When Should a Nurse Hold a Medication?
One of the most common medication questions nursing students have is: How do I know when I’m supposed to hold the medication?
Sometimes the answer is straightforward because the medication order gives you a specific parameter for when to hold it. For example:
Carvedilol 12.5 mg PO BID. Hold if SBP is less than 100 mm Hg.
Before administering the medication, you check your patient’s blood pressure: 93/63 mm Hg
In this situation, the decision is clear. The patient’s systolic blood pressure is below the ordered parameter, so you hold the carvedilol according to the order. But what happens when the order doesn’t give you a specific hold parameter?
Instead of trying to memorize a giant list of medications and hold parameters, start with the situations that should make you stop and take a closer look.
1. When The Medication Could Worsen an Abnormal Vital Sign
Before giving a medication, think about it’s mechanism of action (what the medication does inside the body). Does it have an effect on heart rate, blood pressure, respiratory rate, or another vital sign? If so, compare that expected effect with your patient’s current vital signs.
For example, your patient is ordered Metoprolol 25mg po BID. There are no specific hold parameters included in the order.
Before administering the medication you assess your patient and find:
Heart rate: 48 beats/min
Patient reports weakness and lightheadedness.
You know that metoprolol can decrease heart rate. Your patient is already bradycardic and is experiencing symptoms that may be related to the low heart rate. Even though the order does not say “hold for HR less than 60,” these findings should make you stop before administering the medication.
The question is no longer simply, “Is there an order to give it?”
It becomes: “Is it safe to give a medication that can lower heart rate when my patient’s heart rate is already 48 and they are symptomatic?”
2. When A Laboratory Value Makes The Medication Unsafe
Some medications require you to check specific laboratory values before giving them. But simply checking the lab isn’t enough. You need to understand why that value matters and how an abnormal result could change the medication’s effect or make it unsafe to give.
For example: A patient is scheduled to receive warfarin 5mg po daily. Before administering the medication, you review the patient’s morning laboratory results: INR: 5.0
Warfarin increases the INR and reduces the blood’s ability to clot. An INR of 5.0 is already elevated and may place the patient at increased risk for bleeding. Even if the order does not include a specific hold parameter, this result should make you stop before administering the warfarin and determine what needs to happen next.
3. The Patient Has a New or Concerning Assessment Finding
Sometimes the reason to stop before giving a medication comes from what you find during your assessment.
For example, your patient has several scheduled oral medications due. Before administering them, you notice that the patient is coughing and choking when drinking water. That is new.
Even though there is nothing wrong with the medication orders themselves, you now have a reason to stop before giving the oral medications. Why?
Coughing or choking with swallowing may indicate that the patient is not swallowing safely. Giving pills by mouth could place the patient at risk for aspiration.
The medication may be appropriate. The dose may be correct. The vital signs and labs may be fine. But something about the patient has changed and that changes whether it is safe to give the medication right now.
Something About the Medication Order Does Not Make Sense
Sometimes the concern isn’t a vital sign, lab value, or assessment finding. Something about the medication order itself doesn’t make sense for your patient.
For example, your patient is NPO because of a swallowing problem, but you see that a medication is ordered PO. Before giving it by another route, crushing it, or finding another workaround, stop and clarify the order. The medication may still be needed, but the ordered route may no longer be appropriate for the patient.
You should also stop when you identify a potential medication interaction. Maybe a newly ordered medication interacts with another medication the patient is already receiving and could increase the risk of an adverse effect.
That doesn’t mean you independently decide the medication can never be given. It means you don’t ignore the concern and administer it anyway. If the medication, dose, route, timing, or combination of medications doesn’t make sense, stop and verify before you give it.
4. You Don’t Have the Information You Need to Give It Safely
Sometimes the problem isn’t an abnormal finding. The problem is that you’re missing information you need before you can safely give the medication.
For example, your patient is scheduled to receive Insulin lispro 6 units subcutaneous before breakfast. The breakfast tray has arrived, but you realize the patient’s blood glucose has not been checked.
You don’t know whether the glucose is 240 mg/dL or 54 mg/dL, and that information matters before administering a medication that lowers blood glucose. Don’t just give the insulin and check the glucose later. Stop and get the information you need first.
Sometimes knowing when not to give a medication yet is just as important as knowing when to hold it.
Holding A Medication Is Not the Last Step
Holding a medication does not mean you simply skip the dose and move on. The provider still needs to know that the medication was held and why.
For example, if you hold metoprolol because your patient’s heart rate is 48 beats/min and they are lightheaded, the low heart rate is still a patient problem that needs to be addressed. The provider may need to evaluate the patient, adjust the dose, change the medication, or give you additional instructions.
The same applies when you hold a medication because of an abnormal lab value, change in condition, or other safety concern. Your job doesn’t end with “medication held.” You need to communicate the finding, follow the appropriate orders and facility policy, continue to assess the patient, and document what happened.
Holding the medication prevents you from adding to the problem. It doesn’t address the reason you had to hold it.
When You Study Medications, Go One Step Further
When you study a medication, don’t stop at the classification, indication, side effects, and adverse effects. Ask yourself:
· What do I need to check before I give it?
· Which vital signs, labs, or assessment findings matter?
· What finding would make me stop before giving it?
· Why would that finding make the medication unsafe?
· What would I do next if I decided to hold it?
Knowing the medication is the first step. Knowing when it may not be safe to give is the part you have to practice.
Ready to Strengthen Your Clinical Judgment?
Knowing when to hold a medication is just one example of the decisions nurses make every day.
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