# Calculating the mean arterial pressure (MAP)

MAP, or mean arterial pressure, is defined as the average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP). True MAP can only be determined by invasive monitoring and complex calculations; however it can also be calculated using a formula of the SBP and the diastolic blood pressure (DBP).

To calculate a mean arterial pressure, double the diastolic blood pressure and add the sum to the systolic blood pressure. Then divide by 3. For example, if a patient’s blood pressure is 83 mm Hg/50 mm Hg, his MAP would be 61 mm Hg. Here are the steps for this calculation:

MAP = SBP + 2 (DBP)
3

MAP = 83 +2 (50)
3

MAP = 83 +100
3

MAP = 183
3

MAP = 61 mm HG

Another way to calculate the MAP is to first calculate the pulse pressure (subtract the DBP from the SBP) and divide that by 3, then add the DBP:

MAP = 1/3 (SBP – DBP) + DBP

MAP = 1/3 (83-50) + 50

MAP = 1/3 (33) + 50

MAP = 11 + 50

MAP = 61 mm Hg

There are several clinical situations in which it is especially important to monitor mean arterial pressure. In patients with sepsis, vasopressors are often titrated based on the MAP. In the guidelines of the Surviving Sepsis Campaign, it is recommended that mean arterial pressure (MAP) be maintained ≥ 65 mm Hg. Also, in patients with head injury or stroke, treatment may be dependent on the patient’s MAP.

In what other clinical situations do you monitor MAP?

References
Accessed December 8, 2011.
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition. Philadelpha: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Focus On: Sepsis
Focus On: Stroke

Posted: 12/8/2011 8:49:14 PM by Lisa Bonsall, MSN, RN, CRNP | with 14 comments

Categories: Patient Safety

# When a patient or family member is a nurse

We’ve all been there...getting report when the oncoming shift finishes up and whispers to you that the patient’s family member is a nurse. How do you feel? What is your initial reaction? Do you change your approach to the patient? To the family?

It always made me a little nervous when a patient himself or a member of his family was a health care professional, especially when I was a new nurse. Would he be watching my every move, ready to pounce if I hesitated or didn’t have an answer to a question? Or would he be helpful, offering information and advocating for himself or his loved one?

There was one particular patient* that I cared for when the dynamic of a family member who was a nurse was particularly challenging. I don’t recall the specifics about the patient, only that he’d been transferred several times to different hospitals as a “challenge to wean” patient, meaning he was having difficulty weaning from the ventilator. His sister, a nurse, was his power of attorney and very involved with his care. The issue was that the patient appeared to be in severe pain from contractures and pressure ulcers. He was noncommunicative when he arrived at our hospital, but would have significant changes in vital signs and become diaphoretic and tense his muscles with nursing care. His sister requested that no analgesia or sedation be administered so as not to interfere with his ventilator weaning.

The team caring for this patient was perplexed. We didn’t feel comfortable not treating his pain, but also were being influenced by the wishes of the patient’s sister. Our hospital’s ethics committee was consulted and a careful balancing act was employed to treat his pain adequately while allowing him to be awake enough to wean from the ventilator.

It was challenging to care for him. His sister would check medication doses and keep track of dosing intervals. It was a stressful time for the staff as we all worked together to provide the best care for the patient while being so closely observed.

Of course this is only one example. More often, health care professionals who happen to “cross over” into the patient or family member role leave their scrubs or lab coat outside the door. In my next post, I’ll share my own experience being on the other end of the stethoscope.

*Any identifying characteristics are purely coincidental.

Posted: 8/23/2011 8:00:35 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

# The heat is on

It has been incredibly hot here in the outskirts of Philadelphia as well as in the rest of the northeastern United States.  Last night, as my family and I walked out of an air-conditioned sporting event, I was amazed at the wall of heat and the hot “breeze” that greeted us. It was after 10 pm, shouldn’t it have cooled off by then?

I was reminded how dangerous the extreme heat can be. I coughed as I took a deep breath of that hot air. How would someone with lung disease handle this? I looked at my children, school-age now, but I flashed back to my twins who spent most of their first year of life on oxygen after their premature birth. I thought of my parents, not elderly, but dealing with a fair amount of chronic illness.

For those of you dealing with the extreme heat these days, I urge you to be safe and to check on those around you, especially the elderly and the very young. Remind your patients to be mindful of the heat. Take care of yourself - stay hydrated and cool. Here is the link to the CDC’s Tips for Preventing Heat-Related Illness. Also, Nursing2011 published a great article last year, Summer Emergencies, Can You Take The Heat?  It has information about preventing and treating heat-related illnesses, as well as drowning, insect stings, snake bites, and lightning injuries.

Stay cool and be safe!

Posted: 7/23/2011 7:13:10 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

# Memories of a medication error

A recent study published in the Journal of Nursing Care Quality looks at medication errors from the perspective of nurses.  While the researchers sought information about reporting of errors, importance of technology in reducing errors, and current medication administration procedures, they also asked open-ended questions allowing nurses to share their own experiences with medication errors.

"Nurses were asked, "How did you feel when you made a medication error?" This question yielded somewhat surprising results. Many of the medication error incidents had occurred years before completion of the survey yet responses retained the emotions associated with it. Themes that emerged from these comments included concerns about patient harm; violation of trust; culpability, shame, and self-blame; loss of self-esteem and professional self-image; and an awareness that the system had failed them."

When I was a senior nursing student, I neglected to check a patient’s heart rate before giving him a dose of digoxin. I was devastated. As soon as I saw him swallow the pill, it hit me that I hadn’t taken his pulse. I panicked and grabbed his wrist. His pulse was 62; above the “Hold for heart rate less than 60” but not by much. I hadn’t thought about this incident for a long time, but now thinking back, I can remember this clinical day so vividly. My first concern, of course, was for the well-being of the patient and fortunately, his vital signs remained stable. My own feelings of self-doubt and failure, however, stayed with me for quite some time. How could I have forgotten something so important and yet so simple?

Read the full text of When the 5 Rights Go Wrong: Medication Errors from the Nursing Perspective while it’s on our Recommended Reading list. Please share your own experiences and feelings by leaving a comment!

Posted: 6/7/2011 8:45:13 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

# 8 rights of medication administration

Chances are that some of you may not have known that in addition to the well-known 5 right of medication administration, some experts have added 3 more to the list. When it comes to patient safety, it’s never a bad time to review some of the basics and increase your awareness of newer recommendations.

Please add any of your own tips and medication safety advice by leaving a comment. For more reading and learning related to this topic, please explore our CE collection on medication safety. Thank you!

1. Right patient

• Check the name on the order and the patient.
• Use 2 identifiers.
• Ask patient to identify himself/herself.
• When available, use technology (for example, bar-code system).

2. Right medication

• Check the medication label.
• Check the order.

3. Right dose

• Check the order.
• Confirm appropriateness of the dose using a current drug reference.
• If necessary, calculate the dose and have another nurse calculate the dose as well.

4. Right route

• Again, check the order and appropriateness of the route ordered.
• Confirm that the patient can take or receive the medication by the ordered route.

5. Right time

• Check the frequency of the ordered medication.
• Double-check that you are giving the ordered dose at the correct time.
• Confirm when the last dose was given.

6. Right documentation

• Document administration AFTER giving the ordered medication.
• Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

7. Right reason

• Confirm the rationale for the ordered medication.  What is the patient’s history? Why is he/she taking this medication?
• Revisit the reasons for long-term medication use.

8. Right response

• Make sure that the drug led to the desired effect.  If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
• Be sure to document your monitoring of the patient  and any other nursing interventions that are applicable.

Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.

Drug News
Clinical Nursing Resources
Three Ways to Minimize Your Risk of a Medication Error

Posted: 5/27/2011 8:41:57 PM by Lisa Bonsall, MSN, RN, CRNP | with 26 comments

Categories: Patient Safety

# Patient Safety

This week is Patient Safety Awareness Week, an annual education and awareness campaign led by the National Patient Safety Foundation. I did a quick search of articles from our nursing journals to bring you some of the great content we have related to patient safety...

Want to read more? We also have an entire collection of resources devoted to the topic of patient safety. In addition to articles and continuing education opportunities, Focus On: Patient Safety includes a PowerPoint presentation on medication error prevention and a quick reference on pressure ulcer prevention. Have a good week!

Posted: 3/7/2011 7:31:45 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

# And the winner is...

Just last month, two articles from our journals and one entire journal issue received prestigious Eddie & Ozzie Awards. Please allow me to offer my congratulations here and share this content with you.

In the B-to-B, healthcare/medical/nursing, single article category, Stop the disruption of anxiety (Nursing Made Incredibly Easy!, March/April 2010), by Kathryn Murphy DNS, APRN took the gold! This article shows how you, the nurse, are so vital in ensuring identification and proper treatment of anxiety disorders. You’ll find handy charts and illustrations that explain neurotransmitters and neurotransmission, and a great table of medications used to treat anxiety (includes adverse reactions and important nursing considerations). Here’s the link to the pdf if you prefer.

The silver award in this category went to Gathering pearls of knowledge for assessing older adults (Nursing2010, March 2010) by Peg Gray-Vickrey DNS, RN. In this article, the author not only describes variations with physical assessment, but she also offers insightful tips such as: “Never interpret confusion as a normal part of aging” and “Always expect the unexpected.” There are some great photographs in this article too! Again, if you prefer the pdf, you can find it here.

The March issue of Nursing2010 also earned a bronze award in the B-to-B, healthcare/medical/nursing, full-issue category, receiving high marks for editorial focus and presentation.

Congratulations to the authors, editors, and staff!

Posted: 2/13/2011 8:25:09 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

# You guessed it, another health care emergency...

It always happens whenever I travel on business, there is almost always a health care emergency. I seem to be a magnet for them.

I recently returned from a business trip to China and had the opportunity to see the Chinese Health Care System up close and personal. One of my colleagues had an injury and needed to be taken to the hospital. As the "nurse" in the group, I went with her along with an interpreter. What I saw really opened my eyes to how luckly I am to practice in the United States.

When we arrived in the Emergency Department, there were no wheel chairs to be found, patients were sitting or lying on the waiting area floor. Once back in the treatment area, there were patients on stretchers, in chairs obviously brought from home, and lined up against the walls. The physicians, nurses and many patients were all wearing masks and there weren't any boxes of gloves or containers of anti-bacterial hand wash to be found.

After sometime, we discovered there was a special area for "foreigners" in another section of the hospital. So off we went through dimly lit corridors to our special area. Without an interpreter we would never have been able to register or speak to the nurses and physicians. "Pay for Service" takes on a whole new meaning in this setting. Before every examination and procedure, you had to get an estimate of the cost and then go pay for it with your credit card before the service was rendered. It was the nurses who gave the cost estimates for care. Can you imagine doing that in the U.S.?

Language was a definite barrier. The nurses spoke virtually no English but I was able to communicate with them through the interpreter. The physicians were somewhat more fluent in English medical terminology so it was less difficult communicating with them. When all else failed, hand gestures worked well.

The care my colleague received, once we found the right place to be, was very good. The physicians and nurses appeared to be very knowledgable and skilled at their jobs despite having minimal supplies and staff.

What lessons did I learn?

1.We often take supplies, cleanliness and being able to communicate with our patients for granted here in the U.S. In the rest of the world, that simply is not the case.

2. If you travel to a foreign country where you can't speak the native language, you better know where to find an interpreter.

3. Always carry a credit card or local money so you can pay for services.

4. If possible, travel with a nurse or other health care professional, they may save your life.

And finally, on the flight home, you guessed it, another medical emergency. And yes, I was the only health care provider on the plane.

Posted: 1/27/2011 9:07:48 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

# In case of emergency

As nurses, it is in our nature to want to intervene and “make things better.” Add fundamental medical knowledge and clinical skills to that desire to help and we are the ideal candidates to promptly respond to any emergency situation or mass casualty incident. Right? Not always.

Desire and clinical expertise are not enough when it comes to volunteering during or after a disaster. Preparation is an essential component that cannot be overlooked. If you’ve tried to help in the past but weren’t able, or think you might be interested in being a disaster volunteer in the future, now is the time to look into becoming part of an established disaster response team. Start your research by visiting the websites of organizations such as the National Disaster Medical System, American Red Cross, and Medical Reserve Corps.

Does anyone already belong to any of these groups? Have you been part of disaster relief efforts in the past? What advice can you share with us?

Reference: Adams, L.M. (2010). It’s a Disaster! How can I help? Nursing2011 Critical Care, 6(1).

Posted: 1/11/2011 8:34:48 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

# Family meetings

I can remember a patient with an upper GI bleed, Minnesota tube in place, on maximum vent support and two pressors, who clearly was not doing well. I was checking yet another blood product with a nurse colleague, when a consulting clinician came in and told the family members at the bedside that “his numbers look good.” He then smiled and walked out of the room. The family responded with sighs of relief and “thank goodnesses” while the other nurse and I looked at each other as if to say “what just happened here?”

Have you experienced similar situations? I hesitate to name the clinician’s area of expertise because I don’t want to give any specialty a bad rap or make a generalization. However, the point is that sometimes a person not directly involved with a patient’s day-to-day care can make an observation to patients or families and give them a message that may not be correct. It isn’t always one of false hope either; perhaps a patient is doing better, yet his _______ (you can fill in the blank - rash, glucose level, wound, etc.) is not healing or normalizing and a caregiver might focus on that one clinical finding when talking with the patient and his family members.

It is for this reason that I was both surprised and discouraged when I read the results of a recent study published in Chest, “Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients.” In this study, 135 ICU patients received ‘usual care’ and 346 ICU patients had weekly family meetings where the patient’s progress and goals were discussed. The investigators were looking at the impact of this intervention on length of stay and no significant difference between the two groups was found.

Despite the negative findings of this study, it is important to remember the positives, or benefits, of sitting down with families for formal meetings where information can be shared and questions can be answered. For example, regular family meetings can allow you to:

• Provide personal contact
• Give updates on the patient’s medical condition and treatment options
• Discuss his prognosis
• Learn about the patient and family, including expectations and wishes
• Gain the opportunity to formulate a trusting and caring relationship
• Tailor the treatment plan according to the input of all staff and the patient’s family.

Please allow me to share the following quote from the authors in their conclusion of this study:

"Even if the use of regular formal family meetings does not alter resource use in all settings, the literature is replete with evidence of other beneficial effects of providing families with time to sit in a quiet location and talk at some length about the patient's goals and preferences and to explore issues related to quality of life, and providing families with consistent support as they face difficult decisions."

What is the standard procedure for initiating, scheduling, and attending family meetings where you work?

Posted: 12/20/2010 8:59:56 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

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