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Shortened TXs, elevated HRs and Hypertension - what to do?

Specializes in Dialysis.

I work in a clinic where pts and PCTs pretty much run the place. Wanna leave 15 minutes early? No problem, the PCTs just take the pt off tx and when I ask why they just say because the pt wanted to be done. What?! In my source of knowledge you just don't shorten someone's tx for convenience, and when I try to discuss it the techs get annoyed and say they can't force anyone to stay on tx! But, you shouldn't encourage them to shorten it either!!

Also, we have multiple pts that experience hypertension pretty much the entire tx. When assessing the pt they insist when they are home their bp is often much lower and they have taken bp meds prior to tx. Why then are they persistently running high on tx? Is it due to the basic physiology of the tx itself? I have not been able to get a definitive answer from anyone I have asked, not even the docs.

We have a few that have very high HRs post and they refuse to stay for any further assessment.

I have been told to document pt advised, md aware. Really?! Because I didn't have time to call the doc and no one else has either - to my knowledge.

What is the nonchalant attitude that I have to deal with and why does it happen? I am still fairly new and feel like I am not as comfortable as I had hoped I would be at this point,

Chisca, RN

Specializes in Dialysis.

The patient doesn't have an immediate negative consequence from shortening their treatment but in the long term they are shortening their life. You're the bad guy if you try to explain this. The techs get to be their best friend by enabling the destructive choices patients make and painting you as the mean nurse. All you can do is try and explain how their treatment time is structured to give them the bare minimum to sustain life. In the end it is their choice.

The hypertension is a tougher nut to crack. Guttercat posted up a good article when this subject last came up. It might help.

Intradialytic Hypertension: A Less-Recognized Cardiovascular Complication of Hemodialysis

In our unit, dialysis pts who want to end their tx early must sign a release of responsibility. They are basically agreeing to leave AMA.

Chisca, RN

Specializes in Dialysis.

And after having the patient sign AMA his neighbor says "I want one of those too".

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU.

Well, our transplant team looks at compliance factors when considering pts for transplant. Too many "getting off early" or "no show" notes are a red flag for transplant

diabo, RN

Specializes in hemo and peritoneal dialysis.

Many anti hypertensive are pulled off during treatment. Because of that, some of these patients need a bp med like Clonidine mid tx. Also, lowering the QB to 300 and QD to 500 and raising the temp a little can sometimes help. Dehydrating the patient doesn't always result in a lower bp; it can sometimes raise it. They can still crash.

Many of these AMA folks will eventually end up in the ER and have to be dialysed by me, or someone else on call at 2 am when their potassium goes to 7.9, or they need to be run back to back for 3 days to keep them off the vent. We need scare these patients a little and explain to them that an enlarged heart will eventually become a big useless muscle. Most dialysis patients will die from heart failure, not kidney failure.

for hypertension during treatment we have a PRN clonidine that can be give up to 3 times during treatment for SBP > 180. Idk if you guys have that. It is true that dialysis can be sucking out their blood pressure medicine, I have seen the effects of that before. But another doctor told me there's an effect called renin overproduction where they kidney's still produce renin and overly compensates for loss of fluids by raising BP too high. But that supposedly happens in only 5% of patients. If it's not that, then challenge your patients. If they run SBP > 180, you should automatically be thinking of challenging them up to 0.5 kg depending on what your MD has ordered.

banginplatesrn7

Specializes in ICU, Trauma ER,Open Heart, Dialysis.

Sorry Pom Pom RN. Sounds very negative at your clinic and it will be if you don't have support. The RN runs the floor not the PCT. It's the RN license or your license that is at jeopardy. The other RN's and your manager needs to stop this staff negativity and there needs to be more encouragement from the PCT's. They are part of the team and need to step up for the patients. The doctors need to encourage the patients the benefits of staying on treatment. It's a unit culture that needs to be developed. I know this from first hand knowledge. I didn't say it will be easy, but it can be done. Good luck to you!!!!

Sounds like you work at the prn clinic I do! Omg I feel the frustration. I refuse to increase their goal to "get off the fluid" unless it's a medical/family emergency. The dr is always aware of it and the patient signs AMA prior to being taken off. The techs love it because it starts turn over and they can RUSH the next one on. My full time clinic... The dr reads and questions the patient over every AMA signed. I keep a folder on the rounding cart. We have only one pt to ever sign off their. We have tons of non compliance documentation on her too. And I remind her frequently of the "time she died and had CPR" sometimes that keeps her on.

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