dialysis pts--general ?'s

[dayshiftnurse]

hi,

im a med/surg nurse (sort of) and through my agency often assigned to a floor w/ medical, renal, and chemo patients. i have a couple of questions..

1) just before dialysis should we give their meds if we can, or wait till they come back. the other day, pt was just being pulled off the floor just as i was coming out of report, so i didn't have much time to prepare...so i gave all the meds via peg tube, and sliding scale insulin and requested that his nebs be given in dialysis. when he got back a mdo was written to hold bp meds until after dialysis. when i reviewed this pt's old mar sheets it looked as though the nurses had been holding the bp meds until after the HD as a general rule of thumb. of course this makes sense to me, but can someone please elaborate...and are there other meds i should just know to hold intuitively?

2) after HD, what s/s or things about the pt that i should expect or not expect. so far i am noticing how low their bp can get, and of course lethargic. on one pt, another nurse recd report for me and told me she couldn't get his pressure, i subsequently also could not get his bp, pulse was also quite thready. i waited and watched, and much later in the shift his bp was faint but i was getting ~90/55-60 and pulse 100, and more responsive. other vss. i took a watch n wait approach, the wife was at bedside and even though she was a nervous person, she didn't seem suprised that his bp was so low--like that is how he generally is after hemo. what would you do in a situation like this? the md called me back about him for some other reason and when i reported his vitals, he said "if you cant' get bp and thready pulse you had better call mdoc......" i din't end up calling because as i say, his bp did come up and was able to get faint tachy pulse. can someone pls. advise how you may have handled this, or what i could have done better? he was too weak to eat or take meds most of shift, and then was just able to give 10 pm meds as his LOC improved somewhat.

3) what should the expectations be about urination? what if they don't have an iv/minimal po intake? how long should i wait after HD before being worried about low urinary output?

any ehlp would be great...thanks!

[veegeern, BSN, RN]

hi,

im a med/surg nurse (sort of) and through my agency often assigned to a floor w/ medical, renal, and chemo patients. i have a couple of questions..

1) just before dialysis should we give their meds if we can, or wait till they come back. the other day, pt was just being pulled off the floor just as i was coming out of report, so i didn't have much time to prepare...so i gave all the meds via peg tube, and sliding scale insulin and requested that his nebs be given in dialysis. when he got back a mdo was written to hold bp meds until after dialysis. when i reviewed this pt's old mar sheets it looked as though the nurses had been holding the bp meds until after the HD as a general rule of thumb. of course this makes sense to me, but can someone please elaborate...and are there other meds i should just know to hold intuitively?

2) after HD, what s/s or things about the pt that i should expect or not expect. so far i am noticing how low their bp can get, and of course lethargic. on one pt, another nurse recd report for me and told me she couldn't get his pressure, i subsequently also could not get his bp, pulse was also quite thready. i waited and watched, and much later in the shift his bp was faint but i was getting ~90/55-60 and pulse 100, and more responsive. other vss. i took a watch n wait approach, the wife was at bedside and even though she was a nervous person, she didn't seem suprised that his bp was so low--like that is how he generally is after hemo. what would you do in a situation like this? the md called me back about him for some other reason and when i reported his vitals, he said "if you cant' get bp and thready pulse you had better call mdoc......" i din't end up calling because as i say, his bp did come up and was able to get faint tachy pulse. can someone pls. advise how you may have handled this, or what i could have done better? he was too weak to eat or take meds most of shift, and then was just able to give 10 pm meds as his LOC improved somewhat.

3) what should the expectations be about urination? what if they don't have an iv/minimal po intake? how long should i wait after HD before being worried about low urinary output?

any ehlp would be great...thanks!

I'm a med-surg nurse on an internal medicine floor. Here's how I would answer your questions.

1) I hold all BP meds. The dialysis nurse is going to be regulating the patient's bp throughout dialysis (not sure if I'm say that right), and does not need anything working against that process. Also, many medications filter out during dialysis. I usually hold all medications before dialysis. If I have any questions about a particular medication then I can talk to the dialysis nurse, call the pharmacy, and/or call the MD. If it is a medication that the patient takes at home, then he/she can usually tell me if they hold it before they are dialized.

2) I would always call the MD if I couldn't get a bp or had a thready pulse. Whether the patient is a dialysis patient or not - their blood has to "go round and round." If your having difficulty getting a bp or there is a thready pulse, then the patient isn't perfusing. Most of our patients do feel lethargic after dialysis, and some are nauseated - especially if they are new to dialysis. Their blood pressure is usually a little lower than before dialysis, but nothing like you are describing above.

3) After a patient has dialysis, they will be on the "dry side." Ask the patient, look in the chart, etc...to find out if the patient makes urine at all. I can't answer how long you should wait for them to urinate. Ours either don't make urine, or they have a foley.

I hope this helps. Don't forget to use the nurses on the floor and the dialysis nurse as a source of information. Maybe someone here will have more specific guidelines for you...

[dayshiftnurse]

thanks for the advice...i will keep all suggestions in mind.

--i have noticed that in general the only meds that are held prior to HD are BP meds...i'm wondering about things like diltiazem, cardiazem--im not sure about those types of bp drugs (i was thinking more metropolol or altace, etc.)

--i'm not too clear on the etiology of ability for some HD/renal patients to make urine vs. those who cannot or have very low uo (oliguria bordering on anuria). this is why i have a difficult time knowing what to assess for and when or if i should be worried. i would think that would be noted somewhere, because really a patient is either one or the other--either able to make urine or not.

--and, yes, i didn't feel comfortable w/ watch and wait approach regarding bp. don't the hd nurses have to keep patients on their unit until the patient is relatively hemodynamically stable before booting them out?? i had a freind on that floor who rec'd a hd pt back who basically was coding on the way back to her unit. is that just lazyness, or due to poorly staffed hd units?

thanks,