High blood pressure on the ward
Repeat it properly and look for organ damage. If there is none, don't rush to bring it down, and never give sublingual nifedipine.
"Bed 21's BP is 192/104." He is 58, admitted with cellulitis, known hypertensive on amlodipine 10 mg and losartan. His evening tablets were missed because he was in X-ray. He has leg pain from the cellulitis and hasn't passed urine since the afternoon. No headache, chest pain, breathlessness or visual symptoms.
The nurse asks: "Should I give a nifedipine capsule under the tongue?"
What do you do, and what don't you do?
- Ask about symptomsHeadache, vision, chest or back pain, breathlessness, confusion, weakness.
- Pregnant or recently delivered?Think pre-eclampsia: treat 160/110 or more within an hour.
- Repeat properlyBy hand, right cuff size, after rest, both arms if chest or back pain.
- Simple causes firstPain, full bladder, anxiety, missed tablets, alcohol withdrawal, steroids, NSAIDs.
- Look for organ damageNeuro exam, fundi, chest, ECG, urine dip, creatinine.
- No organ damageGive usual tablets, treat the cause, recheck. Lower over hours to days.
- Organ damageHypertensive emergency: senior, IV treatment in a monitored bed.
- Never sublingual nifedipineSudden falls cause stroke, MI and kidney injury.
- Headache with vomiting, confusion or fits
- Chest pain, back pain or pulmonary oedema
- New weakness or speech problem
- Visual loss or papilloedema
- Rising creatinine, or blood and protein in urine
- Pregnant or postpartum
- Pain, urinary retention or missed tablets
- Hypertensive emergency
- Pre-eclampsia
- Stroke or brain bleed (BP is high because of it)
- Aortic dissection
- Alcohol or drug withdrawal
- Phaeochromocytoma
- Raised intracranial pressure (high BP with slow pulse)
| Severe hypertension | 180/110 or higher |
| Hypertensive urgency | Severe BP without new organ damage: oral treatment, lower gradually |
| Hypertensive emergency | Severe BP with acute organ damage: IV labetalol or GTN in a monitored bed |
| First-hour target in emergency | MAP down by no more than 25% |
| Pregnancy | 160/110 or higher is severe, treat within an hour |
| Amlodipine | 5–10 mg orally once daily |
| Labetalol (oral) | 100–200 mg, may repeat after 1–2 hours |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why it matters
A high BP reading at night is one of the commonest calls. Most patients have no organ damage, and their BP settles with rest, pain relief, an empty bladder and their usual tablets. Lowering BP fast in someone without organ damage can cause a stroke or kidney injury, because the brain and kidneys have adapted to high pressure. A hypertensive emergency (high BP with acute organ damage) is different and needs controlled IV treatment.
On the phone
- Any headache, chest pain, breathlessness, confusion or blurred vision?
- Has the patient had their usual BP tablets? In pain? Passing urine?
- Is she pregnant or recently delivered?
- Ask the nurse to repeat it manually after 15 minutes of rest, check a bladder scan, and give due tablets and analgesia.
When you arrive
- RepeatManual BP, right cuff, both arms if pain.
- SymptomsHeadache, vision, chest or back pain, breathlessness, confusion.
- Organ damageNeuro exam, fundi (papilloedema, haemorrhages), chest, heart, signs of overload.
- Simple causesPain score, bladder scan, drug chart (missed doses, NSAIDs, steroids), alcohol history.
- TestsECG, urine dip for protein and blood, creatinine.
Urgency or emergency?
- Treat pain, retention, anxiety
- Give usual or oral tablets
- Recheck in 1–2 hours
- Day team to adjust
- Brain, heart, kidneys, eyes, aorta, pregnancy
- Senior
- IV treatment in monitored bed
- See hypertensive emergency guide
| Organ | Damage looks like |
|---|---|
| Brain | Confusion, fits, severe headache with vomiting (encephalopathy), stroke |
| Eyes | Papilloedema, haemorrhages, visual loss |
| Heart | Chest pain (ACS), pulmonary oedema |
| Aorta | Tearing chest or back pain, unequal arm BP (dissection) |
| Kidneys | Rising creatinine, blood and protein in urine |
| Pregnancy | Pre-eclampsia, eclampsia, HELLP |
Common ward causes
| Cause | What to do |
|---|---|
| Pain | Analgesia, then recheck |
| Full bladder | Bladder scan, catheter |
| Missed tablets | Give them now |
| Anxiety, poor sleep | Reassure, recheck |
| Alcohol withdrawal | Benzodiazepine per protocol, thiamine |
| NSAIDs, steroids, decongestants | Review the drug chart |
| Stroke | Don't lower acutely unless very high or lysis planned; see stroke guide |
| Raised intracranial pressure | High BP, slow pulse, falling GCS: CT, senior |
Treatment
Sublingual nifedipine (breaking a capsule under the tongue) drops BP suddenly and unpredictably and can cause strokes and heart attacks. If a nurse asks for it, explain kindly and give a clear alternative plan.
Common mistakes
- Treating the number without seeing the patient.
- Giving IV drugs for severe BP with no organ damage.
- Using sublingual nifedipine.
- Forgetting the bladder and the pain.
- Missing pre-eclampsia in a postpartum woman.
- Lowering BP in an acute stroke without senior advice.
- Missing aortic dissection in someone with chest or back pain.
Document
BP readings, symptoms, organ damage checked, what you gave, when to recheck, and when to call you.
Frequently asked questions
Should high BP be treated urgently at night?
Only if there is acute organ damage. Otherwise repeat the reading, treat pain or retention, give usual medicines and let the day team adjust treatment.
Why shouldn't sublingual nifedipine be used?
It causes a sudden, uncontrolled drop in BP that can cause stroke, heart attack and kidney injury.
When is high blood pressure an emergency?
When it is severe and causing acute organ damage: brain, heart, aorta, kidneys, eyes, or pre-eclampsia in pregnancy.
How fast should BP be lowered in hypertensive urgency?
Gradually, over hours to days, with oral medicines.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A ward patient has BP 192/104 after missing his amlodipine. He has no symptoms and no organ damage. What is the best management?
Answer: Usual oral tablet. Severe hypertension without organ damage is lowered gradually with oral drugs.
- Sublingual nifedipine: Unsafe.
- IV labetalol: Not an emergency.
- Transfer to ICU: Not needed.
- IV GTN: Not indicated.
2. A ward patient with BP 200/110 hasn't passed urine for 8 hours and is restless. What should be checked first?
Answer: Bladder scan. Pain and a full bladder commonly raise BP on the ward.
- Renin levels: Not first.
- Echocardiogram: Not first.
- Urine metanephrines: Not first.
- CT head: Not first.
3. Which finding makes high BP a hypertensive emergency?
Answer: Papilloedema. Acute organ damage (brain, heart, kidney, eyes, aorta, pregnancy) defines an emergency.
- Anxiety: No.
- Mild headache with normal examination: Usually not.
- BP above 180/110 alone: Severity alone is urgency.
- Missed tablets: Not organ damage.
4. A 55-year-old who ran out of his tablets has BP 200/120 mmHg with mild headache; fundi, ECG, creatinine and urine are normal and there are no neurological signs. What is the appropriate management?
Answer: Restart oral therapy and lower BP over days. Severe hypertension without acute target organ damage (hypertensive ‘urgency’) is managed with oral agents and gradual reduction over 24–48 hours to days, with close outpatient follow-up; address adherence. Hypertensive emergency: severe BP with acute organ damage (encephalopathy, stroke, ACS, acute heart failure/pulmonary oedema, aortic dissection, AKI, eclampsia, retinal haemorrhages/papilloedema) — IV agents (labetalol, nicardipine, GTN, nitroprusside) in monitored setting with target-specific reduction (e.g., MAP ≤ 25% in first hour; dissection — SBP < 120 within 20 min). Avoid sublingual nifedipine.
- IV labetalol to normalise BP within an hour: Rapid lowering without organ damage risks ischaemia.
- Sublingual nifedipine: Sublingual nifedipine causes unpredictable falls in BP.
- Admit to ICU for nitroprusside: There is no acute organ damage.
5. A woman at 36 weeks with pre-eclampsia has BP 168/112. Which acute treatment is appropriate?
Answer: Oral labetalol or nifedipine. Severe hypertension in pregnancy (≥ 160/110) needs urgent treatment to prevent stroke: oral labetalol, oral nifedipine (modified-release), or IV labetalol/hydralazine if needed, aiming for ≤ 135/85. Consider MgSO₄ for severe pre-eclampsia, monitor fluid balance (restrict to ~80 mL/h), and plan delivery (at 37 weeks or earlier if severe features). ACE inhibitors are contraindicated; diuretics reduce plasma volume.
- Sublingual bitten nifedipine: Bitten sublingual nifedipine causes a sudden, uncontrolled fall in BP that can harm the fetus.
- ACE inhibitor: ACE inhibitors are contraindicated in pregnancy (fetal kidney damage).
- Furosemide: Furosemide reduces plasma volume, which is already low in pre-eclampsia.
6. Which of the following directly stimulates renin release from juxtaglomerular cells?
Answer: Sympathetic stimulation through β1 receptors. Renin release rises with three signals: sympathetic β1 stimulation of JG cells, low perfusion pressure in the afferent arteriole, and low sodium chloride delivery to the macula densa. Angiotensin II and ANP inhibit renin. Beta-blockers lower renin.
- High sodium chloride at the macula densa: Low NaCl, not high, stimulates renin.
- Angiotensin II: Gives negative feedback.
- Atrial natriuretic peptide: Inhibits renin.
- Raised pressure in the afferent arteriole: High pressure inhibits renin.
7. Which adverse effect is typical of ACE inhibitors?
Answer: Hyperkalaemia. ACE inhibitors reduce angiotensin II and aldosterone, so potassium is retained (hyperkalaemia). They also cause dry cough and angioedema (from bradykinin build-up), first-dose hypotension and worsening renal function in bilateral renal artery stenosis. They are contraindicated in pregnancy.
- Hypokalaemia: Seen with loop and thiazide diuretics.
- Hypercalcaemia: Seen with thiazides.
- Hypoglycaemia only: Not typical.
- Bradycardia: Not typical; seen with beta-blockers.
References and dose sources
- Amlodipine dosing: Drugs.com: Amlodipine dosage (see also our amlodipine dose page)
- Labetalol dosing: Drugs.com: Labetalol dosage (see also our labetalol dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.