Frequency of BP in Pediatric Patients

[CLC172]

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 of care for our patients is to do vitals, including a BP, on ALL of our patients, even at night. Although she is a great nurse and a good boss, she does not have any pediatric experience.

Many of the nurses here with pediatric experience claim they have not always done BPs on all patients, every 4 hours. Those who have worked in General Peds say that the standard was generally TPR every 4 hrs and BP every shift. In my experience, it was tailored to the patient's diagnosis and baseline status. And on those who are difficult to obtain a BP on, such as infants and toddlers, I was happy to just get one good BP reading during my shifts.

I am trying to find some written sources regarding the best care for general pediatric patients, regarding BP frequency. I was wondering if anyone has researched this topic and found anything pertinent? I am trying to compile some information to bring to our director. I have a couple of articles so far.

Thanks for all your help in advance!

[NotReady4PrimeTime, RN]

My comment is anecdotal and definitely not evidence-based (in the purest sense ) but I'll share it anyway. With infants and small children (under 3 years old and developmentally normal) with no cardiac history who are not sedated or soundly asleep, it's a waste of effort to get a cuff BP. The second the cuff starts to inflate, the child gets agitated, starts to cry, squirm and flail. The movement causes the cuff to continually reinflate in a futile attempt to sense a pulse and that only agitates the child more. The numbers eventually obtained are not very valuable, with artificially high systolic and artificially low diastolic pressures. BP in children is a (very) late sign of deterioration and usually signals impending collapse, something that should be identifiable by other means - but by that point they're usually in no shape to fight the measurement. So for these little people assessment of HR, colour, capillary refill and urine output are the best way of determining cardiac output, NOT BP. If their HR is within normal range for age, they're pink and warm with brisk cap refill and are sitting in a wet diaper, they're good. If BP measurement is absolutely required then putting a cuff on and leaving it on, waiting for the child to fall asleep or to be snuggly cuddled or having a nurse who is extremely good at distraction and comfort measures are essential elements! As I said, this is not research-based, but the result of 18 years worth of peds nursing and observation. Maybe your director would like to do a few shifts in your shoes and see how well she manages with the BP part.

[hiddencatRN, BSN, RN]

I've worked in two hospitals (one a free standing children's hospital, one a children's hospital within a larger adult medical center) and our standard is to get a BP every time we do vitals. If we can't get a good one due to the patient squirming or screaming we move along, but we do make the attempt with every VS check. Yes, kids can flip out about the BP cuff, but in my experience you can still get a good, calm, reliable read on a significant number of kids in that young age group.

I'm not sure what literature we're using to back up the policy to get a full set of signs, but I do know that the free-standing children's hospital I work at is really big on EBP to back up policies so I would be surprised if we were doing it "just cause."

[MeganNYRN]

I agree with the reply about attempting a BP every four hours but you can't just not try. Blood pressures can be very valuable even in children especially with neurological deterioration and fluid status. I have been a general pediatric and PICU nurse so I have a lot of personal experience with BP changes being crucial. However I believe it is always within nursing judgement to not do a BP on a child who is admitted for respiratory difficulty for whom fluid status is not a major concern. Good luck finding literature.

[Flygirl23462]

I'm a clin tech I'm a Peds/med/ Surg unit. I've been there 6 months so so I'm fairly new.

Bps are the most challenging.. We have different since cuffs and when children are awake we try to utilize the parent and toys .. Bubbles.. If thier infants I will add sugars to thier passifiers. Sometimes the best chance to get a good bp is when they sleep. I will make 2 attempts on each available limb and document . I learning tons and love my job!!

[KelRN215, BSN, RN]

It depends on what the child is admitted for. An oncology patient and a neurosurgery patient need BPs with every set of vitals... a baby admitted for r/o seizures that end up being GERD who's electively placed on EEG and doesn't sit still for 2 seconds and only gets vitals every 8hrs anyway... not so much.

[wooh, BSN, RN]

We attempt them with every set of vitals. On toddlers/younger kids, when they're sleeping is the only time we tend to get relatively accurate ones, so I would say that while sleeping is when you SHOULD be doing them.

I do think BP is one of the less important of the vital signs for your typical floor kid. I'm much more interested in heart rate, respiratory rate and cap refill. I find BP to be more important in terms of, "I was able to get a BP on that toddler without him kicking the whole time the cuff was on. That means he's SICK."

[Guest343211]

My comment is anecdotal and definitely not evidence-based (in the purest sense ) but I'll share it anyway. With infants and small children (under 3 years old and developmentally normal) with no cardiac history who are not sedated or soundly asleep, it's a waste of effort to get a cuff BP. The second the cuff starts to inflate, the child gets agitated, starts to cry, squirm and flail. The movement causes the cuff to continually reinflate in a futile attempt to sense a pulse and that only agitates the child more. The numbers eventually obtained are not very valuable, with artificially high systolic and artificially low diastolic pressures. BP in children is a (very) late sign of deterioration and usually signals impending collapse, something that should be identifiable by other means - but by that point they're usually in no shape to fight the measurement. So for these little people assessment of HR, colour, capillary refill and urine output are the best way of determining cardiac output, NOT BP. If their HR is within normal range for age, they're pink and warm with brisk cap refill and are sitting in a wet diaper, they're good. If BP measurement is absolutely required then putting a cuff on and leaving it on, waiting for the child to fall asleep or to be snuggly cuddled or having a nurse who is extremely good at distraction and comfort measures are essential elements! As I said, this is not research-based, but the result of 18 years worth of peds nursing and observation. Maybe your director would like to do a few shifts in your shoes and see how well she manages with the BP part.

As OP and Jan have said. It totally depends on the kid--specifically.

Little kids and babies hate, say, something like axillary temps enough. What is the point in obtaining a BP on a child unless there is some clear indication for it?? Throughout the night is not necessary UNLESS there is some specific and individual indication for it. To take it just to take in general peds, without some specific indication, is a waste of time and an irritation to the kid, who is already less than thrilled to be there. Kids don't adapt to stress as well as adults. Their coping is different. Some kids do better than others, but in general, it's added irritation and stress to the kid unless there is some reason for it. Better to even spot check as SPO2, unless the kid needs continuous.

I have seen newborns fight cuff pressures all to hell, and it can take some time to get a decent (reliable) BP on them. In cardiac, say they have procedure or surgery, they have art lines. And even if you check the art line against a cuff BP on the monitor, unless there is a problem with the line, we go with the art line numbers over all.

With kids, you don't just do things to do things b/c it's someone's arbitrary idea of a standard protocol. I think it would be difficult to show evidence of the benefits of doing this, w/o certain or special indication, for general peds, just for the hell of it. You assess a kid as a whole. Sure you do this with adults, but kids can change so quickly, you really learn to look at the big picture with them quickly in addition to any monitored data. You may well have to act quickly with a child, but at the same time, you can't, necessarily, just react without sound rationale and specific insight, b/c what you do to them can affect them quite severely--just as much as potentially what you do not for them--say for example, with airway and breathing--that requires very quick and correct intervention--but, if they perhaps need suctioning as opposed to bagging and albuterol or epi, then obviously you don't jump to epi. The tolerance in homeostatic response is more narrow to extreme reactions with children.

See how adults get pizzed off when you go in the middle of the night for a BP? Well, you may well have to do this, depending on their meds and other conditions and situations with them. (And this may well be the case with your pediatric patient.) Well, kids can become supper pizzy. And once that reaction is started, now you will have to invest a whole lot of time on not only hopefully getting a reliable BP, but also in calming them down. In other words, is the benefit of the preventive monitoring worth the risk of a reaction, which could end up causing the kids a whole lot of needless stress and waste a lot of time that could be more wisely allocated? Is it worth making him cry so much now you have to N&P suction the day lights out of him--severely elevating his HR and BP? Is it worth him forgoing a decent period of sleep and rest, which is vital to children, especially sick ones? Will the BP data even be close to anything accurate or usable, and to what end?

I mean evidence based practice is good, but this is a question more along the lines of common sense in terms of working/experience in pediatrics.

Now, of course, if there is clear indication for around the clock BPs, for example, that's a different story, and that child would probably be in a unit bed anyway. To do them more than once a day BP w/o good indication in a child is as Jan said. It's a waste, and it's a needless extra stress to children who will often not response with the same level of tolerance an adult generally might.

Does that make sense?

[hiddencatRN, BSN, RN]

I recently read an article today about how rates of hypertension are on the increase in children, particularly very young children due to the obesity epidemic, so monitoring for hypertension might become more important in peds. And in my experience, the kids that flip out as dramatically as samadams8 describes are the kids it's challenging to get ANY reliable vitals on (screaming and panic don't help a HR/RR and flailing can interrupt a pulse ox read) but we don't just scrap those vitals- we work on our approach, we use distraction, we do our best. You won't get a blood pressure reading on any patient you don't attempt it on, but with a good approach I've gotten reliable readings on more infants and toddlers than not.

[Guest343211]

I recently read an article today about how rates of hypertension are on the increase in children, particularly very young children due to the obesity epidemic, so monitoring for hypertension might become more important in peds. And in my experience, the kids that flip out as dramatically as samadams8 describes are the kids it's challenging to get ANY reliable vitals on (screaming and panic don't help a HR/RR and flailing can interrupt a pulse ox read) but we don't just scrap those vitals- we work on our approach, we use distraction, we do our best. You won't get a blood pressure reading on any patient you don't attempt it on, but with a good approach I've gotten reliable readings on more infants and toddlers than not.

Yes but even that data can be procured once during the day. No, kids can be still as statues, and you stir them once asleep, unnecessarily, and all hell breaks lose.

The doctor or NP should be writing orders on BP based on needs. There is in general, no need for "plain protocol" BPs, just because. It's pretty standard in every children's hospital and peds agency I have worked. It's generally not standard like it is with adults, and generally that is for good reason. Now, if it's an outpt visit that hasn't been done for a while, that is also different. In hospital, it's not like adults.

What are you going to ascertain, around the clock, in doing BPs in kids, unless that particular child requires it for sound reasons?

If the kids in the unit, a cardiac player, or some other reason, then BP frequency should be ordered according to what the team, doc, NP, or PA prescribes.

Otherwise, you are not gaining anything in terms of pt data, and only agitating, needlessly, a child. The order for it should be individualized in other words. From the child's POV, it is like a noxious treatment in many cases. They tend to hate it, especially if they are younger...like less than preteen.

You use distraction and those other techniques when you NEED to get it. That is, for a specific purpose, not just for the Hell of it.

It makes no sense to do round the clock BPs on kids on the floor unless there is a NEED for it. Let the provider write for frequency and the wise nurse use judgment to do it if there is indication.

Don't really see what the issue is. Have been doing peds and peds critical care for years.

[Guest343211]

I recently read an article today about how rates of hypertension are on the increase in children, particularly very young children due to the obesity epidemic, so monitoring for hypertension might become more important in peds. And in my experience, the kids that flip out as dramatically as samadams8 describes are the kids it's challenging to get ANY reliable vitals on (screaming and panic don't help a HR/RR and flailing can interrupt a pulse ox read) but we don't just scrap those vitals- we work on our approach, we use distraction, we do our best. You won't get a blood pressure reading on any patient you don't attempt it on, but with a good approach I've gotten reliable readings on more infants and toddlers than not.

Yes but even that data can be procured once during the day. No, kids can be still as statues, and you stir them once asleep, unnecessarily, and all hell breaks lose. The doctor or NP should be writing orders on BP based on needs. There is in general, no need for round the clock "plain protocol" BPs, just because. This is pretty standard in every children's hospital and peds agency I have worked. It's generally not standard like it is with adults, and generally that is for good reason. Now, if it's an outpt visit that hasn't been done for a while, that is also different. In hospital with kids, it's not like adults. It's based on what the particular child needs.What are you going to ascertain, around the clock, in doing BPs in kids, unless that particular child requires it for sound reasons?If the kid is in the unit, a cardiac player, or some other reason, then BP frequency should be ordered according to what the team, doc, NP, or PA prescribes--and they have their std orders...but it's as per provider, and we have a lot of input too.Otherwise, you are not gaining anything in terms of pt data, and only agitating, needlessly, a child. The order for it should be individualized in other words. You see, from the child's POV, it is like a noxious treatment in many cases. They tend to hate it, especially if they are younger...like less than preteen. If there's no reason to do them around the clock, why are we agitating the. They are already stressed by being there, out of their home environment. Are we going to aggravate the child with an ultra sound of some sort, just bc we can? Same principle. You use distraction and those other techniques when you NEED to get it. That is, for a specific purpose, not just for the Hell of it. It makes no sense to do round the clock BPs on kids on the floor unless there is a NEED for it. Let the provider write for frequency and the wise nurse use judgment to do it if there is indication.Don't really see what the issue is. Have been doing peds and peds critical care for years.

[hiddencatRN, BSN, RN]

I'm really curious now about your technique if you are getting such horrible reactions from older children (up to preteens? Really?) in addition to upsetting babies so much that you have to go nuts NP suctioning them afterwards. I don't even get reactions like that from IV starts.