Podcast
Questions and Answers
What baseline blood pressure is considered acceptable when the patient is in a supine position?
What baseline blood pressure is considered acceptable when the patient is in a supine position?
- Greater than 95 mmHg
- Greater than 80 mmHg
- Greater than 85 mmHg
- Greater than 90 mmHg (correct)
What should be done immediately after taking a baseline blood pressure reading?
What should be done immediately after taking a baseline blood pressure reading?
- Have the patient stand up safely and assist if necessary (correct)
- Have the patient lie down again
- Have the patient sit down
- Have the patient walk across the room
What indicates a positive test for orthostatic hypotension?
What indicates a positive test for orthostatic hypotension?
- Decrease in blood pressure by 15 mmHg or more (correct)
- No change in blood pressure
- Increase in blood pressure by 15 mmHg or more
- Decrease in blood pressure by 10 mmHg or more
What should be monitored during the orthostatic hypotension assessment besides blood pressure?
What should be monitored during the orthostatic hypotension assessment besides blood pressure?
What should the healthcare provider do if the patient shows signs of dizziness during the assessment?
What should the healthcare provider do if the patient shows signs of dizziness during the assessment?
What should be documented during the orthostatic hypotension assessment?
What should be documented during the orthostatic hypotension assessment?
Which of the following symptoms are often present in a patient with orthostatic hypotension?
Which of the following symptoms are often present in a patient with orthostatic hypotension?
When should blood pressure be taken again after the patient stands up?
When should blood pressure be taken again after the patient stands up?
What is the first step in assessing orthostatic hypotension?
What is the first step in assessing orthostatic hypotension?
How long should a patient rest flat before readings are taken when assessing for orthostatic hypotension?
How long should a patient rest flat before readings are taken when assessing for orthostatic hypotension?
At what level should the patient's arm be during blood pressure readings for orthostatic hypotension assessment?
At what level should the patient's arm be during blood pressure readings for orthostatic hypotension assessment?
When should blood pressure and pulse be taken immediately after assisting a patient to stand?
When should blood pressure and pulse be taken immediately after assisting a patient to stand?
What should be noted about sputum characteristics during respiration assessment?
What should be noted about sputum characteristics during respiration assessment?
What does pink, frothy sputum indicate?
What does pink, frothy sputum indicate?
What does a brown discoloration and edema in the lower extremities indicate?
What does a brown discoloration and edema in the lower extremities indicate?
What does a capillary refill time longer than 3 seconds indicate?
What does a capillary refill time longer than 3 seconds indicate?
What should the position of the patient be to observe internal and external jugular neck veins?
What should the position of the patient be to observe internal and external jugular neck veins?
What does clubbing of the nailbeds indicate?
What does clubbing of the nailbeds indicate?
What is the appropriate action if the patient feels dizzy or light-headed during the orthostatic hypotension assessment?
What is the appropriate action if the patient feels dizzy or light-headed during the orthostatic hypotension assessment?
How long should a patient lie flat before taking initial blood pressure and heart rate readings?
How long should a patient lie flat before taking initial blood pressure and heart rate readings?
Which of the following should be documented when recording heart rate and blood pressure measurements?
Which of the following should be documented when recording heart rate and blood pressure measurements?
What might clubbing of the nailbeds indicate?
What might clubbing of the nailbeds indicate?
When assessing venous blood return, what might a brown discoloration around the ankles indicate?
When assessing venous blood return, what might a brown discoloration around the ankles indicate?
How long should the patient wait before repeating blood pressure in a sitting position if they experience dizziness?
How long should the patient wait before repeating blood pressure in a sitting position if they experience dizziness?
What does distention of jugular neck veins observed in a 45-to 90-degree upright position indicate?
What does distention of jugular neck veins observed in a 45-to 90-degree upright position indicate?
What might a longer capillary refill time indicate?
What might a longer capillary refill time indicate?
What is suggested by a reddish-brown discoloration (rubor) found in the lower extremities?
What is suggested by a reddish-brown discoloration (rubor) found in the lower extremities?
What should be done if a patient shows signs of thrombophlebitis during inspection?
What should be done if a patient shows signs of thrombophlebitis during inspection?
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.
