Holding Antihypertiensives

[jamiejohnson2007]

I have a question regarding holding antihypertensive medications. I am currently an LPN, and will be completing my ASN program in May, so will soon be an RN. Today, a co-worker and I had a situation where we decided to work together on our patients, just to make things easier. We work at a rural, critical access hospital. Med-surg, wide variety of patients. Anyway, the patient we were working with has a PEG tube and is NPO, s/p CVA, MI. He is scheduled to receive 6.25mg Coreg (Carvedilol) BID. We assessed BP reading of 83/46 and P-54. (The coworker I was with is an RN.) She saw the pressure and said she was going to hold the scheduled Coreg dose. I agreed with her, as we have both learned in our schooling when BP is

[schnookimz]

It needs to be weaned when discontinuing.

I would have called the doctor. That bp is kind of low to just do nothing at all. This would also be an opportunity to ask the doctor about the coreg and get parameters for holding the dose or lowering the dose.

[jamiejohnson2007]

Same patient has been having antihypertensive episodes with lower pressures than we obtained. I think the prescribed dosage should be decreased?

[itsmejuli]

Were there holding parameters in the doctor's order? If not, I would have contacted the on-call doc.

[LadyFree28, BSN, LPN, RN]

I would've called the Dr. to notify 1. holding Coreg due to the parameters and 2. If the pt was having a trend of low BPs to get recommendations on additional interventions; ie changing the dosage of Coreg.

Just my two cents.

[macawake, MSN]

He is scheduled to receive 6.25mg Coreg (Carvedilol) BID. We assessed BP reading of 83/46 and P-54.

I personally would not administer a betablocker to a patient with those vitals. I'd call the treating or on-call physician to inform her/him of the patients vitals. I'd also ask them to include hold parameters for future med administration if it hadn't already been done.

The patient is borderline bradycardic and with a bp (map) that low I'd start to worry about organ perfusion. Did the patient have any symtoms related to the somewhat low pulse and definitely low blood pressure?

I can understand the other nurses point of view to a certain degree. I've met nurses who are afraid to administer betablockers, antihypertensives or diuretics when the patient has a systolic pressure of for example 100 or a pulse of 60. They're concerned that the medication will lower them even more when in reality their vitals are where they are because they are receiving the correct treatment and they need their meds to keep them there. So, a nurse can be over-cautious in my opinion. But 83/46 is too low and I'd hold the med until consulting with the physician.

This is just my 2 cents, for what they're worth

After reading Sun's post I feel that I must add, I have no knowledge of the legalities surrounding med administration in the U.S. That's why the above is only my two cents. I'm Swedish and here a nurse is obligated to determine if the physicians orders are reasonable (checking relevant labs, vitals among other things). When in doubt, hold and check with the physician.

[Sun0408, ASN, RN]

Legally, you can't hold a med with a MD order. Tricky but I would have called the MD. I love parameters for this very reason, many cardiologist will want to continue meds unless BP is less than 80 or HR less than 50 that I have worked with.

[nrsang97, BSN, RN]

I would have waited to administer until I had paramaters for administration per the physician. I would have looked at the trend and asked the physician about lowering the dose as well. Noting wrong with holding off on giving until clarifying with the MD who ordered.

[Esme12, ASN, BSN, RN]

Same patient has been having antihypertensive episodes with lower pressures than we obtained. I think the prescribed dosage should be decreased?

what do you mean "anti-hypertensive" episodes? did you mean hypotensive episodes?

Here is the deal....some anti-hypertensive mends are given for other reasons that a high blood pressure. Some help the heart work not as hard by decreasing it's work load and increasing efficiency in the setting of heart failure. These patients NEED these drugs to stay out of heart failure. Sudden withdrawal of a beta blocker can result in rebound tachycardia and HTN which can hurt the patient with a new MI.

I would have probably would held the med temporarily but called the ordering MD for parameters or a change in med especially in the presence of bradycardia.

Does this patient have heart failure? Where was the MI? Anterior? Inferior? Lateral? What is the previous medical history? How long has this patient had hypotension and bradycardia? Are there holding parameters?

[Been there,done that, ASN, RN]

Depending on the underlying pathology, many cardiologists WANT the blood pressure/ heart rate that low for treatment purposes.

That being said, any additional parameters should have been addressed by the prescribing physician.

Was the B/P rechecked via auscultation in both arms? Was the patient symptomatic?

P.s. You're beautiful

[sapphire18]

A BP of 83/46 has a MAP of 58...in my ICU, if that patient were on pressors we would still be titrating UP (90% of our patients have MAP goals of 65mmHg)...so yes, this BP definitely warrants holding a beta blocker. A minimum MAP of ~65 is necessary for adequate brain, kidney, and coronary artery perfusion. I wouldn't be comfortable with a HR any lower than the patient already had, either; most BB holding parameters for HR that I have seen are for less than 50-65...this one is really more patient specific. As the patient is a cardiac patient, and not in ICU, I would definitely be calling the MD to let him know that the BB was being held (not to mention finding out if he wants any interventions performed for the hypotension). Best practice would be to have the cardiologist put hold parameters on the coreg for both BP and HR...otherwise technically yes, you do need to call if holding the med. Cards may want you to administer something else instead, especially if he is consistently more hypotensive than they want him.

As for the oncoming nurses being "very adamant that the drug should absolutely NEVER be held, not even in the case of such low pressure"...no prudent nurse would administer a beta blocker to a pt with these vitals. Next thing they'd know, the patient's pressure would be 70s/30s and he wouldn't be making any urine...I'd like to see them explain that one to the MD.

[mh0712, MSN, RN]

Legally you can't hold a med with a MD order. Tricky but I would have called the MD. I love parameters for this very reason, many cardiologist will want to continue meds unless BP is less than 80 or HR less than 50 that I have worked with.[/quote']

A nurse can hold any order he or she deems unsafe. It is "nursing judgement". You can legally hold anything as long as you have a legit reason. You do not give beta blockers when hr is less than 60- unless there is an absolute reason or need. You do not give antihypertensives when blood pressure is low, you do not give a scheduled dose of insulin if pt has a blood sugar of 70. Not trying to be rude but orders can be held, administered late, or whatever else the nurse deems safe for the patient.