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? 

[Hannahbanana, BSN, MSN]

Under-rescuing— what a great concept. That’s what I was trying to describe, however poorly, in recommending that the nurse report any VS that’s out of normal range for this patient regardless of standing protocols. If something untoward were to happen and the prescriber had not been notified, a standing protocol to affirmatively notify if BP>X does not remove liability from failing to report one of X-5 if it’s a new development. Under-rescuing, I love it. 
As to whether there’s an assumption that you are disturbing the prescriber or inappropriately communicating an expectation for treatment, that’s not your call either. 
FWIW as an aside, high blood pressure often has no visible presenting signs or symptoms, as I learned early on when volunteering in a screening clinic. Apple-cheeked cute little granny sits down at my table and chatters brightly about her grandchildren and her BP was 280/140, confirmed on recheck. *I* almost had a stroke on that one. 

[Crystal-Wings, LVN]

Uh, ya. What are the parameters for the patient? 

[Hannahbanana, BSN, MSN]

3 hours ago, Crystal-Wings said:

Uh, ya. What are the parameters for the patient? 

If you're asking me, there were none, this was a walk-up BP check open to the public at a pharmacy. We gave her a little card with her BP on it and told her to check with her doctor asap.

[moonshawdow]

3 hours ago, Crystal-Wings said:

Uh, ya. What are the parameters for the patient? 

There were none set for this patient. That is why I went to the charge to ask what the policy was at this hospital since I am a travel nurse. 

[SmilingBluEyes]

I would at the very least call and if the provider was unconcerned, and patient asymptomatic or unchanged, would request parameters in order not to have to call again. And always follow policy.

[JKL33]

11 hours ago, hppygr8ful said:

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.

I've got some things on my plate tonight but as a basic start, read here

Very generally speaking there is no indication for rapid lowering of elevated blood pressure when a patient presents to the ED; the indication for undertaking urgent lowering of blood pressure is that of true hypertensive emergency--which means there is new/advancing end-organ damage. Pretty much outside of that a gradual lowering of blood pressure for wellness/prevention of future complications is indicated. The article explains.

I was not trying to get all academic on anyone during that incident, though, I just explained that as a basic principle I knew there was no way we in the ED were going to try to make that number look perfect on paper using "blood pressure medications" for a patient who was being admitted to surgery with an infectious process. Some degree of pain may have been involved, too, though that was being addressed and the patient was more comfortable at the time of admit. All of this is simply no reason for a patient to not be admitted to a general M/S floor.

I have no doubt there are are other articles about this, I'm sorry I can't really do a formal search tonight. ?

 

[Workitinurfava, BSN, RN]

The problem with blood pressure is it can change rapidly depending on the patients condition. Always err on the safe side in treatment. Find out how you need to handle it.

[0.9%NormalSarah, BSN, RN]

On 3/17/2021 at 1:19 PM, moonshawdow said:

There were none set for this patient. That is why I went to the charge to ask what the policy was at this hospital since I am a travel nurse. 

But I thought this patient had PRN hydralazine that had been given the two prior nights? Did I read that somewhere? I would assume this med would have a parameter attached to it, such as give if SBP >165. If it were me, I’d check my PRNs and give what is appropriate, then monitor for effect. If no effect, I’d consider calling if patient had many hours to go until normal BP meds are due. I won’t get too excited if a patient is at their baseline and asymptomatic, though, especially if it’s only a couple hours until their barrage of cardiac meds are due in the AM. 

[MunoRN, RN]

On 3/17/2021 at 6:35 AM, hppygr8ful said:

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.

Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions | Cardiology | JAMA Internal Medicine | JAMA Network

How should asymptomatic hypertension be managed in the hospital? | The Hospitalist (the-hospitalist.org)

[MunoRN, RN]

On 3/16/2021 at 8:08 PM, PsychNurse24 said:

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.  

I completely agree with the goal of ensuring we don't miss anything that does or even could lead to harm, whether that 'miss' involves failing to recognize an issue or failing to communicate it.

But what your instructor gets wrong is the idea that over-reporting data which is not meaningful or useful makes it less likely something will get missed.

The practices promoted by Atul Gwande and John Nance are based on the idea that your instructor has it wrong, and that the most important thing is to get rid of all the 'noise' in our communications, yet in many ways we've misapplied that and gotten it completely backwards, with the Sepsis bundles being a good example of that.

There's been near constant debate about the Surviving Sepsis Campaign (SSC) bundles ever since they came out, mainly because instead of using bundles, checklists, and algorithms to foster patient-specific critical thinking, their goal is to improve care by removing the variation that comes from that, and in the process hasn't improved care and has resulted in harm.  I was called to the ER once due to a patient coding after getting the 3 liters bolus called for by the sepsis bundle.  They had hit pretty much every trigger: elevated HR, RR, low BP and temp, elevated lactate, elevated troponin, elevated creatinine.  The bundle was followed to the T.  The problem is that all those triggers weren't the result of sepsis, they were the result of a hemoglobin of just under 4.  The NS bolus diluted them down even further until they went into arrest due to cardiac ischemia.  

As a rapid response nurse I would get an audit every day of all the inpatients who met sepsis criteria, typically 70% or more of the patients in the hospital.  And yet patient who ended up with actual severe sepsis often weren't on the list.  This is the problem with just reporting 'everything' that's 'abnormal', such as a "slight change in vital signs", every vital sign reading, even on someone perfectly healthy is going to have "slight changes", the only time it doesn't is repeat vital signs on a deceased patient, although even that isn't true since their temp will likely change.  

Too much irrelevant information clouds the important information, it doesn't make it more clear.

[hardworkpaysoff, MSN, RN]

Assess, assess, and assess. Look at the big picture.  There are situations where we neglect then they can stroke out. Over treat and they can end up dizzy on the floor like our unit experienced last week.

Some things takes normal body regulation, time, reassessment. Some nurses are straight by the book but I’m very intuitive and take into account their norms, trends, situation, activity, medical history, even emotional state.

Nurses can get sort of focused and forget the human body complexity.  I treat if needed or if there are parameters. When in doubt reassess, do manual, and communicate. Follow policy.
 

I don’t know enough about the patient. It could be permissive hypertension. It could be situational stress if you just woke them up. BP is a snapshot in time.

Would you treat a heart rate of 130s if the patient is up ambulatory for the first time? No. You would sit them down, give them time then reassess. But if their baseline is normally 60-80s then all of the sudden they’re sustaining in 130s while sitting I would definitely intervene.

[calisss]

On 3/15/2021 at 8:39 AM, moonshawdow said:

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

NOT enough info here, did you recheck BP? Recheck BP on opposite arm? Is there any PRN Fast Acting BP meds? I mean come on, not enough info here.