Should I call the doctor for a BP of 175/72?

[moonshawdow]

I always thought it was to call doctors if over 180?  Am I wrong and giving my patient bad care? 

[SarHat17, ASN, RN]

On 3/15/2021 at 3:08 PM, MunoRN said:

You were correct not to call since with the exception of a specific, small group of hospitalized patients this BP should not be treated.

We overtreat hypertension in hospitalized patients and this worsens outcomes, it doesn't improve them, much of this overtreatment is driven by nurses who aren't aware of current best practice recommendations pushing for inappropriate anti-hypertensive treatment.

@MunoRN

I think this could get sticky, depending on the context and interpretation. (I'm not referring to current treatment trends of BP in the hospital.) Using my clinical judgement to call on a patient with an "elevated" BP to let the Dr evaluate whether treatment is warranted or not is completely appropriate within my scope of care and policies/standards on my unit/at my hospital, especially if there are no parameters or PRNs ordered.

Your statement almost reads like nurses are the ones overtreating the patient, which isn't how it works. If there are ordered parameters and PRNs, they are ordered by a Dr for a reason. If I ask for more clarification regarding WHY we are using those parameters, etc, that would be appropriate, but to put the "blame" on nurses who are calling to update the Dr on the current VS and status of their patient and then administering the medications ordered is inappropriate.

Maybe just the way it was worded, but your post didn't sit right with me. If I misread, please help me understand!

[MunoRN, RN]

16 minutes ago, SarHat17 said:

@MunoRN

I think this could get sticky, depending on the context and interpretation. (I'm not referring to current treatment trends of BP in the hospital.) Using my clinical judgement to call on a patient with an "elevated" BP to let the Dr evaluate whether treatment is warranted or not is completely appropriate within my scope of care and policies/standards on my unit/at my hospital, especially if there are no parameters or PRNs ordered.

Your statement almost reads like nurses are the ones overtreating the patient, which isn't how it works. If there are ordered parameters and PRNs, they are ordered by a Dr for a reason. If I ask for more clarification regarding WHY we are using those parameters, etc, that would be appropriate, but to put the "blame" on nurses who are calling to update the Dr on the current VS and status of their patient and then administering the medications ordered is inappropriate.

Maybe just the way it was worded, but your post didn't sit right with me. If I misread, please help me understand!

Treating an asymptomatic BP of 175/72 goes against evidence based practice, it's more likely to harm the patient than to be beneficial.  It's ultimately up to the MD to prescribe medications, but nurses certainly have the power to influence what the MD prescribes, such as calling at 3am presumably to get an order for a PRN antihypertensive.  

If the nurse is for some reason calling the MD with every single set of vitals then one could argue they aren't suggesting treating an SBP of 175, but otherwise I'm not sure what message the MD is supposed to get from getting that call.

[Hannahbanana, BSN, MSN]

On 3/15/2021 at 4:06 PM, moonshawdow said:

I did go to the charge nurse and ask the policy if it was to call for over 180 or 170 she said 180 just like every other hospital I have worked

When I was in nursing school, by chance I came upon a slim little volume called something like "Ritualistic Practices in Nursing." These were the sorts of things that "we always do it this way" and "that's what I was taught" get passed down until they might as well be chiseled into the front steps. There were things like every patient had a resp rate of 20; once I did a PRN shift at a hospital that did that and I charted actual resp rates and there was panic and outrage. RR=20 was their shorthand for "nonlabored, no resp distress." (Just for fun, try breathing every three seconds for two minutes and see how it feels.) Oddly, everybody on that floor also had a temp of 98.6F... and that's not normal either, for lots of people, so there was hell to pay when I charted some as 97.6 or 98.2 ... .

If you have a written policy that states that a physician WILL BE CALLED for a systolic BP of > or =180 mmHg, then fine. But if there isn't one, it's just tradition or "the way it is everywhere I've worked" (hint: it isn't- that's a new one on me) fergawdsakes don't act is if there is and ignore/excuse a BP of 170 systolic if it's an outlier. Make sure your CNAs report every BP to you and YOU make the decision. If a prescriber wants to write for PRN hydralazine q4h or something for BP > X, that's fine. But YOU get to decide whether a physician gets called.

[moonshawdow]

You are extremely rude, there are most certainly vital signs orders for when to call the doctor, don't know what kinda hospital you work at but I Have been traveling for 3 years and this is the first hospital I have seen that did not have standing vital signs orders of calling med if systolic BP greater than 180 heart rate greater then 100 or less then 50 fever of over 38.5 RR greater then 30 ETC  I have mostly worked at level 1 traumas. This pt was asymptomatic had bp in the 180s the night before but the doctor only order a one time does no PRN I wasent worried but another nurse made me question my experience and I went and ask the charge nurse what the policy was ofcourse if I was worried I would of called. I think you need more experience on floors at other hospitals 

[moonshawdow]

1 hour ago, MunoRN said:

Treating an asymptomatic BP of 175/72 goes against evidence based practice, it's more likely to harm the patient than to be beneficial.  It's ultimately up to the MD to prescribe medications, but nurses certainly have the power to influence what the MD prescribes, such as calling at 3am presumably to get an order for a PRN antihypertensive.  

If the nurse is for some reason calling the MD with every single set of vitals then one could argue they aren't suggesting treating an SBP of 175, but otherwise I'm not sure what message the MD is supposed to get from getting that call.

Thanks this this is what I have learned from a really great surgeon but every hospital has certain policy's that I will follow.  I appreciate you sharing your knowledge MunoRN

[PsychNurse24, BSN, RN]

When I was in nursing school about 12 years ago, one of our instructors told us that there had been a trend in Nursing to "under-rescue". What she meant by that was Nurses were waiting and watching rather than acting.  This was not just her observation, she had researched the subject and had data. (There were many reasons driving nurses to watch and wait rather than to act).  She emphasized that it was always better to "over rescue" rather than to "under rescue", even if you upset the patient or Doctor.

I agree with the others in this thread that recommended retaking the blood pressure, assessing the patient, reviewing the vital signs to see if this was an outlier or par for the course, reviewing any BP meds that might’ve been ordered, etc.

I have always remembered the idea of "over-rescuing" if in doubt.  

[JKL33]

18 hours ago, PsychNurse24 said:

I have always remembered the idea of “over-rescuing” if in doubt.  

I understand the point your instructor was trying to make, but keep in mind that her word choice assumes the "rescue" part--the other side of the coin is that in some of these instances there is no matter of rescue at hand. So then it becomes a matter of over-reporting or under-reporting (to the provider). And over-reporting is not benign. It brings with it the danger of over-treating or altogether unnecessary or even detrimental interventions as well as the general distraction to work flow and the care of all patients.

With regard to HTN in particular, not too long ago I had floor refusing to accept an admit until it was clarified what we were going to be doing about the patient's systolic b/p of 167mmHg. Mind you this patient was being admitted to surgery service for an infectious process. They wanted me to talk to ED docs and surgery into giving something to get the b/p down. I told them no and gave rationales. But they would not be appeased until I called surgery. So I called and explained their knowledge deficit and confirmed that the surgeon didn't want that bp treated. Surgeon said, "thanks for the call; their concern is noted." ??‍♀️ This is an example of one of the many scenarios where there is no matter of rescue at hand.

Side note: I also sometimes hear nurses talking in terms of what the provider "refused" to do or "refused" to order (or read where nurses have documented using this language). I think it is unnecessarily inflammatory and is related to what we are discussing here.

[MunoRN, RN]

18 hours ago, PsychNurse24 said:

When I was in nursing school about 12 years ago, one of our instructors told us that there had been a trend in Nursing to "under-rescue". What she meant by that was Nurses were waiting and watching rather than acting.  This was not just her observation, she had researched the subject and had data. (There were many reasons driving nurses to watch and wait rather than to act).  She emphasized that it was always better to "over rescue" rather than to "under rescue", even if you upset the patient or Doctor.

I agree with the others in this thread that recommended retaking the blood pressure, assessing the patient, reviewing the vital signs to see if this was an outlier or par for the course, reviewing any BP meds that might’ve been ordered, etc.

I have always remembered the idea of "over-rescuing" if in doubt.  

There isn't any 'rescue' indicated in the scenario, but if pushing the idea that over-treatment is better than under-treatment was the trend 12 years ago, the trend has now swung the other way.

The general takeaway from a lot of recent research, particularly in critical care but also in terms of all hospitalized patients, is that less is better.  Related to that is while standardized 'guard rails' can be helpful in certain situations, the checklist and standardized algorithm fad of a decade ago caused a lot of avoidable harm, and that a better balance of patient-specific critical thinking and generalized standards and algorithms.  

[PsychNurse24, BSN, RN]

I agree that this example of an elevated blood pressure might not be a “rescue” situation.  And I recognize that you have an expertise in blood pressure.  While I agree with you that over reporting, at times, might be detrimental, I still believe it is best to over report rather than to under report.  

When I was getting my BSN we spent several weeks learning more about sepsis.  And at the same time, the hospital where I worked started requiring us to do a mini course on sepsis and to pay more attention to vital signs.  There was evidence that nursing education did not emphasize sepsis, possibly resulting in poor outcomes for patients.  Two years later, a close friend’s granddaughter died from sepsis.  A slight change in vital signs can indicate the beginning of sepsis, And while I believe her hospital was very proactive in treating her, I couldn’t help wonder if other cases had poor outcomes because slight variations in vital signs had not been reported.  I will always choose to have the Doctor decide whether a treatment is necessary or not.  

So I stand by my original general advice to over rescue, or over report.  

[PsychNurse24, BSN, RN]

2 hours ago, MunoRN said:

There isn't any 'rescue' indicated in the scenario, but if pushing the idea that over-treatment is better than under-treatment was the trend 12 years ago, the trend has now swung the other way.

The general takeaway from a lot of recent research, particularly in critical care but also in terms of all hospitalized patients, is that less is better.  Related to that is while standardized 'guard rails' can be helpful in certain situations, the checklist and standardized algorithm fad of a decade ago caused a lot of avoidable harm, and that a better balance of patient-specific critical thinking and generalized standards and algorithms.  

I am not pushing the idea of over treatment. In my first response I said “under rescue” was watching and waiting rather than acting.  I have countless examples of when watching and waiting was detrimental to a patient.  Action, including contacting a provider, would’ve been much better for the patient.

One, a patient with cellulitis whose pain and vital signs were changing. Nurse did not report this.  On the following shift the nurse did report this.  Gangrene.  

Two, A nurse failed to report to the provider changes in vital signs and behavior. Again, the next shift did report this.  Client had lithium toxicity. 

Three, A nurse on one shift did not report a fever to the psychiatrist. Nurse coming on did report it. Patient was transported to ED and had serotonin syndrome.  
 

I know that all these patients would’ve had better outcomes if a provider would’ve been contacted earlier.
 

Countless times on our inpatient psychiatric unit nurses disregard anxiety which can escalate to agitation which becomes a psychiatric emergency. Watching and waiting in these cases also does not provide good outcomes.

So, over rescue does not just apply to life and death situations.  As I mentioned twice now, the research was about nurses watching and waiting versus acting.  They use the terms under rescue versus over rescue.

In the case with the high blood pressure, watching and waiting might not be a good thing either. As others had mentioned, retake the blood pressure, check for side effects, check the MAR for Htn meds, check the vitals for the entire hospitalization to see if this high blood pressure was unusual or not, etc.  All these things are action, not waiting and watching.  Then the Nurse makes the judgment call whether to call the provider or not.

[Tacocat, ASN, RN]

13 hours ago, moonshawdow said:

You are extremely rude, there are most certainly vital signs orders for when to call the doctor, don't know what kinda hospital you work at but I Have been traveling for 3 years and this is the first hospital I have seen that did not have standing vital signs orders of calling med if systolic BP greater than 180 heart rate greater then 100 or less then 50 fever of over 38.5 RR greater then 30 ETC  I have mostly worked at level 1 traumas. This pt was asymptomatic had bp in the 180s the night before but the doctor only order a one time does no PRN I wasent worried but another nurse made me question my experience and I went and ask the charge nurse what the policy was ofcourse if I was worried I would of called. I think you need more experience on floors at other hospitals 

Who was rude?

[hppygr8ful, ASN, RN, EMT-I]

11 hours ago, JKL33 said:

I understand the point your instructor was trying to make, but keep in mind that her word choice assumes the "rescue" part--the other side of the coin is that in some of these instances there is no matter of rescue at hand. So then it becomes a matter of over-reporting or under-reporting (to the provider). And over-reporting is not benign. It brings with it the danger of over-treating or altogether unnecessary or even detrimental interventions as well as the general distraction to work flow and the care of all patients.

With regard to HTN in particular, not too long ago I had floor refusing to accept an admit until it was clarified what we were going to be doing about the patient's systolic b/p of 167mmHg. Mind you this patient was being admitted to surgery service for an infectious process. They wanted me to talk to ED docs and surgery into giving something to get the b/p down. I told them no and gave rationales. But they would not be appeased until I called surgery. So I called and explained their knowledge deficit and confirmed that the surgeon didn't want that bp treated. Surgeon said, "thanks for the call; their concern is noted." ??‍♀️ This is an example of one of the many scenarios where there is no matter of rescue at hand.

Side note: I also sometimes hear nurses talking in terms of what the provider "refused" to do or "refused" to order (or read where nurses have documented using this language). I think it is unnecessarily inflammatory and is related to what we are discussing here.

I don't know if you did already but could you provide the source for this. I'd like to bring it to my managment who lose their mids for a SBP great than 150.