Low Blood Pressure | Nursing Hacks # 2

You walk into your patient's room to perform your initial head to toe assessment. Your patient has an arterial blood pressure line (also called an a-line). You were told during bedside report that the mean arterial pressure (MAP) goal for the patient was equal to or greater than 65. Currently, the blood pressure is reading 80/30 (46), there are alarms going off, and everyone on the floor is giving you "worried" eyes. What should your next action be? Now, most people would have a knee-jerk reaction and started increasing vasopressors or giving a bolus. But you must slow it down. Start with the patient and work your way out. What do I always say? Assess then act. Blah, blah, blah, I know it's annoying. But that foundation will never change. Don't let dramatic folks provoke you into acting before you properly assess the situation.

First ask yourself, "Is this number real?" Meaning, is it accurate? Here is quick checklist...

• Is the arterial waveform appropriate? 
• Has the arterial line been correctly zeroed?
• Do you see blood backing up in the circuit?
• Is the transducer at the phlebostatic axis? 
• Is the pressure bag inflated to 300 mmHg?
• Are there any loose tubing connections?

There are so many things that can alter your blood pressure reading. You MUST assess that equipment first, before making decisions. There have been many times in my career when I found the transducer on the floor or taped to the bed, the line wasn't zeroed in the last 96 hours, or the catheter was kinked because the patient was agitated and moving. There are simply too many variables for you to react without seeing what is going on with your patient or the equipment.

This same concept applies to blood pressure cuff readings. You walk into your patient's room to perform your initial head to toe assessment and you see your patient's blood pressure cuff reading is 70/15. When I worked on a medical-surgical floor, this happened constantly. I'd arrive and as stated above, I'd assess my patient. For a blood pressure cuff reading to be accurate, it has to be the right size, under the right conditions. In most cases, the cuffs were too small/large, which caused inaccurate results. On top of that, most people are eating during the blood pressure readings, which also caused problems. A provider told me this awesome clinical pearl once and it's helped me from making unnecessary calls related to inaccurate vital signs. He told me to, "Check the blood pressure using another extremity first, at least 5 minutes apart from each other." You might get a low reading once but usually, the next one is normal. I personally follow-up 30 minutes later with another reading just to make sure. The goal isn't to avoid calling. If the blood pressure is definitely low, please call! The aim is to avoid unnecessary interventions being initiated based on false information. Vasopressors have many adverse effects, so do administering multiple fluid boluses.