Holding medications - When to call doctor?

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I worked in sub-acute for 7 months and I have now been in acute care for 2 months. A friend of mine told me I should be more careful when I hold medications and I am a little confused about when to call the doctor and when not to call the doctor. For example, my friend said that if a patient's blood pressure is below the parameters placed on the order, that I must keep re-taking the blood pressure every 2 hours to see if the blood pressure medication should be administered. In the past, if the patient's blood pressure was below the parameters and if there was an order to hold the bp med I would hold it and state that the med was not given as per the parameters. Is this incorrect? Should I keep checking BP every 2 hours and give medication if it goes above the parameters? Some patients get the BP med 3 times a day and that it could get confusing. In addition, should MD be notified if patient refuses medication? For example, what if patient refuses colace? Should MD be aware? What about if the patient refuses an antibiotic? In past I have just stated that patient refused the medication as they have a right to do but now I am thinking maybe I should have called the doctor. I am just hoping that I will not get in trouble. My friend stated that these may count as medication errors. I love my job and I would never want to loose it.

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Specializes in Public Health.

If you do as she says, you will have a lot of very angry doctors on your hands. Just my two cents.

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Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

Most of your questions are critical thinking based. So much depends on the situation and the medication. A refusal of an antibiotic or antiarrythmic , I would notify the Dr, but only after finding out WHY the patient refused and trying to remedy the situation myself if possible. Patients can go septic, etc quickly. But mostly there are way too many variables to say I'd always do something or I'd never do something; so much depends on the patient/situation. And the whole checking BP every 2 hours if out of parameters when the BP medication is due?? That's kind of weird and simplistic. If the BP is out of parameters, my further actions are going to depend on how low the BP is, the patient's presentation, "the whole picture". Sorry if I'm not being clear, but the answer to your questions are "it depends". I work nights and am not going to call the Dr. unless really needed. Sometimes I do bundle info./questions for the Dr. if they are not urgent. I will then speak with the Dr. when another nurse on the unit needs him/her also or if no else needs them I'll wait until around 6am; but again only if my needs are not urgent/important. It's all about critical thinking.

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Specializes in Med Surg.

Every situation is different. You do assessments based on the patient's needs and your judgement. If a BP appears low or sagging you check it - and do other assessments - as you deem warranted. There is no "2 hour" rule. Heck I might recheck it in the other arm right away and if the patient is symptomatic at all I might be checking it every few minutes (setting the machine to automatically inflate).

I was precepting a new nurse who ALWAYS wanted to "Call the doctor" instead of using her judgement at all. I got tired of it and finally said to her: "OK, let's pretend I'm the doctor and I have called you back after you paged me.":

Me: "Hello, this is Dr. Howser returning your page."

Her:"Hi. My patient is ESRD and her blood pressure is low and I'm wondering if I should hold her BP meds."

Me:"Are there parameters?"

Her:"Yes, it says to hold if SBP

Me:"What is her BP?"

Her:" 92/54"

Me:"What the hell are you calling me for?"

She didn't like hearing that, and I explained that orientation is the time to use her judgement and that I was there to help her if she was making bad decisions. She got a little better. I always encourage new nurses to bounce questions of coworkers because everyone learns.

WRT your other questions:

"what if patient refuses colace?"

Most of the time I just chart "refused." However there was one time I told a patient with multiple bowel issues (obstructions, surgeries, perforations, etc) that if she didn't take the colace, she wasn't getting any pain meds and I didn't care what her, my boss, the MD or the CEO says, I wasn't going to give them. It depends.

"What about if the patient refuses an antibiotic?"

This is a bigger deal and it depends on the situation. There are situations where they are free to get up and walk out of the place and others where they cannot refuse and you can call for restraints. Depends.

"My friend stated that these may count as medication error"

In my experience, most nurses who say that in this context are idiots and I stop listening to them.

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Specializes in retired LTC.

Might your new facility have its own in-house protocol requiring you to call?

It would make sense to me that if the MD OK'd parameters, then s/he'd be expecting some variations. I would question though how much was the difference of the variation? Two or four points lower on a BP - no big whoop. But a BP down some 20 points and I'd be calling FAST!!! Also is this a freq repeated occurrence? Maybe time for a dose adjustment?

Know what the usual trend is for your facility to guide you.

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I worked in sub-acute for 7 months and I have now been in acute care for 2 months. A friend of mine told me I should be more careful when I hold medications and I am a little confused about when to call the doctor and when not to call the doctor.

Technically speaking you should call whenever a scheduled med is not given, but in actual practice this would be highly inappropriate in some circumstances.

For example, my friend said that if a patient's blood pressure is below the parameters placed on the order, that I must keep re-taking the blood pressure every 2 hours to see if the blood pressure medication should be administered. In the past, if the patient's blood pressure was below the parameters and if there was an order to hold the bp med I would hold it and state that the med was not given as per the parameters. Is this incorrect? Should I keep checking BP every 2 hours and give medication if it goes above the parameters? Some patients get the BP med 3 times a day and that it could get confusing.

I would do as you are doing and hold it if it's not meeting parameters. If the BP is abnormally high or low with a large deviation off their trend, I would check it more frequently but not on some kind of set schedule like q2h to see if maybe possibly the med should be given. Um, no.

In addition, should MD be notified if patient refuses medication? For example, what if patient refuses colace? Should MD be aware?

No.

What about if the patient refuses an antibiotic?

Yes.

In past I have just stated that patient refused the medication as they have a right to do but now I am thinking maybe I should have called the doctor.

If it's a medication such as an antibiotic (or something directly related to their dx), or a high alert medication such as warfarin, insulin, etc. where a refusal would directly effect lab values or the patient's immediate clinical condition - you should notify and document accordingly.

I am just hoping that I will not get in trouble. My friend stated that these may count as medication errors. I love my job and I would never want to loose it.

Bottom line: you shouldn't necessary page the doctor about routine medications such as colace, miralax, tylenol, etc. but anything that is directly related to the treatment plan or is of a critical or high alert nature the MD must be notified. Your friend is not providing good guidance and is oversimplifying the issue.

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Specializes in Psych ICU, addictions.

I would notify the MD about any medication refusal, even the Colace. However, as others have pointed out, it's not necessary to page the MD stat for every single med refused. If the patient refused Colace or other routine/comfort meds, I would let the MD know, but would wait until I saw the MD to tell them or have the next shift pass it on. IMO, there's no need to wake the MD at 0300 to let them know that the patient has refused a stool softener or declined Tylenol.

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I would not be doing that every two hour check looking to give the med unless the doctor has ordered this action. If this has been happening often, he should have been made aware and the possibility of providing even more inclusive parameters discussed.

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You are comparing two different levels of care. It sounds like you are comparing acute to LTC protocols. In LTC we usually did not call the MD for holding meds for B/P that were below the parameters unless it was becoming a regular occurrance, because then it indicated the medication either needed to be changed or discontinued. In acute care the rules are much different, the pt is there because of an acute event and needs closer observation. If you are holding the B/P medication the MD needs to be notified, however, I would call him with recent vital signs and look at trends to see if the medication has been held before and how the patient tolerates it. I have never heard of taking a pts B/P every 2 hours throughout the shift unless the B/P was labile. As far as the Colace, was this a routine or a PRN medication? If it is routine and the pt is refusing it find out why. Often the pts will say it is causing them to have diarrhea when really what is happening they are having soft stool. If they are having routine stools and this is a routine medication then see if it can be changed to PRN for constipation. You do need to know your facilities policy as far as holding medications and if the policy states it will be noted as a medication error then it is. Now that you are in acute care you need to educate yourself on how the policy and procedures are enforced differently from LTC.

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Specializes in Adult Internal Medicine.

This thread is perfect.

I was the on call provider last night. We had a wonderful little elderly woman admitted for urosepsis around 9pm but they were waiting for a bed. She got up to the med-surg floor around 130am. I had put all her orders in at 9 so they would be ready for her.

New nurse calls me at 230am to let me know she was refusing her Miralax. I sorta laughed and asked why. Nurse didn't know and went to ask. Came back and told me "because she had diarrhea". Then the nurse says "so is there something you'd like me to substitute"?

Sent from my iPhone.

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New nurse calls me at 230am to let me know she was refusing her Miralax. I sorta laughed and asked why. Nurse didn't know and went to ask. Came back and told me "because she had diarrhea". Then the nurse says "so is there something you'd like me to substitute"?

Lol!?

Sent from my iPhone.

Sent from my iPhone using allnurses

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You are comparing two different levels of care. It sounds like you are comparing acute to LTC protocols. In LTC we usually did not call the MD for holding meds for B/P that were below the parameters unless it was becoming a regular occurrance, because then it indicated the medication either needed to be changed or discontinued. In acute care the rules are much different, the pt is there because of an acute event and needs closer observation. If you are holding the B/P medication the MD needs to be notified, however, I would call him with recent vital signs and look at trends to see if the medication has been held before and how the patient tolerates it. I have never heard of taking a pts B/P every 2 hours throughout the shift unless the B/P was labile. As far as the Colace, was this a routine or a PRN medication? If it is routine and the pt is refusing it find out why. Often the pts will say it is causing them to have diarrhea when really what is happening they are having soft stool. If they are having routine stools and this is a routine medication then see if it can be changed to PRN for constipation. You do need to know your facilities policy as far as holding medications and if the policy states it will be noted as a medication error then it is. Now that you are in acute care you need to educate yourself on how the policy and procedures are enforced differently from LTC.

Frankly, the policies are typically no different between LTC and acute care - it's just the culture of practice that differs. I wouldn't have notified the MD if the order had parameters and the med was held based on those parameters. One of the reasons parameters are written is so the MD doesn't get immediately called when the med is held.

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