Clinical Judgement

[janieg44]

Hi, I'm a Nursing and from New Jersey. I'm in my second semester and we had our clinical at a hospital yesterday. My patient, a 92 year old woman with a repaired hip fracture had a blood pressure of 130/45 and was due for Benazipril and Norvasc. I checked her last reading from her med. record and it was 139/43 2 1/2 hours earlier.

My patient (who was awake, alert, and oriented) said she was concerned about receiving her blood pressure medication because her diastolic pressure was so low. I agreed it was low and said I would talk to my Nursing professor before I came back with the meds in case the dose needs to be withheld or reduced.

My Nursing instructor then told me to "talk her into getting the medication." She said my job is to sell it to her.

I then went to the patient's primary nurse and explained the situation to her. She contacted the Dr. who withheld the meds for the day and had us monitor her BP more frequently.

My question is what is the guideline for withholding BP meds?

I need to know so that if this happens again I'll be more sure of myself.

I feel that if I had listened to my Nursing instructor the patient may have been in trouble.

[psu_213, BSN, RN]

Was that a manual BP or one from a machine? If from a machine, recheck manually. If there is no parameters listed, call the doctor and get some--or even guidance for this one dose. Don't make up parameters based on what you have seen from previous cases. I have seen 'hold' parameters all the way from "hold for sys

Also, the pt may be getting the ACE inhibitor more for tx. of heart failure than for simple BP control.

When in doubt call the doctor.

[Esme12, ASN, BSN, RN]

While it never hurts to hold a med you need to check with the MD. Don't hold a med unless you check with the MD. In certain heart failure patients they need huge afterload reduction (workload reduction) to keep them out of failure. So while it is good to be cautious, you also need to clarify it with the MD.

[notyetnurse]

Good for you; arguing with an instructor is NOT an easy thing and it is only now that I am a working nurse that I am even starting to find my voice. The truth is, being new is equivalent to being unsure of ourselves and, as students, we are certainly both. I shudder to think what would have happened if I had been a student and been faced with the same situation. So again, good for you. Sounds like you're going to be a great nurse.

[SwansonRN]

First of all you want to recheck that B/P. If I get a blood pressure reading that makes me go "hmmmm" I always make sure that its an accurate reading before I start treating numbers. How can you be sure that its a reliable B/P if it's over an hour old and you didn't take it yourself? Second, a lot of cardiac meds will have holding parameters in the order, so pay close attention to those. Also, I'm not saying what you did wasn't right, because the patient's nurse and doc agreed with you,which is awesome, but many patients are on 2-3 B/P meds every day for maintenance so just because their B/P is normal does not automatically mean you hold those meds.