New grad-still wondering when to hold certain meds!

[RockinNurse]

I'm a new grad working on a med-surg/telemetry unit. I've been taken off orientation and have been working on my own for about a month. When a new patient is admitted, a formal med sheet is not printed out for them and there is generally a hand written one by the unit clerk. I am always a little bit iffy on when to hold certain meds and when to give them. The other day, a bunch of the nurses were picking on another new nurse for holding lisinopril for a pulse less than 60. I know that generally you would only hold that drug for a low BP (less than 100 systolic) rather than a pulse. But it made me think! The other day, another nurse was giving Procardia. She gave it to a patient with a heart rate of 50. I thought that you should hold this drug for a HR of less than 60 and systolic BP less than 100, but I'm really not sure! What about Cardizem? Hold for a low BP, low pulse, or both? Just wondering if anyone has any info on BP/pulse affecting drugs! Wish I had one of those drug books for nurses to tell you when to hold and when not to!

Also, insulins...I know everyone's blood sugar differs and insulins affect people differently. But at what blood sugar would you typically hold Regular Insulin or other types of insulin? I just started working nights, if a patient has dialysis in the morning, do you hold ALL of their meds or just certain ones? That's a lot of questions for one night...thanks!! :)

[Ruby Vee, BSN]

a lot of it depends upon your patient . . . an athlete may normally have a pulse less than 50 and you might not want to hold his meds. but if that pulse is unusual for your patient, then yes. check with the provider before giving the drug.

there's a lot of information available on the internet, if you have access. and if you don't, drug books are not that expensive. dh has epocrates on his iphone, and we have micromedex on our bedside computers. just keep studying those drugs. it took me a couple of years before i was comfortable with when to hold and when not to . . . when in doubt, ask. don't let fear of ridicule influence your decision making.

[pamelalayn]

Everyone has been a new grad. Nurses that go out of their way to insult and degrade new nurses were probably the sloppiest grads of their class. At the facility I work at we have a real witchy,witch. You would swear on your life she knows more than god. Well come to find out she doesn't. As a matter of fact, the truth is "she was on the longest orientation in the history of the hospital." A whole year, yes a whole year. Miss perfect has been cutting down anyone new to feel better about herself. Come to find out "super nurse" has a drug dependency and a severe drinking problem. In and out of rehab. Everyone of those nurses who snicker at a new grad has a story, and what a story it must be!

If you are not sure at time when to or not to give a drug. A doctor might of written parameters for the med. You can also write down the meds you are not sure of on a index card and carry in your pocket. We have all been there and there is no shame in asking a question.

[L8RRN]

They were talking about the nurse holding Lisinopril for a pulse of

As for other meds, if you don't want to ask toooo many questions, look it up in a drug book to see what the side effects are...it will tell you lowers pulse, etc. If it still isn't clear after looking it up, then ask!! Don't let others intimidate you into not asking because it is your responsibility to know and it is better to suck it up and ask then give something that may cause more problems.

Good luck! It does get better!

[maxthecat]

All of us nurses on the unit I work on are currently on a "plan of correction." This is because a state surveyor found that nurses were holding meds with no written parameters based on the nurses experience and education. The surveyor stated that this is practicing outside of scope. We must contact the doctor immediately and get an order from them as to whether to hold or not. For example, if we get a BP of 89/59, we cannot decide to hold the med on our own, we must obtain an order from the physician. We must also contact the physician immediately if a patient refuses a med, and obtain an order as to what the physician wants done. We had been making these decisions on our own and letting the doctor know in the morning, but this is not acceptable according to the surveyor. So we have been trying to educate our physicians to write parameters on their orders if they don't want to get several phone calls every day. They are loving this new policy--not. And I guess I've been practicing out of scope for years!

[coolpeach]

Practicing outside your scope of practice....REALLY!!!! I thought it was called nursing judgement and critical thinking. GEEZZZ

[pers]

All of us nurses on the unit I work on are currently on a "plan of correction." This is because a state surveyor found that nurses were holding meds with no written parameters based on the nurses experience and education. The surveyor stated that this is practicing outside of scope. We must contact the doctor immediately and get an order from them as to whether to hold or not.

This is where patient education can be your friend! I would go over the med with the patient and explain what their bp/pulse was and that the medication could lower it further, then ask if they want to take the medication. Patients (as a general rule) have the right to refuse regardless of what the doctor orders. I'd then follow up with the doctor in the morning for parameters.

I don't often hold medications, a bp or pulse would need to be pretty low, significantly lower than the patient's baseline or the patient symptomatic and if that was the case I'm probably calling the doctor anyway so asking about meds while I'm on the phone is a no-brainer. Though I will hold potassium and mag supplements when their lab value is high (actually out of the normal range but not necessarily critical).

When in doubt though, I always ask other nurses and if I'm still not comfortable with what I should do, I call the doctor. I'd much rather listen to a doctor yell at me for calling when I shouldn't than not calling when I should have.

[sunnycalifRN]

All of us nurses on the unit I work on are currently on a "plan of correction." This is because a state surveyor found that nurses were holding meds with no written parameters based on the nurses experience and education. The surveyor stated that this is practicing outside of scope. We must contact the doctor immediately and get an order from them as to whether to hold or not. For example, if we get a BP of 89/59, we cannot decide to hold the med on our own, we must obtain an order from the physician. We must also contact the physician immediately if a patient refuses a med, and obtain an order as to what the physician wants done. We had been making these decisions on our own and letting the doctor know in the morning, but this is not acceptable according to the surveyor. So we have been trying to educate our physicians to write parameters on their orders if they don't want to get several phone calls every day. They are loving this new policy--not. And I guess I've been practicing out of scope for years!

Max,

I would be on a "plan of correction", too. Of course, I hold meds that would have adverse consequences to the patient, with or without hold parameters. Sometimes the docs just forget to put in the hold parameters.

I think it's called "using your head"? ( a 60's phrase!)

[General E. Speaking, RN, RN]

All of us nurses on the unit I work on are currently on a "plan of correction." This is because a state surveyor found that nurses were holding meds with no written parameters based on the nurses experience and education. The surveyor stated that this is practicing outside of scope. We must contact the doctor immediately and get an order from them as to whether to hold or not. For example, if we get a BP of 89/59, we cannot decide to hold the med on our own, we must obtain an order from the physician. We must also contact the physician immediately if a patient refuses a med, and obtain an order as to what the physician wants done. We had been making these decisions on our own and letting the doctor know in the morning, but this is not acceptable according to the surveyor. So we have been trying to educate our physicians to write parameters on their orders if they don't want to get several phone calls every day. They are loving this new policy--not. And I guess I've been practicing out of scope for years!

Oh Lordy! I can see this trickling down to everyone. Was this surveyor w/ Joint Commission? This is just going to require us to play Post Office even more. More Post Office = less time with patients cause you know the majority of the docs will not write perimeters. Heck, we can't even get ours to put a time on their orders! Although, since moving to ICU I do find that I get call backs sooner than when I was the Tele charge nurse. Whatever happened to critical thinking?

[LouisVRN, RN]

All of us nurses on the unit I work on are currently on a "plan of correction." This is because a state surveyor found that nurses were holding meds with no written parameters based on the nurses experience and education. The surveyor stated that this is practicing outside of scope. We must contact the doctor immediately and get an order from them as to whether to hold or not. For example, if we get a BP of 89/59, we cannot decide to hold the med on our own, we must obtain an order from the physician. We must also contact the physician immediately if a patient refuses a med, and obtain an order as to what the physician wants done. We had been making these decisions on our own and letting the doctor know in the morning, but this is not acceptable according to the surveyor. So we have been trying to educate our physicians to write parameters on their orders if they don't want to get several phone calls every day. They are loving this new policy--not. And I guess I've been practicing out of scope for years!

Max,

I'm glad to see someone else is going through this as well. I am trying to think of how to keep this from happening as much on my unit. As critical meds and antibiotics are also being held due to "nursing judgement". I didn't know that we were supposed to contact a doc when a patient refuses though, unless of course it is something the patient needs. I document that my patients don't want their Senna/Colace/Protonix all the time because they dont want to start something new just because they are in the hospital.

[AmericanRN]

All of us nurses on the unit I work on are currently on a "plan of correction." This is because a state surveyor found that nurses were holding meds with no written parameters based on the nurses experience and education. The surveyor stated that this is practicing outside of scope. We must contact the doctor immediately and get an order from them as to whether to hold or not. For example, if we get a BP of 89/59, we cannot decide to hold the med on our own, we must obtain an order from the physician. We must also contact the physician immediately if a patient refuses a med, and obtain an order as to what the physician wants done. We had been making these decisions on our own and letting the doctor know in the morning, but this is not acceptable according to the surveyor. So we have been trying to educate our physicians to write parameters on their orders if they don't want to get several phone calls every day. They are loving this new policy--not. And I guess I've been practicing out of scope for years!

OMG I guess we're all practicing out of our scope then. My favorite line in your unit's ridiculous "plan of correction" >>>>

Just what does the surveyor think the physician is going to do about a patient refusing a med from the nurse?

a) scold the pt verbally? b) box the pt's ears? c) hold the pt in the headlock while us nurses jam the medication in their mouths against their will? d) tase the pts like we're on episode of Cops until they agree to comply?

Seriously I hope the physicians complain whine and complain to the powers that be about additional orders for a pt refusing a med. Its a time waster for every discipline involved. The only thing I agree with is getting the physicians to write parameters in the original order regarding when to hold it.

[vindy]

Hi,

I use Davis' Drug guide book. For the example of metoprolol, a beta blocker, under implementation it says to hold if bpm

Cardiazem is a calcium channel blocker and although bradycardia isn't a freq side effect, it can still occur which is where your nursing judgement kicks in. If the patient is bradycardic, would you give a med that could possibly cause bradycardia? Have the other nurses given this med and how was the pt's response after? You may have to look at the times of onset and peak to assess the patient's response. I hope this helps. Good Luck!!!