[gigi69]

When someone is in ESRD (end-stage renal disease), what would be the reason they would have hyPOtension? I just thought it would be hyPERtension. The client that I had today has been on dialysis for 5 1/2 years, and she use to have hypertension. But last Feb. she passed out in the grocery store with a BP of 59/30. And it has been that way ever since. Other than ESRD, she has no other medical problems. I have read my books, but I can't seem to find the answer to my question. Can someone help?

[sarah0119]

Here is an article abstract that might get you on the right path. Sorry I can't explain the why behind this...

Blood pressure instability during hemodialysis.
Commentary
Kidney International. 69(10):1710-1711, May 2006.
Landry, D W 1; Oliver, J A 1
Abstract:
Most patients with end-stage renal disease (ESRD) maintained on hemodialysis have chronic hypertension. However, hypotension is a frequent complication of hemodialysis, probably because of impaired baroreflex function. Less frequently, increases in pressure can be a complication of hemodialysis. Detailed studies of patients with these abnormalities in arterial pressure during hemodialysis may yield insights into the regulation of arterial pressure during ESRD.

[Bonny619]

Which is why when you have a patient on dialysis it's very important to monitor their BP and BP meds they might be on.

[GingerSue]

this is what my textbook says about complications of hemodialysis:
"Hypotension that occurs during HD primarily results from rapid removal of vascular volume (hypovolemia), decreased cardiac output, and decreased systemic intravascular resistance. The drop in BP during dialysis may precipitate lightheadedness, nausea, vomiting, seizures, vision changes, and chest pain from cardiac ischemia. The usual treatment for hypotension includes decreasing the volume of fluid being removed and infusion of 0.9 percent saline solution (100 to 300mL). If a client experiences recurrent hypotension episodes, a reassessment may have to be done of dry weight and BP drugs. BP drugs should be held for dialysis if there are frequent episodes of hypotension during dialysis."

[Daytonite]

Hypotension can occur when there is hypoperfusion of the tissues caused by some kind of vascular occlusion(s), due to the action of antihypertensives or antidepressants, prolonged immobility, any condition that produces volume depletion, conditions where there has been multiple central nervous system degenerative changes and sometimes just being of great elderly age. Chronic adrenal insufficiency and diabetes can cause hypotension. The kidneys are closely linked to the regulation of blood pressure and when they are in failure, then the blood pressure is not going to be adequately regulated. This information is from Pathophysiology: The Biologic Basis for Disease in Adults and Children, third edition, by Kathryn L. McCance and Sue E. Heuther on renal disease and hypotension.

I have seen hypotension occur in long term dialysis patients and it was almost always associated with them either being dehydrated (yes! it can happen) or it was a side affect associated with their medications. Keep in mind that when these patients receive medications for hypertension or depression, their bodies do not metabolize them as efficiently, so the medicines tend to build up in their body along with the other toxins. They are removed with the other toxins when the patient has their regular hemodialysis treatment. For this reason, these patient's tend to get lower doses of these kinds of medications. It will be part of the doctor's investigation of your patient's hypotension to evaluate her medications as well as other likely causes.

You say that her hypotension is something the doctor is investigating as it is a new problem. Please understand that if the doctor does not know the cause of the patient's hypotension, how can a nurse? I would suggest that you need to make this clear to your instructor and merely suggest potential reasons for the low blood pressure. It is never the nurse's job to explain it. Until the doctor determines the true reason, anything is merely a best guess.

As far as your care plan is concerned, you will address this in terms of the symptoms it is causing. Since she had a syncopal episode as a result of the hypotension, then she is at risk for injury if it happens again. So, I would care plan for this as Risk for Injury R/T transient loss of consciensness secondary to hypotension or Risk for Falls R/T transient loss of consciensness secondary to hypotension. If there are skeletal system problems as well I would add those reasons to either of the "Risk for" diagnoses.