs. Someone asked what parameters to use. Again we were told to use nursing judgment... one of the seasoned (30+ yrs) said that she wouldn't have considered around 100 to be low enough to report, that around 90 is the parameter she uses... then someone said something about reporting in the low 100's if the person is on BP meds... and the unit manager said again to use nursing judgment.
So, we weren't actually given any parameters to go by even after everyone questioned it... I was screamed at and embarrassed to death, we were reported...but yet we still weren't given much to go by? I'm about ready to call it quits... I'm starting to seriously question if I was cut out to be a nurse....
How do you veterans decide what needs attention regarding BPs?
Thanks to all!

inre the bold: do not tolerate this behavior....period.....and she/he was wrong....120/80 may have been normal when he/she went to school, but not now; and you had followed the standing orders. If the medicos are having issues, they need to address them, ie giving parameters on ea and every patient.

WalkieTalkie, RN · Sep 16, 2009

Jeeze, a systolic BP of 100 is fantastic. If the patient is on BP meds, it sounds like they are well controlled. No way I would have called anyone to alert them of this normal BP. Sounds like you did use good judgement by looking at the patient's other BPs, and you also followed your own facility's policy.

I guarantee that if you would have called the doc with the BP, he/she would be annoyed that you called them. Your manager sounds like a dimwit as well. I think you did everything right. I'd start looking for a better place to work with nurses who critically think like you do, and with more supportive management.

Tait, MSN, RN · Sep 16, 2009

I would have the nurse that slammed the book at me in the hot seat pretty damn fast. No one needs to deal with that to start with.

Second I would demand management get clear cut parameters from the MD, or I would call the bastage myself and ask him what the hades he wants!

:icon_hug:

Tait

meandragonbrett · Sep 16, 2009

Tell that nurse and the PA to go pound sand. If they want to be called for a SBP of 100, then they need to write parameters. I don't call based on systolic pressure. I call based on MAP and whether or not they have UOP.

kanzi monkey · Sep 16, 2009

"Go pound sand"-- I like that.

Docs should write parameters for BP meds, and include a standard "call the doc" order for vitals they deem unacceptable. In theory, this gives the physician the opportunity to customize the treatment plan for the patient--because in theory, the doctor KNOWS the patient s/he is writing orders for, while nurses coming on shift are meeting patients for the first time.

As far as "using your nursing judgment"--anyone who says that to you without offering examples or any other useful info is blowing you off and skirting their responsibility to teach and support nurses. One way to use your own judgment is to determine if the patient is symptomatic or not (ie, do they get dizzy going from supine->sit->stand; do they feel uncharacteristically tired; are they tachycardic, etc.). Another thing to check (which you did) is a trend of their vitals (BP and HR specifically)--if their SBP varies throughout the day, consider if they are on any medications that lower BP (ie, pain medicines or BP meds...of course). Also, is there any reason they may be volume depleted (post-op, etc)--check I&Os.

These are all some things you can do to defend your action to either CALL or NOT CALL a physician. If you make a choice based on a solid patient assessment, you can feel confident that you are doing well by the patient, regardless of how a doc or another nurse may feel. If a doc gets in your face for not calling about an asymptomatic pt with an SBP above 90, then s/he DEFINITELY needs to write parameters--otherwise, s/he is taking away the nurses ability to work within the nursing model, and forcing him or her to try to be a mind-reader. Not fair to you and irrelevant to patient care. If a nurse gets in your face about not calling for an asymptomatic patient, let her know that that was your decision to make, that it was valid, and that nursing is a 24 hour job and she is welcome to call the doc if she feels it is in the patient's best interest.

Take home message: your patient assessment will give you your most important answers, and will free your conscience of feeling guilty for not being psychic.

RNperdiem, RN · Sep 16, 2009

What is considered low blood pressure depends on the individual patient, and the condition they have.

100/70 might be too low a pressure for a neurosurgical ICU patient with high intracranial pressure.

I took care of a lady last week in the cardiac unit with pressures around 85/32 all day with no symptoms. (I did call the doctor about that).

The experienced nurse in me would assess the patient's mental status first.

Ask them if they feel dizzy or lightheaded. I would see if they are making adequate urine output. Urine output drops if pressure is lower than the body tolerates.

Recheck the blood pressure again.

Then you can call the doctor and say that the patients BP is 100/70, she complains of dizziness, has not made urine for 5 hours and has not taken any blood pressure meds today.

rita359 · Sep 17, 2009

Sounds to me like you did what you should have done. Evaluate pts other bps. I take it you were on nights so probably would not get pt out of bed to eval hypotensive status. The nurse you gave report to was out of line. However, if she had recently gotten ripped by the dr for same issue maybe you can give her a little leaway. However, once she got ripped SHE should have gotten parameters for that pt so there would not have been further issues. Personally, after evaluating pts other bps, I would have waited 30-60 min and repeated bp. Next one could have been 90/ or 120/. If it was 90/ I would have called.

SunnyAndrsn · Sep 17, 2009

I guess I would have put in a call/fax, with the information you included on the 24hr board.

"Please note that resident's BP has fluctated from 100-140 systolic during the past 7 days. Denies dizziness or lightheadness (or pt. c/o...) Current medications include...

Please advise."

You may also want to consider WHEN the BP's were taken. Were they checked after any cardiac/BP meds were given or before? Was the pt. laying down or sitting? Has anyone checked orthstatic BPs?

And a lot will depend of course on the pt's diagnosis. We have a pt. with dramatic hypotension r/t to the pts' autonomic dysregulation. We monitor qshift and the MD checks them weekly to make med adjustements. However, we do call if the systolic is below 80 or above 200. I've seen 260/125 for this particular pt and then 90/40 all in the same shift.

Ask yourself what is the pt's medical diagnosis that can contribute to bp fluctuations, what medications is the pt. on, and what symptoms does the pt have r/t BP (lightheadness, dizziness, any falls, c/o HA, orthostatic fluctuations, lower extremity edema, etc)

While it's nice to have clear cut orders, sometimes it really IS a judgement call, and in that case collect as much data as possible to present to the MD to CYA.

I'm a fairly new nurse and would like some info about using nursing judgment on when to call the doctor regarding a pts. BP reading. When I was in school, we were to report to our nursing instructor (clinical setting) systolic BPs under 90. At my place of employment, on our 'standing order' guidelines, it says to call the doc if systolic is under 90 or if there is a 40 mm/hg drop within a 24 hour period.
I had a resident the other day whose BP was 100/70. Since I considered it a little low I checked the resident's BPs that were recorded each shift for the past week. She fluctuated quite a bit, from the 100 to 140, all in a weeks time, not in 24 hours. It wasn't a constant drop - it was a fluctuation. So, I just wrote the BP on the 24 hour report.
When I was giving report to the 2nd shift nurse she tore me a new one. She said that that should have been reported to the doctor. She grabbed a book and slammed it down - vital signs book - and started pointing out some low BPs that had been previously recorded, about in the same range as mine. She said the PA threw a fit when she was in that week and saw those and found out that the Dr. hadn't been called. So, I asked what the parameters were that we should call. She said "normal blood pressure is 120 over 80!" And I said, "so, we're supposed to call if it's under 120?!" and she said "No, used nursing judgment!"
So, a couple of days later we were in our unit meeting and the manager brought up the BPs and how angry the doc and PA were and they actually reported us... so she said to watch the BPs. Someone asked what parameters to use. Again we were told to use nursing judgment... one of the seasoned (30+ yrs) said that she wouldn't have considered around 100 to be low enough to report, that around 90 is the parameter she uses... then someone said something about reporting in the low 100's if the person is on BP meds... and the unit manager said again to use nursing judgment.
So, we weren't actually given any parameters to go by even after everyone questioned it... I was screamed at and embarrassed to death, we were reported...but yet we still weren't given much to go by? I'm about ready to call it quits... I'm starting to seriously question if I was cut out to be a nurse....
How do you veterans decide what needs attention regarding BPs?
Thanks to all!