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?
I learned from different instructors and doctors that BP guidelines of 120/80 are just a guideline, and sort of outdated now anyway. There are many people whose BP is under 120 systolic, and it's normal for them. I happen to be one of them, usually with a systolic of 100-110 on some days when I've gone to get bloodwork done during fasting, it was between 90-100, and doctors were never alarmed. Some people can be fine with that BP.
I also read that recent research shows a systolic below 120 is actually better, and people live longer that way. Now if someone normally has 120 and suddenly goes down that's different. But I think you would have to know what the pt's actual 'normal range' is to be sure what is normal or not for them, esp. when they take BP meds. I think alot of pts fluctuate though, and from what you wrote it didn't seem like an alarming situation. I think some nurses just like to give other nurses a hard time for whatever reason, especially if you are a fairly new nurse. Don't be so hard on yourself though.
Specializes in Management, Emergency, Psych, Med Surg.
When deciding to call a physician about a blood pressure I do a couple of things. First of all, as you did, I look at the trends in the pressure. Have they been running about the same as usual. A 100/70 is not a low blood pressure for most people unless the trend has been much higher. As a general rule I would not call for this blood pressure reading. Second, I would assess the patient for changes in mental status or heart rate. Is the patient tachycardic? (Listen to her chest. Don't trust your machine. Is it regular?) Is the patient hydrated, making urine and has the patient had blood pressure medication today? Does she look pale (check her nail beds, inside her lips and her sclera). If those areas are pale, then she may have a low H&H which may be causing her low blood pressure. If no changes are noted, good. Then I might verify her blood pressure in the other arm. There can be great variables between one are to another, especially in the elderly who may have advanced circulatory disease. If all things are normal and there is no change, chart what you did and leave it at that.
If the nurse in the morning feels that you made an error, simply hand her an incident report form and tell her to fill it out and give it to the manager, then go on with your report and go home. You did nothing wrong and the patient was in good hands and was not harmed. Nursing is not cookbook. With any one question, you will get a million different answers. As always, assess your patient. That is key. Nursing is about 20% book work and about 80% horse sense.
If someone wants to talk to you about it, the manager needs to do it. Otherwise, tell them to read your note. Most of our docs establish parameters of when they want to be called, but if they don't we just use our judgment. And so far, it is never been a problem.
Ps. also, please don't forget to read the doctor progress note. He may have already noted the low pressure which indicates he already knows about it. Work done!!
MiaNJ
198 Posts
I learned from different instructors and doctors that BP guidelines of 120/80 are just a guideline, and sort of outdated now anyway. There are many people whose BP is under 120 systolic, and it's normal for them. I happen to be one of them, usually with a systolic of 100-110 on some days when I've gone to get bloodwork done during fasting, it was between 90-100, and doctors were never alarmed. Some people can be fine with that BP.
I also read that recent research shows a systolic below 120 is actually better, and people live longer that way. Now if someone normally has 120 and suddenly goes down that's different. But I think you would have to know what the pt's actual 'normal range' is to be sure what is normal or not for them, esp. when they take BP meds. I think alot of pts fluctuate though, and from what you wrote it didn't seem like an alarming situation. I think some nurses just like to give other nurses a hard time for whatever reason, especially if you are a fairly new nurse. Don't be so hard on yourself though.