Why are pts with low BPs still on meds that could lower their BPs even more?!

[christvs, DNP, RN, NP]

I've only been working on a med/surg/tele unit for 3 months now (I'm a new grad RN) but my question is this: I notice that I spend a lot of my time on the telephone with my patients' docs asking things like "Hey, Mr. X's BP was 92/60. Is it safe for me to still give him his 9 PM dose of Lasix and Cozaar, or should I hold them?" I feel like half the docs say hold them, but the other half still tell me to give it! So I always document what they tell me & then I feel like I spend even more time re-checking vitals to make sure the pt. is still fine. But if the docs know how low a pt's BP is, then why do they still feel the need to keep them on anti-hypertensives or huge doses of Lasix? Regardless of whether or not these meds have other purposes

(like the pt has CHF & really needs fluid removed so he can breathe more easily), how is it truly still safe to give them if they can potentially cause even more dramatic hypotension?

-Christine

[papawjohn]

Hey Christvs

In lots of cases the Pt in a cardiac unit might not be able to sustain an arterial BP anywhere near 'normal'. When I started off in this strange trade, the really sick Pt's had EjectionFractions of like 30 to 35%. Today there are lots of cardiac Pts out there (in your unit) with EFs of 20-25%. They are ALWAYS in CHF. If their hearts were required to maintain an arterial BP of 110/60 to 140/90, they'd be dead.

Once I say that, I want to hasten to add--if you think you have a good reason to question giving meds, call the Dr!!! Your knowledge of your Pts and their Vital Signs TODAY and their meds NOW exceed his.

If I were your charge nurse or mentor, I'd think you're doing a fine job.

Papaw John

[Tweety, BSN, RN]

People with cardiomyopathies and disease need their meds. Without it they would be sicker.

It does get a little hairy for the nurse when their meds have the side effect of lowering their blood pressure, but to not give it would be inviting further problems.

It usually is best to get some parameters. Different docs and different patients are going to have differing parameters.

[christvs, DNP, RN, NP]

Thank you guys for responding. It is slowly dawning on me that there are good reasons patients are on these meds, I just get freaked out when they run such low BPs before I give them. I'm going to do some reading up on the meds some more, now that I have the basics down. Thanks again Papa & tweety! :)

-Christine

[caroladybelle, BSN, RN]

It may be that the BP med is maintainng the pressure at a low level.

Not all antihypertensives are being used for the patient as a antihypertensive. Frequently, these drugs are being used primarily to support cardiac function/treat arrhythmias/improve cardiac output. If you hold them, from those with low BPs, it may worsen a serious condition. Many MDs place parameters on the med order to follow. Otherwise, call for any questions.

As an example, a hard headed veteran nurse decided to give a half dose of an antihypertensive to a chemo patient....despite the fact that the cardiology had specified that SBP parameter was to give for anything more than 80. The patient was receiving a form of chemo that is notoriously nephrotoxic, and would be receiving large amounts of IVF and diuretic to flush the kidneys and prevent damage. She also decided to hold the diuretic, as the systolic was low (though well within the parameters to give BP med), again of her own accord without calling the physician.

Needless to say, when the NOC nurse came on, the patient was in fluid overload, was having SOB and CP with worsening cardiac output, and in danger of renal compromise.

The NOC had to speak to the onco and the card. MD after midnight about the problem and got her rear chewed off...even though s/he did not commit the error. And the patient had to stay extra time in the hospital, to correct the damage.

(Now if my rear end would just heal)

[nursek05]

HI, my sign on name is nursek05, I also work on a Cardiac unit. I see where you are coming from with the low BP. I just try to out weigh the risk and benefits of that patient before I give their BP medications and I also assess if they are symptomatic or not if their BP are low. I also like to get parameters with their medications order and I realy like to monitor their labs and heart rate.

[RN12345656]

I think everyone pretty much cleared up the reasoning and the importance of why you would give the antihypertensives...

When I was a new nurse, I too had the same questions--It is always in the best interest of the patient to clarify parameters per patient (as you did).

I am not sure what shift you work, but I always ask the doc when they round for BP parameters. In the area where I work, the docs will get upset if you hold the pts betablocker, ace, etc. Generally, I would question giving the med for a BP less than 90 systolic and 50 diastolic. But again..you will probably give the med anyway for a pt with CHF, cardiomyopathy, and/or poor ventricular dysfunction.

[ZASHAGALKA, RN]

Some of those meds, like Cozaar that you mention, are evidenced based to prevent future complications.

JCAHO is monitoring if we are starting pts on them and for good reason - they save lives.

My guess is that you will find that the cardiologists are the least likely to withdraw those meds unless BP is under 90 or 95. They are proven to be successful. And in many cases, it is the previous doses of those meds that is creating that wonderful 95 b/p (where the doc most likely wants that pt to be) - is giving the next dose gonna tank that b/p, or maintain it?

~faith,

Timothy.

[geekgolightly, BSN, RN]

I know that this is probably going to be one of the hardest things to get used to when I begin my new job in Progressive Care/Telemetry. I am coming from a neuro floor where we like our pressures UP 140's 160's to prevent vasospasms, so whenever I see a BP of 100 systolic, I hold the med. It's going to just feel wrong to give beta blockers for a 95 systolic. I hope the tele nurses don;t think I am stupid. I am nervous about starting this job; my experience is so different from theirs!

[HappyNurse2005, RN]

Had a CHF/cardiomyopathy pt, who's BP's were routinely in the 70s. if we got a 91 systolic out of her, would be thrilled. LOL. She was on Coreg 6.25mg. We were wary of giving it for her systolic's in the 70s (asymptomatic). BUT b/c of the benefits of the med for her sick heart, he just said to give 3.125 if under 85 systolic.

[shirleyTX]

From what I gather from this forum, it seems that it is the norm to give antihypertensive meds with SBP

[gauge14iv, MSN, APRN, NP]

Some of the antihypertensive medications are used for things other than hypertension.

For instance - a person with normal BP who is diabetic or has CAD or with renal problems will be place on an ACE Inhibitor to protect the kidneys, or reduce left ventricular dysfunction. Certain drugs HUGELY reduce the risk of events such as stroke, MI or renal failure. Sometimes they are given (Coreg is a good example) for their protective effects on the heart or other organs and for the fact they are risk reducers - not just by a small margin either!

There are dosing guidelines based on studies that show that a certain dose is required to provide the protection - but sometimes to attain that dose, the patient may feel like a wet dishrag while getting there. It is a fine line between tolerance and therapeutic. If you aren't sure why a patient is getting a particular med, I would ask the doc - that way it will be better understood as to when any given patient should have a dose held or not. The old - "Always hold anti-hypertensives if the systolic or diastolic is a certain number" doesn't really apply anymore in many cases, but the doc needs to provide some guidelines applicable to each patient. If there aren't any - we need to ask for them!