Multiple BP meds & dialysis- to give or not to give.......

  1. Currently I am 3 weeks away from graduation and doing a clinical rotation in a long term critical care setting (it is that place between ICU and rehab), Yesterday the RN asked me to pass 3 BP meds (lisinopril, lopressor, and something else) to a patient that had just finished dialysis and had a BP of 124/66. I told her I wasn't comfortable doing that and I would be glad to put them onboard an hour or two apart. She was having a rough day and she said in the real world you don't have time for that and if you go back in the chart you will be able to see where they did that all along with this patient. I still didn't feel comfortable and refused to pass all 3 meds at the same time.

    This RN is one of the best I have ever worked with! She is efficient, really knows her stuff, is a great mentor, and gives really super good nursing care. We kissed and made up 10 minutes after she gave the med and the rest of the day went smoothly. As she had said the pt was fine.

    My instructor said I did the right thing. I feel like I did the right thing. Did I do the right thing? Any feedback or insight would be appreciated.
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    About groovy jeff

    Joined: Jun '08; Posts: 356; Likes: 303
    Telemetry & PCU; from US
    Specialty: Telemetry & PCU

    19 Comments

  3. by   morte
    what is your rationale for NOT giving them?.....what is the peak and 1/2 life of ea.? has the patient had problems in the past with this being done?
  4. by   groovy jeff
    My thinking was that she had just had 2-4 L of fluid taken off, her BP wasn't at all high, and to give her 3 BP meds simultaneously would possibly bottom her out. Had she not had dialysis and was hypertensive, I would have gave them. I did not look at half life or look up each paticular action; I was just thinking on my feet. What would you have done? I am not looking for anyone to support my decision, I am merely looking for insight from the folks that I would consider the experts: ICU nurses.
  5. by   morte
    ooo i stepped in this one, no icu nurse here! lol .....however, you need to know the things i mentioned and, which if any of her meds she had had earlier in the day (they should have only given those that will not dial. out.)
    remember, a HTN person's BP is good BECAUSE of the meds, and ordinarily they wouldnt be held for this BP....now, that said, were these meds routinely , ie every day, given together? or only on dialysis days? if the latter, the drop, if it were to happen, may not be apparent for a while (again depending on peak of ea) perhaps the next shift. If you get a chance, check her trend of BPs.......it is better to be cautious.....good luck
  6. by   vashtee
    If they had different mechanisms of action, I would have looked to see how the previous nurse handled it, and if they were given together, I would have done it again. If there was no previous record, I might have spread them out a bit.

    I'm not an ICU nurse, but I'm not sure you need an ICU nurse for this question - lots of patients are on dialysis and blood pressure meds.
  7. by   truern
    I would have given them unless there was an order to hold them. morte is absolutely correct...the patient's BP was wnl *because* the meds were effective. Besides, they have different actions: lisinopril is an ACE inhibitor that relaxes blood vessels --> easier blood flow --> the heart pumps more effectively; metoprolol is a beta blocker and has a SHORT half-life so is usually given BID. It reduces the HR, heart muscle contractility and cardiac output --> reduced BP.

    When in doubt about what meds to hold or give to dialysis patients I've always found the dialysis nurses to be great resources
  8. by   lunden
    i work for davita dialysis and they always tell the pt's never to take bp meds on dialysis days becuz the pts always come in with low bps. but i guess you have to do what you are instructed to do by your instructor
  9. by   truern
    Quote from lunden
    i work for davita dialysis and they always tell the pt's never to take bp meds on dialysis days becuz the pts always come in with low bps. but i guess you have to do what you are instructed to do by your instructor
    This patient had already been dialysised and had a bp wnl. I would also be willing to bet that those meds were home meds.
  10. by   flightnurse2b
    Quote from lunden
    i work for davita dialysis and they always tell the pt's never to take bp meds on dialysis days becuz the pts always come in with low bps. but i guess you have to do what you are instructed to do by your instructor
    i'm not a dialysis expert by any means, but i'm assuming they tell the patients not to take their BP meds right before dialysis.... and to monitor the BP afterwards.

    if my pts are going to 1st shift dialysis in the AM, i don't give the BP meds, and then i check the BP when they come back and make my decision from there.

    if they are going to 2nd shift dialysis in the PM, i will give the BP meds, as they have time to peak and do their job, pt has a stable BP, and let dialysis do it's thing at night.
  11. by   lunden
    you are right but our 2nd shifts starts between 10am and 12 noon so the same thing applies to them to, no pm shift
  12. by   shocker29
    I am an ICU nurse, but I won't rush to the title of expert...

    I understand your thinking. Usually though, in my experience, if someone's pressure is going to take a major dive, it is going to be during the dialysis run. That is usually when we have to kick on the pressers. 2-4 liters is alot of fluid (depending on the patient's unique situation), so that is definitely something to keep in the back of your mind. However, the patient made it through dialysis, and still had a systolic in the 120's. You would have to look at a number of different factors. How much fluid does the patient usually have dialyzed off? Is this pressure consistent with what they run after dialysis? Do they normally get all three meds after dialysis and do okay? I am assuming this info would be available, since this person sounds like a long-term patient. If I didn't have any of this info, I would have to look at the dosages of the meds. I'd ask the patient if they had been on these for awhile. If they had (and had also been on dialysis for awhile), then they will probably be okay.
    The hard position that you were in is that you were the student... it really wasn't your ultimate decision whether or not to give them. However, you were definitely right to ask the question. And anytime, if you don't feel comfortable, politely ask the nurse to give them. When you are an RN, you will have the lee-way to do more critical thinking and make the decisions yourself. You could certainly stagger them a little (as long as you have a good rationale to back yourself up) or even call the doc if you are really worried. However, with a systolic in the 120's, you have quite a bit of lee-way in either direction.

    Hope all that rambling helped...
  13. by   shocker29
    I doubt those meds were strictly home meds since that person had been in the ICU for awhile. Probably monkeyed around with quite a bit, if they even started out on them. Good chance that they didn't start out on dialysis.
  14. by   groovy jeff
    Quote from shocker29
    I am an ICU nurse, but I won't rush to the title of expert...

    I understand your thinking. Usually though, in my experience, if someone's pressure is going to take a major dive, it is going to be during the dialysis run. That is usually when we have to kick on the pressers. 2-4 liters is alot of fluid (depending on the patient's unique situation), so that is definitely something to keep in the back of your mind. However, the patient made it through dialysis, and still had a systolic in the 120's. You would have to look at a number of different factors. How much fluid does the patient usually have dialyzed off? Is this pressure consistent with what they run after dialysis? Do they normally get all three meds after dialysis and do okay? I am assuming this info would be available, since this person sounds like a long-term patient. If I didn't have any of this info, I would have to look at the dosages of the meds. I'd ask the patient if they had been on these for awhile. If they had (and had also been on dialysis for awhile), then they will probably be okay.
    The hard position that you were in is that you were the student... it really wasn't your ultimate decision whether or not to give them. However, you were definitely right to ask the question. And anytime, if you don't feel comfortable, politely ask the nurse to give them. When you are an RN, you will have the lee-way to do more critical thinking and make the decisions yourself. You could certainly stagger them a little (as long as you have a good rationale to back yourself up) or even call the doc if you are really worried. However, with a systolic in the 120's, you have quite a bit of lee-way in either direction.

    Hope all that rambling helped...
    That helps quite a bit-Thanks

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