To hold or not Hold=That is the Question

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Specializes in Med/Surg, Tele, PCU.

Hi everyone!

I'm a 2-year old nurse working on a Tele floor. I understand what the different cardiac meds (beta blockers, Ace-inhibitors, antihypertensives,ARB's etc.) do-or better, what their function is. But I have a hard time knowing when to hold a med (particularly when there are no parameters) when the blood pressures are borderline systolics maybe 100 or in the 90's, maybe with a low diastolic as well. The heart rates can sometimes be within normal range or slighlty bradycardic (in the 50's). Unfortunately I work on a unit where questions aren't welcome very much.

Can someone shed some light on this subject?:confused:

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Specializes in Tele, ICU, ED, Nurse Instructor,.
Hi everyone!

I'm a 2-year old nurse working on a Tele floor. I understand what the different cardiac meds (beta blockers, Ace-inhibitors, antihypertensives,ARB's etc.) do-or better, what their function is. But I have a hard time knowing when to hold a med (particularly when there are no parameters) when the blood pressures are borderline systolics maybe 100 or in the 90's, maybe with a low diastolic as well. The heart rates can sometimes be within normal range or slighlty bradycardic (in the 50's). Unfortunately I work on a unit where questions aren't welcome very much.

Can someone shed some light on this subject?:confused:

I understand what you are feeling. I have worked Tele for over 3 years. Usually when there are not orders to hold; you may want to call the primary, heart, or whom ever ordered the med to notify them the patient BP or HR because you dont want to be holding no meds and the docs do not know. The reason is the docs can either decrease the dosage or discontinue the med all together. Before you hang up with them; ask them if they would like parameters on the med to prevent from calling them all the time. Some docs may say no because some may want to be called due to some patients BP and HR decreases or increases different time such as morning or night. Make sure you document your findings and make notes on your assessments. So if others nurses have other questions like you; they can review your notes and they would be helpful. Good luck.

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Specializes in Cath Lab/ ICU.

It can be tough. But remember that they have low BPs and HRs because of these meds. Meaning: the meds are doing their job, so we need to continue to let them work. If there are no parameters, and the pt is not symptomatic, then I'd give the meds.

A little history goes a long way here too. What was their BP yesterday? Did they get their meds then? What happend on previous days after receiving their meds? Hopefully you have access to this information since you don't work in a helpful learning environment...

Btw, SBP of 90's is just fine, and what many cardiologists shoot for. All depends on the situation.

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Specializes in Med/Surg, Tele, PCU.

Thanks for your terrific advise!

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Specializes in Med/Surg, Tele, PCU.

I guess what I haven't been able to find an answer for is ...approximately how much (in percentage or value) do this blood pressure meds bring down the systolic (and/or diastolic) blood pressure. This would at least give a good guideline to base a decision on. I know that every patient is different, but there must be an "on average" type of value.

Any suggestions? References? sources, etccc?

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hmmm i would check if you have bp hr trends and are still confused. it all depends on the pt. are the meds new? then bradycardia/low bp will mean something different than if you have a pt. taking bb's for a long time and are bradycardic obviously.

sometimes bb will improve SBP when given if the HR is too fast due to decreasing chronotropy and increasing filling times. just like diuretics---sometimes giving the 'water pill' or what have you will increase a low bp due to reduction in preload.

also be very very very VERY careful with your aortic stenosis pts. a SBP in the 80/90's may be the norm for some CHFers but you would want ot pay close attention to those with critical AS...for me, a pt with AS and low bp would warrant a call to the care team to run it by them.

hope this helps. :twocents:

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Specializes in Med/Surg, Tele, PCU.

Hi surferbettycrocker (love that name!),

Can I ask you how long it took you to become a good critical thinker when it comes to cardiac meds? I'm a two-year old nurse. The more I read on these meds, the more confusing it gets! I mean, for instance....inotropic meds, then there's positive and negative inotropics. The negative inotropics like the beta blockers decrease hr, contractility and peripheral bp. Then to make it more complicated, they are also used as anti-arrhythmics. Then calcium channel blockers (also negative inotropics)..they reduce contractility). And then when you blend in the sympatholytics (also negative inotropics) like clonidine and cardura...I sometimes feel like I'm giving this patient a cocktail of heart meds!

There are times that for instance I have to give 50mg Lopressor scheduled and an hour later clonidine-also scheduled! So I'm thinking to myself..why is this scheduled so close together? This pt. is gonna go hypotensive on me. I'll tell you the truth, if I worked the day shift, i would call the physician and ask him/her the reason for the medication and for the scheduling of same. But I'm a night-shifter (love my night shift) and a physician would not appreciate it if I called to question his/her rationale after hours.

There's this gentleman by the name of Mark Hammerschmidt, he's an old ICU nurse. He's on-line and also wrote a fabulous book for new and old ICU nurses. In my opinion, he's got a great sense of humor and he really simplifies all the mystery behind some complex issues. I'm going to e-mail him and see if he can update his website (if he hasn't already) with information on cardiac meds. I think this is his website http://www.amazon.com/Notes-ICU-Nursing-Files-Second/dp/0741417057/ref=sr_1_1?ie=UTF8&s=books&qid=1270003688&sr=8-1 for any newbies out there who have question marks on their heads about this as I do :confused:.

Surferbettycrocker, and all others on this thread, thanks for your input and please.....if anyone else has more information, please by all means I could use it!:yeah:

Keep on truckin' and thank the Almighty for nursing!:redbeathe

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Dear GoNightengale--I too feel like a newbie just a few short years in nursing but it feels like dog years. hmm working nights with little to no support is very tough and like you mentioned calling the doc after hrs is not something you would want to do for little things. i think its nuts that pts may get bp meds round the clock--would they do that at home? no. if you feel like you can't ask other nurses on the nite--there is always the medication admin history, but its not gospel which is the hard part. you would think people would give a med and document it but....:redbeathe

for me i space bp meds. some nurses dont b/c thats how the meds are ordered and if the pt takes em at home that way it should be fine..alas if they are in the hospital they are not 'at home' and they needs a little more care..

cardiac pts are tricky i think as are renal. like rolling dice. i have seen lots of bad things happen to critical AS patients when the bp goes low, and i have had some very smart people around me. honestly, if you can switch to day shifts you may pick up more IMO. i say that only b/c there are more 'resources' during the day. :redbeathe

i am a nervous nelly. i know this, my pts do not. and i am perfectly fine with it!

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The MD, particularly if a cardio, may want a beta blocker given even if the pt's BP is low. It's a different risk-benefit calculation for every pt, so there is no hard and fast rule. In a post-MI pt, beta blockers are significant in preventing another MI. I don't presume that a lack of parameters means the MD hasn't thought things out. I read the progress notes and consults, and if the answers aren't there, I call.

Treat the pt, not the numbers. Abnormal BP in and of itself isn't bad. Is the pt symptomatic? Is the doctor, having taken into account expected low BP, driving for prevention of or recovery from remodeling? If a pt's BP is very high, you might not want to take them down too fast. A sudden decrease may reduce brain perfusion to the point of precipitating a stroke.

Learn your meds in depth. Learn about clonidine rebound and paradoxical reaction to labetalol. Learn about the interaction between IV cardizem and beta blockers. At every hospital there is a cardiac med guru. Seek that person out and learn.

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Specializes in Tele, ICU, ED, Nurse Instructor,.
The MD, particularly if a cardio, may want a beta blocker given even if the pt's BP is low. It's a different risk-benefit calculation for every pt, so there is no hard and fast rule. In a post-MI pt, beta blockers are significant in preventing another MI. I don't presume that a lack of parameters means the MD hasn't thought things out. I read the progress notes and consults, and if the answers aren't there, I call.

Treat the pt, not the numbers. Abnormal BP in and of itself isn't bad. Is the pt symptomatic? Is the doctor, having taken into account expected low BP, driving for prevention of or recovery from remodeling? If a pt's BP is very high, you might not want to take them down too fast. A sudden decrease may reduce brain perfusion to the point of precipitating a stroke.

Learn your meds in depth. Learn about clonidine rebound and paradoxical reaction to labetalol. Learn about the interaction between IV cardizem and beta blockers. At every hospital there is a cardiac med guru. Seek that person out and learn.

I totally agree with you my mother has had two MI's. She was on Toprolol 200 mg a day. Earlier this year she was diagnose with a CHF a mild case with a EF 50%. Toprolol was discontinued and started on Coreg which is non selective beta blocker. While on this med she has been on different dosages especially after her open heart surgery.

When dealing with any Cardiac meds each patient is different. I believe with when these meds are initiated for the first time all precautions should be taken. You have some doctors juggling with these meds. As nurses it keeps us on our toes.

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Specializes in CVICU.

Technically, you are supposed to call if no holding parameters are written. Do I always do this? No... sometimes I will wait until morning and let the doc know they need to write holding parameters (i.e. patient is maxed on Levophed, so yeah, I'm not giving the dose of Lopressor tonight which was previously ordered during their stay when they were actually hypertensive).

There are certain meds docs will want given despite the patient having a low MAP or SBP. Some examples would be ARBs and ACE inhibitors following acute MIs, and meds such as Coreg. If in doubt, just call and ask for holding parameters. I really wish that more docs and NPs would write parameters to begin with, so I could avoid a few phone calls!

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Specializes in ICU, MedSurg, Medical Telemetry.

Completely selfishly, I'm glad to see that other nurses who have been nurses longer than I have still have these questions. I've almost been a nurse a year and I'm always asking questions that feel like dumb questions. It doesn't keep me from asking the questions, but sometimes I wonder if I'm just really slow.

Thanks for being open about your questions (and answers!). It helps to know that I'm not just stupid!

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