Blood pressure meds..without parameters???

Nurses General Nursing

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I have this patient that the Doctor Discontinued the Blood pressure Parameters. We have been holding her Blood pressure medication because of her low blood pressure. The parameters were : Hold if SBP

The Doctor discontinued the Parameters. The Doctor is aware of the Low Blood pressure. The patient Code Status is DNR.

I haven't called the MD. I didn't carry the order. It was the Nurse who worked at that time. I talked one of the Supervisor about this. And they say that it is Doctor's Order...and we should follow it. My license is covered since it is ordered.

The problem here is that.....Can we hold the BP meds if it's SBP

Specializes in Emergency.
And they say that it is Doctor's Order...and we should follow it. My license is covered since it is ordered.

NEVER believe that!!!

What if the MD orders the wrong dose and pharmacy doesn't catch the mistake? Are you still going to give it? Of course not. What if the MD misses an allergy? Are you going to give THAT med just because the doc ordered it? I don't think so.

There will be times in your career that you will disagree with the MD about giving a drug. You can't give a drug without a valid order, but you can certainly hold a drug if you have a reasonable expectation that it may harm the patient. Not only can you hold that med, you are morally obligated to do so.

There have been a couple of times that I have refused to give a med (inappropriate dosage) and told the physician that if they really want the patient to have the med that they can give it themselves. Neither MD took me up on that offer.

But don't use this "veto" power indiscriminately. Make sure you know what you're talking about.

Any and every action that you take can impact your nursing license. Never depend on someone else to protect it.

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Many BP meds have other uses, too. Like increasing cardiac output. So if you hold the med for a lowish BP, you might end up causing more harm than good.

Also, my dad has BP in the 100/60s with his BP meds. So, he thinks that is getting close to too low, and holds them. And his BP shoots up to the 170s/110s. His BP is low because of the meds. Right? Maybe it is the same with your pt.

Unless something else is going on, I wouldn't automatically hold the meds. I'd check what his baseline is. You indicate that he has been tolerating this, and that the physician specifically wrote to NOT hold the BP med even with a low BP. So it sounds like he has been tolerating it just fine, and that the BP med is doing it's job, and the physician is wanting him to continue it. I'd also check if the doc mentioned anything about the rationale behind eliminating the parameters in his notes (if you can read them!). And, don't forget your pharmacy is a fantastic resource for you. Call them up. Give a brief explanation and ask "Does this seem right?" They might be able to reassure you that yes, it is, because of X, Y, and Z. Or conversely, no, the doc is smoking crack and this needs to be addressed.

Of course, clarify anything you need to; but I can't help but wonder if your BP med that concerns you is actually ordered for some other cardiac issue.

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Specializes in Peds, ER/Trauma.
My mother's doc has told her never to hold Metoprolol because of rebound B/P - something never mentioned by my doc.

I guess since I work in ER, I was thinking of this in terms of how we give Lopressor in the ER- usually IV, not orally. If my patient's SBP was

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Specializes in Cardiac Telemetry, ED.

SBP

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Specializes in ICU, nutrition.
If the doctor didn't leave any parameters, call him/her before giving the med, and say "Mr. Smith's BP is 95/42. Would you like me to hold the Lopressor?" If the doc says to give it anyways, make sure you chart "Dr. Brown called and notified of BP: 95/42. Dr. Brown stated to give Lopressor as ordered." This way you're covering your butt if the pressure bottoms out. Just make sure you have IV access, fluids ready to go, and can quickly put the pt. in trendelenberg should the pressure bottom out......

Yes but if you go against your judgement, even though you have an order, you are still responsible. For instance, I call Dr. A at 3 AM and report that Mrs. B's BP is 80/50 and she's had no urine output for 3 hours in spite of irrigating her foley. If he tells me to give her 100 mg of Lasix, if I judge that to be incorrect but I give it anyway, I'm liable too if something happens to her. So I may suggest something I think is more appropriate and see if he bites. If not, what to do? Use my judgement and go through the chain of command if I have to.

Doctors occasionally write stupid orders. :icon_roll We have to use our NURSING judgement when carrying out any orders, period.

Having said all that, I'd probably give Mr. Smith's Lopressor, unless his heart rate was really low too.;)

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Of course, clarify anything you need to; but I can't help but wonder if your BP med that concerns you is actually ordered for some other cardiac issue.

That's what it sounds like to me too.

I don't mind taking calls like, "SBP is

What I do mind is rounding on a patient with chronic afib in the morning, and finding out that the beta-blocker was held overnight for SBP

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Just to add this in:

What medication are you holding with those parameters? Example: metoprolol is given more for heart issues than for BP so is normally given even with the blood pressure in the 90s. This is something that needs to be clarified with the physician.

I forgot what the medicine is...It sounded like Hydrazaline..something like that.

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Yes but if you go against your judgement, even though you have an order, you are still responsible. For instance, I call Dr. A at 3 AM and report that Mrs. B's BP is 80/50 and she's had no urine output for 3 hours in spite of irrigating her foley. If he tells me to give her 100 mg of Lasix, if I judge that to be incorrect but I give it anyway, I'm liable too if something happens to her. So I may suggest something I think is more appropriate and see if he bites. If not, what to do? Use my judgement and go through the chain of command if I have to.

Doctors occasionally write stupid orders. :icon_roll We have to use our NURSING judgement when carrying out any orders, period.

Having said all that, I'd probably give Mr. Smith's Lopressor, unless his heart rate was really low too.;)

Thanks you...We are the patient Advocates after all =D

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Specializes in Cardiac Telemetry, ED.

Was it hydralazine? Hydralazine is indicated for management of hypertension, but may be used off-label in the management of heart failure. By dilating peripheral arterioles, hydralazine decreases afterload, which decreases the workload of the heart. If this is why the physician is ordering this medication, then an SBP of

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Specializes in surg/ortho/trauma- float-travel nurse-ic.

Hey, I agree with Kymmi...just because a doc "ordered" you to give something it comes down to nurses judgement. And you are NOT protected because the doctor ordered it. You still dispensed the med against your professional judgement. I have lived this experience but I was lucky enough to go with my professional opinion. After notifying the doc that I'm using nursing judgement and am not comfortable performing a task (and won't) as ordered I carefully documented everything. I was comfortable with my decision and actually the "higher ups" wanted me to write an incident report as I was the one supported. Next day, I was the one backed up and the patient ended up in surgery and the doctor was fine with me. It's scary today and we have to protect ourselves. It's usually the nurse that gets blamed....I've seen too many lawsuits where the nurse was blamed.

I also want to stress that I did this respectfully and did not cause a scene. That helps. :lol2:

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Specializes in Cardiac.

Here's the deal....The pts BP is 'low' becaue the meds are WORKING. That's the point! And, I don't find an SBP of 95 to be all that shocking.

And yes, you can't just hold a med. You have to get an order, otherwise you are practicing medicine without a license.

And if you call to ge that order, and the MD tells you to give it anyway, then you have a choice. Give it, or move up the chain. But you can't just hold a med, and let it be that. A little research and history (like seeing what happend yesterday when the med was givien previously) goes a long way.

Many pts have had major problems with the progression of thier care because meds were inappropriately held.

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I work with a lot of cardiac patients and I agree, many of the meds have dual purposes so I would NOT automatically hold the med. If this is a new patient for me, I ask myself a series of questions. What's the general problem the patient has, what could this med be for, is this a new med, if not what happened when they took it prior, and what is the general status of the patient. A person who is sitting up, eating breakfast looking good with a sbp of 92 is quite a different story than a patient laying in the bed that states they feel weak and look pale with a sbp of 98. Its all part of nursing judgement I guess but I would never automatically hold a med without going through that process and/or calling the doc unless there's a direct contraindication (allergy, overdosing, etc.).

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