should i have questioned it??

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Hey everyone!! im a student nurse who is graduatin in may 07. I have a question about a med that i was concerned about administering, any advice would be great!~~

My last clinical day I was team leader and overlooked 3 students with a total of 6 ortho/trauma patients. As team leader, my instructor allowed me to check the po meds, while she had to check the injections, IV etc. Anyway, this one patient was getting cozaar for her BP. As i was looking at her kardex, it noted an allergy to Lisinopril in one section, then further down it said allergy to ACE inhibitors. I was concerned about the allergy and wanted clarification....was she allergic to ALL ACE inhibitors or just lisinopril??:uhoh3:

And if she was allergic to ACE(angeiotensin converting enzyme) inhibitors....was it risky to be giving her a angiotensisn II receptor antagonist? I understand that angiotensin is already present in the body but there was no documentation about what she was allergic to within the ACE inhibitor or what S/S she had to call it an allergy? So who knows if whatever she was allergic to could also be present in cozaar.

As a student nurse, we learn to always check and this rang a bell in my head and I said that I wasnt comfortable giving the student the "OK" to give it so we talked to the instructor that was thankful i caught it and advised me to contact the pharmacist, which I was already in the process of doing. The Pharmacist said if she is allergic to ACE inhibitors ----no way do not give Cozaar...tell MD to clarify allergy.....then another said that as long as she was having a cough and not angioedema it was fine to give it.....esp since she had been gettin it everyday while at this hospital....for me i dont care how long she was gettin it it doesnt mean im givin it unles I know its ok....

I was just confused could anyone shine any light on it?? Overall.....if the pt was allergic to ACE inhibitors.....would they give Cozaar instead??Thanks ...sorry for the long post~~:monkeydance:

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What did you end up doing? What you should have done was A) talk with the pt to find out just what she was allergic to, and B) call the doc to verify the order. While being allergic to one med in a class makes the pt susceptible to all meds in that class, it doesn't necessarily follow that line.

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Specializes in Diabetes ED, (CDE), CCU, Pulmonary/HIV.

I think you did a good job to question the med. You might also ask the pt if s/he takes Cozaar at home and also ask pt to clarify allergy information. When I ask pt for allergy information, I always ask what the reaction is. People have told me they are allergic to morphine because it makes them dizzy. Another said she was allergic to cortisone because it makes her blood sugar go up. You'll find that many people consider any unpleasant reaction to a med as an allergy. You will also see many doctors' orders for antibiotics followed by doc's written comment "aware of PCN allergy."About 90% of pts from Cuba will tell you they are allergic to PCN.

Continue to question, and don't give a med unless you understand its actions, intended effects, and side effects.

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Specializes in Cardiac.

Has she been getting the med prior to your clinical day? Did she get it yesterday?

She is probably 'allergic' to the ACEi due to the cough, and that's why she's on an ARB.

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Thanks so much for your quick replies!! well it wasnt my pt, i was the team leader but I felt like it was my question so I should find the answer. If it was up to this student she wouldve given it. I talked to the pharmacist, then the nurse and she said she would call the MD to verify.

The pt was 86 and confused, so it wad difficult to get info from her. After talkin with the nurse, she talked to the doc and he ok'd it bc she has been taking it for yrs in the nursing home. But I think they had a hard time finding the info from her about her reaction to it,and just simply had the info from the transfer report from the nursing home. The pharmacist said that alot of times people c/o cough and say they are allergic to ACE inhibitors, which I know I haev heard before about other meds, but it didnt state anyehwere that that was her reaction, so thats why I made sure to question. Im not comfortable with giving meds if I have an instinct not to, so we let the nurse know, she got the OK and she gave it, not the student or I.

I just was writing to see if anyone ever had a similar situation with this allergy and another med that was prescribed for replacement. Or has anyone ever still questioned an order even though the MD ok'd it and not given it?? Thanks again just lookin for some advice before we don't have an instructor to go to!!

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Specializes in Float.

It is my understanding these drugs are NOT in the same class. I just did an education module on htn meds at works and it said the angiotensin II receptor antagonists (___sartan) are used when the pt can not tolerate ACE inhibitors (___pril)

Of course it's best to consult the pharmacist as you did if there is any doubt.

PS...saw your new reply...YES always question. I have seen on at least 2 occasions a HCP prescribe a drug that was listed as an allergy. They are human too.

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Specializes in Med/Surg, Ortho.

You can always call the patients pharmacy and see if they have been taking it at home. Or in this case look at the Nursing home med sheet and see if she had been getting it previously. There is a date on all NH med sheets as to the date the order started and that might have cleared up any problems. I see you got it cleared up, good job. Congrats on your graduation.

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hey mommy nurse a quick question in reponse to your post....i did read somewhere that angiotensin receptor blockers are used more now d/t decreased SE and are more tolerable......but my main concern was that the pt was Allergic to ACE inhibitors.....(in my mind thinking like anaphylactic shock bc there were no documented reactions) rather than being intolerable to it (in my mind like a undesired SE or it wasnt working for the pt). In your findings, did you happen to see pts getting it if they were actually allergic? Im still pondering it and wanted to see for further situations what to do if I ever come across it again...thanks!!! love this place!!!

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Specializes in Float.

Well I'm not a nurse yet (grad in 11 days and then gotta pass boards) :) but there are different forms of allergies. As teh other posters said it's good to ask the pt what happens..it's not always as drastic as anaphylaxis. In my intern job I take a TON of histories and in our software there is a place for allergies and we have to check what type of reaction for instance some faint, some have a rash, some vomit..etc. Sometimes the med just didn't work and it wasn't an effective and the pt THINKS this means an allergy

The meds I saw: one was my own husband. He is allergic to Mobic and his doc ordered Mobic and I had to remind him of the allergy (hubby broke out red like a lobster, face hot, increased RR, took him to ER) the other was in clinical. I was making my med list and saw a med ordered that was listed in the allergies..I think it was morphine..it was a few semesters back. My instructor just told me to notify the nurse. I don't think it was a med I was giving .. I think I was just doing PO or something...

But to answer your other question... yes the side effects are different and more tolerable. And yes... your pt may very well have had a true allergy...but from what I read (and I"m not a pharmacist nor a nurse lol) the reason they have diff side effects is because they are diff classes and have diff modes of action.. that is why I wouldn't have really thought much about an allergy to ACE inhib because that is a diff class..albeit same end result.

For instance with my hubby, Mobic is an NSAID. So the doc prescribes a corticosteroid. Both accomplish same goal to dec. inflammation but they are different classes and diff modes to do that.

I would have to look in my drug book to see exactly how the __prils and the __sartans work to make a more educated comment but my main point was they are different classes. Again..you were right..always go with your gut to question, talk to the pharmacist and if there is still question talk to the doc.

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Specializes in Float.

I just noticed you are about to graduate too..congrats! :smiley_aa

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Hope this helps...

The ACE Inhibitors work on the Renin-Angiotensin-Aldosterone system, which normally causes vasoconstr., Na and H2O retention, and increased BP to bring more blood flow to the kidneys as a compensatory response to decreased blood flow to the kidneys. ACE Inhibitors stop this by blocking that process, therefore preventing vasoconstriction, increasing volume, and lowering BP.

The point behind this is that renal failure pts cannot tolerate ACE Inhibitors b/c they really impact renal function by stopping this process meant to send blood flow to the kidneys.

Was the pt. a renal pt? Had any hx of renal flr or impaired renal function?

If so, these pts are most commonly put on ARBs b/c they work as well as ACE Inh. but block a different pathway (directly block all receptors on cell membrane) to lower BP. They are not considered the same class, so it was ok to give....but so good of you to dbl check.

Hope this makes sense....

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Specializes in Float.

That makes great sense... thanks for the reminder about the renal pt. So much to figure out about the impacts of the meds with diff pt diagnoses.

Another tidbit from the training module I took was that ACE inhib also block degradation of bradykinin which is a vasodilator... so that is another way it works by inc. bradykinin and helping with vasodilation.

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