pharm question

[joy1]

Hi all!

New to the forum…not sure how to start a new thread.

Just starting the excelsior program. I only have the nursing courses to take. Preparing to take the health safety exam, hopefully before the end of the month…the content guide seems rather overwhelming…but manageable.

Will appreciate if I could get an answer to this question.

If a pt has an apical pulse of 62 prior to administration of Digoxin –what do you do?

I will hold the med, since an apical pulse of 62 is borderline. Not sure if this is a good answer choice, as there's not much given for this theory question, eg. parameters.

Thanks;)

[carolmaccas66, BSN, RN]

There's 2 ways I've seen RNs handle Digoxin in the HOSPITAL SETTING ONLY:

1) The CN told me they don't bother taking the pulse because the patient doesn't do that at home, so in the hospital they just give the Digoxin.

2) Take the patient's pulse and if it's under 60 we don't give Digoxin.

You could also write in your answer that it depends upon the health care facilities policy as well. You also have to do what you think is right as a RN also, not what everyone else does.

This is just my experience thus far with Digoxin, so anyone elses experience may be different.

[thestrella]

Dont give Digoxin if Pulse is =

[MunoRN, RN]

It depends on the patient. If a patient regularly takes digoxin, I'll still give it even with a pulse of 50, you have to remember that the pulse of 50 is with Dig already on board, the next dose shouldn't change the pulse at all. Also, the main assessment factor for Dig is Dig level. In patients with a normal Dig level and a normal HR, you'll see more of a inotropic effect than a chronotropic effect and you may not even say any chronotropic effect at all with a HR

If it's their first dose, it's more of an issue and you may want to check with the MD first.

[ImThatGuy, BSN, RN]

And that's the good answer.

[Up2nogood RN, RN]

There should be parameters written for that specific patient, if not I would contact the MD before holding a med which is practicing medicine, something as nurses we are not licensed to do, unless there are specific parameters to follow.

[kyle2550web]

You follow policy and follow the MDs paramaters for the med. Typically Dig is held for a HR

[ObtundedRN, BSN, RN]

There should be parameters written for that specific patient, if not I would contact the MD before holding a med which is practicing medicine, something as nurses we are not licensed to do, unless there are specific parameters to follow.

Holding this med wouldn't be "practicing medicine," it would be called practicing nursing and using "professional nursing judgement."

The way I would personally handle this would be to hold the med for about an hour and reassess the HR. If it has come up from 62 then I'd give it. If it was still 62 then I'd probably call the MD and see what they want to do. And if they say give it with a HR of 62, I'd CYA. I say this because any HR is going to vary slightly. If you continuously monitored the HR for a minute or two, you'd probably see it vary between 58-68. So you could always argue that it was either too low or just enough.

The textbook answer for this would probably be to give the med since it technically isn't too low.

[SCnurse2010]

On a multiple choice test, I agree with ObtundedRN, give because the "hold" number is 60 for adults. In real life, I'd hold off, check for parameters specific to this patient, recheck the pulse, look at their history- is this their first dose, how long have they been taking it, what does their heart rate usually run, etc. Putting all those things together, I'd give/hold/call MD depending on what I found.

[Up2nogood RN, RN]

Holding this med wouldn't be "practicing medicine," it would be called practicing nursing and using "professional nursing judgement."

The way I would personally handle this would be to hold the med for about an hour and reassess the HR. If it has come up from 62 then I'd give it. If it was still 62 then I'd probably call the MD and see what they want to do. And if they say give it with a HR of 62, I'd CYA. I say this because any HR is going to vary slightly. If you continuously monitored the HR for a minute or two, you'd probably see it vary between 58-68. So you could always argue that it was either too low or just enough.

The textbook answer for this would probably be to give the med since it technically isn't too low.

Policies vary and where I work we are not to hold a medication based on *nursing judgement* without notifying the MD. If a med has parameters than that's fine but we really can't just hold meds without justification and I leave that to the docs since that's what they were educated for. Like another post said sometimes the HR can be as low as 55 and still okay to give. I don't assume it's 60 if there aren't written parameters in the order and I would call for parameters to cover my a%%. Just my opinion.

[Phil313]

I have never heard of that, I could never work somewhere that my Nursing Judgement wasn't valued. At my Hospital we hold meds all the time and document our justifications. It has never been an issue.

[BluegrassRN]

Textbook answer: give it. It's above the cutoff.

Real life answer: Check and see if there are any other parameters. Has the pt been receiving this dose of dig? What is his baseline heart rate? If this is not a new med or dose, no other new meds that could drop a heart rate, his baseline heartrate is in 50-60, and his bp is baseline, give the med.

In our facility, we need to notify the physician if we hold a med. That notification can take the form of a clinical note, as the physicians are expected to read all nursing notes. So yes, in that manner, I notify a physician if I withhold a med. If I feel something's going on, for example, there's not readily apparent, reasonable, benign reason for a sudden drop in blood pressure that necessitates withholding a bp med on a pt that has been hypertensive until this time, yes, I will be consulting the physician by phone.