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Holding "Ordered Meds"..... What are the rules?

Specializes in CCRN.

Often, in my short career, I've encountered times when prescribed medications are ordered, but questionable. We've all been there, beta-blockers ordered with vital signs barely above the "OK to give" parameters. Maybe Heparin or Lovenox when a procedure may or may not happen in the next 12 hours.

I seem to be that nurse that irritates providers with those "annoying" questions like should I hold Metoprolol with a HR of 62 or a systolic in the 90s? or is it OK to give Heparin before a heart cath or other procedure? "I held the Lasix because their CVP was 5 and they're down a liter, that OK?" 9 out of 10 times I'd get the eye roll with a tired, annoyed sigh and a "Yeah, give it, it's ordered isn't it....I wouldn't order something if it wasn't safe." But, 10% of the time I get a,"Oh thanks for catching that" or "You didn't give it did you????"

So my question is: How do you all balance just following orders (dangerous) with using your nurse brain and being overly-safe (if that's even possible)? Especially with BP meds, diuretics, and anticoagulants.

Following parameters will always include nursing judgment. Consider the baseline patient vitals when holding anything. Heart rate of 62 and giving a beta blocker is not a concern, unless the patient has OTHER issues.

As long as you notify promptly when you decide not to give a prescribed medication, you will ( and the patient will )be okay.

Too bad if the provider is "bothered" ..better safe than sorry.

Carry on.. good job.

I have found that as you develop a relationship with the ordering physician you get used to their orders and know what they want without having to ask. Also your facility should have policies in place so if you have a question and can't get a hold of the physician, defer to the policy. For example BP and heart rate control is usually guided by facility policy and can differ for cardiac patients and A-fib/stroke patients.

ixchel

Specializes in critical care.

And if the provider does happen to feel bothered, maybe they should pay better attention while putting in orders. :)

What gets me is when each doctor within a specialty feels passionately about something, only they have opposite opinions.

NPO before cardiology review for CP and negative biomarkers?

One will freak out you ordered it. The other will freak out if the patient even smells food. Grrrr yell at the hospitalist for missing the right diet order! Not me!

I use "nursing judgment" in charting skipped orders sparingly, but I do use it. Nursing judgment means you are willing to go on the record to say what was ordered wasn't appropriate or safe at that time, even though numbers say it was. If the physician disagrees, it'll be ugly. Stand your ground if you are right!!! If they agree with your judgment call, they'll be thankful since you might have just saved their butt.

Always put your head together with a nurse you trust is knowledgable if you aren't sure what to do. I find myself talking with other nurses through these scenarios, to be sure I haven't missed something.

You're doing an excellent job thinking through these things and knowing they need to be thought of!

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine.

Develop relationship with physicians. Let them know you are thinking and interested person.

Get medschool or NP school level pharm book and read it. It is not rocket science, I assure you.

ALWAYS think about baseline. Know it. I cannot emphasize it stronger.

ALWAYS consider where symptoms are coming from. If you do not know it, ask physician. Many of them love to teach.

ALWAYS think of your goals in treatment, both medical and nursing.

DO NOT hold on numbers. You do not treat heart rate or blood pressure; you treat Mr. Jones, 56.

Become good friend of pharmacy people. They will love to teach you, and you'll like to teach them, as they are not clinicians.

Access, analyze, access again.

Remember to treat Mr. Jones, not your policy book.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine.

. :)

What gets me is when each doctor within a specialty feels passionately about something, only they have opposite opinions.

Oh, yeah.

ASA and Plavix from Cardiology #1, as a gold standard for stents protection;

+

Heparin drip for subtherapeutic INR for coumadin bridge for being gold standard for stroke prevention by Cardiology #2

+

aforementioned coumadin in increasing dose by Neurology

+

Lovenox SQ as golden standard for PE prophylaxis on high risk patients (the guy is indeed high risk) by hospital internal medicine.

The guy happened to be somewhat of VIP. It was kinda funny seeing those four docs plus critical care one loudly quarreling between each other about who was going to be responsible for the utter mess named "expanding retroperitoneal hematoma" while the unconscious victim of their best intentions and gold standards was dragged down to ICU.

P.S. I do it too, and, I would say, less than sparingly. If I see creatinine sharply climbing up in a patient recovering from ARF, I would hold all nephrotoxic stuff till all involved providers know what each of them actually wants to see, symptoms or not (of course, I do it only if patient doesn't also have LVEF of 20%, sky - high calcium or something else along this line). If I see "impossible combination", like Levophed and b-blocker, I will hold the less "acute" drug, parameters or not. I would hold almost anything if it smells like known severe side effect coming. And our pharmacists are my best buddies and not afraid to speak with docs directly anymore.

Edited by KatieMI

ixchel

Specializes in critical care.

Oh, yeah.

ASA and Plavix from Cardiology #1, as a gold standard for stents protection;

+

Heparin drip for subtherapeutic INR for coumadin bridge for being gold standard for stroke prevention by Cardiology #2

+

aforementioned coumadin in increasing dose by Neurology

+

Lovenox SQ as golden standard for PE prophylaxis on high risk patients (the guy is indeed high risk) by hospital internal medicine.

The guy happened to be somewhat of VIP. It was kinda funny seeing those four docs plus critical care one loudly quarreling between each other about who was going to be responsible for the utter mess named "expanding retroperitoneal hematoma" while the unconscious victim of their best intentions and gold standards was dragged down to ICU.

Honest to god, THIS is where protocols SHOULD be, but instead we get protocols for stupid crap, taking away their autonomy when it should be allowed.

MaxAttack

Specializes in Critical Care.

It's easier to determine what to give if you look at why it's ordered.

I'm not giving a beta blocker for hypertension if their pressure is 92/40. I'm not giving a diuretic for edema if they're dehydrated.

A medication was ordered for a specific indication. If that indication isn't there when it's time to administer it, you're pretty safe in holding it.

Pheebz777, BSN, RN

Specializes in ICU, CVICU, E.R..

It's easier to determine what to give if you look at why it's ordered.

I'm not giving a beta blocker for hypertension if their pressure is 92/40. I'm not giving a diuretic for edema if they're dehydrated.

A medication was ordered for a specific indication. If that indication isn't there when it's time to administer it, you're pretty safe in holding it.

As what others have said, treat the patient, not the numbers. If a BP of 92/40 HR 150 and adequately hydrated, no fever, no pain/anxiety... giving the beta blocker most likely will bring the BP up if the drop in BP is related to inadequate filling time substantiated by the tachycardia.

However a BP of 92/40, HR 65, EF 15%, with mild aortic stenosis. Now we're talking.

If renal function is acutely impaired, a diuretic would help. Many toxins and medications are excreted through the kidneys and holding a diuretic because you think a patient is dehydrated is just asking for trouble. There are many nephrotoxic agents as well. Diuresis is part of the goals in restoring renal function from acute renal abnormalities.

I would be more concerned if the patient was not getting enough fluids, via P.O. or IV if dehydration was an issue. Call the MD if no urine output inspite of the fluids and diuretics given. But holding a diuretic simply for dehydration isnt the way to handle it.

Edited by Pheebz777

Pheebz777, BSN, RN

Specializes in ICU, CVICU, E.R..

I get the eye roll from MDs a lot for being extra curious as to why they order stuff. One thing I do a lot is ask for "parameters".

"Hold beta blockers if HR is below 55"

"Don't call for troponin less than 2"

I think half the time, MDs give nurses a hard time because sometimes, it's the nurses who are at fault.

One nurse I remember kept on holding off the Procardia because the HR was less than 60. And the BP would be on the high 160's low 170's. The MD chewed him out for holding the Procardia. He asked me why it was wrong to hold a "calcium channel blocker" for a low HR?

I told him Procardia doesn't lower the HR as it belongs to a different class of CCB. It's different from cardizem. It belongs to the dihydropyridine class of CCB.

littlelimabean01, LPN

Specializes in Geriatrics, Trach Care, Diabetes.

You went to school, and are required to use "prudent judgement". Meaning that what the majority of nurses do in the situation you are speaking of. If you feel you need to hold a med based on the parameters for giving the med Documentary is key. Take BP and HR after you decide to hold the med every hour post your decision to hold and Document your findings. It is honestly on our backs as nurses, more than the docs when it comes to med administration. Protect your patient most of all and protect your license too. You seem to really care and this wold needs nurses like you. Don't be afraid to use your discretion.

As others have mentioned, know the patient's baseline. If someone has been getting the med and is stable, I will give the med, despite being only slightly within the hold parameters. One thing I learned by questioning orders is that sometimes there is a patient-specific medical reason to give the med. I found that with CHF patients, cardiologists can be comfortable with a medicated systolic in the 80s.

gonzo1, ASN, RN

Specializes in CEN, ED, ICU, PSYCH, PP.

The first thing I do is look to see if the medication order came with any parameters. Often blood pressure meds will say hold if systolic less than 90 etc.

I just completed a legal class while working on my BSN and that class teaches/preaches that you must always notify the MD that you are holding, or want to hold a med.

This is easy where I work nights (ICU) because we have a secure messaging system where you send the doc a text message that you have done something and they can reply or not, but at least you have notified them. This helps cover your a$$.

TheCommuter, BSN, RN

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

In the case of antihypertensives, some nurses hold them for low-normal BPs without realizing that holding one dose will cause the BP to skyrocket in some patients.

I often became annoyed when the day nurse would hold the medication for a BP of 100/56 without any parameters to hold and no phone call to the physician. The patient's BP is now 190/96 by the time I administer the evening medications.

In many cases it's the medication keeps something within normal limits.

MaxAttack

Specializes in Critical Care.

I knew as soon as I hit submit someone was going to do that. There are exceptions to everything, but regardless of treating the numbers or the patient, there has to be a reason to give a med. If there's a diuretic routinely ordered because the patient has a history of overload and is now in shock on pressors, that med should not be given. Anymore so than giving the antihypertensive mentioned earlier to the patient on Levo.

But we're arguing two sides of the same thing. Diuresis in ARF is an indication, no?

I knew as soon as I hit submit someone was going to do that.

It would be helpful if you'd use the quote feature so we could know what you mean by your comment above.

In the case of antihypertensives, some nurses hold them for low-normal BPs without realizing that holding one dose will cause the BP to skyrocket in some patients.

I often became annoyed when the day nurse would hold the medication for a BP of 100/56 without any parameters to hold and no phone call to the physician. The patient's BP is now 190/96 by the time I administer the evening medications.

In many cases it's the medication keeps something within normal limits.

Especially clonidine! rebound hypertension.

Your comment is so true- it 's sometime the meds that keep a person in their ranges.

The decisions have to be individual.

Tweety, BSN, RN

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

The "rules" are "what would a good and prudent nurse do in this situation" for the best outcome for the patient. Nurses don't blindly follow orders without using their brains, and a board of nursing isn't going to stand by you for giving an unsafe medicine "because it's on the patients medication list to give".

However, it's practicing medicine without a license if you don't notify the MD when you withhold an ordered medication. Always, always cover yourself.

I work in a teaching hospital at night and often deal with residents who are more often being taught to listen to their nurses these days (yea!!!). Nursing judgement is key to keeping patients safe & I often hold medications that don't make sense at the time. I'll alert whomever is on call, as well, and discuss if they still want it given.

I work in a teaching hospital at night and often deal with residents who are more often being taught to listen to their nurses these days (yea!!!). Nursing judgement is key to keeping patients safe & I often hold medications that don't make sense at the time. I'll alert whomever is on call, as well, and discuss if they still want it given.

I work in a level 1 teaching hospital in the ER. This whole conversation is amusing to me. I hold a med and walk over and tell the doc. No waking someone up, no 12 hours later someone is asking about xyz. One of the awesome aspects about my Dept. Of course we get a lot of exposure to communicable diseases (pt in room 12 for 6 hours, guess what? He has TB, PT through triage, into a room, down to X-ray and ct, back and forth to the bathroom, he has cdiff, and bed bugs, etc) but never why didn't you give X med 12 hours ago.

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