Frequency of BP in Pediatric Patients - page 2

I work for a hospital that recently opened a general pediatric unit. My background is in pediatrics, but only at large Children's teaching hospitals. Our director has insisted that the standard... Read More

  1. by   hiddencatRN
    If you look at my first post in the thread, I state that I work in both a freestanding children's hospital as well as a children's hospital within a larger medical center. The standard at both is to obtain complete vitals based on acuity. So while it may be standard not to attempt routine BPs where you work, it's certainly not universal.
  2. by   wooh
    Quote from hiddencatRN
    If you look at my first post in the thread, I state that I work in both a freestanding children's hospital as well as a children's hospital within a larger medical center. The standard at both is to obtain complete vitals based on acuity. So while it may be standard not to attempt routine BPs where you work, it's certainly not universal.
    Also work in a ped hospital, and don't see the severe trauma aspect of a BP. I will, as a nursing judgment, skip a BP occasionally on the occasional kid. But once a kid's asleep, if a nurse or tech can't get a BP cuff on a kid without all this trauma, I do have to wonder about their technique. While awake, distraction while you give their leg a hug is enough to calm most kids.
  3. by   samadams8
    Quote from hiddencatRN
    If you look at my first post in the thread, I state that I work in both a freestanding children's hospital as well as a children's hospital within a larger medical center. The standard at both is to obtain complete vitals based on acuity. So while it may be standard not to attempt routine BPs where you work, it's certainly not universal.
    So if we are agreeing about it being based on acuity, what's the issue?

    Baseline Vital Signs ARE the standard. It is the frequency in which they are obtained that is based on the needs of the particular child at the moment and the orders written, and/or nursing judgment.

    So, I guess, what? We all agree on that? Not seeing where the problem is then.

    Family-centered care may not be universal either. It doesn't mean that, in general, it shouldn't be. The benefits of FCC clearly outweigh any problems or inconvenience. Certain limitations may be made on any serious treatment blockage or interference with comfort of the child, other children, and other families. That's to be expected.

    Now, this is a very simple example of critical thinking. You make decisions re: approaches to treatment based on the individual and the given particulars--not just b/c it's done somewhere else, or someone thinks it is or isn't a good idea. What is necessary or works for one child may easily be different for what works or is necessary for another.

    Wooh, for some kids, doing BPs around the clock is distressing and unnecessary. If they are necessary, then of course you use distraction and other techniques b/c the benefit of procuring the BP outweighs the distress to the child. Now, that can change on an hour to hour or even minute to minute basis--either way. That's why the nurse is to be working closely with the attending, fellow/s, NP, PA, whomever regarding orders. In the unit, we are used to having orders changing even on a minute by minute basis. Also, nurses are to be a part of the rounds, b/c their input as to what is going on with the child at the particular moment as well as re: trends is essential. If I have a stable kid that we are moving to the floor, we get the standard signs, but I'm not necessarily getting q 1 hour BPs on them. We also rarely make decisions on kids based on one number or parameter. If there is a problem, it is usually showing in terms of a clinical picture.

    No, in general kids don't like it. Some kids are more cool about things than others. Let's see what else do they not care for. . .axillary temps can annoy them. If they are trached, they tend to get protective and pizzy about trach care and or messing around their trach, if they have one. Hell, I am pretty protective about my airway too. Pretty much all kids tend not to like being suctioned nasally. I've seen certain kids be more OK with things like sq injections than messing around their airway--that can depend on developmental/psychological age as well. It's scary for little ones--the sensation of some interference or what they perceive may be some interference of breathing. With older ones, they may be more tolerant, but that can depend on a number of things too--like, regardless of age, what they real developmental/psychological age is. It can depend upon how sensitive they are to stuff in general, or the way their parents have set the tone in regard to things perceived as noxious or uncomfortable.

    Many babies and toddlers don't like BPs. There are adults that complain about having BPs--especially if the machine has to go slowly or if the clinician has to go slowly in hearing the diastolic beat, for example.

    People in general aren't thrilled about procedures. Kids often may not like the otoscope, but older ones tolerate it. It all depends.

    Whenever we touch anyone for anything, I feel we have to think about what they may feel, developmentally and otherwise, about being touched for a procedure. They are surrendering themselves, in a way, regardless of however briefly, to someone else touching their body or doing things that they don't understand or see the need for. People can be very sensitive about these things. I know I am.

    Now, imagine a kid that hasn't fully learned or perhaps is unable to learn, at least at a particular period of time, to just go with the flow over what and who is touching their bodies for whatever reason/s. That's another reason why FCC is good. A trusted family member can help the processes along.

    Finally, working in the many centers I have, I will tell you this as generally quite true.. Kids that are sick, weak, resentful of a condition or illness, or that are out of their home and comfort spaces, they aren't sweet--they aren't tolerant--they perceive just about anything you do to them as added stress, and their coping is limited--very much so, as compared to most adults in general. Now some can be more tolerant than others. But my point is, sick kids, if they have the strength and are not sedated, are not necessarily pleasant or fun, and no one should expect them to be. In fact that one's that aren't fighting many times concern me. Usually when a kid doesn't have some fight in him, it's not a good indication, unless the kid is just incredibly phlegmatic or has a condition that would cause this, or is under sedation.

    In general kids don't care nor have they necessarily learned or are able to learn about cultural conventions in terms of behavior and "sucking it up."

    Add to that these kids that have been "procedurized" over and over. What a number of these kids have had to go through is unreal, and frankly, I don't know if I could tolerate a lot of the junk they've had to go through.

    Some of them, depending on developmental age, may adapt, and others of them simply grow more protective and resentful, even though they are there to be treated. You can't expect them to be as tolerant and socially conventional about things as most adults. Understanding this is a huge part of pediatrics. Pediatrics can require a great deal of tolerance, and that's part of the reason some nurses just won't do peds.

    So, no. I'm not going to unnecessarily expose a kid to anything he or she doesn't want and absolutely doesn't need. Hell, half the time the parents will say, "Ok. The nurse did this at x period of time? Why are you doing it again? Is it really necessary?" Saying ot them that it is protocol isn't always good enough. The parent or guardian expects their child to be dealt with on an individual level. Many parents today are much more savy about what is going on with the kids' disorders and are very watchful of those providing care to their children. Frankly, I can't blame them one bit.

    I'd also like to say that a number of kids wake up very easily. I know people that do things like given tylenol to keep the kid sleeping, etc. I am NOT saying that applies to anyone here. I just do NOT believe in that. I give something like that only when there is signs of discomfort or temp elevations that could lead to problems. Parents both in the hospital and in home care aren't big on people taking license for giving such things. I reserve giving anything unless it is clearly needed. In the home, unless life or death, the parent has to be on-board with it.

    In the hospital, a kid can be on any number of agents or prn agents to help them to sleep and not be bothered. Or they may be limited, or the clinician will give them only if they are really needed. Many of those kids do wake up easily and are out of their element, so yes. Even procuring a BP or axillary temp or even a temporal temp--in order to get an accurate reading may disturb them. I have certainly cared for kids in the thousands by now. Many kids are easily disturbed or don't sleep well in the unit or hospital. And they may get something to help with this, but their parents may be against this. It really depends, but I 'm pretty careful about giving prns--even acetaminophen. People can tend to give this like it's candy to quiet a kid. Not me. If they need it and its ordered fine. Otherwise, no. So, many of us say in cardiac units with little newborns that are going to be op'd or are post-op and past are they big time interventions and treatments have learned to become quite the bottom patters, if that is what works to sooth a kid. I take exception to the comment re: technique, b/c I have seen many a medicated as well as non-medicated kid wake up very easily. There again, parent close at hand can be helpful.

    It's just damn stupid to make a general rule without consideration of the individual and the family member there. Why the hell should I aggravate a baby and mom unless it's absolutely necessary--with all the stress and the little bit of true sleep they get already? God, if people can't use good judgment about these kinds of things, they might as well go home and call it a day.

    As a parent, if there isn't a good reason for you to disturb my sleeping kids, I may well send you out of the room. The new NM the OP talks about needs to use some sense.
    Last edit by samadams8 on Feb 5, '13
  4. by   hiddencatRN
    Quote from samadams8
    So if we are agreeing about it being based on acuity, what's the issue.(Snip)Family-centered care may not be universal either. It doesn't mean that, in general, it shouldn't be. The benefits of FCC clear outweigh any problems or inconvenience.
    I'm not sure that we do agree that it is based on acuity but OK. I think a more likely outcome if this is that we agree to disagree on whether to attempt a complete set of vitals or not when caring for patients. My hospitals both explicitly include family centered care as a guiding principle and I don't find blood pressure measurements to be at odds with that.

    In the end, no one is providing solid evidence supporting the necessity of regular BPs or the safety of routinely skipping them. I'd actually be interested in seeing what literature is out there. We could continue to debate "common sense" but common sense sometimes turns out to be medically wrong once we start to look in to it, and we are clearly coming from different perspectives on what is common sense here. I only have Google search at home (and have been lucky to find time to pee at work lately so journal research there is out of the question at the moment) and so far I'm not finding anything that really answers that question.
  5. by   samadams8
    BTW, OP, why in the hell do they have someone without pediatric experience directing a pediatric floor? If she is over multiple areas such as maternal health as well, she should have both. But what the hell. Places do whatever they want.
  6. by   samadams8
    [BP determination is difficult in children because of lack of cooperation, difficulty
    remembering the proper cuff size and errors in interpretation. For patients less than
    three years of age these technical difficulties reduce the value of a BP. When shock is
    suspected in this age group based on other parameters (e.g., history, mechanism,
    PAT), attempt BP once, but do not delay management further
    BP may be misleading. Although a low BP definitely indicates decompensated shock,
    a "normal" BP frequently exists in compensated shock. ]

    (PAT is recommended--Pediatric Assessment Triangle). It is the whole picture that should be recorded throughout all shifts, not merely a set of vital signs. Most pediatric issues of decompensation or potential compromise are d/t something of a respiratory nature. However, many cases are admitted related to issues of dehydration. The HR going up and BP being lower may tell you something, but there is a wide range of variation; therefore use of something more like what is used in the
    The Pediatric Assessment Triangle-->Appearance--> Effort of Breathing-->Circulation--skin warmth, color, pulses and signs regarding central circulation in assessment are generally more valuable. Certain cardiac children may be the exception, but if they required closer observation, ideally, they should be in a pediatric center that facilitates high level cardiac observation and care.

    See Ronald Deckman, MD, at

    "Blood pressure is a poor indicator of shock in children as it is maintained until the child has advanced circulatory collapse (Advanced Life Support Group 2005)," and also:

    Oliver, A. (2010). Observations and monitoring: Routine practices on the ward. Paediatric Nursing, 22(4), 28-32. Retrieved from Log In - ProQuest
  7. by   CLC172
    Thank you all for your responses. I apologize that it's taken me so long to get back to you.

    I usually attempt once, maybe twice, and chart "Unable to obtain BP, pt kicking", as a night nurse.

    We have found literature that states that taking children off of their schedule, and waking them up in the middle of the night for vitals can be detrimental to their overall health. What I found was in the PALS study book. Basically it states that even for fluid deficit, BP is generally the last vital to go. Heart rate, cap refill and urine output are much more important signs to look out for in evaluating for shock, as BP will generally remain the same, or possibly even slightly elevated, until the patient is REALLY going downhill.

    So, I have to agree with samadams8, that the whole picture is much more important than BP. Other vitals, respiratory rate, heart rate, temp and even pulse ox can be taken much more easily and less invasively than a BP.

    I only come from teaching hospitals, and my background is mostly neurosurgery and general surgery. If I'm concerned about a neuro status, yes, the BP can be very important with peds.

    I've yet to see a patient be diagnosed with hypertension as an illness on its own in a hospital. Hypertension in the pediatric population is definitely a serious concern, but I think it's something that's going to be diagnosed by their PCP, rather than in the hospital. Generally my patients' BPs have been unusually elevated in the hospital due to anxiety or pain, and wouldn't be a good indicator of chronic hypertension.
  8. by   samadams8
    Yes, I hear you CLC. Putting patients first and doing stuff, just to do stuff, are not necessarily the same thing. There are a number of things that make peds a bit of a different animal from adult care or even what someone may have gotten in a matter of weeks in a peds clinical rotation.

    The thing we see with kids is that they can seem and by all general measurements be fine, and then BOOM! They start swirling the bowl--or rather, in less than an instant, they are alreading halfway down the drain.

    This is a big difference, in general, from adult patients--even critically ill adult patients. They can tend to give you lead-in time about where they are going with their presenation, b/c their compensatory and homeostatic measures have learned" to gradually adjust to things over time.

    Generally this is just not so with kids. You can never, EVER take their status for granted; b/c in less than a hiccup, they are in trouble, and everyone is like, "What the heck?" That's why I say the whole picture should be noted and documented with each kid whenever you are assessing or re-assessing them. It's not enough to just do vital signs on them. This is a big difference from adult acute and critical care. Kids often will not show you a trend in the same way an adult may. It's probably why those that work in peds should line their undies with panty protectors. I mean, many times it happens that fast.