Hypotension is low blood pressure. An individual who is highly trained physically (athlete, military) may be expected to have low blood pressure. To help the nurse recognize cues, information about the two types of hypotension is discussed.
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Hypotension
Orthostatic (Postural) Hypotension
Definition
A decrease in blood pressure (as shown in the image, BP 76/37 with pulse 46 and O 2 sat 98%)
A decrease in blood pressure upon a change in position, such as from lying to sitting to standing
Causes and Contributing Factors (not all-inclusive)
Reduced cardiac output (e.g., heart attack or heart failure)
Decreased peripheral vascular resistance (e.g., shock)
Reduced blood volume (e.g., hemorrhage or blood loss from injury)
Extreme vasodilation (e.g., severe allergic reaction)
Certain medication side effects, especially blood pressure medication
Vasodilation causes blood to pool in lower extremities rather than being returned to the heart
Aging
Certain medication side effects, especially blood pressure medication
Prolonged immobility
Dehydration
Anemia (low red blood cells)
Recognize Cues/Signs and Symptoms
Patient Observation Cues
Cool, clammy skin
Confusion
Patient Observation Cues
Dizziness
Feels faint upon position change
Medical Record Cues
Vital signs flow sheet/graphic indicates systolic blood pressure less than 90 or diastolic less than 60
Vital signs flow sheet/graphic indicates 20 to 30 mm Hg below the patient’s expected systolic blood pressure
Vital signs flow sheet/graphic indicates tachycardia and will eventually become thready
Intake and output flow sheet indicates decreased urine output
Medical Record Cues
Vital signs flow sheet/graphic indicates sudden drop of at least 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure upon position change
Immediate Concern
Is an immediate concern and can become a medical emergency
Is an urgent concern unless the patient begins to fall, then becomes immediate
Putting It into Practice
The patient is a 73-year-old male recovering from hip replacement surgery. The patient has been experiencing dizzy spells when sitting up. The nurse assesses the patient’s blood pressure lying down, and it registers 124/85 mm Hg. Then, after sitting up for 1 minute, the blood pressure is 100/70 mm Hg. Ensuring that the patient is secure, the nurse then assesses the BP a third time while standing. This BP is 98/66 mm Hg. During the interview the nurse discovers that the patient has not been eating or drinking regularly since the surgery and that he was immobile for 5 weeks before surgery. Finally, as the nurse reviews the chart, the nurse notices that the patient is taking several new medications.
Using Clinical Judgment: Recognize Cues
Which cues are of immediate concern and require you to take action?
Drop in blood pressure of at least 20 mm Hg systolic and 10 mm Hg diastolic from previous blood pressure after changing position (124/85 to 100/70 to 98/66).
Dizziness when getting up after lying down.
What is your first impression?
The patient is experiencing orthostatic (postural) hypotension.
Question 1 of 5
Which area is the most common site for a blood pressure measurement?
Exactly!
Wrist
Lower leg
Upper leg
Upper arm
Wrist
The radial artery at the wrist is used to palpate a blood pressure measurement, but it is not the most common site.
Lower leg
Palpating the dorsalis pedis or posterior tibial artery of the lower leg is sometimes used to palpate blood pressure; however, the lower leg is not the most common site.
Upper leg
Although the popliteal artery can be used if the brachial is not accessible, it is not the most common site.
Upper arm
The upper arm at the brachial artery is the most common site to measure blood pressure.
Question 2 of 5
Which questions would the nurse ask the patient before measuring blood pressure?
Exactly!
Are you in pain?
Do you feel stressed?
Have you exercised within the past 5 minutes?
Have you consumed any caffeine in the last 30 minutes?
Have you been to physical therapy within the past 15 minutes?
Do you continuously monitor your blood glucose levels with a device on your arm?
Are you in pain?
The nurse would ask this question because acute pain can increase blood pressure.
Do you feel stressed?
The nurse would ask this question because stress can increase blood pressure.
Have you exercised within the past 5 minutes?
The nurse would not ask this question because exercise affects blood pressure for about 15 minutes, not 5.
Have you consumed any caffeine in the last 30 minutes?
The nurse would ask this question because caffeine can affect blood pressure.
Have you been to physical therapy within the past 15 minutes?
Physical therapy is exercise; thus, the nurse would ask this question because activity can affect blood pressure for about 15 minutes.
Do you continuously monitor your blood glucose levels with a device on your arm?
The nurse would ask this question because blood pressure must be taken in the other arm if this device is present.
Question 3 of 5
Which blood pressure measurement is an unexpected finding?
Exactly!
Newborn: 70/40
6-year-old: 90/60
15-year-old: 110/68
Adult: 128/84
Newborn: 70/40
This is an expected finding rather than an unexpected finding because the expected blood pressure for a newborn is 60–90 over 20–60.
6-year-old: 90/60
This is an expected finding rather than an unexpected finding because the expected blood pressure for a 6-year-old is 84–<120 over 54–<80. 15-year-old: 110/68 This is an expected finding rather than an unexpected finding because the expected blood pressure for a 15-year-old is 94–<120 over 62–<80. Adult: 128/84 This is an unexpected finding because the expected blood pressure for an adult is 90–<120 over 60–<80; this patient’s blood pressure is 128/84. Question 4 of 5 Match the blood pressure measurement to its classification. Exactly! Hypertension stage 1 130–139 systolic Elevated <80 diastolic with systolic 120–129 Hypertension stage 2 ≥90 diastolic Question 5 of 5 Which cue would alert the nurse that a patient may be experiencing orthostatic hypotension? Exactly! Patient feels faint upon position change. Blood pressure increases when patient stands. Patient experiences paralysis in legs. Blood pressure remains constant during transfers. Patient feels faint upon position change. A patient with orthostatic hypotension will feel faint upon position change because of the sudden drop in blood pressure. Blood pressure increases when patient stands. In orthostatic hypotension, blood pressure decreases when the patient stands rather than increases. Patient experiences paralysis in legs. Paralysis in the legs is not a cue for orthostatic hypotension. Dizziness upon position changes is a cue for orthostatic hypotension. Blood pressure remains constant during transfers. There are sudden drops in blood pressure during transfers if the patient is experiencing orthostatic hypotension.
