Multiple BP meds & dialysis- to give or not to give.......

[groovy jeff]

Currently I am 3 weeks away from graduation and doing a clinical rotation in a long term critical care setting (it is that place between ICU and rehab), Yesterday the RN asked me to pass 3 BP meds (lisinopril, lopressor, and something else) to a patient that had just finished dialysis and had a BP of 124/66. I told her I wasn't comfortable doing that and I would be glad to put them onboard an hour or two apart. She was having a rough day and she said in the real world you don't have time for that and if you go back in the chart you will be able to see where they did that all along with this patient. I still didn't feel comfortable and refused to pass all 3 meds at the same time.

This RN is one of the best I have ever worked with! She is efficient, really knows her stuff, is a great mentor, and gives really super good nursing care. We kissed and made up 10 minutes after she gave the med and the rest of the day went smoothly. As she had said the pt was fine.

My instructor said I did the right thing. I feel like I did the right thing. Did I do the right thing? Any feedback or insight would be appreciated.

[groovy jeff, RN]

I am an ICU nurse, but I won't rush to the title of expert...

I understand your thinking. Usually though, in my experience, if someone's pressure is going to take a major dive, it is going to be during the dialysis run. That is usually when we have to kick on the pressers. 2-4 liters is alot of fluid (depending on the patient's unique situation), so that is definitely something to keep in the back of your mind. However, the patient made it through dialysis, and still had a systolic in the 120's. You would have to look at a number of different factors. How much fluid does the patient usually have dialyzed off? Is this pressure consistent with what they run after dialysis? Do they normally get all three meds after dialysis and do okay? I am assuming this info would be available, since this person sounds like a long-term patient. If I didn't have any of this info, I would have to look at the dosages of the meds. I'd ask the patient if they had been on these for awhile. If they had (and had also been on dialysis for awhile), then they will probably be okay.

The hard position that you were in is that you were the student... it really wasn't your ultimate decision whether or not to give them. However, you were definitely right to ask the question. And anytime, if you don't feel comfortable, politely ask the nurse to give them. When you are an RN, you will have the lee-way to do more critical thinking and make the decisions yourself. You could certainly stagger them a little (as long as you have a good rationale to back yourself up) or even call the doc if you are really worried. However, with a systolic in the 120's, you have quite a bit of lee-way in either direction.

Hope all that rambling helped...

That helps quite a bit-Thanks

[Mommy_of_3_in_AL..RN]

We usually hold all meds DURING dialysis, then when dialysis is finished, we draw labs, and give the meds. If the pressure is WNL, 120 systolic or above i would give them all, and watch the patient. CHances are, they wont bottom out, but the meds hopefully will keep their pressure fom climbing during the day. IF you dont give them, and 6 hours later, their pressure is 170 systolic, you would probably have to call the doc for a PRN, since it would be too close to their next scheduled dose to give them then. If their pressure did bottom out, you can always push fluids, give a pressor, and let the doc know, and hopefuly he would adjust the timing of the order so that in the future the patient would not get all at once..maybe stagger them a couple hours apart. Of course, like others have said, it is always wise to go back and look at their trends, see what their pressure usually does after the dalysis and meds, and decide from there.

[CNA764]

I'm still learning too, so here's my questions:

What if the pt's SBP was 100 then what?

ACE inhibitor for an HD pt? is this common?

[Mommy_of_3_in_AL..RN]

I would not give for SBP of 100..The ultimate goal is to lower the pressure, and you dont want to lower that..unless you want to give pressors and/or fluid bolus..and depending on the patient, that may not be a good idea. If you are worried about getting in trouble for holding them, go to the physician,your charge nurse, or instructor (if you are a student) and explain your rationale for not wanting to give the med, and get that second opinion. If you are comfortable with that physician enough to do so, and he/she still tells you to give it, make sure you get an order for something to raise pressure when it bottoms out!

[dorie43rn]

I"m sorry, you did not do the right thing. That patients bp was within range to give those meds, I don't care if she just got off dialysis. If the order was not written to hold them, and they were on the MAR, they should have been given. You have alot to learn about medications and critical care. Go back to your drug book and read up on meds and what they do.

Doris

[labcat01, BSN, RN]

I think you definitely did the right thing. It is never a bad thing to ask questions or to refrain from doing things you are not comfortable with. I think that shocker29 gave you some spot-on advice. Good luck!

[I_LOVE_TRAUMA, RN]

I"m sorry, you did not do the right thing. That patients bp was within range to give those meds, I don't care if she just got off dialysis. If the order was not written to hold them, and they were on the MAR, they should have been given. You have alot to learn about medications and critical care. Go back to your drug book and read up on meds and what they do.

Doris

I really don't think that we have enough information to tell this student that he "did not do the right thing" there are a lot of times where holding bp meds is warranted (critical). I also don't agree that "If the order was not written to hold them, and they are on the MAR, they should have been given." If I followed that logic I would have killed several patients thus far! Ultimately it is my license on the line, and we need to use our critical thinking and training to determine what to do in each individual case. If the patient would have "bottomed out" there is not an MD out there that would not have questioned why the meds were not held.

The scenario was much to vague to give much advice on (although most of the ideas posted here were right on).

To the OP, I think that it is wonderful and very smart of you to question the rationale behind a situation like this, this is how you learn-keep up the good work, you will learn a lot. And remember this, I have been an ER/ICU nurse for a long time, and I still have a lot to learn (and learn something new everyday, don't ever think that you know it all, even when you have been a nurse for 3 years or so!

[Mommy_of_3_in_AL..RN]

Noone knows everything. Even the most seasoned nurses have to refer to some sort of reference now and then. With some meds, especially those that lower BP and HR and RR, docs often dont write an order to hold if less than whatever. At least in my facility, docs expect nurses to have the knowledge to KNOW that a certain med may harm that patient at that time, and hold if warranted. If you arent sure, always ask for a second, or maybe third opinion. If still not comfortable, there is nothing wrong with directly asking the doc. If nothing else, it covers your butt. Most docs would rather you ask than give the med and harm the patient. Just remember when you hold a med for a reason, to document that it was held, and why.