more BP questions

[VentMedic]

Actually we have barely skimmed the surface of BP.

Nursing Assistants and Patient Care Technicians in the hospital setting spend many hours learning class room things about BP before they are allowed to do an actual BP in the hospital. Accuracy and knowledge about the different indications and contraindications are stressed. The CNA's textbook is over 800 pages of "general" education and skills. To become a PCT, it is another 400 page text book and more training. All of the things mentioned in this thread, including MAP, are found in these textbooks. There is no heresay or "opinions" for some of the basics.

Yes, there are exceptions in some emergencies. But, you should know the basics so that you know when you are making an exception.

I am beginning to think that being a CNA or PCT should be a prerequisite to the Paramedic program.

 

[Ridryder911]

I am beginning to think that being a CNA or PCT should be a prerequisite to the Paramedic program.

Wow! That would be interesting... instead of being a basic for one year, require being a CNA... hmm?

I would start another thread on different areas of B/P, but that would involve many multiple posts and threads; again all regarding the same topic..blood pressure.

R/r 911

 

[VentMedic]

I made the remark based on the actual number of BPs an EMT or EMT-P may do per shift or even in a week as compared to the RN, CNA, PCT or ER Technician per shift.

Yes, getting to do "ride time" is important, but what if they did 40 hours (and that is a conservative number) of just taking vitals, basic assessment skills and documentation all day long on a hospital floor or busy ER?

 

[Airwaygoddess]

Not to mention the number of patient contacts with multi system health problems, and learning how to work with sick patients, medical and trauma.

 

[Airwaygoddess]

a second thought

I also think that it would be the best training of both worlds in the field and in the clinical setting.

 

[Arkymedic]

Just an FYI:
Yes, we all are taught to watch our patients blood pressure, and then to take it at least every 5-10 minutes on critical patients. But very few if any pay enough attention to the mean arterial pressure (MAP)? Many see it as that tiny innocent little number that is usually placed in brackets or hiding off to one side of the monitor screen of electronic blood pressure cuffs or on the cardiac monitors.
.
So what the heck is that number? Is it important? Should I record it?
YES !

MAP is defined as the average arterial blood pressure during a single cardiac cycle. The amount of stroke volume (blood ejected from the ventricle) cardiac output (blood perfusion).

The reason that it is so important is that it reflects the hemodynamic perfusion pressure of the vital organs. In other words how much blood supply is reaching or going through your patient.

So what if we do not have a electronic B/P cuff, can we still obtain a MAP reading ? YES !

If so, how can we calculate it?
The simple way to calculate the patients MAP is to use the following formula:
MAP = [ (2 x diastolic) + systolic ] divided by 3. (i.e. 155/85 the MAP would be 108)

The reason that the diastolic value is multiplied by 2, is that the diastolic portion of the cardiac cycle is twice as long as the systolic. Or in other words, it takes twice as long for the ventricles to fill with blood as it takes for them to pump it out….. that is at a normal resting heart-rate.

In bradycardia or tachycardia conditions; in a patient this relationship between systolic and diastolic values may have some changes, and the formula may not be as always accurate, but still is an important.

One may see the use of invasive monitoring of BP (using an arterial line) in the ER and especially in ICU/CCU settings. This gives a true and only real accurate blood pressure reading (single digit). This uses a complex formula and real time value, very few understand the formula for this method.
Okay, if you want to know ...it is obtained via Fourier analysis of the arterial waveform, or as the time-weighted integral of the instantaneous pressures derived from the area under the curve of the pressure-time.
Understand it ?.. me neither....LOL okay a little bit...

Does EMT's need to watch it MAP?
Definitely. I would describe MAP as that as the RPM or oil pressure in an automobile.
A MAP of at least 40-60 is necessary to perfuse the coronary arteries, brain, and kidneys. The normal range is around 70 - 110 mmHg.

This should be taught as another vital sign for all EMT'sto monitor. It should be monitored anytime the patient has a potential problem with perfusion of their organs. For example (and there are many more):

Shock : especially pt.'s with septic shock and are on vasopressors (Levophed, Dopamine, etc).
CHI :head injured patients, and those with suspected ICP.
Cardiac patients on vasodilator med.s such as NTG, Nipride drips
Patient with a suspected dissecting abdominal aneurysm (AAA)> They need to have their BP controlled within a narrow range so as not to cause increased bleeding or tear.
In the head injured patient, the brain is at risk of ischemia injury if there is insufficient blood flow if the MAP falls below 50. On the other hand, a MAP above 160 reflects excess cerebral blood flow and may result in raised intracranial pressures (ICP).

So, one can see obtaining a blood pressure is important but just getting the numbers is not the real purpose. What those numbers reflect is the main importance. This is why, I am so picky of my blood pressure readings. It is much more than just pumping up a sphygmometer up and listening to some lubb.. dubbs... Any idiot can do that!... Being able to distinguish the true sounds, having the knowledge of what is going on inside your patient is the whole point.

How will this affect my call.. this can lead to a more accurate diagnosis as well as knowing how well my patient is being perfused .... What kills most patients is multiple end organ perfusion.. being secondary to shock, sepsis, post arrest.. what ever. Having a knowledge of thorough assessment, just by understanding the basics of numbers ... can make one understand the "big picture".

Hopefully this answered your question + some...

This is a very well put and articulated post. I also think that MAP should be another v/s taken and monitored and wished we had discussed it in more greater detail in my medic course.

 

[triemal04]

So, aside from RN's that work in clinics and for doc's in private practice, (and often a lot aren't even nurses) I don't honestly know when I last saw an RN, CNA, LPN, ER Tech or anyone who works in a hospital take a manual blood pressure.

That's all well and good that CNA's have to spend all that time learning HOW and WHY to take a blood pressure, but in the end they take it using a machine. Almost every medic I know (and most I's, and a lot of Basics) can tell you all about a BP, including what the MAP is why is matters.

I guess my point is...if you know how to take a BP, are good at it (which will ONLY come from practice, not from reading about it) and know what the little numbers mean...who cares how long it took you to learn, or how often you take one.

 

[VentMedic]

So, aside from RN's that work in clinics and for doc's in private practice, (and often a lot aren't even nurses) I don't honestly know when I last saw an RN, CNA, LPN, ER Tech or anyone who works in a hospital take a manual blood pressure.

Actually, if you notice next time you are in the hospital setting, there are still manual BP cuffs everywhere. If they are not mounted on the wall by the beds, there are usually at least one in each section of the ED and definitely on the med-surg wards. Most of our med-surg rooms have at least one in each room. The ICUs will usually have a manual cuff at each bedside. Per policy for all including PCTs, CNAs and RNs, if there is a discrepency between the last set of vitals, the BP must be confirmed manually. The manual cuff is available for all emergency situations when the machine just won't do the job. Part of being a good clinician also involves knowing when the numbers on the machine and the patient's appearance don't appear to match.

That's all well and good that CNA's have to spend all that time learning HOW and WHY to take a blood pressure, but in the end they take it using a machine. Almost every medic I know (and most I's, and a lot of Basics) can tell you all about a BP, including what the MAP is why is matters.

I would say you know an elite group of people. Not all paramedics have the same educational background. MAP to many is a formula mentioned somewhere in paramedic school and then forgotten.

CNAs/PCTs are relied upon to provide accurate information to the licensed staff. They also spend the most time during a 12 hour shift with the patients doing direct care. Part of their training is knowing when a patient is not tolerating certain basic activities. Obtaining vitals at the time of some change can provide valuable information for the patient's overall care. It's not just about "taking a BP" but relating it to the patient's overall activity tolerance and condition at that particular moment in time.

I guess my point is...if you know how to take a BP, are good at it (which will ONLY come from practice, not from reading about it) and know what the little numbers mean...who cares how long it took you to learn, or how often you take one.

Technology has made some manual skills weak. Even those that have had excellent skills get used to using technology and their skills start to suffer. I see this frequently when someone is asked to do a manual BP during an emergency. They get that stunned and fumble moment. This can be anyone with any credential.

Reading and continuing to learn/review can enhance your overall awareness in different patient presentations. There is so much to learn from those "little numbers".

 

[VentMedic]

Originally Posted by triemal04
Almost every medic I know (and most I's, and a lot of Basics) can tell you all about a BP, including what the MAP is why is matters.

I would say you know an elite group of people. Not all paramedics have the same educational background. MAP to many is a formula mentioned somewhere in paramedic school and then forgotten.

I did mean that as a compliment. Educational BASICS vary in different areas. If the prehospital providers in your area have a thorough understanding of BP and MAP, then it is a good achievement for your EMS education system.

 

[triemal04]

Actually, if you notice next time you are in the hospital setting, there are still manual BP cuffs everywhere. If they are not mounted on the wall by the beds, there are usually at least one in each section of the ED and definitely on the med-surg wards. Most of our med-surg rooms have at least one in each room. The ICUs will usually have a manual cuff at each bedside. Per policy for all including PCTs, CNAs and RNs, if there is a discrepency between the last set of vitals, the BP must be confirmed manually. The manual cuff is available for all emergency situations when the machine just won't do the job. Part of being a good clinician also involves knowing when the numbers on the machine and the patient's appearance don't appear to match.

I would say you know an elite group of people. Not all paramedics have the same educational background. MAP to many is a formula mentioned somewhere in paramedic school and then forgotten.

CNAs/PCTs are relied upon to provide accurate information to the licensed staff. They also spend the most time during a 12 hour shift with the patients doing direct care. Part of their training is knowing when a patient is not tolerating certain basic activities. Obtaining vitals at the time of some change can provide valuable information for the patient's overall care. It's not just about "taking a BP" but relating it to the patient's overall activity tolerance and condition at that particular moment in time.

Technology has made some manual skills weak. Even those that have had excellent skills get used to using technology and their skills start to suffer. I see this frequently when someone is asked to do a manual BP during an emergency. They get that stunned and fumble moment. This can be anyone with any credential.

Reading and continuing to learn/review can enhance your overall awareness in different patient presentations. There is so much to learn from those "little numbers".

Not to be a jerk or anything...but not every ER is the same as the one in the hospital in which you work. Yes, some do have manual cuffs in each room, sometimes mounted on the walls. And a lot don't. Including many that I have seen. As far as taking a manual to check discrepencies...same deal. Things are different everywhere (this is ignoring the part about how people will not follow their protocolls in some situations...whole 'nother topic), and a lot of people rely way to much on a machine to take vitals for them. My point was that just because someone has an RN, CNA, LPN or whatever after their name doesn't make them more proficcient in something than an EMT. Ever.

Far as the MAP goes...it's part of the medic curriculum here. Everyone learns about it. Most seem to remember it. And to relate the automatic BP's...most machines I've seen will also display the MAP...and most people I know want to know what the equipment they use tells them.

But, you are absolutely right, taking vitals isn't the end, it's looking at those vitals and knowing if they are accurate based on what your pt's presentation is. This will come in part by reading a book, but again, the ultimate way to know is to go out there and DO IT. Again and again and again. Like I said, it has nothing to do with what your cert is or where you work, but how much you do it, and how much you practise.

 

[VentMedic]

Actually I get to see a lot of hospitals on two different coasts. Both areas are prone to disasters, earthquakes and hurricanes. Having manual cuffs and other equipment readily available for disasters, power failures and for just regular emergencies is a must. I do like working for hospitals that are well prepared.

I would hate to see anyone try to defend NOT doing a manual BP if there was doubt in the machine reading in court.

But you are right some hospitals just like some professionals just barely meet minimum standards. Hopefully with the raised JCAHO standards, these hospitals will get their acts together.

My point was that just because someone has an RN, CNA, LPN or whatever after their name doesn't make them more proficcient in something than an EMT. Ever.

Now that is a strong statement and could definitely be up for debate. There are definitely things that each of these professions do more proficiently than an EMT. Of course, there are prehospital things that an EMT has definitely got more proficiency in. The average CNA in our hospital will take a minimum of 50 BPs/shift and those are just the scheduled ones. Some are manual and some are by machine. They get very proficient at what they do. Not many paramedics will have the same indepth understanding of MAP as an ICU RN. Healthcare is very diverse with many different skilled and educated professionals. There are things every professional can learn from other professionals.

 

[triemal04]

Now that is a strong statement and could definitely be up for debate. There are definitely things that each of these professions do more proficiently than an EMT. Of course, there are prehospital things that an EMT has definitely got more proficiency in. The average CNA in our hospital will take a minimum of 50 BPs/shift and those are just the scheduled ones. Some are manual and some are by machine. They get very proficient at what they do. Not many paramedics will have the same indepth understanding of MAP as an ICU RN. Healthcare is very diverse with many different skilled and educated professionals. There are things every professional can learn from other professionals.

It's a true statement though. Sure there's going to be people that work in hospitals that are better at a specific skill than some EMT's. And the reverse will be true too; a lot will depend on the individual though, and what system they work in. But just because some has a certain certification or licence does not mean that they will be better at something than an EMT. Ever. I know I'm repeating myself, but I don't know how much clearer I can get. The only way to get good at something is to do it; if you don't, it doesn't matter what you cert is, you still won't have the skills. And again, good for the CNA's where you work; again though, it isn't like that everywhere.