Interventions and Evaluation: Hypotension and Orthostatic Hypotension
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Hypotension and orthostatic hypotension involve low blood pressure readings. Take action and evaluation are presented.
Hypotheses and Expected Outcomes
Actions/Interventions
Evaluation
Hypothesis
Altered Blood Pressure
Hypotension (as indicated in the image, BP 75/55 with pulse of 104)
Expected Outcome
Patient’s blood pressure will return to expected ranges 2 hours after treatment (timeline may vary depending upon severity of BP).
Administer prescribed intravenous (IV) fluids.
Administer blood if low BP is from blood loss.
Administer prescribed oxygen.
Position supine with legs elevated to promote blood back to the heart.
Improving
BP returns to expected ranges or starts to progress upward.
Signs and symptoms improve, such as less confusion, skin becomes warm and dry.
Declining
Unfortunately, if the patient declines, it can lead to shock symptoms and even death (notify health care provider, increase frequency of vital sign monitoring).
Unchanged
If condition remains unchanged, patient will move into a declining state (notify health care provider and rapid response team).
Hypothesis
Altered Blood Pressure
Orthostatic (postural) hypotension
Expected Outcome
Patient’s blood pressure will not drop more than 20 mm Hg systolic or 10 mm Hg diastolic when standing or sitting from a lying position within 3 days (timeline may vary depending upon severity of BP).
For immobile patients, encourage patient to sit up each day if possible.
If patient feels dizzy, lie back down.
Rise slowly from a lying position or sitting position.
Encourage fluid intake.
Limit or avoid alcohol intake.
May increase sodium intake if there is no history of heart disease.
Improving
Blood pressure rises less than 20 mm Hg systolic or less than 10 mm Hg diastolic when changing position.
Signs and symptoms improve, such as dizziness decreases or resolves.
Declining
Blood pressure continues to fall upon position changes (review chart to determine if other issues, like anemia or electrolyte imbalance, are occurring; perform a head-to-toe assessment).
Faints or falls upon standing (assess patient, assist back to bed, notify health care provider, complete incident report).
Unchanged
If condition remains unchanged after treatment (assess patient head-to-toe; review electrolyte and complete blood count to determine if another issue is occurring, such as anemia or electrolyte imbalance).
Putting It into Practice
Remember
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.
The patient is diagnosed with orthostatic hypotension.
Update
The nurse develops mutual goals/outcomes with the patient to address the orthostatic hypotension.
Using Clinical Judgment
Take Action
What patient education topics would you teach the patient?
Rising slowly when changing positions.
Drinking plenty of fluids.
Eating more salt.
Calling for assistance before transferring or ambulating.
Limiting alcohol intake.
Encouraging the patient to stay active.
Discussing wrist BP devices if home monitoring is required.
Evaluate Outcomes
If the patient declines, what additional patient care strategies can you consider in helping the patient reach an ideal state?
Perform a head-to-toe assessment.
Review the patient’s electrolyte levels.
Review the patient’s red blood cell count in the complete blood count because anemia can lead to orthostatic hypotension.
Emphasize the importance of regular eating and drinking.
Provide emotional support.
Use therapeutic techniques to determine if other issues have developed.
Question 1 of 3
Which finding alerts the nurse that a patient with hypertension is improving?
Exactly!
Salt intake increases.
Weight increases.
Nose bleeds decrease.
Exercising decreases.
Salt intake increases.
Increasing salt intake indicates the patient is declining; salt can increase blood pressure.
Weight increases.
Gaining body weight indicates the patient is declining; body weight gain increases blood pressure.
Nose bleeds decrease.
Nose bleeds decreasing indicates the patient with hypertension is improving.
Exercising decreases.
If exercising decreases, this indicates the patient is declining; exercise is beneficial for hypertension.
Question 2 of 3
Which action would the nurse take for a patient with hypotension?
Exactly!
Apply oxygen.
Increase salt intake.
Restrict fluid.
Ambulate patient.
Apply oxygen.
The nurse would apply oxygen for a patient with hypotension to provide supplemental oxygen.
Increase salt intake.
Increasing salt intake is an intervention for orthostatic hypotension, not hypotension.
Restrict fluid.
The patient with hypotension needs fluids, not restriction of fluids, to increase fluid levels.
Ambulate patient.
Ambulating the patient with hypotension is unsafe; this can cause the blood pressure to drop even further.
Question 3 of 3
Which patient care strategy would the nurse take for a patient with worsening orthostatic hypotension?
Exactly!
Emphasize the importance of restricting fluids.
Perform a head-to-toe assessment.
Review the white blood cell count.
Prepare to transfer to intensive care unit.
Emphasize the importance of restricting fluids.
The nurse would emphasize the importance of regular eating and drinking rather than restricting fluids.
Perform a head-to-toe assessment.
The nurse would perform a head-to-toe assessment to determine if another issue is causing the orthostatic hypotension, like anemia.
Review the white blood cell count.
The nurse would review the red (not white) blood cell count to determine if anemia is causing the problem.
Prepare to transfer to intensive care unit.
Orthostatic hypotension does not require a transfer to the intensive care unit; however, it may be necessary for a patient with hypotension who is not improving with treatment.
Summary
Blood pressure refers to the force of blood as it is exerted against the arterial walls during circulation. Factors such as compliance (elasticity), emotions, pain, and medications can affect blood pressure measurements.
Blood pressure is commonly measured in the brachial artery in the antecubital fossa, but other sites can be used as well. BP can be taken manually, electronically, or even palpated. There are several different pieces of equipment and techniques that can be used to measure blood pressure, but avoiding errors is essential to ensure accurate measurements. The nurse recognizes cues to identify the primary alterations in BP: hypertension, hypotension, and orthostatic hypotension.
The nurse analyzes cues to determine and prioritize BP hypotheses. From these hypotheses, the nurse develops goals, outcomes, and possible solutions. Solutions focus on increasing or decreasing the BP, depending upon the hypothesis developed.
The nurse implements interventions during take action. The nurse evaluates outcomes and interventions to determine effectiveness of care by comparing preintervention baseline BP readings to postintervention BP readings.
Transcript
Blood pressure is the force that blood exerts on vessel walls, as it circulates throughout the body to deliver nutrients and oxygen to tissues and organs. When measuring your patient’s blood pressure, you will follow the steps of the Clinical Judgment Measurement Model, or CJMM, to make clinical decisions about patient care.
Okay, let’s review the physiological regulation of blood pressure. First, when the heart contracts and pumps blood through the body during systole, the blood pressure rises. On the other hand, when the heart relaxes and refills with blood during diastole, the blood pressure decreases.
In addition to the heart, there are other internal factors that regulate blood pressure. The elastic arteries maintain blood pressure and help propel blood forward through the body by expanding and recoiling with each heartbeat. In addition, the autonomic nervous system can increase the blood pressure by increasing the heart rate and by causing vasoconstriction, where the arteries constrict, or it can decrease blood pressure by lowering the heart rate and by causing vasodilation, where the arteries relax.
Blood pressure is also influenced by hormones, like the renin-angiotensin-aldosterone system, which increases blood pressure by causing vasoconstriction and increasing the circulating blood volume; and through antidiuretic hormone, which also increases blood volume.
There are also some external factors that can increase blood pressure, too, like aging, which causes arteries to become stiffer and less compliant; and emotions, like anger and pain, which can stimulate the autonomic nervous system.
Now, blood pressure is measured in millimeters of mercury, or mm Hg for short; and is written as a fraction, like 118 over 72. In this example, 118 represents the systolic, or peak pressure in the arteries during systole; whereas 72 represents the diastolic, or lowest pressure in the arteries during diastole. Blood pressure can be measured manually, electronically, or even palpated from the brachial artery in the upper arm.
Alright, when assessing your patient’s blood pressure, you will use the Clinical Judgment Measurement Model to gather and recognize important cues, including the blood pressure reading, measurement site, equipment used, as well as the patient’s age, health conditions, and baseline blood pressure.
In addition, you will recognize other objective cues associated with alterations in blood pressure like cool, clammy skin or facial redness; as well as subjective cues like dizziness, blurred vision, or headache.
Next, you will analyze the relationship between the cues and link them to your patient’s history and clinical presentation. For example, you’ll consider whether your patient’s report of blurred vision and headache are consistent with a high blood pressure reading, or if tachycardia and light headedness are consistent with hypotension.
Then, you will determine a priority hypothesis related to altered blood pressure, such as hypertension, hypotension, or orthostatic hypotension. You will rank the hypotheses by considering whether the findings are potentially life-threatening, like extremely high or low blood pressure; or an immediate concern, like chronic hypertension.
Based on this information, you will address the most serious hypothesis first, and then generate solutions, such as “My patient’s blood pressure will return to the expected range within two hours of treatment.”
Okay, once you have generated solutions, you will take action to implement them. For patients with hypertension, administer the prescribed antihypertensive medications and provide a calm, restful environment. For patients with hypotension, administer the prescribed IV fluids and oxygen, as well as blood products if the hypotension is from blood loss. Lastly, for orthostatic hypotension, encourage your patient to increase fluid intake, and change positions slowly to prevent falls.
Lastly, you will evaluate whether the expected outcomes have been met by reassessing your patient’s blood pressure, to determine whether your patient’s condition is improving, declining, or remains unchanged. If your patient’s condition is declining or hasn’t changed, you will need to revise the plan of care accordingly and take additional actions to guide care.
Alright, as a quick recap… Blood pressure is the force blood exerts on vessel walls, as it circulates throughout the body to deliver nutrients and oxygen to the tissues and organs. When measuring your patient’s blood pressure, you will go through the steps of the Clinical Judgment Measurement Model to make clinical decisions about patient care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.
