When to hold cardiac meds?

caliotter3 · Oct 19, 2011

If no facility policy in place, when in doubt, call the doc, report, and follow his instructions. If nothing else, if you are bothering him too much, he might give some parameters for the order.

suanna · Oct 19, 2011

You studied your meds in school- or after. You know the effects of the meds. As a rule, don't hold cardiac meds unless the patient has unstable VS that would be made worse by the medication. There are a lot of nurses that think thier primary job is to second guess the decisions of the attending cardiologists. It does so cheer the docs up to find out a patient whos heart is so weak that they have to walk a fine line between crashing thier pressure and unloading thier SVR far enough to allow tissue perfusion, only to come in the next rounds to find the patient in renal failure or CHF because some smart nurse decided a SBP of 102 was too low to give the ACE inhibitor. Now they have a SBP of 110 but have a HR of 130 because the heart can only generate a SBP of 115 and is ejecting 5cc/beat. Use common sense with your nursing judgement- has the patient been on these meds for a while without problem? Are you seeing problems from the meds that are worse than the problems you saw before the meds were started? There are no magic pills- every med has side effects and complications that can be a trade-off with the benefits. I'm not saying NEVER hold cardiac meds- just be very sure-call the doc- talk to pharmacy, talk to your suporvisor. You cannot legally hold a med and tell no-one. The managing physician has the right and the obligation to tell you to give a med you questioned, approve the holding of the med or change the med to something different. If you have parameters in the order- no call is necessary- the decision of what to do is made. If you have no parameters you are sticking your neck out quite a bit to decide not to follow the attending physicians orders without calling.

xtxrn, ASN, RN · Oct 19, 2011

Every patient is different. If the doc has not left parameters, get some :) You can also call pharmacy and ask them what the manufacturers recommendations are :up:

But you deserve to get some answers vs some willy-nilly nonspecific responses to your questions. :)

allthesmallthings · Oct 19, 2011

You studied your meds in school- or after. You know the effects of the meds. As a rule, don't hold cardiac meds unless the patient has unstable VS that would be made worse by the medication. There are a lot of nurses that think thier primary job is to second guess the decisions of the attending cardiologists. It does so cheer the docs up to find out a patient whos heart is so weak that they have to walk a fine line between crashing thier pressure and unloading thier SVR far enough to allow tissue perfusion, only to come in the next rounds to find the patient in renal failure or CHF because some smart nurse decided a SBP of 102 was too low to give the ACE inhibitor. Now they have a SBP of 110 but have a HR of 130 because the heart can only generate a SBP of 115 and is ejecting 5cc/beat. Use common sense with your nursing judgement- has the patient been on these meds for a while without problem? Are you seeing problems from the meds that are worse than the problems you saw before the meds were started? There are no magic pills- every med has side effects and complications that can be a trade-off with the benefits. I'm not saying NEVER hold cardiac meds- just be very sure-call the doc- talk to pharmacy, talk to your suporvisor. You cannot legally hold a med and tell no-one. The managing physician has the right and the obligation to tell you to give a med you questioned, approve the holding of the med or change the med to something different. If you have parameters in the order- no call is necessary- the decision of what to do is made. If you have no parameters you are sticking your neck out quite a bit to decide not to follow the attending physicians orders without calling.

You sound experienced! You understand your cardiovascular algebra, at least! I was just thinking that SBP 100 was kind of low for an Ace-Inhibitor, then I read your post.

Anyway, OP: in my own experience, 1) the beta-blockers have less effect than the ace-inhibitors; 2) I look back at the vitals to see how the BP's been, and how it's tolerated the BP meds; 3) if I hold a BP med, I circle the time and write the BP value beside it so that at least someone knows WHY it was held; 4) also, I sometimes ask the Pt if he takes the med at home and how he tolerates it, and if he checks his BP before he takes BP meds, and if he holds his BP meds for a certain value.

When in doubt, call MD; or, hold the med, wait an hour or two (or until next vitals sign) and see what the BP is then, or if it goes up if the Pt gets up out of bed to walk. Suanna sounds correct; its just that on my floor, an orthopedic floor, HTN isn't a primary issue; we don't get a lot of crazy-sick cardiovascular cases; our concern tends to be more "hmm, if I give this med and the BP goes down, the Pt might faint when we get him out of bed to go to the bathroom" (orthopedics is big on fall prevention) more so than thinking about their stroke volume and renal perfusion and what not.

dizzyray822 · Oct 20, 2011

Its just on my floor I'll have a pt on Metoprolol, Lisinopril, and Norvasc all at once and NO parameters. So when my preceptor says hold Lisinopril on one pt then next time hold the metoprolol it has me confused. I had a pt a few days ago with a BP of 178/87 but HR in 50s/60s. The doc wrote for 0.1mg Clonidine and 20mg of Lisinopril, knowing the HR, and said to give them now. Plus Vasotec PRN with parameters. Anyway, after the doc left I took the pressure again before I went to give the meds and it was 125/75. Okay....so now I held the meds. At lunch, it was 141/103. I spoke to my preceptor and she said give the Clonidine and Lisinopril. Gave it and an hour later he was 95/55 with HR in the 40s and 30s. Now I called the doc and we had to bolus the pt. I felt frustrated. Is this just the case sometimes? Crazy BP's drive me crazy as a newbie!! I just don't want to hurt anyone.

raskol · Oct 20, 2011

I find it helps to know why they are on each medication. Is the EF low? Am I trying to increase cardiac output or coronary perfusion? How have they tolerated the meds in the past? Am I trying to keep them in sinus rhythm?

poopprincess · Oct 20, 2011

I hold Metoprolol all the time. If my patients systolic is 102 then I hold it. I once bottomed out a patient because she INSISTED that I give her BP med anyways. She said that she took it at home, had a history of a MI and had been on that BP med for years. I gave it to her (with the permission of the charge) and ended up with a low BP and a HR in the 50's. That was Coreg 6.25, which my charge with a cardiac background, said should be fine because it was a low dose. The Dr. was angry at me in the a.m. because the charge told me to tell him what happened and it made me look irresponsible because I gave it. It does get tricky but I work in LTAC. I get a lot of cardiac patients and with the exception of the one lady I just discussed, I have never been in trouble for holding a cardiac med. I put the BP/HR on the Mar and move on.

xtxrn, ASN, RN · Oct 21, 2011

If the patient is in there for unstable BP/heart rate, there may be a bunch of chaotic readings until the meds get straightened out. :) Sometimes it will be sort of nuts- but the rationale should be consistent - imo :up:

CorazonDeOro · Oct 21, 2011

If the docs have not left me parameters (I work on a surgical unit, not cardiac), and I have any question (SBP around 100 or so), I always call them. I have never had a doc get irritated with me about it. If I call enough they usually just give me a telephone order for parameters anyway. I figure its better to call than to give it, bottom the pt out, and then have to deal with that. They will usually tell me which ones told hold and which to give as well (Like give the beta blocker because the HR is fine, but hold Clonidine or whatever).

3fins · Oct 21, 2011

I used to get annoyed when I have a BP med to give that's "Hold for systolic less than or equal to 100." and a systolic of 102.

What I do is look at the patient's vital's history and trend (how did he previously handle the drug?) and consider the big picture. Then think about the actual order - if the parameters are low, they're low, and that's how the doc set them, and if you give the medication you're 100% in the clear. Not sure, call the doc and ask if he wants to keep the same parameters.

turnforthenurse, MSN, NP · Oct 22, 2011

When in doubt...call the doctor and ask. And ask them for parameters. Typically they are held if the HR is

For antihypertensives, such as clonidine or hydralazine, that is at the discretion of the physician. You need to ask for parameters. I have seen parameters for clonidine to only give if SBP >160 as well as SBP >165. For hydralazine, I have seen orders stating to give is SBP >160 and/or DBP >100; I have seen orders to only give if SBP >180 and/or DBP >110.