Can someone help me out?

gam3rchic · Jul 19, 2007

i am a first year nursing student during clinical rotations on the renal floor. i have a patient, who i have not seen yet (i have clinicals on friday) with the following problem, and i'm not understanding it the way i should.
43 y.o female who was admitted with an infected dialysis catheter. this person has esrd with chronic hypotension (bp 63/32). i thought with esrd that you would have hypertension d/t excess fluid volume. maybe i'm just confused.
her past medical history:
focal segmental glomerulosclerosis (no clue what this is)
dyslipidemia
secondary hyperparathyroidism
previous history of bacteremia
any information would be greatly appreciated. thank you

i feel for you as a nursing student (wasn't too long ago i was in your shoes) and it seemed like if i didn't understand something like that, the teachers would belittle me b/c i didn't understand. :trout:

ok, yes, usually people with esrd are hypertensive, but if she's admitted with an infected line, maybe she's septic? that would account for the low bp. that's my first thought anyway. good luck in clinicals and hang in there! :lol2:

nightmare, RN · Jul 19, 2007

noticed this thread further up the new posts page,don't know if it will help.

https://allnurses.com/forums/f50/renal-question-237281.html

RNSPARKS · Jul 21, 2007

As a hemodialysis nurse, I know how confusing ESRD can be to someone new to it. It is possible this person has been a non-compliant renal/cardiac/diabetic patient for a while and as a result, the strain of consistent excess fluid volume on the heart has caused permanent damage, thereby the heart muscle is weakened and is unable to pump effectively. My question is this: with a blood pressure chronically this low, how does the dialysis graft stay open (not clotted) and how are they able to dialyze this patient at all.?

Sunshine97 · Jul 21, 2007

i am a first year nursing student during clinical rotations on the renal floor. i have a patient, who i have not seen yet (i have clinicals on friday) with the following problem, and i'm not understanding it the way i should.
43 y.o female who was admitted with an infected dialysis catheter. this person has esrd with chronic hypotension (bp 63/32). i thought with esrd that you would have hypertension d/t excess fluid volume. maybe i'm just confused.
her past medical history:
focal segmental glomerulosclerosis (no clue what this is)
dyslipidemia
secondary hyperparathyroidism
previous history of bacteremia
any information would be greatly appreciated. thank you
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i would say you patient as mentioned in one of the replies earlier might have been none complaint, from reading your question i would say this is a peritoneal dialysis pt with esrf. pt might have not be complaint with diabetes, and treament regimes medication, so that affects the bloods. maybe hand hygiene is not excellent with this pt that's why history of bacteremia. not sticking to right regime on pd mihgt have caused fluid overload and using the wrong streghth of pd fluid.
let us know the ans when you know.

sueinga · Jul 22, 2007

Focal segmental glomerulosclerosis is scar tissue that forms in areas of the kidney that filter certain things out of the body. These areas are called glomeruli. The help the body get rid of harmful or unnecessary substances. Each kidney has thousands of glomeruli.

"Focal" means that some of the glomeruli become scarred, while others remain normal. "Segmental" means that only part of an individual glomerulus is damaged.

The cause of focal segmental glomerulosclerosis is usually unknown. A small number of cases result from reflux nephropathy. The condition affects both children and adults. Males are affected slightly more often than females, and it also occurs more frequently in African Americans.

Focal segmental glomerulosclerosis causes about 10 - 15% of all cases of nephrotic syndrome.

MSLNT1.1 · Jul 22, 2007

I tend to agree with the other posts. The majority of ESRD patients don't start out with cardiac complications, but if they continue to miss treatments and become fluid overloaded then for a while will exhibit symptons of hypertension but as the muscle around the heart tries to pump faster to compensate for the extra fluid the muscle becomes stretched and weakened and it affects the hearts pumping ability. Does the patient have CHF? They tend to function with a lower BP, but always seems to be SOB and is edematous because the fluid is still there but can be a challege to remove because the BP is so low. Hope this helps.

Trauma Columnist · Jul 22, 2007

I agree with above posters: ESRD pts don't die from renal failure per se, they die from cardiac complications. As to the hypotension, they might give midodrine before and during dialysis to compensate and allow for dialysis to continue, they might run the patient "even" meaning they just filter but don't remove volume, the pt may have so little cardiac output that dialysis might not be effective much longer.

Good luck - our ESRD population are challenging.

Pamilina · Jul 23, 2007

When a patient comes in with an infected dialysis catheter. That usually means the vas catheter (temporary or permanent). The catheter is like a central line only bigger and made for dialysis use only. Those usually have a higher rate of infection since, it's invasive, and the bacteria can congregate on this within the Internal jugular area where it rests inside of the patient or at the tip (superior vena cava). Bacteria enter via the entrance site, or the ports when they are opened to connect for dialysis if Sterile technique is broken.

With a history of bacterimia, the patient probably has a staph infection in the blood...just guessing here. This will cause sepsis, and Staph in the blood is a terrible infection to fight. Sepsis, is the bodies response to a severe infection, WBC's can get as high as 50,000! The vessels vasodilate in septic shock (hence the extremely low BP); along with fever and chills.

That's why more and more doctors in nephrology are trying to have all patients with renal disease requiring dialysis...to get fistula's, which is made from their own vessels that the vascular surgeon puts together. However, while it is a maturing vessel, they will have a temporary access, or a permanent access while the vessel matures. Sterile technique is of monumental importance, when accessing these ports on the catheter!

For a 43 year old to have such a low BP chronically? I would read her history and physical. She has had previous bacterimia (bacteria in the blood), which through her course of treatment may have caused problems with her heart. Poor filling pressures ect...the vessles might not be as elastic. Or she may have some form of heart disease, and that could be the problem. They would have done an echo on this patient, and you can look to see what her EF(ejection fraction).

Let us know how it turns out. Also, if you have anymore questions.

DeLana_RN, BSN, RN · Jul 28, 2007

In my hospital dialsyis unit, we would not touch a pt with a systolic BP in the 60's (actually, rarely below 90's)! She may be chronically hypotensive due to cardiac damage, as pp have pointed out, but most likely she's normally at least in the 80's or 90's systolic. The BP you observed is probably due to sepsis secondary to the infected dialysis catheter.

What did you find out during your clinicals with this patient?

Good luck to you,

DeLana :)