Dialysis and medication administration

RNeyez, RN · Jun 9, 2004

I'm a med-surg nurse and we deal with many dialysis patients on our unit. My gut instinct was always to hold meds (especially the BP/DM meds) before dialysis. However, at the hospital I currently work at, the MD will specifically write "give meds before HD" or something to that effect with the BP parameters specified. Makes it cut and dry for us nurses....especially when we get the docs that are too quick to say, "you are not to 'interpret' my orders...just follow them".

Lori

p.s. By the way, how do you guys pass on reports to the HD unit (if at all). The first hospital I worked at didn't pass on any reports at all...but the hospital I'm at now is trying to get some type of uniform system going. Too often, we're wasting time trying to find out if the Vanco, epogen, etc was given after HD while IN HD or not...among other things...like if the patient's BP bottomed out, etc.

jnette, ASN, EMT-I · Jun 9, 2004

It is always wise to hold antihypertensives until AFTER the patient has been dialyzed. The patient's BP drops during tx. due to fluid being pulled off, and if they take these BP meds before, their BP will bottom out.

Sometimes even pain meds need to be taken into consideration.., as these also tend to lower the BP... but I would certainly inquire with the doc about these first; obviously if the patient is experiencing any type of severe pain, you would want him/her to have relief.

At our dialysis clinic, we have zero communication from the hospitals when our patients need to be admitted for anything. This is so frustrating... they don't even let us know the patient has been dc'd and will be back to dialysis the next day. Nor do they send us any info... what was done, what meds given, how treated, what to expect.

There really does need to be a continuum of care.

Usually vanc is given the last hour during tx., gent the last half hour by IV push. Epo in most cases is also given during tx.

Hope that helps.

mercyrn02, RN · Jun 11, 2004

RNeyez said:
I'm a med-surg nurse and we deal with many dialysis patients on our unit. My gut instinct was always to hold meds (especially the BP/DM meds) before dialysis. However, at the hospital I currently work at, the MD will specifically write "give meds before HD" or something to that effect with the BP parameters specified. Makes it cut and dry for us nurses....especially when we get the docs that are too quick to say, "you are not to 'interpret' my orders...just follow them".
Lori
p.s. By the way, how do you guys pass on reports to the HD unit (if at all). The first hospital I worked at didn't pass on any reports at all...but the hospital I'm at now is trying to get some type of uniform system going. Too often, we're wasting time trying to find out if the Vanco, epogen, etc was given after HD while IN HD or not...among other things...like if the patient's BP bottomed out, etc.

When a pt is scheduled to have HD usually our nurses will call to report only if there is something specific that the HD nurse should know ,such as labs that need to be drawn, the pts bp required dosing of bp meds before HD, the pt is diabetic,or the pt is on isolation precautions. report must always be called to the primary nurse from HD to report # of liters taken off,all vital signs, and administration of meds or blood,and any adverse event. The only thing I do not like about our system is we have to take meal trays to HD for the pt. and also do our own accuchecks. Thanks a lot for the info. It is the most solid answer I have ever received.

wmarat, BSN, RN · Jun 12, 2004

I've been working as a nephrology nurse for about 11 years and our usual practice is not to give antihypertensive meds, however I've happened to see a few cases of uncontrolled HTN when those meds is given before tx.

Farkinott, RN · Jun 12, 2004

jnette said:
It is always wise to hold antihypertensives until AFTER the patient has been dialyzed. The patient's BP drops during tx. due to fluid being pulled off, and if they take these BP meds before, their BP will bottom out.
Sometimes even pain meds need to be taken into consideration.., as these also tend to lower the BP... but I would certainly inquire with the doc about these first; obviously if the patient is experiencing any type of severe pain, you would want him/her to have relief.
At our dialysis clinic, we have zero communication from the hospitals when our patients need to be admitted for anything. This is so frustrating... they don't even let us know the patient has been dc'd and will be back to dialysis the next day. Nor do they send us any info... what was done, what meds given, how treated, what to expect.
There really does need to be a continuum of care.
Usually vanc is given the last hour during tx., gent the last half hour by IV push. Epo in most cases is also given during tx.
Hope that helps.

You MUST be walking in my shoes!

Allaroundnurse · Jul 22, 2004

mercyrn02 said:
I am a tele RN and frequently work with pts. on hemodialysis. Usually my pts. have a boatload of meds especially antihypertensives, nephrocaps, renagel,etc.
I have been a nurse for 1.5 years and have asked everyone I know ,which meds should not be given before dialysis and I always get varied ,if any, answers. I am very concerned and do not want to make any mistakes, I have even surfed the web trying to find the answer but have not come up with anything are there any guidelines for this. My current practice is to give or hold antihypertensives before dialysis based on the bp. help!

I wish every nurse would be like you and ask!! Your acute dialysis nurse should help you. There is a book that is published (it will fit in your pocket) the 2003 version was put out by Bone Care (they make Hectoral), I'm sorry to say that I don't know who did the 2004 version, and it has which drugs are dialyzed out. The antihypertensives are held if the patient has a problem with having low B/P during treatment. Ask the patient if they take their B/P meds prior to going to their treatment in the outpatient facility. Naphrocaps are a vitamin and vitamins usually dialyze out, if the chronic nurse (the outpatient facility nurse) did good teaching the patient can also tell you this. The binders (renagel, phoslo, tums, magnabind) there are a few more, are given with food to bind with the phosphorus in the food so that it can be excreted in the stool. That is why we call them binders, the other reason is because these meds can also cause constipation (with the exception of magnabind -diarrhea). http://www.davita.com is a good web site to visit to get information for the health care professional. Again talk to your acute dialysis nurse and ask for an inservice on medications and dialysis. If I can be of any assistance please let me know.

TallCoolOne · Mar 29, 2007

Great question.... I am a dialysis nurse, and have been for many, many years. I am an acute dialysis nurse, and I wish more nurses were concerned about medication administration as it relates to hemodialysis. Reading the responses to your posting, they are right on the money. That pocket guide that has been mentioned is readily available and most dialysis nurses carry one with them or have one easily accessible. We have a chart in our medication room that covers a huge portion of the wall that has most frequent medications listed. So, if your dialysis nurses aren't being helpful, it isn't because the information isn't available. (dialysis nurses can be a little obstinate, in my opinion - I think many of them go into dialysis because they don't play well with other!) As a "rule", we do not administer drugs during hemodialysis with the exception of dialysis meds (epogen, zemplar, iron, etc...), certain antibiotics, and prn medications for pain/anxiety.

One reply to your post mentioned bringing food trays to the dialysis unit. This should not be an issue. I recently researched just this subject, and conducted a very thorough literature review. All of the studies that I found were 100% against patients receiving food during dialysis... for various reasons. First and most important, postprandial hypotention. If there is food in the gut, there is diversion of blood flow to aid in digestion. This shunting of blood can cause a decrease in blood pressure. Another reason follows that same reasoning... with the blood shunting/diversion to the gut, the dialysis clearances are effected (i.e., less efficient hemodialysis).

MSLNT1.1 · May 12, 2007

After reading everyone's post I have to agree being a dialysis RN and educator that they all have valid and strong points when it comes to whether you should give antihypertensives. And as it has been said in general you advise the patient not take the BP meds prior to treatment. Also make sure if you know if any of your patients have uncontrolled hypertension. We need to be more assertive with the MD about guidelines as to when we should administer the patient their BP meds. I always educate my patients to bring their medication with them especially their BP meds and diabetic medications so that if an emergency situation occurs we can be as prepared as possible. Another thing to keep in my is that patient who have uncontrolled HTN may need to receive their epogen within the last hour of treatment or sometimes the MD may change the dose because it can cause exacerbate the patient's HTN. Look at http://www.ferrlecit.com. Also, I can't recall how many times I have seen a nurse push a patients iron fast and not as recommended. The possible side effect of that is also hypertension.

jnette, ASN, EMT-I · Dec 30, 2007

Thank You. ?

Always nice to have this list posted in the med room.

crystalclear13 · Mar 17, 2009

Okay what about diuretics? Should they be held prior to hemodialysis? And does it make a difference as to whether it is a loop diuretic or a potassium sparing diuretic?

RheatherN, ASN, RN, EMT-P · Mar 25, 2009

I know it depends if the med will be dialysized (spelling right?) out. If so, not worth it as you understand. So if you actually just call the dialysis techs and/or get in touch with and MD, they can clarify better for you. Just simply ask them what they usually go by. Docs are pretty good about explaining why.

-H-RN