PRN Blood Pressure Medicine Is Garbage: Change My Mind

DavidFR, BSN, MSN, RN · Dec 2, 2022

Asymptomatic hypertension may not be an immediate emergency but my personal opinion is that it shoud not be left untreated.

I speak not just in a professional capacity but as somebody who had a CVA as a result of untreated and then badly treated hypertension. I ignored peaks thinking they'd only be temporary, or I'd brush off 160 saying to myself "well it's not 200". Big mistake.

Where I currently work any blood pressure above 170 gets repeated after 30 minutes at rest. Still above 170 and it's repeated again after a further 30 minutes at rest. Still above 170 and the patient gets either Nicardipine 20mg or Amlodipine 5mg orally. Nicardipine 3mg IV if unable to take oral meds.

Repeated peaks of hypertension are sent off for cardiology investigation.

My neurologist is convinced that peaks of hypertension were a contributing factor to my CVA. I have a not completely normal venous anatomy in my brain stem, and herein lies the rub - you don't know what else is going on in a person's body. Hence I would never encourage nurses to ignore peaks of hypertension. It may not be an "emergency" but it does require attention.

Tegridy · Dec 3, 2022

Great post and I agree. Giving PRN bp meds makes it difficult to acquire a true trend for appropriate oral medication adjustment on an inpatient basis which is already often difficult enough with pain/anxiety/lack of sleep often attributing to high numbers.

The main point of the post was to dampen some of the backlash we get when we decline to put PRN whatever for blood pressure. When many hospitalist providers still do it, it tends to be taken as the norm even though it has been shown to have slight risk of harm and no benefit. It’s just not good medicine.

Susie2310 · Dec 3, 2022

I disagree with the OP.

This is my view: I understand not wanting to be woken up (provider and patient), but this is secondary to our duty to patients. A blood pressure that is elevated, let's say 180 systolic, even if the patient is asymptomatic, if not treated timely/promptly and instead allowing hours to elapse before reporting the blood pressure and before the patient can receive the medication, has the potential to cause harm/deterioration and can cause harm/deterioration for some patients including patients with chronic renal failure/insufficiency, patients with heart disease including heart failure, heart valve problems, stenotic lesions of the carotid and other arteries, and patients with cerebrovascular disease. Some patients can experience heart failure, worsening heart failure, stroke, or ocular damage as a result of elevated blood pressure that is not treated promptly, and the elevated blood pressure doesn't need to be at the numbers one would associate with hypertensive crisis to cause harm. I see cardiologists promptly treating blood pressure that is elevated and that poses a risk of deterioration/harm for the patient's clinical condition. Even though the patient's high blood pressure could be due to pain or poor sleep, in my view, it should be reported promptly so that prompt investigation of the cause of the high blood pressure can happen and so the patient can receive appropriate treatment e.g. relieve pain, decrease BP, promote sleep.

Tegridy · Dec 4, 2022

On 12/3/2022 at 2:56 PM, Susie2310 said:

I disagree with the OP.

This is my view: I understand not wanting to be woken up (provider and patient), but this is secondary to our duty to patients. A blood pressure that is elevated, let's say 180 systolic, even if the patient is asymptomatic, if not treated timely/promptly and instead allowing hours to elapse before reporting the blood pressure and before the patient can receive the medication, has the potential to cause harm/deterioration and can cause harm/deterioration for some patients including patients with chronic renal failure/insufficiency, patients with heart disease including heart failure, heart valve problems, stenotic lesions of the carotid and other arteries, and patients with cerebrovascular disease. Some patients can experience heart failure, worsening heart failure, stroke, or ocular damage as a result of elevated blood pressure that is not treated promptly, and the elevated blood pressure doesn't need to be at the numbers one would associate with hypertensive crisis to cause harm. I see cardiologists promptly treating blood pressure that is elevated and that poses a risk of deterioration/harm for the patient's clinical condition. Even though the patient's high blood pressure could be due to pain or poor sleep, in my view, it should be reported promptly so that prompt investigation of the cause of the high blood pressure can happen and so the patient can receive appropriate treatment e.g. relieve pain, decrease BP, promote sleep.

Most of this is actually not true. Hypertension kills over months to years not minutes to hours. Unless there is acute end organ damage occurring (acute chf, PRES, nstemi, intracranial hemorrhage etc.). It’s a common fallacy that asymptomatic hypertension needs to be treated urgently with IV push meds. And whether we agree or not the data agrees with this perspective. Treating chronically uncontrolled htn too aggressively has been shown to be harmful, especially when control is attempted with IV push meds which tend to cause precipitous drops below what the patient is used to.

The cardiologists as depicted above were likely treating symptomatic hypertension, which is excluded from the discussion.

If anyone has any data to the contrary it would be excellent to reveal this.

Good discussion.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204996/

https://pubmed.ncbi.nlm.nih.gov/21890447/

https://pubmed.ncbi.nlm.nih.gov/30811319/

https://pubmed.ncbi.nlm.nih.gov/21890447/

allnurses Guide · Dec 4, 2022

On 12/2/2022 at 8:32 PM, Tegridy said:

Great post and I agree. Giving PRN bp meds makes it difficult to acquire a true trend for appropriate oral medication adjustment on an inpatient basis which is already often difficult enough with pain/anxiety/lack of sleep often attributing to high numbers.

The main point of the post was to dampen some of the backlash we get when we decline to put PRN whatever for blood pressure. When when many hospitalist providers still do it, it tends to be taken as the norm even though it has been shown to have slight risk of harm and no benefit. It’s just not good medicine.

I tend to agree . I worked with adolescents in a psychiatric setting and frequently see nursing supervisors lose their minds over a BP of 140/89. Our Hospital policy even says to hold treatment until SBP is over 150 or DBP is over 90. These kids come in detoxing off alcohol and meth and even when they aren't they are scared, angry, hallucinating and/or delusional. On top of that we are frequently using the wrong cuff size so the numbers aren't always accurate. When blood pressures are consistently on the high side of normal we give a referral to PCP to follow up but I do get tired of the paniced response that they are on the verge of a stroke.

Hppy

LovingLife123 · Dec 4, 2022

It honestly depends on what floor you work on. Some patients need tight BP parameters and their chronic hypertension is the root of the cause of why they are there.

I don’t like blanket statements Like you just posted.

Also maybe change admission order sets. Many say call if SBP>180.

I’ve worked neuro for most of my career. A lot of these people live high but now they’ve had a stroke. I’ve given more PRN labetalol and hydralizine than I can ever count.

You won’t fix papaw who has a one night stay for a hip replacement. I get that. But im also going to stay if papaws pressure is 220/110, im probably calling no matter what. And then once you tell me you don’t care, I document that and I’m cool with it.

Tegridy · Dec 4, 2022

19 hours ago, LovingLife123 said:

It honestly depends on what floor you work on. Some patients need tight BP parameters and their chronic hypertension is the root of the cause of why they are there.

I don’t like blanket statements Like you just posted.

Also maybe change admission order sets. Many say call if SBP>180.
I’ve worked neuro for most of my career. A lot of these people live high but now they’ve had a stroke. I’ve given more PRN labetalol and hydralizine than I can ever count.

You won’t fix papaw who has a one night stay for a hip replacement. I get that. But im also going to stay if papaws pressure is 220/110, im probably calling no matter what. And then once you tell me you don’t care, I document that and I’m cool with it.

It’s not what I like it’s just what the current evidence says. Most of the situations you described are symptomatic htn, like the acute cva…. Which even then it’s even more reason to not acutely lower the bp unless they got thrombolytics or are 220/110 or whichever the hospitals protocol is for permissive htn.

I agree w the order set change usually I just put 200/100 or whatever even though I’m probably not going to start someone hospitalized for another reason on anti hypertension meds at night. Usually just pass off to the day team.

I don’t think I’ve ever seen someone achieve “tight” control with PRN meds though, too many peaks and dips.