How to choose which PRN blood pressure med

[vashtee, RN]

I am wondering if anyone can offer guidance about how to choose which PRN blood pressure medication to give when there have been multiple types ordered.

For example, when might you choose a calcium channel blocker over a beta blocker?

Patient (in the 80s) has had a hemorrhagic stroke and now comatose and DNR, SBP in the 160s, A-Fib/A-flutter with a HR to 110, RR irregular (20-40 throughout the day). A hospice eval was already done, but I still felt bad when the patient passed, and wonder if I chose the wrong medication to treat her HTN with.

Thanks in advance for your advice.

[vashtee, RN]

I should add that the patient was experiencing heart pauses throughout the day, 2-3 seconds long.

[TX.RN.Shannon]

It sounds like this patient had a life-ending event and nothing you gave or didn't give would've changed that.

If I have a situation where there are different PRN meds, I try to look at the whole picture. For example, maybe each med had different parameters regarding vital signs (like give this one if SBP is over 160 or that one if over 180). If there is a beta blocker ordered, you have to consider the heart rate; maybe it's too low to use that med.

But sometimes, it's just trial and error---you try one med and see how it works. If it doesn't work too well, then try another.

It's definitely hard to pick which med to use, but hopefully the MD has provided detailed and specific parameters. If not, you have to look at the patient/vital signs/history and pick one.

Good luck!

[MomRN0913]

The blood pressure did not kill the patient. The hemmoragic stroke did. The brain could no longer regulate the blood pressure and heart rate. Did the patient die peacefully? If he did, nothing else really matters at that point. And a SBP in the 160's is not bad in a stroke. Usually you want to keep the systolic between 140-160.

[nurseprnRN, BSN, RN]

In answer to the original question, any prn must have definite parameters. If there are two prn antihypertensives, for example, it's quite possible that somebody didn't realize there was already one in the medical plan of care when s/he wrote for the second one. You should never, ever be in a position to have to guess about a prn or "just pick one." Call the physician or APRN and get a clarification immediately if you notice this sort of thing.

[eatmysoxRN, ASN, RN]

I typically have a PRN order on almost all my patients for IV Lopressor, IV Vasotec, PO clonidine. I usually give Lopressor if heart rate is up. Vasotec if I need a decent drop in BP. Really depends on the patient.

[Bec7074]

Just came across the thread but wanted to add:

I don't think more than 1 anti-hypertensive prn is weird.

If the pt is having sinus pauses do not give any beta blockers!!! Scheduled or prn. This can create more pauses By slowing the conduction.

Without pauses, I would have chosen the beta blocker first because of the high HR and bc they were in fib/flutter. In this situation beta blockers help to break up the chaotic fibbing and slow conduction down sometimes converting to sinus.

[LogCabinMom]

I was going to say this too - the latest recs say to keep the BP elevated in case of a stroke (at least that's what another nurse just told me) -