Holding diuretics, beta-blockers, and nitrate when there are no parameters

[JJBookman]

I Work at a skilled nursing facility as a registered nurse. When I look at the administration record of some of my residents, I see particular nurses do not give medications because the resident’s blood pressure is borderline (e.g., 119/62). But, there is no parameters set by their doctor. I would understand Holding it if their BP or HR is abnormally lower than normal. But there are no parameters. Some nurses hold it, but would not let the doctor/NP know.

Why is that?

And they call every medicine they give “BP meds”, like Carvedilol, furosemide, and HCTZ. There are patients who are prescribed these medications and they’re not taking it’s to specifically treat high blood pressure So, Why?

[Here.I.Stand, BSN, RN]

That sounds dangerous... the pt’s BP is normal BECAUSE they are on whatever BP med. Plus diuretics are frequently (usually?) not for BP but to avoid a CHF exacerbation... or a beta blocker can be used post MI or as an anti-arrhythmic. I’ve known some physicians to be quite tolerant of a low BP because the benefit of the med outweighs the risk of a soft BP. Besides the resident lives on these drugs. A regular dose isn’t going to randomly tank someone’s BP when they’ve been on it months to years.

If in doubt they really should be calling to clarify

[FolksBtrippin, BSN, RN]

What is the point of this post?

The decision to hold a med is based on the specifics of the situation.

Nurses can and should hold medications sometimes for a variety of reasons.

If you want to criticize a particular instance of holding a med here, then present us with all the clinical information.

But If you want to make an argument that nurses should never hold meds without parameters, that's wrong.

[JKL33]

119/62 is not a borderline blood pressure. You probably don't have all the information about these nurses' decision-making but if they are indeed just holding meds without parameters or good judgment that is then communicated to the provider, then they are essentially practicing outside their scope. This is not good care.

[Corey Narry, MSN, RN, NP]

OP, you're in a tough situation and your concern is legitimate. Unfortunately, I think a lot of staff education must happen in your setting. Typically, the residents in your SNF has had at least a 3-day acute care hospital stay where hopefully the medication list for each particular resident were fine tuned and reviewed by a provider in the hospital prior to discharge so that there shouldn't be any reason to hold the medications because they are prescribed at maintenance dosing just like what would happen if the resident was at home recuperating.

That said, your patients are in a nurse-monitored setting in terms of vital signs and clinical assessments so it is reasonable for a nurse to question whether to give a medication or not based on assessment findings. That, however, should be communicated to a provider not because the nurse has no independent judgement skill but because the legal scope for acting on whether meds must continue rests on providers not nurses. You're right to say that not all "BP lowering meds" are purely used for BP control. That is where speaking to the provider will help to clarify indications.

For medication safety and to advance the quality of care of our elderly in SNF's, I'd say this is a serious issue in your institution and you might want to discuss it with whoever is in charge of staff development or even the DON.

[FolksBtrippin, BSN, RN]

One thing to keep in mind, especially when it comes to blood pressure, is that fall prevention is a nursing responsibility, not the responsibility of the doc.

While I agree that 119/62 is not a borderline pressure, if my patient is normally running at SBP 140, is telling me he feels dizzy, had a recent fall, and is taking propranolol for tremor I would probably hold the propanolol. Unless some other clinical finding made it necessary to take the risk of him falling and just give it to him.

You can't just look at the MAR and decide that some people are holding meds inappropriately. You have to look at the whole picture.

[JKL33]

3 minutes ago, FolksBtrippin said:

While I agree that 119/62 is not a borderline pressure, if my patient is normally running at SBP 140, is telling me he feels dizzy, had a recent fall, and is taking propranolol for tremor I would probably hold the propanolol.

Reasonable. It would also be expected that the nurse communicate these observations/concerns to the provider. What if they find the nurse's assessment info significantly concerning such that they would want to cancel the order altogether? What if (random general example) there is another med that can substitute for the current treatment, with a lower risk of the current adverse effect? What if the nurse's concern was well-intentioned but a little off track and the provider wanted the med given for reasons the nurse hadn't considered? What if it was some other med that was even more likely to be causing the problem and the provider wanted that one held instead? What if the nurse's thought process was just erroneous altogether? What about all caregivers being made aware of a potential ongoing issue through appropriate communication that may result in a care plan change?

These are a lot of "what ifs," I know--but they are realistic ones. That's why the system is set up the way it is, with us making real-time assessments and decisions that, when they involve matters that we are not legally authorized to handle completely independently (like a patient's medication regimen) we then must communicate with the person who is legally charged with that area of the patient's care. The problem in the OP isn't nursing judgment (or at least not only nursing judgment) but communication. There is no shame in any of this; it is the role of professional nursing.

[Corey Narry, MSN, RN, NP]

@JKL33, agreed.

There are nuances to the OP's concern. The setting is a SNF where patients are technically stable enough that they are no longer in an acute care setting but not quite stable to be completely independent at home. The question of do you just hold the medication and chart it on the MAR as such? For a patient with symptomatic hypotension or a 20 point drop in SBP with dizziness? yes, hold the medication and make sure the provider knows about it...that's a status change that warrants further investigation and conversation with a provider. I have remote SNF experience and in some of these places, residents are only seen by providers once a week. You don't always want to wait that long for a provider to notice that meds are being held.

[JJBookman]

5 hours ago, JKL33 said:

119/62 is not a borderline blood pressure. You probably don't have all the information about these nurses' decision-making but if they are indeed just holding meds without parameters or good judgment that is then communicated to the provider, then they are essentially practicing outside their scope. This is not good care.

Some nurses withhold meds like metoprolol, furosemide, HCTZ because they say it’s “borderline” or “low”.

[JJBookman]

On 8/6/2020 at 7:52 AM, FolksBtrippin said:

My question is perfectly legitimate. Did I struck a nerve with you or something.

[JKL33]

3 hours ago, JJBookman said:

Some nurses withhold meds like metoprolol, furosemide, HCTZ because they say it’s “borderline” or “low”.

I know they do, but it isn't. If they have a more reasoned rationale like that given by @FolksBtrippin that's another matter.

For yourself it would just be important to make sure you are making thorough assessments, communicating status changes to the responsible provider, documenting and following through appropriately. If, in your nursing judgment, you believe you should temporarily hold something, just follow those steps. ???

[FolksBtrippin, BSN, RN]

@JJBookman My question to you was "What is your point?" and that is also legitimate.

You present a wide and vague criticism of nurses you work with. I can think of several reasons why you might do this and I am directly asking you what yours is.

If you are their supervisor, get more info to determine whether education is needed. It would be your job to sit each nurse down and ask her about her rationale, and whether or not she called the doctor.

If you are a coworker on the same level, it isn't appropriate for you to spend your work time asking the necessary questions and doing the necessary investigation to evaluate your coworker's clinical judgment.

If you want to know what we think about holding a med in any particular instance, be specific. I can't and won't judge your coworkers based on the info you gave me. I also would appreciate your question more if you were asking about your own practice. I love to help other nurses.

I gave you an example of when I would hold a med for SBP 119. I would probably call the doc, but not necessarily, like if I know I'm going to see the doc for rounds, or Doc and I had already discussed what might happen and I know she is going to be looking for my note.

If that situation happened and you, as my coworker, started grilling me in an accusatory way about why I held the med and did I call the doc, I would be highly annoyed with you and rightly so. You might even damage your relationship with me.

More than once, I have been questioned in an accusatory way by a nurse who was not my supervisor and who actually knew less about the situation than I did. Some nurses think they should do that, and that's unfortunate for the culture of the working environment.

If you are actually concerned about patient safety, go to your supervisor and report your concerns.