Questions and Answers
What baseline blood pressure is considered acceptable when the patient is in a supine position?
Greater than 90 mmHg
What should be done immediately after taking a baseline blood pressure reading?
Have the patient stand up safely and assist if necessary
What indicates a positive test for orthostatic hypotension?
Decrease in blood pressure by 15 mmHg or more
What should be monitored during the orthostatic hypotension assessment besides blood pressure?
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What should the healthcare provider do if the patient shows signs of dizziness during the assessment?
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What should be documented during the orthostatic hypotension assessment?
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Which of the following symptoms are often present in a patient with orthostatic hypotension?
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When should blood pressure be taken again after the patient stands up?
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What is the first step in assessing orthostatic hypotension?
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How long should a patient rest flat before readings are taken when assessing for orthostatic hypotension?
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At what level should the patient's arm be during blood pressure readings for orthostatic hypotension assessment?
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When should blood pressure and pulse be taken immediately after assisting a patient to stand?
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What should be noted about sputum characteristics during respiration assessment?
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What does pink, frothy sputum indicate?
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What does a brown discoloration and edema in the lower extremities indicate?
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What does a capillary refill time longer than 3 seconds indicate?
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What should the position of the patient be to observe internal and external jugular neck veins?
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What does clubbing of the nailbeds indicate?
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What is the appropriate action if the patient feels dizzy or light-headed during the orthostatic hypotension assessment?
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How long should a patient lie flat before taking initial blood pressure and heart rate readings?
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Which of the following should be documented when recording heart rate and blood pressure measurements?
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What might clubbing of the nailbeds indicate?
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When assessing venous blood return, what might a brown discoloration around the ankles indicate?
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How long should the patient wait before repeating blood pressure in a sitting position if they experience dizziness?
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What does distention of jugular neck veins observed in a 45-to 90-degree upright position indicate?
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What might a longer capillary refill time indicate?
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What is suggested by a reddish-brown discoloration (rubor) found in the lower extremities?
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What should be done if a patient shows signs of thrombophlebitis during inspection?
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Study Notes
Orthostatic Hypotension Assessment
- Assess orthostatic hypotension by determining vital signs, including baseline blood pressure (in bed or supine, if > 90 mmHg), pulse readings, and respirations.
- Check for fall risk and safety.
- Take blood pressure and heart rate readings with the patient lying down, then after 1 minute, have the patient stand up safely while taking another blood pressure reading.
- Monitor for signs of dizziness and decreased LOC.
- If the blood pressure drops by 15 mmHg or more, it is positive for orthostatic hypotension.
Assessment Procedure
- Explain the procedure to the patient.
- Ensure the patient does not exercise, eat, or smoke 30 minutes before readings.
- Have the patient lie flat in bed for at least five minutes before readings.
- Use the correct size blood pressure cuff.
- Take the patient's lying blood pressure and heart rate.
- Assist the patient to a sitting position and take blood pressure and heart rate readings.
- Wait three minutes and take the patient's sitting blood pressure and heart rate again.
- If the patient is dizzy or light-headed, continue sitting position for five minutes if tolerated.
- Assist the patient to stand and take blood pressure and pulse immediately, then again in three minutes.
- Document all heart rate and blood pressure measurements, including the extremity used and patient position when the reading was obtained.
Inspection
- Observe skin for signs of oxygenation status, including pallor, cyanosis, and rubor.
- Note hair distribution on the extremities and observe for decreased hair distribution, thick, brittle nails, and shiny, taut, dry skin.
- Inspect extremities for varicose veins, stasis ulcers, or scars around the ankles and signs of thrombophlebitis.
- Observe the patient's internal and external jugular neck veins for distention in a 45-to 90-degree upright position.
- Check capillary refill time by briefly squeezing the patient's nailbed, causing blanching, and then releasing; a time of 3 seconds or less indicates normal arterial blood flow.
- Observe for clubbing of the nailbeds, which occurs from oxygen deficiency over time.
Respirations
- Observe the rate and ease of respirations.
- Auscultate breath sounds.
- Note sputum characteristics, such as amount, color, and consistency; pink, frothy sputum indicates acute heart failure.
- A dry cough can occur from lung congestion resulting from heart failure.
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Description
Assess and manage orthostatic hypotension, a common condition in older adults. This quiz covers the steps to determine baseline blood pressure, pulse readings, and fall risk assessment.
