by erin01

I work on a tele unit, and i find myself trying to decide when to hold meds. A lot of my patients have been hypotensive, 90's/60'-50's hr normal to tachy. Some of the nurses dont think its a big deal, and have been told its a judgement call. My question is when looking at this which is more important to you...diastolic or systolic bp number? is that a stupid question? one of the rns said i dont panic unless systolic starts to drop below 90. I thought this was a good rule, but want to understand what that means psychologically. I am a night nurse, so there are not a lot of doc around to ask for parameters just "hospitalist" who usually just bolus everyone. Thanks for any info. =)

Re: b/p ?

When deciding to hold BP meds, in a situation like you are describing, there are so many different factors, as I'm sure you're aware of. Of course, you want to look at your physician order... did he/she write "hold if SBP <100"?

I also will look at the history of the med. Did the patient get the previously ordered dose of this drug? If the previous dose was held, and the patient's systolic is still 90, I would probably rethink giving the med.

Also, we have to look at the patient's medical history/current illness. I've seen many heart failure patients who benefit from the lowered heart rate and are able to tolerate systolic blood pressures in the 80s on a daily basis.

Re: b/p ?

I take into consideration the MAP and UOP more than just the numbers. Some patients need to be kept bradycardic depending on what their underlying pathologies are. It takes time and experience.

Re: b/p ?

First, get clear hold parameters from the covering provider.

SBP - product of vasc tone and the ventricular upstroke (more dependent upon heart function)
DBP - primarily from vasc tone (lower in vasodilated states)
MAP - you know the forumula- anything affecting the above will affect the MAP.

The MAP is the true measure of organ perfusion- the "driving pressure", so that's what I use in almost all cases. The books cite 60-70 mm hg MAP as the lower acceptable limit. As above, look at this along with UOP, cap refill, mentation etc other measures of end organ perfusion.

Again, any pt that looks marginal call the person on call at the beginning of your night shift and lay out the plan for the evening...."if the pressure does this, then we do this" eg volume vs pressors vs inotropes......

Re: b/p ?

Firstly know your drugs and the effect they have on the heart and vasculature. If a pt is on metoprolol and they have a HR of 50 and a SBP of 90-100 that may not be safe to give because the BP may be low d/t the low HR . But if the pt had a HR of 130 and a SBP of 90-100 then give the metoprolol to reduce the HR and thereby INCREASE the BP. Remember that BP= HRxSV.
For DBP, again know the drugs and how they affect the afterload (PVR).

When I make a decision on whether to give or hold a med I consider the risks and benefits of the drug and what effect it will have on perfusion/cardiac rhythm. To choose an arbitrary SBP of 90 as a general rule for holding a med can get you into trouble. If a pt needs a pressure of 120 to perfuse the kidneys or brain then you can see how this rule would jeopordize the pt. MAP is very useful-but when using MAP consider the clinical findings of your pt as well. Are they making urine? What is their LOC? Are you having to titrate your drips up to achieve BP (could indicate acidosis d/t hypoperfusion/hypoxemia). Lots to consider, so try to think it through rather than use a generic guideline. Good luck!

Re: b/p ?

Great advice from all the above posters. I will add though that holding meds without clear parameters from a physician is "practicing medicine" or "prescribing" without a license to do so. While I may not administer the medication initially based on my judgment I always clarify with the physician and have written orders with parameters.