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

[SnowboardLovinRN]

I would have probably rechecked the BP in an hour. If still low call MD, hopefully someone will round on the pt before. If not give the med then. Another post said it well... BP is so transient sometimes.

Another thing that is sometimes best is to look at your AM meds and stagger the ones that have an effect on the BP. Not all daily meds need to be given at 9am... and BID (depending on your facility policy) could possibly be retimed a little while later. Unless a SBP is >130 or the pt is a chronic HTN pt this is something I often look at.

[arlel58]

Another name for Coreg is Carvedilol..Pulse (HR) was never metioned in the scenario we know that the "olols" are also to treat HR and Pulses. By then maybe nursing judgement can be applied and can be held if hr lower than 60. Or if i was the nurse I should have checked the BP on the other arm as well to just get a comparison. Critical thinking is very important in this kind of scenario.

[LaylaHendrix23]

I always just "CYA" and call the Doc for parameters! Like others have said the Docs sometimes hold for different parameters depending on the pt, so I always like to just know what the Doc wants. They are getting paid the big bucks to make those decisions, so whenever I am second guessing myself I always just "CYA." =)

I also have done what others have said, where I will re-check the BP in a half hour or so before calling the Doc to see how the pts BP is doing and if it is still low I will call and then get parameters!

[ZippyGBR, BSN, RN]

At my place, we are not allowed to hold without an order, it's called practicing medicine without a license.

.

'Just following orders' is not a defence , why do you think that Medication Adminstration is an activity restricted to Health Professionals in settings where patients are deemed to require Nursing care ? If the plan of care is not clear then yes you do need to speak to other members of the team , but blindly giving a medication just because it is prescribed is not good Nursing Practice.

[Mulan]

'Just following orders' is not a defence , why do you think that Medication Adminstration is an activity restricted to Health Professionals in settings where patients are deemed to require Nursing care ? If the plan of care is not clear then yes you do need to speak to other members of the team , but blindly giving a medication just because it is prescribed is not good Nursing Practice.

I'm not saying blindly give it, I'm saying if you are going to hold it, you have to call.

Big difference. Comprehension problem?

[Mulan]

'Just following orders' is not a defence , why do you think that Medication Adminstration is an activity restricted to Health Professionals in settings where patients are deemed to require Nursing care ? If the plan of care is not clear then yes you do need to speak to other members of the team , but blindly giving a medication just because it is prescribed is not good Nursing Practice.

Conveniently take something out of context and quote what suits you.

The next sentence states to call and get parameters.

[gninab]

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

(2xSBP+DBP)/3

I believe it is (2xDBP + SBP) divided by 3.

[Anna Flaxis, BSN, RN]

I believe it is (2xDBP + SBP) divided by 3.

Thank goodness our monitors tell us the MAP!

[AgentBeast, BSN, RN]

I believe it is (2xDBP + SBP) divided by 3.

Actually we are both correct and both formulas are correct. I was taught (2xSBP+DBP)/3=~MAP Either formula is just an estimation as the only way to know for sure is to put in an arterial line.

Not that wikipedia is a great source, but . . .

http://en.wikipedia.org/wiki/Mean_arterial_pressure