Beta-blocker administraion error?

[Bosco15]

Hello fellow nurses.. Need some advice,

I am a new nurse (6 months) in a ICU. I administered 2 beta blockers (metoloprol 50mg and coreg 6.25mg) to a pt that had SBP of 190, HR 150. I checked with another anor nurse about administering all 4 bp meds total and was told to give them. I separated them in to two administrations on at 21 and the other at 22. Was it wrong to administer 2 beta blockers. I didn't even realize it until after administer them. Just curious?

[healthstar, BSN, RN]

It's epocrates. You can get it for iPhone, iPad, iPod Touch, Windows mobile and I believe Blackberry devices. I assume it is available for the Android platform as well.

I love Epocrates...I keep looking up the drugs all day to learn them...I have it on my IPOD Touch----it is extremely helpful it also shows pictures of how the meds look like.

It is amazing, easy to look things up. For those of you who don't have and want to have it, let me tell you it is easy to download, and it is FREE....Google it!!

[whichone'spink, BSN, RN]

Is it completely free, with no subscription?

[GilaRRT]

Is it completely free, with no subscription?

Yep, it's free.

[suanna]

Was the patient ordered those two medications- were they ordered by the same doc or service? ? I must assume so since they were "due". Where I work the medical staff would have kittens if every time they made a decision it was questioned and picked apart by the nursing staff. We have a role in patient care coordination- BUT WE ARE NOT DOCTORS. despite our education it is the medical staffs responsibility to manage these drugs. Was the patient having bradycardic periode after giving these meds? If so they need to be held pending clairification by the doc on call. Splitting the dose was a great idea. Honestly, if a doctor has to justify the course of treatment to every new nurse on every shift- they would get very little patient care done.

[NYRN05]

Was the patient ordered those two medications- were they ordered by the same doc or service? ? I must assume so since they were "due". Where I work the medical staff would have kittens if every time they made a decision it was questioned and picked apart by the nursing staff. We have a role in patient care coordination- BUT WE ARE NOT DOCTORS. despite our education it is the medical staffs responsibility to manage these drugs. Was the patient having bradycardic periode after giving these meds? If so they need to be held pending clairification by the doc on call. Splitting the dose was a great idea. Honestly, if a doctor has to justify the course of treatment to every new nurse on every shift- they would get very little patient care done.

Well I honestly have been in your shoes...worked on a cardiac step-down before going to the cardiac ICU. It was on the step-down that the patient was ordered for coreg and lopressor. Kudos! to you for questioning it...who cares if they have kittens, let them have 2 litters! More than likely it was some little resident who was in the ICU ( I assume-if it was the attending then shame on them) and not the attending, who didn't really understand that the Attending Cardiologist wanted the patient to get 2 B Blockers. When I questioned it, they had the exact rationale for it....although I cannot remember now lol. But as a Registered Professional Nurse, these interns and residents still don't know it all, and neither will you, so you learn together and from eachother. To try to make you fell inadequate is totally uncalled for. I don't think it is entirely up to the doctor to manage those meds, because they make mistakes as well, and sometimes pharmacy does too, so who is the last person the medication goes through before the patient gets it, THE RN ! So to say we are not responsible is crazy, just because something was ordered by an MD, and delivered or entered into the system by the pharmacist, DOES NOT MEAN YOU DON'T QUESTION IT. Even more so in the ICU, you have 1-2 patients for a reason, so knowing each and every little detail is necessary. It is within our scope of practice to educate and advocate for the patient, which first includes educating ourselves and standing up for our own thoughts and concerns before just following through with an order by an MD. I don't know where you work susuana but I have yet to see a MD do ANY patient care, they round, discuss the plan of care, course, medications, treatments, tests, but never have I seen them perform patient care-except for doing procedures at the bedside, but where you work may be a totally different place. It is their responsibility as the MD to justify the course of treatment to all disciplines, we have a professional job and taking a backseat or subserviant role to the MD is what will keep nursing behind in my opinion, keep on questioning to the OP. If the attending explains it clearly to a resident, or charge RN, or the nurse who is providing the care to the patient, that information can be passed along, so you won't have to keep "bothering them" so to speak. I work in a university teaching hospital-for a reason, and I question them all the time-remember they are learning. They are there for a reason as well. In the end, in court, it's my license, not some resident who is no longer there. Thats my 2:twocents:

[netglow, ASN, RN]

Epocrates has a lesser version that is free. It is an expansive program that has many facets... if you want to drop some $. Many physicians have the full deal. I have the free version but rarely use it, as I did purchase Davis Drug Guide from Skyscape. That one has all the details nurses must have for drug admin. as well as an interaction checker. Epocrates only really shows the very basics more geared for dosing (writing scripts). One thing about Skyscape tho, their latest update causes everything to crash, and that really sux! I erased it from my iTouch and reinstalled my earlier version off of my laptop. If you join Medscape they also have a free drug reference that is more useful to me than Epocrates.

[CNL2B]

I don't see this as an error. Your patients VS warranted what you gave him.

Although Lopressor and Coreg are both B-blockers, often times Coreg is specifically prescribed for heart failure and is more helpful for that type of problem than other B-blockers. So, they are not exactly the same, which would be my guess as to why they were both prescribed. However, if you had a question about it, I don't see any problem with asking. Other posters are correct however in that as RNs, we don't really have the authority to not give a medication unless it is a potential safety issue -- not really up to us as far as what they are going to get and not to get.

I work in a SICU and we often give scheduled Lopressor to OHS patients. If the effect isn't what was desired (B/P or HR are still out of range) we often will use IV Lopressor or Labetolol on top of that. Sometimes they get dosed as frequently as every 3-4 hours if necessary and their VS tolerate it.

I wouldn't worry about the second code. It doesn't say but I am wondering if your patient had a big MI (from the code scenario that is what it sounds like.) Sometimes in spite of our best interventions nature takes it's course. I don't think it was anything you did or the meds you gave. Critical patients often have a second arrest shortly after the first if the reason why they coded in the first place isn't remedied, and it's been my experience that the second code is typically fatal.

[wtbcrna, MSN, DNP, CRNA]

FYI: Lopressor is a Beta 1 selective blocker and Coreg is nonselective beta blocker and an alpha 1 blocker. Log In Problems Coreg has also been shown to be an Calcium channel blocker at higher doses, although the CCB portions insignificant.

[Bosco15]

I don't see this as an error. Your patients VS warranted what you gave him.

Although Lopressor and Coreg are both B-blockers, often times Coreg is specifically prescribed for heart failure and is more helpful for that type of problem than other B-blockers. So, they are not exactly the same, which would be my guess as to why they were both prescribed. However, if you had a question about it, I don't see any problem with asking. Other posters are correct however in that as RNs, we don't really have the authority to not give a medication unless it is a potential safety issue -- not really up to us as far as what they are going to get and not to get.

I work in a SICU and we often give scheduled Lopressor to OHS patients. If the effect isn't what was desired (B/P or HR are still out of range) we often will use IV Lopressor or Labetolol on top of that. Sometimes they get dosed as frequently as every 3-4 hours if necessary and their VS tolerate it.

I wouldn't worry about the second code. It doesn't say but I am wondering if your patient had a big MI (from the code scenario that is what it sounds like.) Sometimes in spite of our best interventions nature takes it's course. I don't think it was anything you did or the meds you gave. Critical patients often have a second arrest shortly after the first if the reason why they coded in the first place isn't remedied, and it's been my experience that the second code is typically fatal.

I drew cardiac enz right at the beginning of my shift. The troponin was critically elevated. The more I think about the situation she probably had a large MI. Later that night the Dr. said the same thing, so your are right. I think it was just drugs that were keeping her alive through out the night until the pt was made DNR. I feel better about the situation. I just wanted to understand everything, which I am doing due to this board!! THanks..

[suanna]

Well I honestly have been in your shoes...worked on a cardiac step-down before going to the cardiac ICU. It was on the step-down that the patient was ordered for coreg and lopressor. Kudos! to you for questioning it...who cares if they have kittens, let them have 2 litters! More than likely it was some little resident who was in the ICU ( I assume-if it was the attending then shame on them) and not the attending, who didn't really understand that the Attending Cardiologist wanted the patient to get 2 B Blockers. When I questioned it, they had the exact rationale for it....although I cannot remember now lol. But as a Registered Professional Nurse, these interns and residents still don't know it all, and neither will you, so you learn together and from eachother. To try to make you fell inadequate is totally uncalled for. I don't think it is entirely up to the doctor to manage those meds, because they make mistakes as well, and sometimes pharmacy does too, so who is the last person the medication goes through before the patient gets it, THE RN ! So to say we are not responsible is crazy, just because something was ordered by an MD, and delivered or entered into the system by the pharmacist, DOES NOT MEAN YOU DON'T QUESTION IT. Even more so in the ICU, you have 1-2 patients for a reason, so knowing each and every little detail is necessary. It is within our scope of practice to educate and advocate for the patient, which first includes educating ourselves and standing up for our own thoughts and concerns before just following through with an order by an MD. I don't know where you work susuana but I have yet to see a MD do ANY patient care, they round, discuss the plan of care, course, medications, treatments, tests, but never have I seen them perform patient care-except for doing procedures at the bedside, but where you work may be a totally different place. It is their responsibility as the MD to justify the course of treatment to all disciplines, we have a professional job and taking a backseat or subserviant role to the MD is what will keep nursing behind in my opinion, keep on questioning to the OP. If the attending explains it clearly to a resident, or charge RN, or the nurse who is providing the care to the patient, that information can be passed along, so you won't have to keep "bothering them" so to speak. I work in a university teaching hospital-for a reason, and I question them all the time-remember they are learning. They are there for a reason as well. In the end, in court, it's my license, not some resident who is no longer there. Thats my 2:twocents:

I can only hope we can agree to disagree. Do you trust the docs you work with?, Do you have any other sources of input ( senior nurses, pharmacy, supervisor...)? Is the patient showing any sign that these medications may be causing a problem?

A cardiologist may have as many as 50 patients in the hospital at one time. The resident staff can help with rounds and progress notes, but he still has to see patients in his office as well as in-patient, do proceedures, teach, run the business side of his practice, and perhaps eat, sleep, pee, ... I can find a good reason to question EVERY med my patient is on, but if I challanged the medical staff on every dose of every medication they order neither they nor I would get much work done. Sometimes it's hard to know when you are using sound clinical judgement to protect a patient, or just nit-picking to make sure you have covered to "patient advocate" role. The practice of nursing involves mentoring less experienced staff- the senior nurses or pharmacy would have been a better resource before calling the doctor to reaffirm the order he had given. Order from different services, junior intern, having clinical changes that could be side effects- you are right to clairify, but if the patients attending doc has made this call, he gets a bit of the benefit of the doubt.