Two questions

I don't know that we have a specific P&P for holding B/P meds. I have always been told it is a nursing judgement. Here's what I do though-if the initial B/P is low like 110/60 or below and it has been taken with a machine, I always get a manual. If the manual is still low, then I will look at the trends of the patient (if they have them), ask the patient if this is a normal for them, if they say that is normally like that then I will give the med. If they don't know then I will hold it and recheck once the patient is a little more awake or has been a little more active.

As far as IV starts go that just comes with practice. Wow-I wish we had an IV team but I just keep on getting hit and miss but I don't feel bad anymore b/c I watch the "senior" nurses do the same thing!!

It will be interesting to see what kind of responses you get on the B/P question.

Hey!!!

It's swell to have a 'new' nurse seriously thinking these kind of thoughts. We are the responsible person on the scene when these decisions are made and thinking about it now makes the decision-making easier tonight at 2100 when we've suddenly got the problem!!!

Here are two examples that might clarify the problem. Pt A is here because of several days of nausea & vomiting and he's pretty dehydrated, getting IVFluids, various diagnostic procedures planned and the order is written--Continue Home Meds. (Pretty silly order--but you might see it happen someday.) One of his home meds is 10mg Vasotec (enalapril) daily. His heartrate is 110 lying in bed and his BP is 96/40. You realize that his problem of dehydration is MUCH more serious than his problem of chronic hypertension. So you hold the med. Good for you and every nurse would agree with you.

So, what have you done? You have evaluated how the ordered med would affect the Pt's most important problem. That is one way to decide when to HOLD a med.

Second example: Pt B comes in for procedure. Is NPO all day. Unfortunately, procedure is postponed til the AM--you're watching them over night and they'll be NPO after Midnight. Same order: Continue home meds. This time the meds are: Vasotec 10mg daily and Toprol XL 100mg po daily. Neither was taken this morning because they were NPO. Vital Signs are HR 100 while in bed and BP 100/50. You think, if I give NOTHING--they'll be hypertensive as soon as their fluids are caught up. But if I give them both meds--they might have really really LOW BP before that happens. So I'm gonna give one and hold one. Now which one?

You have to think about the characteristics of the meds. You would give the Toprol because stopping Beta Blockers can cause 'rebound' hypertension.

There are other considerations. Those two jump to my mind.

You might also think of changing the times of meds, rather than holding them altogether. So you could hold it on your shift and space the meds out differently.

Hope that helps

Papaw John

If the pulse is less than 60, I'll hold any antihypertensive or cardioactive drugs.

If the blood pressure is less than 100/60, I'll hold any antihypertensive drugs.

These are my personal guidelines, and I have never gotten into trouble for holding certain drugs if the pulse or BP is too low to handle. Just objectively document your reason for holding certain meds and you'll be covered. Most importantly, the patient will remain safe.

In general, I have to agree with The Commuter. These are good parameters for the new nurse. If you feel you should hold any medication, of course, you might just clear it with your charge nurse or even better, the doc who ordered the med. We've often called the ordering doc and asked if we should give the med, followed by, "Would you like to give parameters for giving or holding that particular med, Dr., so we won't have to call you so often?"

(That's our very polite way of suggesting that if the doc had ordered the blinkin' parameters in the first place, they wouldn't be having to answer a page at 0200! )

As you gain experience, you'll find that Papaw John makes a very important point--why is the patient getting the medication and how will this change in condition affect it?

As a cardiac nurse, I have sometimes had patients whose heart rates go into Atrial fibrillation. Their heart rates were sky-high and very irregular, which caused a resulting drop in blood pressure, so we'd go ahead and give meds that looked like they'd drop the BP, but actually restored the HR and once the heart rate came down, the BP went back up.

The arrhythmia may have been caused from a low electrolyte imbalance, or low fluid volume...just to expand on what Papaw was saying.

Look around your unit to see if there is a book of standing orders. These usually contain an information sheet for each doc that list parameters for v/s, labs and other considerations and tell when they want to be called for abnormal values. It should also tell how they want to be notified--called at home, paged, called through answering service (they'll know who is on call).

If you don't have such an animal available, you might want to consider putting one together. Each doc has his/her own quirks and a standing order book is much easier than trying to remember details on fifty docs.

That said, Papaw John gave you essential advice. THINK about the rationale for giving, holding, or delaying a med. Write it down so you have the answer at your fingertips if someone takes exception later on. Find the med in the unit drug book and see if your reasoning is taking everything into account (rebound htn is something that might not leap to mind). And don't be afraid to ask your co-workers and especially your charge nurse. Sometimes you can also get valuable info from pharmacy.

As always, document, document, document. You don't need to go to great lengths if parameters are spelled out on the MAR. Just write the v/s that fell outside the parameter on the MAR sheet and circle the med (or do whatever else your facility does to show a med wasn't given). If, however, vitals are within the parameters and you hold the med anyway (or they fall outside the parameters but you still decide to give the med), be sure to document everything that led you to that decision.

Finally, be sure to evaluate whether or not you need to inform the doc of what is taking place. Is the patient trending in one direction or the other? Is he being watched for certain responses? Will holding the med affect other things?

Eventually, your gut will point you in the right direction. In the meantime, use the many resources at your disposal. And think about putting together a standing order book if your unit doesn't have one.

Take care,