Held Coreg w/ BP of 100/55

[noyesno]

[New grad here. Ortho/Neuro/Trauma floor.]

I held Coreg yesterday and I'm thinking I should have probably called the MD instead to see if the dose should be adjusted or if he wanted it held or not.

Here are the details:

-50 year old male, 140 lbs

-Patient had a nephrectomy

-On post op day 1 he had some minor chest pain, got stat labs drawn and his troponin was elevated

-Called a RRT and got a cardiologist on board

-Cardiologist ordered Coreg 6.25 BID

-The next day, in the morning, his BP was 100/55

-I looked to see what his BP went down to following his first dose of it on PM's and it went from 122/85 to 94/54

-Thought that was a pretty big drop and I worried what it would drop to if I gave it with a BP of 100/55

-He was also on a PCA that he was using very regularly which made me extra worried he would bottom out

-His hemoglobin was also 8.1 (had dropped from 16, urologist didn't want to transfuse, cardiologist did, urologist won and no transfusion was to be done) and it seemed like a bad idea for him to be anemic and also hypotensive

I should add, from reading the cardiologist progress note it appeared that the chest pain and elevated troponin was not related to CHF or anything but rather to his surgery and cancer. I know beta blockers shouldn't be held for CHF patients so if it wasn't CHF, I thought it would be okay. However, I also know beta blockers are given following a heart attack so I'm thinking I shouldn't have held it because of this.

Also, on post op day 1 the attending MD had discontinued the patient's lisinopril due to low BP (I think from the PCA).

My preceptor was okay with me holding the Coreg but I don't think she was very sure about it.

Overall, I'm not happy that I did not call the MD and I'm feeling a little dumb. Would like to learn from this situation.

Any pointers?

Thank you all in advance.

noyesno

[Miller86]

I've given coreg with a BP close to that, but I did talk with couple of other nurses before proceeding. Later during physician rounds, I asked the doctor to put in parameters for that patient. He wanted 'hold when systolic

If you're unsure just call the doctor, that's what they get paid for after all. Yeah they won't like it but they need to deal with it. Mostly they get annoyed with questions that appear "stupid" to them but are vital for safe patient care. When in doubt, just call and ask.

I gave a BP medication once when the patient's BP was 104/60 (parameters were to hold if HR

Just an example I wanted to share!

Don't beat yourself down, next time just call them. They will dislike you for it but you will be doing it for your patients and that's what matters.

[AgentBeast, MSN, RN]

MAP > 60 pass the med unless the orders specify something different.

(2xSBP+DBP)/3

[glencovediva]

You cannot hold meds without an MD's order. If you are not sure, call the MD. Better safe than sorry.

[Amanda.RN]

I also would have contacted the doctor. Don't beat yourself up though. You mentioned your preceptor thought it would be okay? I think it'd be reasonable to discuss this further with your preceptor to see what his/her rationale was. You could also consider consulting with the charge nurse to see what input he/she may have.

- Amanda

[MunoRN, RN]

You cannot hold meds without an MD's order. If you are not sure, call the MD. Better safe than sorry.

You can absolutely hold meds without an MD order. If you believe the MD may disagree with holding it, you need to notify the MD, but even if they tell you give the drug the drug regardless of your concerns, it's still your decision to give the drug, the MD can give it himself if he really wants it given.

[RockinChick66]

Great responses. Thanks everyone.

Our docs rarely give parameters and the nurses on our floor hold BP medications all the time without consulting the docs. This is something I do not feel comfortable doing and will be calling to get parameters in the future.

It's not within our scope of practice as RNs to practice medicine; when we "hold" doses we are practicing medicine if we do it without a doctors order. If I feel like a medicine needs to be held, I will hold it at that time then call the doctor within an acceptable time frame to get the order to cover me. If there are parameters, then it's okay to hold without calling. But you must ALWAYS call when you decide to hold a particular medicine, if you don't, then you are practicing medicine.

[MunoRN, RN]

If in doubt, calling the Doc is always a good idea. Some things to think about with Coreg; The drop in BP you might see with the first dose will probably be larger than with subsequent doses. With the first dose, the BP prior to giving it doesn't reflect the action of the Coreg, with the next dose, the BP will be affected by the previous dose since coreg has a fairly consistent level of action through 12 hours, meaning that in theory the BP shouldn't change too much before and after each dose. Also, the BP change you saw after the PM dose may have been at least partly due to normal BP changes between day and night.

The added BP alpha effect of coreg is both a blessing and a curse. With heart failure we often don't hold unless it's less than 80, although the cardiologists I work with have pretty much all switched back to metoprolol for the most part which has made things a little easier. Treating BP separately from beta blockade allows each to be titrated independently, plus the main study used to support coreg's advantage was impressively flawed.

[MomRN0913]

I would have held it. Parameters always do help. What was the HR? In the ICU where I worked, we kind of had freedom to do that, to use our critical thinking. But yes, calling the doc, and having them put parameters on it is always good, and even if you go against parameters, you should notify the MD if you think the patient will still drop.

I had a patient once who's BP would go very high if he was awaiting HD. he just needed HD. I knew this patient could go from 200/100 to 80/60 when undergoing HD and would have ot be SPA for BP support. I did tell the cardiologist (very old school) that HD would not be for a while, can I give him a small dose of clonidine or hydralizine in the meantime. Instead he orders Metoprolol 10mg IVP Q4! The guys HR was in the 70's! I was not giving it!!! Thank God the Nephrologist came in right after him and I showed him the order and he goes "is he ******* crazy?" and DC'd the order. I would go with your gut, but notify the MD

[nrsang97, BSN, RN]

I would have held and called MD for paramaters. Then recheck BP if within ordered paramaters given the med.

[sonja77]

I would have given the Coreg. Our cardiologist wants us to give low-dose Coreg regardless of the BP. In the past she had problems with Coreg being held for low BP, so she started writing "do not hold Coreg unless SBP

[psu_213, BSN, RN]

Our docs rarely give parameters and the nurses on our floor hold BP medications all the time without consulting the docs.

This is very unfortnate in my mind. I've seen hold parameters on Beta blocker that range from SBP

[danh3190]

We have a lot of cardiologists on our floor and they're all different. I've gotten chewed out for holding beta blockers on patients with HR in 50s even though 60 was the written parameter on the order. Cardiology attendings often like their patients a little bradycardic and hypotensive. I'm willling to follow their orders as long as I'm convinced that they understand the patient's situation when they give the order. I kind of think that if I explain the situation and then refuse to follow their order, that would be practicing medicine without a licence.