Chronic Patient Dilemma

[westieluv]

Patient: Mid-50s male in our chronic unit who dialyzes three times/week and has chronic HTN. He will often arrive for tx with BP 180/100 or higher

Problem: He takes his BP meds just before coming to tx because he says that if he takes them earlier in the day so that he can arrive with lower BP pre-tx, he "feels like crap" and can barely make it to tx. It appears that meds are being dialyzed out because his BP will climb to as high as 205/105 during tx, yet he refuses to take the PRN Clonidine that we offer because then his BP plummets on tx and he will leave sometimes with a systolic of barely 100 and feeling woozy.

Nephrologist has adjusted BP meds several times, but nothing resolves this problem. I document that Clonidine was offered and refused, but honestly, I still don't want anything to happen to him. He walks to and from tx so I am really concerned when he walks out of our clinic with a BP of 205/105, but it is also concerning when he takes Clonidine and walks out with BP 100/55 and feeling woozy.

I have discussed with his nephrologist and his NP, but no one seems to be able to come up with any ideas except to adjust BP meds, which isn't helping.

Any ideas from you experienced dialysis nurses? Our standard Clonidine dose is 0.1 mg, so it's already the smallest available dose. Maybe I should ask MD to order 1/2 tab instead? I have never seen this done, I'm not sure what he would say, but it seems like it would be worth a try.

ETA: Arranging for him to get a ride to HD is not an option, I have tried that too. He has no available family or friends to drive him, and his income is too much to arrange free or cut rate cab rides so he won't consider that option at all.

Also, he is not overweight and controls his fluids pretty well. He usually arrives up 1-2 kg over EDW and we have no trouble removing that fluid. At EDW he has little to no edema and lungs are clear, HT regular, and he cramps when we have tried to challenge by 0.5 kg, so I think his EDW is ok where it is.

[Chisca, RN]

If you set his UF rate to 8cc per kilo per hour how long would his treatment last?

[westieluv]

If you set his UF rate to 8cc per kilo per hour how long would his treatment last?

If I did the calculation right, it comes out to just over four hours. Right now he runs 3.5 hours.

Of course, the day I post this things change. Today he came in with BP 190/100 but his BP dropped during tx until he came off at 132/70. Perfect, except that he didn't feel very good at that BP and had to sit and drink some water before he attempted to leave. He also said that when he left his tx on Monday he wasn't feeling great by the time he got home so he checked his BP and it was 90/50..without any Clonidine and having left at 205/105! He says he didn't do anything different as far as meds, etc. between the two tx, so I have no idea why such different end results.

Either way, his BP issues are so frustrating!

[nutella, MSN, RN]

Just another thought - perhaps check with your patient on compliance with BP meds in general and fluid restriction.

If somebody is not compliant with BP meds, it can become sort of labile - up and down. Some people really do dot take BP meds and only when they are nagged in HD or before they see a doctor. That can lead to a wrong picture. The MD pay think that the pat has high BP despite BP meds but in fact he may not even take them, so the ordered dose becomes too high.

Or the patient is truly fluid overloaded and that pushes the BP high.

[westieluv]

Good points, nutella, but you know how it is. You can only go by what the patient tells you he is doing, and this patient tells us that he is taking all of his meds as ordered.

Based on his assessment, he does not appear to be fluid overloaded, with the exception of some minor ankle edema at times. I know that people can hide fluid in places where it is not evident, especially if they are overweight, but he is not overweight at all and actually looks very fit. He is also never more than a few kilos over EDW when he arrives, and we take that off. He pretty much always leaves at EDW and if we try to challenge his EDW, even with the help of a Na+ profile in the past, he always cramps and "feels like crap", so I think EDW is probably pretty accurate.

I'm still in the process of "relearning" dialysis, since I left the field for two years to work in hospice, so I'm just going on my experience, but I know that you and others here have much more experience in dialysis than I do, so I really appreciate your input. : )

[Chisca, RN]

I'd try longer treatment times.

[BNgurl]

Other than CCBs, most patients take their BP meds post run. We would notify MD as an FYI, BP is say>180/100. We expect BP to trend down and if it remains high after the 1st hr would page for a rx usually Clonidine. Since pt says he's compliant ask him to bring in med bottles when you do ur monthly med reconciliation and compare the rx history (#refills/how often). Is he on UF/Na profile? What is his Na when he comes off? Kt/v adequate? I can't think of anything else..

Blood glucose within range?

[BNgurl]

Assess for hidden Na in diet: soups, canned tomatoes, crackers etc