PEG Tube & Low Blood Pressure Scenario for Student Nurses | Recognising Subtle Deterioration

🚨 WHAT WOULD YOU DO?

 

“His Blood Pressure Keeps Dropping…”

You’re on placement looking after a lovely gentleman who is palliative and living with advanced Parkinson's Disease. He’s bed-bound, needs full assistance with all his care and speech is incredibly difficult for him.

Most of your communication happens through yes/no questions, a thumbs up or down, or an alphabet board. He also has a Percutaneous Endoscopic Gastrostomy (PEG) in place, so he’s only allowed tiny teaspoon sips of water orally for comfort.

Everything initially seems quite settled. But then you notice something during his hourly checks: His systolic blood pressure keeps dropping below 89 every few hours.

Not just once. Repeatedly.

Your brain starts working. Not panic. Not running to call a doctor for no reason. Just that internal: “Why does it keep dipping like that?”

 

1. Assess: What’s the full picture?

Future nurse thinking means you don’t just look at the flashing number on the monitor and walk away when it beeps. You look at the person attached to it.

• You stay by the bed and look at him:
• Is he more sleepy or lethargic than he was this morning?
• Does he seem confused or distressed?
• Are his hands and feet warm, or do they feel cool and clammy?

You also think about his situation. He is palliative, bed-bound, reliant on others for all hydration and living with advanced Parkinson’s. The picture is starting to look a bit mismatched.

 

2. Verify: Think through the possibilities

You pull up his charts and start doing some detective work. What could be causing this?

Could it be the Parkinson’s itself? Parkinson's Disease can affect the autonomic nervous system - the part of the body that helps regulate things like heart rate and blood pressure. Patients with advanced Parkinson’s are often highly prone to postural hypotension, especially after being repositioned, washed or moved for personal care.

Could medications be contributing? Take a quick look at his MAR chart (or prescription Kardex). Could his Parkinson’s medications or palliative pain relief be contributing to the blood pressure drops?

What’s normal for him? Some palliative patients naturally sit much lower than textbook “normal” blood pressures. You need to look at the trend across the last few days: Is this worsening, or is it an established baseline?

Could he be dehydrated? This is the big one. Grab the fluid balance chart. Even though he has a PEG tube, is he actually getting enough water?

 

The Clinical Why: A PEG is a feeding tube inserted directly into the stomach through the abdominal wall. These patients often rely entirely on prescribed feeds and water flushes for hydration. They cannot simply grab a drink when they feel thirsty and some cannot easily communicate thirst at all. Dehydration doesn’t always present the same way. Sometimes it looks like recurrent low blood pressure and educed urine output.

Suddenly, your thinking changes from “That BP is low” to “Why is this vulnerable patient repeatedly dropping their blood pressure?”

 

3. Escalate: Bring your assessment, not just a number

You don’t want to walk up to your staff nurse and simply say: “The patient in Bed 4 has a low BP.” That’s just reading a screen. Instead, you explain exactly why you’re concerned:

“I’m a bit concerned about Bed 4. His systolic has dropped below 89 a few times today. Looking at his fluid balance chart, his urine output is quite low and his water flushes are a bit behind. I’m wondering if he’s becoming dehydrated or if repositioning is contributing to the drops.”

That wording changes everything. You aren’t just reporting a number; you’re showing that you understand your patient.

 

4. Respond & Reassess

After chatting with your nurse and checking the fluid plan, you give the prescribed water flush through the PEG tube and make sure he is resting comfortably in bed before reassessing him.

Thirty minutes later, you go back in to repeat the obs:

• His systolic is back up closer to his normal baseline (98 mmHg).
• He looks more alert.
• He gives you a small thumbs-up on the communication board.

With complex palliative patients, there are often multiple overlapping reasons why blood pressure drops. But by paying attention to the pattern, you recognised a subtle change before it became a bigger deterioration.

 

5. Document & Handover

You write everything down clearly in the nursing notes: the repeated drops below 89, the fluid balance review, what you escalated, the PEG water flush, the repeat BP and how the patient responded.

Then at handover:

“Bed 4 had recurrent systolic BP drops below 89 today. He remained alert but appeared more lethargic than earlier. Escalated due to repeated hypotension and reduced fluid intake concerns. Prescribed PEG water flush given with improvement back towards baseline BP. Please continue monitoring fluid balance, BP trends and his response after repositioning or personal care.”

 

🏥 Real-World Reflection

This scenario was inspired by a real placement with a palliative patient who had advanced neurological disease and communication difficulties. The repeated low blood pressures weren't brushed aside as random blips; once the pattern was spotted, the patient was placed on a strict fluid balance chart to closely track their hydration, PEG water flushes and urine output.

Because they couldn't verbally tell us when they felt dizzy or dehydrated, their deterioration had to be caught through vigilant observation and knowing their baseline. It was a reminder that nursing isn't about reacting to a single number on a screen, it’s about recognising patterns, understanding physiology and acting when "something doesn’t feel quite right.”

 

🧠 Bleepbook Takeaway

Spot the Pattern: A single low reading might be a blip. Repeated drops every few hours are a trend telling you something has changed.

Be Their Voice: Patients with advanced illness or communication difficulties may not be able to tell you they feel dizzy, thirsty or unwell. Your observations help speak for them.

PEG Feeds Aren’t “Set and Forget”: Always double-check fluid balance charts and prescribed water flushes. Delays happen easily on busy shifts.

Think Beyond the Number: Future nurse thinking means asking “Why is this happening?” Not just documenting that it happened.

 

“Have you ever had a patient who couldn’t verbally tell you they were deteriorating? What soft signs helped you recognise the change?”

 

Bleepbook Disclaimer:

These scenarios are written to help UK student nurses connect theory to real-world clinical thinking. While based on realistic practice situations, they are educational resources only and should never replace local policy, supervision or professional clinical judgement. Patient conditions can deteriorate quickly and every clinical situation is different. Always follow your Trust guidelines, NICE recommendations and the NMC Code and escalate concerns to your mentor or senior clinician if you are worried about a patient.