Question about holding meds

Nurses General Nursing

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Hi everyone. Brand new nurse here, just started in med/surg (yay for a job!) and I am in orientation right now. I am with multiple preceptors, there are never any parameters for blood pressure meds, and each preceptor seems to have widely differing perspectives of when these meds should be held. One nurse had me hold all of a patient's bp meds when his bp was perfectly normal (~124/70-something), and then chart them as being held for a low blood pressure. Heart rate was normal as well. Her thinking was that she didn't want to give them and have the bp drop out of the normal range. My thinking is that the meds are what is keeping it normal and it should be given to keep it from jumping up. I really did not feel comfortable charting her reason for holding it either, as the bp was not low. Anyhow, I wasn't in any place to argue at the time as we were scrambling and, with me having graduated last spring and just now getting a job, I am not entirely confidant in my nursing judgment just yet. Oh, and no one ever seems to notify the doctors when any meds are held either. Is that normal? Any advice? The last thing I want to do is pick up bad habits...

Thanks in advance!

Specializes in Sub Acute Rehab/ Oncology Med-Surg.

i wouldn't have held the medication if the bp is wnl.. doesn't make sense. a doctor should always be notified if a medication is held or refused. if the bp is wnl now, in an hour it may not be because the medication wasn't given. if a bp is running low, maybe the medication has to be adjusted.

Specializes in Psych Charge RN/ Med Surg/Float Nurse.

I think you are right. I would not hold bp meds for a normal blood pressure. As you said, the meds are what are keeping it normal. Just go with your preceptor for now. You will be on your own soon and can do things your way.

Specializes in critical care, PACU.

yeah I am so glad I learned this randomly a while back on Allnurses, because I went through an entire nursing education without ever seeing a nurse call an md for a held med so I had no idea this should be done.

I think your judgment was spot on. I start my preceptorship soon. Anyone have any tips for how the OP (and me in the future) can dart around the sticky situation of how to handle the preceptor?

Specializes in Med Surg, Home Health, Dialysis, Tele.

if your preceptor wants to chart something like that make sure that it is in her name, not yours. remember one thing, that all your charting should be done so that if you went to court you could paint an accurate picture of what was going on. to me, if she was called into court and her reasoning was low bp when it was clearly wnl, that would put into question anything she charted or told the jury.

with that being said, i don't always call the doctor when a pt refuses or a med is held. of course it also depends on what it is. if a pt is refusing blood infusion and the hgb is 7.5, yeah i think i will call the doc. if the bp is held due to a bp below the parameters, probably won't. a lot of things are a case by case basis.

:heartbeatto me there are no set answers, it is clinical judgement, that is what makes nursing sooo special. :redbeathe

Specializes in trauma, critical care.

I agree with your rationale. The BP meds should have been given. Try to find the actual policy at your institution for clarification. It is possible that that P&P doesn't exist or is inadequate, in which case, you could bring it to your supervisor's attention and offer to participate in your facility's P&P committee. You are also correct that the provider should be notified if a med. is held, but use your nursing judgement here! Are you really going to call the doc. every time you hold a med (you'll be calling a lot)? Are you going to notify the house officer when a Colace is held for loose stools at ten o'clock at night? Technically, you should alert the ordering doc. or cross-cover when any med. is held, but doing so will not make you any friends on the medicine side of things. I usually group my notifications and tell the doctors when they round or when I see them.;)

Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.

Your judgement was exactly right and unfortunately the one who was supposed to be teaching you was wrong. The decision to hold a bp medication should be done based on pt condition and history and "not" because it might make them fall out of normal range.

For example - if your patient was a liver/renal disease pt who presented with new onset HTN, and was given metoprolol to bring it down - and you noticed a steady decline in the SBP - you could hold the meds and call the doctor with your concerns - namely that you feel the medication is not being cleared fast enough and that it is having a cumulative effect.

However, if the patient normally suffers from HTN and his BP is 120-130's with his medication - why would we hold it? Unless we want his blood pressure to go up.

Also never sign any charting that you don't agree with, unless it is something you did - you could sign you held the bp meds (because you did), but don't sign for low bp (since you don't agree with that). As the poster above mentioned - this is a legal document and can be used in court. It is much easier to answer questions about your documentation if you at least agree with what you said.

Hope this helps

Pat

Specializes in critical care, PACU.
Are you going to notify the house officer when a Colace is held for loose stools at ten o'clock at night? Technically, you should alert the ordering doc. or cross-cover when any med. is held, but doing so will not make you any friends on the medicine side of things.

For someone working nights, how would you recommend I accomplish this. I definitely dont think it prudent to call over inconsequential med holds in the middle of the night, but I wont be seeing them before I leave. Do you just trust that acknowledging it in the chart is enough?

Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

I also would have given the meds.

Specializes in ICU/CCU, Home Health/Hospice, Cath Lab,.
For someone working nights, how would you recommend I accomplish this. I definitely dont think it prudent to call over inconsequential med holds in the middle of the night, but I wont be seeing them before I leave. Do you just trust that acknowledging it in the chart is enough?

We have a doctor communication sheet in front of the order section in our charts. Nurses can relay concerns or questions there. For a held med we would document a prog note and then write a communication note if we wanted a change or clarification. Also our medication charting is computerized so if we hold a med it literally says on the screen "Med held" and then gives the reason - so the doctor perusing the charting will know why we held it.

As long as you somehow document why you held it, and the matter is not urgent (colace at night for example) then that should be sufficient.

Hope this helps

Pat

Specializes in trauma, critical care.
For someone working nights, how would you recommend I accomplish this. I definitely dont think it prudent to call over inconsequential med holds in the middle of the night, but I wont be seeing them before I leave. Do you just trust that acknowledging it in the chart is enough?

If I held a med. and wanted to notify the physician., I used to flag the chart/progress note section (this was the days of paper charts and post-it notes) notifying the MD. I also passed it on in report. Today, using electronic charting, maybe you could send them a note to their "in-box." I've also always worked in large teaching facilities where the doctors often review the MAR for the last 24 hours before rounds. And, honestly, there are many instances where I haven't told the doc. a med. was held. EX.: Patient was made NPO and Regular insulin held before surgery, patient had an episode of N/V and MV, Fe, and Vit. C were held, etc. Often, I do not notify when the meds are held for discreet, self-limiting reasons. Instead, I look for and report trends in the patient's condition -- are the patient's BP meds being held every shift because the patient is hypotensive, has the patient's Colace been held for two days because they've had diarrhea? This information is often more useful than reporting a single instance of a med. being held.

Specializes in Acute Care, Rehab, Palliative.

Yes I agree with other posters. I would have given them. Your reasoning sounds right. In the hospital where I work we never call for held meds unless someone has an ongoing issue.If a med is being repeatedly we ask the doc(we only have one) to reassess.

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