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

[jk2185]

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.

[gonzo1, ASN, RN]

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]

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, BSN, RN]

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?

[Horseshoe, BSN, RN]

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.

[martymoose, BSN, RN]

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]

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.

[SerenaTabladillo]

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.

[AZQuik]

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.

[smusher83]

If I am working with a doctor that I am unfamiliar with I will hold a medication until I receive clarification, you can always give a medication later if you hold it, but you can't take it back once it is given. You need to be able to justify your actions and document why something was held, it is also good to present your worries to the doctor as well when asking for clarification. Here are a few tips that I have learned to follow, they have never steered me wrong before.

1) Know why the medication is being given! Many medications have multiple uses, so know the specific reason they are taking it. Is the Metoprolol being used for blood pressure control or for an arrhythmia? (usually 12.5 is for arrhythmias).

2) Know your patient's normals and trends. Is the patient's blood pressure normally low? Is the HR normally slow? Are they symptomatic for low profusion?

3) Review the MAR to see how the medication has or has not been given in the past by other nurses. Once you know this you can review the VS after it has been given or not given, to find a correlation and help you determine what to do.

4) Think of the worst case possible with each medication that is given, using the information that you have available. Perhaps the patient has scheduled insulin but a poor appetite. I might hold the insulin because a patient can die a lot faster from a low blood sugar than one that is to high.

Each patient and situation is unique, there is a lot to consider. If in doubt ask another more experienced nurse.

[Ryn RN]

Notifying M.D. was mandatory in our facility. And if doc gets upset, too bad, that's their job! Always document you contacted doc too, just in case there's a problem.

[AnnaPat]

Well, during my recent clinical i gave one HTN med at 105/90 .. Client went to 90 and 85 (shortly after) systolic. My Clinical instructor insisted it was Ok to give to keep the Client within the base line (your point), Client's primary nurse was Not happy.. not at all.

[NotAllWhoWandeRN, ASN, RN]

Well, during my recent clinical i gave one HTN med at 105/90 .. Client went to 90 and 85 (shortly after) systolic. My Clinical instructor insisted it was Ok to give to keep the Client within the base line (your point), Client's primary nurse was Not happy.. not at all.

Was the patient already getting the medication?

Was the BP stable and WNL while already on the medication?

If your answers are yes, and the BP was not below ordered hold parameters, there was no reason not to give the med. The patient had a reaction that you could not have reasonably anticipated.

If it was a new med, if it was an increased dose, if the BP was trending down, if there was a hold order, or if there were some other acute change in patient status that gave you a valid reason to believe their blood pressure would dip too low, then it was a bad move.

Sometimes stuff happens. You have to use your best judgment in each situation.