Is it too much to ask for the time to be documented when a blood pressure is taken? - AgingCare.com

Is it too much to ask for the time to be documented when a blood pressure is taken?

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My father in law has Vascular dementia, heart block, diabetes & prostate cancer. (wait & watch slow growing) I don’t expect anything to be cured at this point however I’m not ready to give up on him. He has lost a lot of weight, can’t communicate well about his needs or how he feels. So it is up to others to figure it out. When his BP was 90’s/40’s with heart rate in the 40’s at his afternoon Dr appointment, I asked the assisted nursing facility to take his BP in the afternoon. I explained since he gets his BP medication in the morning it may be making it go too low in the afternoon. As I would check his documented BP, I noticed there was no HR documented. I was concerned since in the past the Doctors were OK since his BP would go up to compensate the low HR. I saw there was no time of BP taken last week & all BPs looked higher. I discovered: They were taking BP before Lunch so they didn’t have to bother the caregiver twice. 1 for giving his vitamin. 1 for taking his BP. Yet the sheet they document this on for his chart clearly says “take BP after Lunch per family”! I was told there isn’t space to write the time on the sheet. The Dr didn’t order for the heart rate to be documented. His points of caregiving will go up if the more times the caregiver has to interact with him. They are not a skilled nursing facility. ..... Nevermind that they are missleading me and all who look at the BP recorded & thinking it was done after lunch. So I asked the Dr for a specific order to do BP & HR after lunch and to record the date, time and if HR is irregular. However he did not specify to “document” the time. Thus, we still do not know the time frame that his BP may be dropping. They have gone from someplace I trusted, to a place I don’t trust. There is no common sense. I also figured out he was not getting a snack in the evening. He eats when he likes the food. His meal exchange if he doesn’t like stuffed peppers or stir fry etc, is a peanut butter and jelly sandwich. Too many times a week. I believe they are giving him a snack of a half a PB & J now that I brought it up. They don’t communicate well with each other or family. They get their check every month & don’t seem to try anymore. This is how they have made me feel since I found the discrepancy of documented BP. How can I give accurate information to the Dr if they are dishonest. He continues to lose weight. He eats good when he has simple foods. It is not that he has given up on life. I don’t understand why I should have to go back to the Dr and try to explain he NEEDs to write the order to include the documentation of the time because they are an assisted living facility instead of a skilled nursing facility. I don’t know why “they” didn’t tell me that there was a problem with how I thought things were being done, or how we were led to believe as he keeps losing weight and having bad days.

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To inmyshoes, thank you for common sense answer. The reason I asked to take BP after lunch is to see how much it dropped when Med kicked in. They otherwise took in the morning as they gave the medication. It was mostly out of his system by then. They seem reluctant to take it more often & Dr says “what do you expect at his age” Well, I expect to do simple things. I don’t want to have his BP drop and have him fall, break a hip and die! I don’t see why taking his BP to monitor how his medication is working through the day should be a big deal. At this point if I ask for them to check his BP 3 times a day which seems VERY reasonable to me, I wonder if they will think I am doing it to be difficult. But I know the medication should not be stopped if BP gets in the high range at other times. I think a simple tweaking of medication combination could be a simple answer. Combination BP/Diuretic is what he is on. Making the diuretic as needed seems easy enough. Also, the Dr must be agravated with me also. He doesn’t want to be called unless his systolic BP is below 90. I don’t know any way to take this except as a slap in my face. There are other things going on also. Very poor communication from Dr office and Hospital lab and Assisted living. I do try to pick my battles. Then I get so frustrated with them I can’t hide my frustration. I put it in God’s hands and try to do what I can. I learn and hope things go better next time. I start to trust and things go wrong again. This is our elderly population and in the end, I feel “THEY” think “they are going to die anyway” so there is no consequence to the Dr or facilities. (Well this took a dark turn. Apologies, I’m not very uplifting today.)
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Your dad's blood pressure should be taken first thing in the morning before he has eaten breakfast or given any medicine. A log needs to be kept to track his blood pressure and time it was taken. 

My father started having low blood pressure so the doctor told me to give my dad his blood pressure medicine only if his blood pressure was on the high side. I also took his blood pressure at night before he went to bed. 

The log should be taken to the doctor's office.  You would need to get special orders from the doctor to change anything. 

My father also had vascular dementia. Most of his medication was stopped because it wasn't helping him any. His doctor said as you get older the drugs react differently. 
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Thank you all for understanding. You pretty much get it. I already have a wrist BP cuff in his room. It’s readings correlate with the facility BP cuff. Both are wrist monitors. He eats ok but slow as long as he likes the food. With the weight loss, my thinking is that his BP Med could be decreased or changed to one without the diuretic. Drs choice. I can’t have an intelligent conversation without proper documentation of BP. The BP Med also had a benefit for how his heart muscle is beating. He gets his BP Med in the morning so the medication doesn’t take full effect in just 2 1/2 to 3 hours, however after lunch or mid afternoon it does. I have considered all I see suggested above. I really thank you for reinforcing that I pick my battles. I try. It isn’t my call. I make suggestions but... as I said, I know we can’t fix him or his conditions. I gave up on fixing a long time ago. It doesn’t mean we stop all meds or ignor a red flag for what he is taking now. Palliative care or hospice may get more help for him than me being a squeaky wheel. Less stress on me & others too. I think I needed to be reminded of this possibility again. Thanks for the needed hugs. Oh, and yes I have talked with the manager and the staff nurse. Still disappointed with that. 
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I might discuss his medication with his doctor. With Palliative care, they can discontinue meds that are not required for comfort care. Recently, I did that with my LO's doctor and we are now on the same page. He discontinued several meds and we may do more. Do you know that he still needs the blood pressure meds? Is his blood pressure pretty good without them?

In late stage dementia, I know that my LO is not going to recover. So far, she hasn't lost weight, but, I know that will likely come next. With the progression, she'll likely encounter weight loss and have eating difficulties. Can you see if they can change his meal exchange to something else? Is he on soft food yet?
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Tinkerbelle; JoAnn took my thought!!

Hospice might be the best level of care right now; Hospice is NOT giving up. Hospice is getting the patient the best palliative (non-curative) care that they need and all the comfort that can be had. Plus counseling for the family about what can be done...and what doesn't make a big difference.

What I hear in your post is that you are still in "fix-it" mode; you understand in your head that what he has is life limiting, but it seems like your heart hasn't accepted that yet.

Be well, and let us know how this is going. We care here AND we learn greatly from each other.
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By law in DE and NJ there has to be an RN at AL facilities. LT always has them. Your Dad may need more than an AL is capable of. It maybe time for LTC. Have him evaluated for Hospice. You may be able to work with them better.
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Many states do not have registered nurses and BPs are only taken a few times a year by CRNAs who are not trained to diagnose blood pressure and are not accountable to report. Some states will not allow staff to inject insulin. Of course those states that have nursing and more ability to administer more cost more. There is a big sticker shock just comparing CT to MA where one has a medical model compared to a social model. I am not sure what your state rules are on BP accountability. Meanwhile are you aware that you can purchase an automated BP monitor for about $50 that he can keep in his room. While accuracy may be a little off compared to human ears, the device can be compared to a manual one. The advantage to an automatic is that each reading is date and time stamped. I hope my response helps.

As far as your dissatisfaction, have you spoken to the administrator? Or perhaps it is time to move him.
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Adding my hugs. It can be VERY frustrating to not have control of all care in the ALF or other care center. If we had our loved one at home, we would do it this way ... It is hard to accept that the care center has other procedures. I saw this again and again in my caregiver support group. I experienced it some myself with my mother in an NH.

You are certainly correct that we have to be advocates for our loved ones. It is also smart to pick our battles.

When does your FIL get his vitamin? Just before he goes to lunch, or mid morning? If it is just before lunch then there wouldn't be a big time difference between before and after lunch. Maybe 11:30 if they take it before lunch, and 12:15 if they take it after. But if I'm understanding correctly, you'd like it taken in the afternoon, maybe 2:00? I'm just saying be careful that you don't put a lot of effort into changing from one procedure that you don't like to another one that doesn't meet your request anyway. Or would it?

What do you think might change if you had all the bp information you want at the time you want it? Maybe change the time his bp med is given? So then his bp would drop later in the day instead of afternoon? Or might the doctor change the med completely? Can you discuss this with the doctor to get a clear understanding of the importance of the timing? Obviously monitoring the blood pressure is important. How important is the timing? How critical is having the HR at the same time?

Do you think that his blood pressure and specifically when it starts dropping has anything to do with his losing weight and having bad days? Did his doctor suggest that? Losing weight is very common in dementia, for many reasons. It is the nature of dementia to have good days and bad days, and as it progresses the bad days become more frequent. That is the nature of dementia.

My heart goes out to you. It is very distressing to watch the decline of someone with dementia.

Keep advocating for FIL
Pick your battles
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Hugs, Tinkerbelle. Bumping this up.
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