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

[jk2185, BSN, RN]

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.

[Been there,done that, ASN, RN]

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.

[VTsquach]

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]

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]

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]

. :)

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.

[ixchel]

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, BSN, RN]

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]

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.

[Pheebz777, BSN, RN]

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]

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.

[NotAllWhoWandeRN, ASN, RN]

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.