Low BP and BP Medication question

[Jackfackmasta, ASN, RN]

I am a level 4 student and I have a question.

I had a 96 y/o female pt today who has a long medical hx that I won't list but she is on a beta blocker Sotalol, a diuretic Maxizide and Norvasc. Looking at her am vs I noticed her pulse was 49 and BP was like 118/50.

So I went in the room and did her apical which was 50, and manual BP 116/50. I held the beta blocker and the order for Norvasc said to hold for systolic

I asked another nurse whether we use both systolic and diastolic to hold a medication or use just the systolic and I was told systolic. I was concerned that her diastolic was low that the the combo of BP meds would lower her diastolic to much.

We ended up giving the norvasc and Maxzide and held the beta. Her BP later that day had come up a little bit.

I am just wondering what other experienced nurses out there would have done? The way I was thinking was maybe give her 1 BP medication to prevent her BP from coming back up and see how she does with that. I was afraid giving both the BP meds would cause he pressure to drop and she has a hx of stroke and DVTs.

How do you determine when to hold certain BP meds when the diastolic may be low and systolic normal? Thanks

[Do-over, ASN, RN]

It depends. On the patient, on his or her trends, on the intended action of the drug, home medication or new order, etc. When in doubt, you call the physician, explain your concern and ask what they want.

Some affect HR more than others, etc etc. I wouldn't worry about a DBP of 50, not unusual depending on the patient population.

Really should have an order to hold meds, or ordered parameters.

Here is an example of something I ran into not too long ago. Previous nurse had held PO cardizem d/t low-ish BP. However, when I came on shift family asked what the patient's HR was. Still in the 130-140s... Turns out the cardizem was a new order for the heart rate and the previous nurse had held the med (d/t the BP) without contacting the doc. I took a BP, was satsified with it and gave the med. HR came down beautifully, which is what the med was intended to do...

[NCRNMDM, ASN, RN]

I agree with everything Do-Over said. It depends on the drug, the patient, and the situation. Of course you don't want to give a beta blocker, which is going to slow the heart rate, to a patient whose heart rate is 50. In that situation, I probably would have gone ahead and given the other two drugs. Norvasc is a calcium-channel blocker which works by producing vasodilation and reducing the workload of the heart, so it is beneficial to the patient in more than one way. With a DPB of 50, I doubt the patient was going to totally tank and end up with a terrible pressure. I would really look at the trends before administering anything. Go back and look at what the BP was prior to the administration of the Norvasc, and then compare it to what it was after the Norvasc. If you find that the patient has been trending in the same BP range, and has had no ill effects, go ahead and give the Norvasc. If you are ever unsure of anything, ask a more experienced nurse, and call the doctor for clarification if needed. It's better to be safe than sorry.

[turnforthenurse, MSN, NP]

I agree with everything Do-Over said. It depends on the drug, the patient, and the situation. Of course you don't want to give a beta blocker, which is going to slow the heart rate, to a patient whose heart rate is 50. In that situation, I probably would have gone ahead and given the other two drugs. Norvasc is a calcium-channel blocker which works by producing vasodilation and reducing the workload of the heart, so it is beneficial to the patient in more than one way. With a DPB of 50, I doubt the patient was going to totally tank and end up with a terrible pressure. I would really look at the trends before administering anything. Go back and look at what the BP was prior to the administration of the Norvasc, and then compare it to what it was after the Norvasc. If you find that the patient has been trending in the same BP range, and has had no ill effects, go ahead and give the Norvasc. If you are ever unsure of anything, ask a more experienced nurse, and call the doctor for clarification if needed. It's better to be safe than sorry.

I would have done exactly this. Sotalol's incidence of hypotension seems to be less than other beta blockers, probably because of Sotalol's mixed class II (beta-blocking) and class III antiarrhythmatic (potassium channel blocker) properties. I have given Sotalol with a BP in the 90's (but the HR was >60) but I questioned the physician prior to giving it. Sotalol is used to help prevent arrhythmias but at the same time it can be pro-arrhythmic because it prolongs the QT interval. One of the most serious side effects is developing torsades.

Always look at the trends. What was the patient's HR and BP when they received their last dose? If in doubt, ask the physician. Most cardiologists do not want a patient to miss doses of cardiac meds and most of the time they may ask you to give a decreased dose of a medication. Again, ask the physician or a more experienced nurse.

[fiveofpeep]

I would not have given the norvasc because of the concern of bradycardia being potentiated as norvasc is a CCB. I also wouldn not have given the BB for same reason.

I would give the diuretic.

If you're on day shift, it's always good to check with the MD, but on nights you have to pick your battles and be more autonomous. I agree with what others have said re: asking another nurse...especially the charge nurse.