BP situation

[Standoe3]

I just completed my orientation and was released so I am a newgrad LVN working fulltime days. I had a situation with a pt who has a Hx of HR of 60 at best he has bottomed out before around 45bpm when given meds. I gave lasix, lisinopril, coreg, and held digoxin V/S 130's/60's hr 58 at 9am pass around 3 the MD came on the unit and i notifed him of the situation and new V/S 98/63 hr 54, and the MD verbalized to give digoxin. I confirmed with pharmacy and they stated the pt might experience syncope with walking i replied he is bedbound...I gave the digoxin documented MD aware and apical pulse 54...he stayed at a HR of 49-50 for the rest of my shift at 7pm...what would have you done I looking to learn one nurse on the unit agreed with what i did another said she would have presented the situation to the MD that she is holding the med and not giving it and notifing the MD of the action.

[Anna Flaxis, BSN, RN]

Still a student and would like to ask a question, if I may. I've only done one clinical rotation and it was in ltc. The patients with whom I had contact DID have HR parameters set, not only for dig, but also for antihypertensives, and in at least one case, a parameter for SBP.

Is this the norm or did I just luck out and should expect that more often than not it will be as in the OP's case, where there is no written parameter?

It's difficult to learn in advance of actually having the patient experience, but being able to lurk in this forum is the next best thing. So thank all of you for that.

I don't know if this is the norm for LTC, as I have never worked in that environment as an RN. However, at the hospital I worked at, the VS parameters were built into the order sets and protocols. If a physician wanted to order different parameters than what was in the protocol, they had to write an order. For example, I had a patient with severe aortic stenosis, and the cardiologist wanted the systolic blood pressure in the 80s. He had to write an order to supersede the protocol parameters, or he would have been getting several phone calls every day.

[cardiacrocks, BSN, RN]

If ever I have a concern it is my practice to always check with the MD so good job. What I sometimes do is re-time the meds, so they aren't always given at once. Also, you stated the patient was on lasix, this med pulls potassium from the body, what amt of lasix and dig is the patient taking? Low k+ can cause dig toxicity, so you need to be careful, where you also replacing k+? Also you need to remember if this patient takes these meds everyday for some period of time then they are use to having a heart rate relatively low. I work on a cardiac unit a HR of 50-60 would not alarm me. Coreg and lisinopril can also lower HR. Either way you did the right thing, way to go!!

[twinkletoes53]

I would have felt more comfortable with having the MD write an order specifying something like "Patient's HR is 50; give Digoxin as ordered". Because if something untoward had happened to the patient, it would have been your word against his.

I worked in pediatrics; it was unit policy to have 2 nurses check Digoxin dose. We also documented patient's HR in MAR at time the medication was given.

Just wondering, does your unit check a Digoxin level if the patient's resting HR was below a certain level? Especially if HR has changed from that the patient's baseline.

[Standoe3]

K was 3.1-3.2 it was replaced and no labs for the previous 3 days. And for dig levels I don't recall seeing a lab for that. All the nurses on my unit document BP and HR with all cardiac medications and K levels with Potassium meds/ k wasting ect.

[psu_213, BSN, RN]

How come in NS they teach you to "always" hold Dig/cardiac meds if HR is less than 60 bpm. At least that's what I was taught to do...was I misinformed then? They made such a big deal over it too...

In nursing school, VS were either normal or abnormal. While some instructor mentioned that all normals are individualized, the prevailing thought in school is that any HR less than 60 HAS to be abnormal, and therefore is the cutoff for any med that lowers HR. In practice, this is not true. We had a pt whose HR was hovering the in the high 50s, low 60s. He had a cardiac hx. and was having some nonspecific EKG changes. The cardiologist wanted him Beta-blocked to a HR in the 40s. The nurse, who was a relatively new nurse, was dragging her feet about giving him his lopressor because his HR was often below that 'magic number' of 60 (even the the cardiologist was quite clear he wanted the HR to be much lower). In an appropriate way, the cardiologist 'got on' the nurse to get in there with the med to get the HR down.

[Anna Flaxis, BSN, RN]

Coreg and lisinopril can also lower HR. Either way you did the right thing, way to go!!

Not to hijack the thread, but I have never heard of lisinopril having any effect on HR. Can you explain this comment?