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
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
There are times however that using her/his judgement can/will get one into trouble. A simple call to the MD is all that is needed. I ALWAYS to get parameters for certain drugs to clarify the order and save the MD a phone call. They might be annoyed....but I remoind them that they can be annoyed now or later when they get called....it's their call. Life is all about choices.
There are many reasons for giving certain cardiac/HTN meds. Pre-load/After-load reduction to decrease the hearts work load which decreases the hearts oxygen usage and increases the cardiac overall function. There are patients awaiting transplant that have B/P's consistently LOW, with PA pressures consistently MUCH higher, due to the failure of the heart.....that would suffer pulmonary edema/CHF respiratory distress and possible cardiac arrest if certain meds are not given.
You usually cannot say always and never in medicine. There is just too much grey.
Hold the med, call the doc. Only smart thing to do.
It is our imperative to hold and not do something to a patient if it seems wrong, but we then need to contact the doctor and discuss the matter with them.
I try to never call my docs, but they get paid lots of money so I will call them at 0200 if needed. Better a mad doc, then a dead patient.
In our unit we always run questions by our charge nurses first and collaborate. We have many, highly experienced nurses and learn from each other every shift.
Think outside the box. Many "cards" strive for a lower BP so the patient's failing heart does not have to work so hard.
Feel free to talk to a "card" about that.
That's why I said that *since the pt is a cardiology pt and not in ICU*, I would call the physician in this case. Whether a cardiologist wants a low BP or not, the correct thing to do in this situation is still to hold the med, call the MD, and see what s/he wants to do. :)
From the other side of the issue, I would hope the nurse would hold it an contact me. I would not expect a nurse to give the med with a BP that low but there are also two other concerns: the etiology of that low BP and the abrupt withdrawal from a BB.
Sadly, we ended up losing a patient with a scenario very close to this a few months ago. A visiting nurse held Coreg d/t a BP of 96/54. The patient ended up in pulseless VT in his home, was shocked by medics and survived another several days in the unit before ultimately passing. No one wants that in the back of their minds.
That's so sad! It amazes me how many nurses, including seasoned ones, don't understand how medications work and why their patients are receiving them. I see this too many times with beta blockers (I've administered these to patients with heart rates in the 50's) and insulin, especially lantus (I've adminstered to a patient with a blood sugar of 68 per the endo). If you want to hold a med, you call the md. You could be harming the patient by holding it per nursing judgement.
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.
I am talking legally, of course we have nursing judgement but that does not equal "practicing medicine" which is by many states what we are doing when we hold meds that do NOT have parameters OR without a MD order.
I am talking legally of course we have nursing judgement but that does not equal "practicing medicine" which is by many states what we are doing when we hold meds that do NOT have parameters OR without a MD order.[/quote']
Practicing medicine would be changing the dosage, giving another medicine, or something like that. Patients are instructed to check their pulse and blood pressure before taking antihypertensives. Typically if their hr is low or blood pressure is low they don't take it. Nurses are taught to be critical thinkers and often have judgement to know when and if meds should be held. Legally holding a medicine is within our scope regardless of parameters or orders if we deem it is unsafe. To me it appears you are always calling a doctor because where I work I often am holding blood pressure meds, insulin, and other drugs since they would make the patient worse. If your patient had had stool
Softeners three days straight and is now doubled over in cramps and having explosive diarrhea would you give your offered dose or hold it? Hopefully you would hold it since another dose would just cause more pain. Nurses should have the sense to know what every med they give does and how it will effect their patients.
I am talking legally, of course we have nursing judgement but that does not equal "practicing medicine" which is by many states what we are doing when we hold meds that do NOT have parameters OR without a MD order.
It's not only legal, but expected for Nurses to hold a med based on their judgement. You do need to inform the MD when you hold a med, but if the MD says "give it anyway" you are still expected to follow your judgement, not the order, the MD can come in and give it himself if no agreement can be reached.
Any decision making needs to be based on good awareness of the patient-specific plan, which will always mean call the MD if the plan hasn't been communicated.
For some patients a BP of 83/46 would be more than enough reason to hold the dose and notify the MD of a status change, in other patients however 83/46 might be right in the middle of goal range. Not all patients are able to achieve the "ideal" BP parameters, and for some patients 80/40 is "ideal" (it's no picnic living with an EF of
Another very important thing to keep in mind is that there is a huge difference between the vitals prior to the first dose of a med and the vitals prior to med where a steady-state metabolism has already been reached, in other words, there is a huge difference between starting coreg when their BP without coreg is 83/46, and giving a continuing dose when their BP is 83/46 as a result of coreg.
I've had patients where a BP in the mid to high 90's is a reason to increase the dose, not to hold it, so there is no general rule that can be followed and general parameters are fairly useless, particularly in the case of coreg which is used for anything from simple BP control in patients with trivial failure to patients who given the right circumstances have a bridge or destination VAD.
The bad part about that, is if he says give it, you have to decide what you're going to do. I know ultimately the person who administers the med is the one responsible if something goes wrong. If you refuse to give the med, you have one really mad doctor who can make your life miserable.
Hold the med and call the doc is the best answer, but it sure isn't the easiest.
Esme12, ASN, BSN, RN
20,908 Posts
There are times however that using her/his judgement can/will get one into trouble. A simple call to the MD is all that is needed. I ALWAYS to get parameters for certain drugs to clarify the order and save the MD a phone call. They might be annoyed....but I remoind them that they can be annoyed now or later when they get called....it's their call. Life is all about choices.
There are many reasons for giving certain cardiac/HTN meds. Pre-load/After-load reduction to decrease the hearts work load which decreases the hearts oxygen usage and increases the cardiac overall function. There are patients awaiting transplant that have B/P's consistently LOW, with PA pressures consistently MUCH higher, due to the failure of the heart.....that would suffer pulmonary edema/CHF respiratory distress and possible cardiac arrest if certain meds are not given.
You usually cannot say always and never in medicine. There is just too much grey.