Post-operative Hypertension

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Specializes in ER, SCTU, PACU.

Does anyone have any policies to share for how they manage post-op HTN? What are your cut-offs for "abnormal" vital signs before the patient has to be transferred to step-down? I am a PACU nurse and we are running into roadblocks trying to get ortho post-op patients to their floor because their pre-op BPs run 160s/90s, 170s/90s on a good day and the ortho floor will not accept them unless the BP is below 160/90. The floor can only give IV Hydralazine (10mg max) or IV Vasotec (not sure of max dose). Most of our BP management comes from Anesthesia, and they are (just like we are) reluctant to drop a patient's BP too low. 9 times out of 10 our HTN patients are asymptomatic with the elevated BP (no headache, no dizziness, no chest pain, neuro intact). Our options in PACU are vast, ranging from IV Lopressor, IV Labetalol, IV Hydralazine (20mg max), IV Vasotec, IV NTG and Nitro-paste, but it depends on what the Anesthesiologist wants to give. Overall, our approach is "if it ain't broke, don't fix it" - if the patient is at least at pre-op baseline, they will leave well enough alone and let tincture of time work it out.

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Specializes in Med/Surg, OB/GYN, Informatics, Simulation.

I'm not sure if my facility has a specific post op HTN protocol. However we do have a policy regarding patients with known hypertension, namely that they can come to the floor with BP's up to 180. There would need to be something else going on medically for them to go to Step-Down/ICU or tele.

I do post-op women's health, non tele so I can't give any BP meds IV unless the patient has been on some BP med at home. I'm limited to Lopressor and Hydralazine. That said if we know a patient has HTN, I wouldn't be that concerned especially if I got in report that their pre-op BP was that high. Also in my experience the first night they're getting IV pain meds anyway, and that usually drops them at least a little.

I'm surprised they're so worried, my facility is more concerned with dropping them too quickly, so we would rather leave them high then anything else.

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Specializes in PACU, pre/postoperative, ortho.

I don't think we have any actual policy for the floors regarding post-op BP. In pacu, we treat about the same as you do & as long as the pt is at baseline, we send them up. I just make sure the receiving floor knows what the pre-op BP was so they can see that it just may be the pt's norm.

Do you think there is an actual policy for the floor? I know for our floors, policy is to call SBP above 160 or 170 for any pt; perhaps the nurses there are hoping you'll take care of it so they don't have to make that call, but there probably is really no policy stating they can't receive that pt.

Your anesthesiologists should simply state the pt meets discharge criteria from pacu & not be coerced into ordering meds they wouldn't normally order. I also suggest speaking with your manager to clarify with the floor's manager about this since it has become a frequent problem.

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Specializes in Pediatric Critical Care.

If a patient is at their baseline....why wouldnt they go to the floor? Does the floor not take any patients with chronic HTN? That seems silly.

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Specializes in ER, SCTU, PACU.

The PACU nurses seem to be the only ones sharing this concern "my facility is more concerned with dropping them too quickly,". The floor nurses want them picture perfect or off their floor (to the point where they tried to tell me to take my patient back to PACU because the BP was elevated and they considered the totally asymptomatic patient too unstable for their unit).

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Specializes in ER, SCTU, PACU.

RainMom, we've tried, all of those suggestions, but we are still butting heads with the floor. No there is no actual numbers in the policy. Strangely enough we only have this problem with the ortho floor, which is managed by an RN who oversees the ortho surgical floor and the medical-surgical floor (hernias, colons, appys, etc.) - we don't have this issue with the medical-surgical unit. Ultimately, the ideal solution is to have the surgeons optimize their patients prior to surgery; but clearly that's not going to happen, so we're trying to figure out how to get the ortho floor to take the patients who fall into their vast area of expertise. It would be a huge disservice to the ortho surgical patients to go to step-down, who have limited experience with ortho post-ops.

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Specializes in PACU, pre/postoperative, ortho.

The anesthesia director probably needs to make an issue of it then if your manager isn't getting anywhere. Or, I wonder if you write an incident report every time the floor tries to refuse a pt that the anesthesiologist has approved for discharge from PACU, if that wouldn't light a fire under somebody to clarify a policy to follow?

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Specializes in Med/Surg, OB/GYN, Informatics, Simulation.

What about discussing this with a nurse educator? Obviously there seems to be a learning opportunity for these units.

(My guess is since you're not having problems with the med-surg units, and it sounds like this particular unit I'm almost wondering if it's just a few bad eggs permeating this idea that patient's need to be picture perfect to arrive back and teaching other nurses this behavior. Or sounds like they want to avoid admissions!)

If your manager isn't getting anywhere, they need to escalate this situation because it not only does a disservice to patients, but removes those higher acuity beds for patients that could actually use them.

I once had a patient on my unit with a BP of around 190. We were giving her everything we could IV and nothing dropped her BP. I think if I recall only IV Fentanyl got her down to maybe 170. And even then this was just a med/surg unit, non tele- no one was concerned since it was just the patient's baseline. So for her it was 'healthy'.

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