I would like to have some opinion on this issue before I take it further. I work in LTC as an RN and a resident was having dizziness, lightheadedness, extreme fatigue, hypotension, borderline brady and 2 falls in one week. The MD was faxed of resident's current s/sx,BP's & AP's, and Rx's. Since this resident was hypotensive, 2 BP/cardiac meds were held. This was put in the fax. A PA(who works under the primary MD), who has a reputation for being rude, answered the fax by only decreasing a med that wasn't held and didn't address the meds that were being held. The next day, the other RN addressed the situation over the phone and received orders for ER eval. The resident was sent back without any changes and to F/U with primary. EKG,CPK, Chem 14, U/A, ect. all WNL. Resident was still symptomatic, and bps now only borderline hypo. I sent another fax stating that 2 meds were still being held per nsg judgement and this needed to be addressed. The PA calls the DON and says he wasn't aware of 2 meds being held (it was in the first fax that he replied to and signed) and no nurse should take it upon his/herself to hold cardiac meds without an MD order since harm could have come to the resident! Now, as an RN, do I or do I not have the scope of practice to hold cardiac meds if I have properly assessed the resident and notified the MD by fax?
Apr 4, '02
I believe that you DO have the right to withold the med but then must contact the Doctor with your reasons for doing so. I hope that this incident was well documented.
Apr 11, '02
I also believe that you can AND should use nursing judgement. Nurses are the ones at bedside and unless the MD (or PA) comes to assess the patient for themselves I think that nurses have the responsibility to do what they think is right for the patient. If you would have given the meds and the patient would have become very brady or hypotensive - that PA would have being singing a different song. Good nursing judgement abbysmama!
Apr 11, '02
I agree with the others. As long as you have a sound, very well-documented basis for withholding the med, then do it. The same thing would apply to giving a.m. insulin to somebody with a BS below normal, if you aren't using sliding scale.
One thing that concerns me, since all of the labs and EKG was okay-has this person had a CVA or head injury of some sort? That could account for all of the sx you describe, too. Another thing-how about diabetes insipidus? That would be kind of hard for the ER to miss, but it could be something to consider.
Have you taken pulse and BP when the patient was in the "falling out" mode? Was the pulse regular, fast slow, irregular? Was the BP low? Sick Sinus Syndrome is something else to consider here, and would not necessarily be picked up on EKG. A person can go in and out of it.
My thoughts only...
Let us know when you find out what the problem is.
Jun 11, '02
GOOD CALL ON HOLDING THE MEDS, I MIGHT SUGGEST THAT YOU DISCUSS RATIONAL FOR HOLDING MEDS WITH YOUR CHARGE NURSE/ANM SO THAT YOU HAVE SOME ONE TO BACK YOU UP. AND THAT YOU ARE SURE TO DOCUMENT, DOCUMENT, AND DOCUMENT ALL FACTORS LEADING UP TO YOUR PRUDENT DISICION TO HOLD MEDS. OUR PATIENTS ARE OUR PRIMARY CONCERN, NOT MD OR PA EGOS
Aug 11, '02
I think you were completely right to hold the med and you did everything you should have. I don't work in LTC, I work in CV-surgical, but after so many calls after the surgeons go home about holding a med for low B/P or low HR, we start getting parameters a little more often!!
Aug 11, '02
I too believe that we as nurses have to use, to the best of our ability, our own judgement when it comes to the wellfare of our pts. I will also hold bp meds if the pt is unstable but always make the MD was aware of why it was done and document If I am told to give it. Most of the time the MD agrees and they usually give paremeters so there wont be any questions. Sometimes a pt may need the med for heart rate rather than bp, even though it may affect both.
Aug 18, '02
I believe you were correct in holding the meds. Document to cover your rear!!! If you notified the MD that the meds were held, made him/her aware of vital signs, symptoms etc... then you were correct.
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