# A nurse is caring for a 65-year-old client with chronic kidney disease receiving hemodialysis. During the treatment, the client develops muscle cramps, nausea, and headache. The client's blood pressure has dropped from 150/95 mmHg to 105/65 mmHg. What is the most appropriate immediate nursing intervention?

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## 문제

A nurse is caring for a 65-year-old client with chronic kidney disease receiving hemodialysis. During the treatment, the client develops muscle cramps, nausea, and headache. The client's blood pressure has dropped from 150/95 mmHg to 105/65 mmHg. What is the most appropriate immediate nursing intervention?

## 보기

1. Increase the ultrafiltration rate to remove more fluid quickly
2. Administer normal saline bolus immediately
3. Decrease the ultrafiltration rate and notify the physician **✔ 정답**
4. Stop the dialysis treatment and return the blood to the client

**정답: 3**

## 해설

The client shows signs of disequilibrium syndrome from rapid solute removal. Decreasing ultrafiltration rate slows fluid shifts and prevents cerebral edema while continuing dialysis. Other options may exacerbate symptoms or are not the most appropriate immediate actions.

## 심화 해설

Understanding Intradialytic Hypotension (IDH)

The client is exhibiting classic signs of intradialytic hypotension (IDH), a common complication during hemodialysis. The symptoms—muscle cramps, nausea, and headache—coupled with a significant drop in blood pressure from 150/95 mmHg to 105/65 mmHg, indicate that fluid is being removed from the intravascular space faster than the body can refill it from the interstitial tissues. This rapid reduction in plasma volume compromises cardiac filling and output, triggering the observed adverse symptoms [1]. While research indicates that not all threshold-based drops in blood pressure are associated with patient-reported symptoms, the presence of these specific complaints and the need for intervention are key clinical markers that define a symptomatic hypotensive episode requiring immediate action [1].

Analysis of Intervention Options

The priority is to restore intravascular volume and stabilize the patient without abruptly terminating the treatment if it can be safely managed.

- Why option 1 is incorrect: Increasing the ultrafiltration rate would accelerate fluid removal, further depleting intravascular volume, worsening hypotension, and potentially leading to shock or loss of vascular access.

- Why option 2 is incorrect: While administering a normal saline bolus is a common intervention for hypotension, it is not the most appropriate immediate step in isolation. The underlying cause—an excessive rate of fluid removal—must be addressed first. Giving a fluid bolus without reducing the ultrafiltration rate is a temporary fix that does not stop the ongoing rapid volume depletion.

- Why option 3 is correct: Decreasing the ultrafiltration rate immediately slows the removal of fluid, allowing the body's natural compensatory mechanisms (plasma refilling) to stabilize blood pressure. This action directly addresses the pathophysiological cause of the hypotension. Notifying the physician is essential for further evaluation and potential orders, such as a fluid bolus or adjustments to the dry weight prescription. This two-part intervention follows the principle of managing the cause before or concurrently with treating the symptom.

- Why option 4 is incorrect: Stopping dialysis and returning blood is a more drastic measure reserved for severe, non-responsive hypotension or life-threatening complications such as air embolism or a dialyzer reaction. In this scenario, a stepwise approach starting with reducing the ultrafiltration rate is appropriate and may allow the treatment to continue safely once the patient is stabilized.

Clinical Reasoning and Evidence-Based Practice

Intradialytic complications like hypotension are prevalent and can significantly impact both the safety and comfort of the patient, as well as the adequacy of the dialysis treatment . The clinical factors associated with these events often relate to the rate of fluid removal and the patient's cardiovascular stability. The nurse's role is to recognize the pattern of complications early and intervene based on an understanding of the underlying plasma volume dynamics. By reducing the ultrafiltration rate, the nurse directly counteracts the mechanism causing the hypotension, a strategy aligned with managing the most common intradialytic complications to ensure treatment can proceed with minimal risk .References (research sources)

- [1]Intradialytic Hypotensive Episodes are Only Occasionally Associated With Adverse Symptoms.Research articleChaara S, Rootjes PA, Bergtop MIY, Grooteman MPC, Liu P, Nubé MJ, Wijngaarden G, de Roij van Zuijdewijn CLM. (2026) · DOI: 10.1016/j.ekir.2025.103718

## 임상 시나리오

Managing Intradialytic HypotensionImmediate Steps for Symptomatic BP Drop
Recognize intradialytic hypotension (IDH) by a systolic BP drop below 100 mmHg or a 20 mmHg decrease with symptoms like cramps, nausea, or headache.

The first intervention is to decrease the ultrafiltration rate (UFR) to slow fluid removal and allow the plasma refilling rate to restore intravascular volume.

CautionPlace the patient in the Trendelenburg position and administer a 100-200 mL normal saline bolus only after reducing the UFR. Stopping dialysis is a last resort for unresponsive hypotension.

## 핵심 개념

- **Intradialytic Hypotension (IDH)** — A drop in systolic BP ≥20 mmHg or mean arterial pressure ≥10 mmHg during dialysis, associated with symptoms like cramps, nausea, or dizziness due to rapid fluid removal.
- **Ultrafiltration Rate (UFR)** — The rate at which fluid is removed from the blood during hemodialysis, measured in mL/kg/hour. Excessive UFR is a primary cause of IDH.
- **Plasma Refilling Rate** — The physiological process where fluid shifts from interstitial tissues into the intravascular space to compensate for volume loss during dialysis.

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