CASE SCENARIO. LOWER GI BLEEDING/ ESRD/ HYPERTENSION.

A 48years old man came to emergency room with lower GI bleed,history of end stage renal disease on hemodialysis (Monday , Wednesday and Friday), hypertension. Peg tube in place.Peg tube site cleaned .Ashcath left femoral for hemodialysis.Dressing intact and clean, changed by hemodialysis nurse.Right External jugular clean ,dry and intact. Vital signs Q4hours, Glucerna 1.5 at 75ml/hour flush with 30ml of water Q8hours.Bilateral lower extremity weakness,bedbath given after morning medications. Turned and reposition frequently for comfort. Up to the chair Q4hours as ordered. PT/OT consult for evaluation and treatment. Medications:

Protonix 40mg po Bidac scheduled 07am and 1600.Heparin 1000unit UD upto five doses during hemodialysis. Zofran 4mg IVP Q4hours prn nausea/ vomiting. Lovenox 30mg SubQ Daily scheduled. Multivitamin 1cap po/peg tube 09am Daily scheduled. Metroprolol Tartrate 50mg po/ peg tube Bid scheduled. Clonidine Hcl po 0.1mg TID scheduled. Hold for systolic blood pressure less than 100.Nifedipine 90mg po Bid scheduled 09am ,2100.( Hold for sbp less than 100)Meropenem 1gm in 100ml of sodium chloride 0.9%IV Q24hours. Calcium 1 tablet peg tube TID scheduled MW,07am 12noon,1630pm.Acetaminophen 650mg Q6hours prn temperature. Blood pressure 170/92,Heart rate 78,Respiration 18,02 saturation 96%. Medicated as ordered. Laboratory test: CBC with differential, Chem 7,Coag (PT/PTT/) at 05am.

Discharge to Skilled Nursing facility in two days if medically stable .QUESTIONS AND ANSWERS.

1.A patient has intravenous fluid in the left arm The nurse should take blood pressure on the?. A.Take the blood pressure on the left arm.

B.Take the blood pressure on the right arm. C.Look for the smallest cuff to take the blood pressure.

D.Let your charge nurse know.Correct answer is A.The blood pressure should be taken in opposite arm of the infusion unless contraindicated.

2.A patient has a high blood pressure of 150/90.The nurse should ?. A.Repeat the blood pressure again one minute apart if it is still high medicate as ordered. If it continues to remain high notify the doctor.

B.Do nothing because it will go down.

C.Call and notify the doctor. D.Recommend a balance meals with low sodium.

Correct answer is A.A single blood pressure measurement that is slightly high is insignificant.The measurement should be taken over again to determine if hypertension is a problem.

Reference.

Dialysis Coalition@cdc.gov