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.
A couple of weeks ago I got a new admit. I always go over the meds that I'm giving a pt before I give them. The patient said he doesn't take one particular med so like an idiot I didn't give it, and I didn't call the doc to talk to him about it. Turns out it was a new med ordered for the pt. The doctor wasn't mad at me or anything (I got lucky). But I should have called the doc and clarified the med before I held it on my own.
Unfortunately this is a system breakdown because our docs don't talk to the nurses about their plan of care for the patient (ICU). If our docs would say "you're getting this pt and I'm doing this and this" it would provide for a more seamless transition from ER to ICU.
ALWAYS clarify with the ordering doc before you hold a med, unless there are specific parameters listed in the MAR. And don't feel bad about it. It's your license on the line.
If there are parameters given and nothing indicating something new happening, I follow the parameters (and am grateful the MD took the time to put them in there). If there are not parameters or my nursing gut says something doesn't feel right (or it obviously is an issue), I page the doctor with the critical information and ask for clarification on whether or not to give the ordered medicine. I then monitor the patient. The med is still available if the BP starts to climb (or whatever is the concern). Most doctors don't have any issue when I don't challenge their orders but ask for "clarification".
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.
Well.....? Be careful, though. As others have already said, you must use your judgement, based on knowledge when you are 100% confident in your rational. Sometimes there are holes in our knowledge. For example, holding a beta-blocker for a BP in an ideal range may NOT be the best thing to do. Sometimes beta-blockers are given for other reasons than HTN, such as migraine headaches. Also, possibly the reason the BP is in an ideal range is because they have been regularly given the beta-blocker. There are many "off-label" uses for meds these days. When not sure, ask colleagues, ask pharmacy, and go ahead and ask the doctor. Too bad if they are annoyed. That's not your problem. Hard to take the eye rolling, etc., but the patient comes first...along side your license! Cannot stress that enough.
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.
This is EXACTLY what I commented on. Also, You don't always know the reason certain meds are ordered. Not always ordered for the common use. It's always best to double check when you are not sure. The mistake is NOT questioning when something doesn't make sense to you. Clear communication is key. As knowledgeable as nurses are, we are bound by policy and following orders. Not that we should be sheep, but just ask when something doesn't make sense.
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 think the point here is not the specifics of the indications for certain meds. It's about how to safely, and effectively care for a patient when you have questions about following an order.
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.
That nurse seriously needed to chill out. Seriously?! Last time I checked, normal systolic BP is 90-120. I still have not figured out why nurses freak out over SBPs that are 90-110. 90-110 is BEAUTIFUL! What the heck!
Giving a BP med with a SBP of 105 was a reasonable thing to do. If there was a problem with that, the nurse should have communicated that to your instructor PRIOR to that dose. It is NOT appropriate to hold a dose until the patient becomes hypertensive again. Exactly what SBP did the nurse feel it was worth waiting for???
Seeing that BP change could have signaled multiple things, all totally unrelated to giving that med. I don't know the patient's history or admission reason, so anything I might suggest would be nothing more than a guess. But....
If it was the med - this dose was necessary to learn how this patient responds to it. The prescriber had to know that prior to discharge. How else would they find out? Finding the right med and dose is a reason to admit a malignant hypertension.
Hemorrhage or hematoma
Nervous system dysfunction/damage
Septic shock
Hypovolemia
Broken BP machine
BP cuff placed incorrectly
The cuff is the wrong size. Does this hospital staff people who believe with all their heart that blood pressure cuffs only exist in one massive size? Mine seems to. If it seems big to you, it is. Go raid clean utility for the right size.
Other medications (so many drop BP)
Regardless of the reason, you always need to verify manually. And, of course, use the correct size. Go to peds or bariatric if you have to (if you have these patients/units).
And I say again, strongly - if the drop is legit, it is valid, required information that the nurse should be glad was caught and recorded. No, it's not the best news ever, and yes, it sucks to have yet another crappy thing to "fix". But, this clue might lead to the thing that gets the patient better with more appropriate meds. This clue happened at a hospital, with people nearby to help. This clue happened in a place and time that will result in a better outcome for the patient.
(This clue was also an irritation that certainly wasn't worth treating you like crap over. NOT COOL!)
This is EXACTLY what I commented on. Also, You don't always know the reason certain meds are ordered. Not always ordered for the common use. It's always best to double check when you are not sure. The mistake is NOT questioning when something doesn't make sense to you. Clear communication is key. As knowledgeable as nurses are, we are bound by policy and following orders. Not that we should be sheep, but just ask when something doesn't make sense.
I recently learned of a case in which a person received a head injury that severely injured both the frontal lobe and the superior longitudinal fasciculus. Some time after, the person was diagnosed with intermittent explosive disorder.
Young person, tends to be on the low end of all the normals (HR, BP, RR, etc.). Beta blockers are the most effective for this person's IED. I wouldn't want to hold those BBs at all!
Drug parameters are something I struggle with at work. Some of the parameters seem vague or lacking in proper definition. For example, my manager ******* me out for holding Xanax and not notifying the Dr. The pt. was sleeping and the parameter said "hold if sedated". I work in LTC/ Rehab, not postop or med/surg so am I too assume he means sleeping. If I call the Dr, they act like I'm an idiot because they all understand his 'script linguo'.
gonzo1, ASN, RN
1,739 Posts
A couple of weeks ago I got a new admit. I always go over the meds that I'm giving a pt before I give them. The patient said he doesn't take one particular med so like an idiot I didn't give it, and I didn't call the doc to talk to him about it. Turns out it was a new med ordered for the pt. The doctor wasn't mad at me or anything (I got lucky). But I should have called the doc and clarified the med before I held it on my own.
Unfortunately this is a system breakdown because our docs don't talk to the nurses about their plan of care for the patient (ICU). If our docs would say "you're getting this pt and I'm doing this and this" it would provide for a more seamless transition from ER to ICU.