Hypertension Parameters

[hmvassar, ASN, RN]

Hi everyone, I'm on my 6th month as a new nurse and I'm working in home health after leaving the emergency room setting. I'd like some insight into some of the parameters in our plans of care. Many of our aging patients have hypertension, take blood pressure medications, and have multiple comorbidities. Our parameters read as following:

RN and Pt will contact physician if SBP is above 170 or below 100 or DBP is above 90 or below 60.

I feel that this blood pressure parameter is too high and the patient should be going to the ER if the BP is sustained above SBP 170 after taking blood pressure medications.

So I'm trying to provide better values to educate my patients on when to call the doctor (while taking their home blood pressures) versus when to go to the emergency room. Every patient is different, this I know but I need a good starting place for advising. (I am teaching them the signs and symptoms to monitor for as well and tailoring it to each patient.)

For example, one of my new patients SBP was 174 (can't remember diastolic off top of my head) HR 64, patient was asymptomatic. Called PCP, pcp stated to check it again next week at next visit. Educated patient on how to take BP and pulse and keep a log and check it first thing in the AM and then in the afternoon after BP meds have kicked in. Checked on patient today and her BPs were 154/68 and HR's were 54 1+ edema in calves, lungs clear, no other s/s of hypertension noted. Called PCP to report BP (even though it falls within parameters but outside of a healthy BP range) and PCP wants her to come in for an appt because the BP is too high. I don't feel that the parameters are fitting and the PCP made it more confusing considering the high reading that I took 3 times over the course of 45 minutes did not concern the PCP. So i'd like some better guidelines for myself and for patients to monitor for hypertension to prevent future complications.

Thank you. Any resources for me or for patient education in relation to hypertension are warmly welcomed!

[Party_of_five, BSN]

As an ER nurse, if someone come into the ER with a "high BP" of 170 they are going to get an eyeroll. Stuff like that needs to be managed by the PCP, not the ER. Sure, we can lower it but most of our docs won't. I'm sure there are situations that warrant an ER visit but for the patient you described above I would not recommend the ER. I think your current parameter are ok.

[hmvassar, ASN, RN]

As an ER nurse, if someone come into the ER with a "high BP" of 170 they are going to get an eyeroll. Stuff like that needs to be managed by the PCP, not the ER. Sure, we can lower it but most of our docs won't. I'm sure there are situations that warrant an ER visit but for the patient you described above I would not recommend the ER. I think your current parameter are ok.

Thank you! That's why I'm going back and forth. Because after being in the ER and seeing patients with a SPB in the 180's symptomatic and not receiving BP medications I was having a hard time with this number. Would it be appropriate to tell the patients call the PCP if your SBP is above 170 and are asymptomatic? And call 911 if your SBP is above 170 and you are symptomatic (chest pain, sob, weakness, severe HA, etc.). I just feel that if I'm consistently seeing a patient with a SBP in the 150's taking BP medications and they are following a low sodium diet, getting exercise, then their BP medications aren't working or they are continuing to retain fluid and need a med change and in that case I should use my judgment to contact the PCP even when the values are in parameters.

[psu_213, BSN, RN]

I just feel that if I'm consistently seeing a patient with a SBP in the 150's taking BP medications and they are following a low sodium diet, getting exercise, then their BP medications aren't working or they are continuing to retain fluid and need a med change and in that case I should use my judgment to contact the PCP even when the values are in parameters.

Unfortunately, there is really no one size fits all protocol that can be used. For example, I took care of the pt's who systolic BP was in the 150s. Evidently, he has gotten orthostatic and passed out with systolic BPs as high as 140. While it may seem unnatural, a BP in the 150s in this pt is fine.

Also, kidney function is a consideration. For someone with a creat that has been creeping up over the last year, the physician is not going to be as aggressive at treating that retained fluid as he/she would in a pt with normal kidney functions.

I've never worked home health, so I am not in a position to tell you when to (or when not to) contact the PCP, but my guess (!) is that he or she is not going to prioritize someone for an appointment if the pt's SBP is "only" in the 150s.