blood pressure drops after dialysis

Pangea Reunited, ASN, RN · Mar 20, 2016

I worry if I am unfamiliar with the patient, but most of our HD patients are frequent flyers. I typically don't give medication during dialysis (unless it's urgently needed), but I would have gone ahead and given it after dialysis is the blood pressure was still high or at least normal. Vomiting is common with renal patients from what I've seen. The HD nurse may have been guessing as to the cause, but the guess may or may not have been correct.

JustBeachyNurse, LPN · Mar 20, 2016

If you weren't sure and it was outside physician ordered parameters (hold if SBP

nynursey_ · Mar 20, 2016

I hold most medications prior to dialysis, including blood pressure medications. There are medications know to dialyze out during treatment, and often times antihypertensives are one of those medications. If I'm not sure, I call the dialysis RN and ask her. And often in many cases I simply send the medications down with the patient and the dialysis RN administers them post-treatment.

I understand your concern over the Hydralazine, but once a patient has finished tx, blood pressures normalize. In any event, you weren't wrong to use your nursing judgement, but it may have been pertinent to ask the doctor to put in parameters.

allnurses Guide · Mar 20, 2016

I always held all meds prior to dialysis for the most part except for those ordered specifically to be given..usually psych meds. If the patient was trending as high as yours I would call the dialysis dept to find out when the patient would be sent for and alert them that the patient needed to be dialysed soon due to likely fluid overload. Whether I gave the missed dose upon return depended on how the patient was doing after, but usually that dose would be charted as missed.

nutella, MSN, RN · Mar 20, 2016

I worked in acute dialysis inpatient and the usual is that patients do not get blood pressure medications prior to dialysis, also most physicians are ok with holding everything else - no matter if it gets dialyzed out or not - partly because it gets too confusing for most nurses, patients, and MDs to check all meds and give some and not others. Some patients are prone to throwing up with dialysis if they are really sick or very overloaded and drop BP. There are still HD unit that will not allow pat to eat while on the machine (in the hospital) because it used to be a frequent issue. Now that machines are better and HD not as aggressive there is less throwing up though pat new to HD should really not eat while on the machine...)

It makes a lot of sense to hold BP meds unless specifically said otherwise because a lot of HD patients who come to the hospital with fluid overload have a higher than usual BP due to overload. Of course - if BP is outside or parameters you need to call the MD and report it.

If a BP is high due to fluid overload, the BP will come down with HD when fluid is being pulled.

When you give a BP med before HD and it kicks in while you are pulling water, BP can drop significantly leading to syncope, nausea/vomiting, chest pain..... .

If that happens, the nurse may be unable to pull out enough fluid, leaving the patient overloaded, which means they need to get dialyzed next day again...

Here are some pointers for taking care of chronic HD patients who are in the hospital for whatever and need inpatient HD:

1. ask the patient if they are taking meds before HD or not and let the MD know if there is something special

2. ask if they need an early snack when they go to HD early - some chronic patients need breakfast and it is too early to order something, so the nurse or CNA have to make a toast and coffee...

3. make sure they are on the right diet - I have seen patients getting orange juice, ketchup, potato products, and so on... patient should know what they can or cannot eat & drink if they are chronic HD patients - but when the food comes up it can be hard to resist.

4. Fistulas shoudl have a positive bruit and pulse and the little pressure bandaid should stay on for some hours,just ask the patient how long they usually keep it on. A lot leave it on until next morning.

5. If a fistula starts to bleed (usually a lot, it is under pressure), grab some gauze, fold it to a small piece, put it on and hold pressure tight and call for help.

6. Drop in BP that is not just short lived can occlude a fistula - oh and no BP or blood draws on that arm...

Here are tips for new HD patients in the hospital:

1. they tend to pass out or N/V due to blood in pressure so usually NO BP meds and food/drink just before they go to HD (if in doubt check with MD and HD nurse).

2. it creates anxiety in a lot of patients - if the pat has an order for as needed meds it may be a good idea ...

3. HD catheters are only for HD - NOT to draw blood because it is convenient ...

Guttercat, ASN, RN · Mar 21, 2016

When I have a patient present with a BP that high, I still usually ask the primary RN to hold the BP meds until I get a sense of how the patient is responding on the machine.

If the BP is downtrending nicely during the treatment, then I continue on. If the BP remains significantly elevated, I call the primary RN and ask for the meds to be given.

Someone mentioned calling the HD RN to find out when the patient will dialyze. If the patient is not to have HD until the afternoon, it is reasonable to go ahead and dose them with their AM BP meds.

CVARN · Mar 21, 2016

Thank you for all your responses... What I m understanding is that in most of your hospitals, there are parameters written for when to hold blood pressure meds, especially for hemodialysis patients? hmmm... what a luxury! I have never worked in another facility, and the hospital I work in relies heavily on nursing judgement (with the exception of this new doctor). I believe many of our MDs would think we had lost our minds if we called to ask for parameters!

For the record, my patients are dialyzed bedside, and of course I consulted with the HD nurse, who told me she usually doesn't advise medicating for at least an hour after HD to give the BP a chance to stabilize.

Anyway, thanks again.

HouTx, BSN, MSN, EdD · Mar 21, 2016

In my state, a Standard Delegated Medical Order (SDMO) MUST be in place to guide any of these medication decisions. To do otherwise is a violation of nursing scope of practice - practicing medicine without a license. The physician is responsible for establishing all the parameters. If anything unexpected arises, she must be contacted to deal with it.

CVARN · Mar 21, 2016

In my state, a Standard Delegated Medical Order (SDMO) MUST be in place to guide any of these medication decisions. To do otherwise is a violation of nursing scope of practice - practicing medicine without a license. The physician is responsible for establishing all the parameters. If anything unexpected arises, she must be contacted to deal with it.

To be honest, the more I thought about your post, the more shocked I become! It is very different, indeed, to be a nurse in California, at least in the facility I work in!

CVARN · Mar 23, 2016

Update: I spoke to management yesterday, who support my actions 100%, and will be discussing this (as well as many other issues) with the MD.

Thanks again for all your input.