Help me with patient with unstable diastolic blood pressure

[Blackheartednurse]

So one of my patients recently developed a low diastolic blood pressure (I'm a home health nurse) and it is strange.She is on 3 blood pressure meds (ACE inhibitor (Captopril),beta-blocker mixed with diuretic(Tenoretic),and a calcium channnel blocker (amlodipine) and a drug dipyridamole which is known to also decrease the blood pressure and had anticlotting properties.She also takes glyburide for diabetes and lovastatin for her hypercholestermia.The fist time I visit her at home,her BP was within normal range.That day she informed me that couple weeks ago she fainted and was taken to a hospital.The lady is not overweight,she weight 130 pounds.She is also diabetic and has some problems with eating because she is waiting for her dentures to be fixed.I orginally thought that the reason for her fainting was hypoglycemia but also I'm aware that she is on 3 blood pressure meds and also on another blood-pressure lowering drug Dipyridamole,although its action seems kinda confusing to me although I know for sure that when given in high doses they dilate blood vessels significantly,altough my patient is not on high dose but not at the lowest either.So Monday I saw the patient and her blood pressure was 132/55,pulse 60.Patient was asymptomatic.I notified MD,he said to hold Captopril and Amlodipine temporarly,increase frequency of visit,monitor BP,so the patient stopped taking the captopril and amlodpine as ordered,I made an appointment with her for today.So I come in today and patient states she feels fine,I checked her blood pressure it was 142/50.So her systolic increased 10 and diastolic decreased by 5.I'm calling MD again of course he did not call me back yet.Its been like 2.5 hours.His secretary havent even called me back.In your opinion what would be the reason for her low diastolic pressure.Any tips suggestions,thanks.

[klone, MSN, RN]

That's why your medical director gets paid the big bucks.

[roser13, ASN, RN]

I think you need to wait for the doctor to call back.

[Blackheartednurse]

I think you need to wait for the doctor to call back.

I spoke with his assitant while ago and she said to keep holding off Captopril and Amlodpine and contiue to monitor blood pressure.My dillema is that I'm scared that my patient will be ****** of at me.She has been taking Captopril and Amlodipine for some time now.Her bottles are almost empty.She refill it at the end of the month.The end of month is here.I told her we are discontinuing those two meds temporarily.Today she ask me if she should refill her Captopril and Amlodipine I said yes just in case she gets rebound hypertension.She told me that she wants to continue taking those meds later on (since she was taking these meds for long time) I'm scared she will go back to taking them later on regardless what the doctor says.Also she might get ****** in the case she refills it and her blood pressure will continue to run low and I will instruct her to stop taking pernamently (of course with doctor order).I'm so confused I mean it is only been 2 days...I went to visit her today,maybe that was a mistake and I should have had visit her tommorow,or friday,maybe I went too soon,even the assistant was surprised that I went to check on her so soon.

[mamamerlee, LPN]

You don't say what her pressure usually ran, so it is hard to know what to tell you. I have had more than a few patients with diastolic pressures in the 50's.

Always call your clinical manager to keep them up with what is going on. And ask the doc to fax the orders into your office.

[Blackheartednurse]

You don't say what her pressure usually ran, so it is hard to know what to tell you. I have had more than a few patients with diastolic pressures in the 50's.

Always call your clinical manager to keep them up with what is going on. And ask the doc to fax the orders into your office.

It usually runs in 70-80

[JulieCVICURN, BSN, RN]

We're never concerned about unstable diastolic BP in the ICU when it's low. It's only when it's high and the pulse pressure narrows that we worry. I don't think I've ever called a doc about a low diastolic, and often when we give report we don't even mention the diastolic, only the systolic. Maybe I'm missing something, but in my vast 3 years (joking - I know that's still a neophyte!) of CV ICU experience I have never once known this to be an issue. Her MAP is 80.7, which is almost right smack in the middle of normal and at worst the lower end of normal, so I don't see what the problem is. Even when her pressure went to 142/50, her MAP remained in normal range.

Also, quite often in older people you can hear a diastolic beat all the way down, so it's entirely possible you've got your diastolic numbers incorrect.

[CNL2B]

We're never concerned about unstable diastolic BP in the ICU when it's low. It's only when it's high and the pulse pressure narrows that we worry. I don't think I've ever called a doc about a low diastolic, and often when we give report we don't even mention the diastolic, only the systolic. Maybe I'm missing something, but in my vast 3 years (joking - I know that's still a neophyte!) of CV ICU experience I have never once known this to be an issue. Her MAP is 80.7, which is almost right smack in the middle of normal and at worst the lower end of normal, so I don't see what the problem is. Even when her pressure went to 142/50, her MAP remained in normal range.

Also, quite often in older people you can hear a diastolic beat all the way down, so it's entirely possible you've got your diastolic numbers incorrect.

Totally agree with this. The only time I worry about a dB/P is when it is too HIGH -- like over 90-100-110. Typically your systolic is way up there too then. I've seen a number of patients with some degree of heart failure with VERY low dB/Ps -- we are talking in the low 40s and 30s though. I wouldn't bat an eyelash at the B/Ps you are talking about.

[morte, LPN, LVN]

Is this change noted with the same BP cuff.? has it been dropped or exposed to other potential damage?

bring another one for next visit and compare. Take pressure on other arm. Was this noted before her fainting episode?

[Blackheartednurse]

We're never concerned about unstable diastolic BP in the ICU when it's low. It's only when it's high and the pulse pressure narrows that we worry. I don't think I've ever called a doc about a low diastolic, and often when we give report we don't even mention the diastolic, only the systolic. Maybe I'm missing something, but in my vast 3 years (joking - I know that's still a neophyte!) of CV ICU experience I have never once known this to be an issue. Her MAP is 80.7, which is almost right smack in the middle of normal and at worst the lower end of normal, so I don't see what the problem is. Even when her pressure went to 142/50, her MAP remained in normal range.

Also, quite often in older people you can hear a diastolic beat all the way down, so it's entirely possible you've got your diastolic numbers incorrect.

Well,according to the parameters I have to notify the doctor if the diastolic blood pressure is less than 60 and more than 100.I could get in trouble if I didnt notify the doctor.I'm just surprised that he discontinued Captopril and amlodipine all of the sudden.Yes she will continue to take the combination of beta blocker with diuretic but stil should he wean her off from the other blood pressure meds slowly>Plus she has a recent episode of fainting.

[Blackheartednurse]

Is this change noted with the same BP cuff.? has it been dropped or exposed to other potential damage?

bring another one for next visit and compare. Take pressure on other arm. Was this noted before her fainting episode?

Yes I'm using the same cuff all the time,also when I take the BP for another patients it comes out ok.But you know that is good idea.I should take it on both arms and compare you know.I'm not sure if this was noted before her fainting episode.

[JulieCVICURN, BSN, RN]

That's an interesting parameter. I've never had a cardiologist or a primary ask me to notify them about any low diastolics. I wonder what that particular doctor is up to, because that seems strange to me. Maybe he's trying to catch early heart failure symptoms or something.