Holding medications - When to call doctor?

[blackdiamond407]

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.

[dudette10, MSN, RN]

Depends on the med, the current, documented hospital problems, the reason for the refusal.

One thing no one has mentioned here is education. Knowing that some nurses will accept the refusal and leave it at that, I would encourage education to the patient, especially for a critical med like a BP med, an antiarrythmic, an antibiotic. Does the patient know why he/she is ordered the medication? Why are they refusing? Does the patient understand the relationship between their reason for admission and the med?

I had a patient with an MI and s/p stent placement with placement of one more stent scheduled in 5 weeks. Her lipid panel was covered in red values. Her A1c was 13. She was refusing her Lipitor because "I don't need that!" which, in my experience, is the number one reason that patients refuse. I went over the relationship between MI, high cholesterol, and diabetes. She changed her mind and took her Lipitor.

Critical thinking includes increasing your knowledge base about disease states, the relationship between them, the meds to treat them, and the side effects that would cause noncompliance. As a new nurse, you need to continue studying in order to educate your patients.

In my opinion, this thread isn't so much about a patient's refusal to take a med and calling the doc; it's also about what the nurse has done to educate the patient when faced with an initial refusal.

[blackdiamond407]

Thank you all for your insightful responses. They are all truly appreciated and have given me a lot to think about. Regarding LTC and acute care, I believe that the rules regarding care are the same but I believe that there are different expectations regarding LTC and acute care facilities, if this makes sense. I always do try to educate my patients regarding their medications and why they were ordered. Sometimes, however, no matter how much education you provide, the patient still does not want the medication. For example, I had a patient with a UTI diagnosis. She took an antibiotic for two days in a row. The third day, she refused to take the antibiotic. I told her about the negatives of stopping antibiotics but she insisted the antibiotic was making her urinate more frequently. I told her that urinary frequency was a symptom of UTI but she still did not want the antibiotic. Regarding BP meds, it is my thinking that the doctor has written parameters for a reason. For example, if the patient's BP is 110 and the order calls to hold the med if BP

[Salter444]

I agree with a comment above that stated it is a critical thinking process. These type of situations will be different among nurses with different levels of experience and the many different practice areas.

When it comes to a BP medication in an area where continual vitals are not monitored I would be more inclined to hold the medication and recheck as needed. If it is an area that does VS Q4 hours I would just review the BP the next time the vitals were taken and inform the MD if he happens to be in the unit on rounds - I do not se the need to call him/her with the information as long as you provided documentation that explains why the med was held.

Holding and calling also depends on the medication and reason it has been held. If the patient has a concern about the med and refuses the medication I would think this should be relayed to the provider. IF missing the dose could lead to immediate harm call at once. If missing the dose could cause harm days later - then I would wait until he/she rounded. We hold drugs all the time for many reasons and if we think about the action of the missed and drug and how it impacts the patient then make our decisions from there we should be okay.