When to hold bp medications

[MelissaLPN, ASN, LPN, RN]

Hi, I am a pretty new nurse and I have a question about when to hold bp medications. I come across one to two patients a night whose systolic is below 110. For medications such as beta blockers I know to check apical pulse and I always hold for pulse less than 60 or systolic less than 110 ( this is what I learned in nursing school). But for medications like norvasc or bumex I am not always sure how to proceed. When I call the MD they never seem concnered for bp of 100/60. Other nurses tell me they either given them po fluids and still give the medication or watch their bp and try to give it later. I have searched my drug books for official parameters but have not found anything solid. Some medications have MD ordered parameters but most dont. What is the standard practice of care?

Thanks again. I try to be as careful as I can.

Melissa

[nerdtonurse?, BSN, RN]

It depends. I have had patients that their best effort SBP was 90. You'd have to put them on Levophed or Dopamine to try to drive up the systolic. I've had docs who weren't concerned with a SBP of 150.

The big thing is look at your patient. Is this person symptomatic? Do they sit up and feel dizzy? Then hold the BP med and cover yourself by calling the doc if you're new (run it by the charge nurse, first).

What I look at is the MAP (mean arterial pressure). If you keep that above 60, you're perfusing the brain and the kidneys. That's actually more accurate than just looking at a SBP, since there's a big difference between 120/80 and 120/44. MAP is diastolic + 0.3*(SBP - DBP). So, for 120/80, that's 80 + 0.3(120 - 80) or 92. For 120/44, your MAP is roughly 66, which is getting close to the cutoff for perfusion. For 100/60, the MAP's actually higher than 120/44, so it's actually a "healthier" BP in terms of perfusion. You'll get some nurses who fixate on keeping that systolic above 100, no matter what, and if your charge nurse is one of those, follow what she or he says, or those of your facility. But if you keep the perfusion above 60, you're not harming your patient as long as they aren't symptomatic or it's not a big, sudden change from their norms.

[NurseStephRN]

Many times the physician who ordered the BP meds will write parameters along with the order. I've seen orders to hold a BP med for SBP below 90, below 120, but i mostly see hold for SBP below 100. It depends on the patient, the goals for the patient and their condition, for example. I've held BP meds on patients because the SBP was 105 (for example) and when I went back about 2 hours later for a recheck, they were up in the 140s. Not all patients are symptomatic with an SBP we are taught to consider as "low" way back when in nursing school :) I had a patient last month for whom SBP 105 was borderline hypertensive! lol.

If you don't feel comfortable giving the med at the scheduled time, it is ok to hold it and recheck the BP a little while later and make a decision. As long as there is a reason documented for holding a med, my facility doesn't reprimand us. And it is always ok to call the doc and let them know the patient's BP trends in respect to the meds. Maybe the meds need to be reviewed or maybe they needs to give parameters.

[OutlawNurse86, BSN, RN]

You also gotta look at the dose of the drug, how long the pt has been on it (tolerance), and why they are receiving it (may not just be for BP, could be for cardiac output). Also look at the health history (renal impairment pts are likely to have jacked BPs). I also look back at the previous shift (if it is a BID or more often med) look at the VS and look and see if the med was given and what effect it had. When in doubt, go ahead and call the doc.

[enigmaticorange]

I am a cardiac nurse, so I give BP meds to nearly all of my patients. It always depends on the patient, and you have to learn what this means through experience. I have patients who maintain a BP of 90/65 and the doc still wants beta blockers given. Why? The doc is more concerned with the HR at 100, and the pt is known not to bottom out. (Afib/tachy) Other pts can be extremely hypertensive (220/110) all the time... so the doc wants to hold bp meds for systolic

[Scarlette Wings]

wow, sounds like a perfect opportunity to approach the doctors and ask for a perimeter order if a patient is consistently being on the cusp of hypotension. doc's won't know we are "having to hold it and push fluids" a great deal. they may change the dose, frequency, or order if they knew that. of course some are just stubborn.

then, if i were in ltc, i would approach my nursing leaders and ask if there are any policies that provide guidance.

[neutrophil]

Wonderful questions and answers. Suppose you are a registry nurse working in a snf, you don't have a clue about the patient. I don't hold diuretics especially if they are on potassium. I hold other BP meds if systolic is under 100. Put on the MAR why and endorce it.

[CapeCodMermaid, RN]

When it doubt about giving any medication, call the doc.

[indigonurse]

If there is a parameter it should be written in the order. I would call the MD and get the order clarified. I am surprised that the pharmacy consultant overlooked that.