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?
From what I gather from this forum, it seems that it is the norm to give antihypertensive meds with SBP
In ICU at least, I sit on 80's sys all the time. It certainly isn't standard to start dopamine on a pt's whose blood pressure is temporarily low because of routine meds.
There'd be alot more ICU pts if that were the case.
IF I were concerned, I'd try a fluid challenge first. But most of the time, if a pt can be aroused enough to pass a newspaper test, I let them be. (newspaper test: if they can be aroused enough that I think they could read a newspaper.)
The other thing that you have to take into account is that the human body isn't designed to be horizontal for a long period of time (you are normally vertical 16-20hrs/day.) Prolonged exposure to horizontal positioning can have serious effects on bp. That's why those pts that have been lying down for a day plus ALWAYS get dizzy the first time you sit them up.
But there has been a revolution in thought about low bp. Therapeutically induced low bp is much more tolerated than it used to be.
Specializes in Geriatrics/Oncology/Psych/College Health.
It would be a heckuva lot easier if the doc would just specify a tolerably low BP parameter (not that you wouldn't be expected to still think and call if the pt were symptomatic, but just to give you a "don't sweat it" range for an asymptomatic person.) Most of our docs at the hospital I recently left eventually figured out to clarify this in the intial order.
I think what really makes the biggest difference most of the time is symptoms and patient tolerance. If the patient is assymptomatic and can tolerate a SBP in the low 80's, then it is less of an issue. Remember that patients with severe LV need a decreased preload and afterload for the heart to be able to do it's job.
Originally posted by guage14iv
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!
14,
I'd be cautious throwing out this advice, as often times patients with renal insufficiency or renal artery stenosis may actually suffer severe renal damage from the use of ACE-I's and ARBS. Remember the Renin-Aldosterone-Angiotensin thing. That's the way the kidneys often communicate to the body that they are in need of improved blood flow, ACE-I's and ARB's tell the body to "ignore" what the kidneys are saying. I've personally seen probably a couple dozen patients who've suffered this fate because of uneducated Dr's, and my own mother was near the same fate, when I fired her doctor.
It wasnt advice - it was the reasoning behind what is done based on current medical guidelines. As nurses, it isnt our decision to make - it's the physicians call. If the patients blood pressure it outside of normal limits its up to us to call the doc and let him make the decision.
It isn't up to us to decide what blood pressure is appropriate for a patient if it is outside of norms.
ETA - there are contraindications, but there are also solid well tested guidelines for use in patients without those contraindicatinos. With RAS the trouble arises when a person has it and the presciber is not aware. but as I said - the point is pretty moot as a nurse, because thats the prescribers call to make.
Some patients have CHF. Some heart medications that can potentially lower blood pressure also help reduce the workload on the heart for these patients. For example: Coreg.
Some patients have CHF. Some heart medications that can potentially lower blood pressure also help reduce the workload on the heart for these patients. For example: Coreg.
And they (Beta Blockers, ACEI and prob ARBS) can reduce negative post MI remodeling. That can give long term benefits as far as reducing the risks of MIs down the road.
So, do you want to prevent a drug from providing permanent protection to the heart for the sake of a temporarily uncomfortable (for you, the nurse) BP.
The key is the old BLS/ACLS ABC's - are they getting enough circulation to get oxygen to the brain/organs. Can they wake up and talk to you coherently? Is the urine output satisfactory? If, so, let these drugs do their wonderful jobs.
The other consideration, of course, is that, as the ultimate and most expensive bedside monitor, it is your job to function within your parameters and report important findings, like low bp. I'm not saying don't report it; I'm saying UNDERSTAND why it might not be as critical a finding in a cardiologist's eyes as you've been previously trained to interpret it. (And I'm also saying that, if you report it, report it to the CARDIOLOGIST, if available. I'm sure you can get a non-specialist to focus on BP, just like you: we've all been trained that way. But the new data provides a rationale to change our way of thinking: so if you report it, report it to the docs that are trained to interpret this data in the new, right way.)
It's time to start thinking of these drugs like we think of chemo. Are we causing a temporary setback for a permanent gain? If so, what's more important, the temporary setback or the permanent gain. We should be thinking about 'managing' the temporary affects to get that permanent gain. Yes, you don't want the temporary affects to be more detrimental then the long term goal. But you WANT the long term goal.
ZASHAGALKA, RN
3,322 Posts