Blood Pressure, High / Elevated (Hypertension)

Also Consider:  Low Blood Pressure, Shortness of Breath, Chest Pain

1. Take Vital Signs

• Temperature:

• Blood Pressure lying:

• Blood Pressure standing:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Acute mental status change

• Not eating or drinking as much as usual

• Unrelieved pain

• If Pain:  exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent

• Acute decline in ADL abilities

• Diaphoresis: Cold, clammy, pale skin

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress

• Cardiovascular:  Chest pain, new irregular pulse, edema

• GU: New or worsened incontinence, urinary retention / bladder scan

• Neurologic  changes: headache, consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)

• Fingerstick glucose (patients with diabetes)

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness 

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • BP  greater than 200 systolic or greater than 115 diastolic, OR 

  • Recent increased BP with severe headache, chest pain, change in level of consciousness, or abnormal neurologic signs

• Notify medical staff on the next business day 

  • BP >180 systolic or >90 diastolic, without accompanying signs or symptoms

• Notify medical staff at the next regular rounds 

  • Blood pressure consistently higher than patient’s baseline

4. Implement Management Plan

• Monitor vital signs every 4-8 hrs for 2-3 days

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)

• Review status and plan of care with designated representative

2025-04-26