Dizziness-Vasovagal Response-Syncope

Dizziness-Vasovagal Response-Syncope

Clinical Findings

Neuro: Dizziness, lightheadedness, faintness, anxiety, syncope. Resp: Shortness of breath, hyperventilation. CV: Hypotension, tachycardia, bradycardia, chest pain, chest tightness or pressure, palpitations, dysrhythmias. Skin: Cool, pale, and diaphoretic. GI/GU: Nausea and vomiting. MS:Weakness, fatigue.

Nursing Interventions

■ Stay with Pt until you can assist him or her to chair or back to bed (if, during assist, Pt experiences syncopal episode, gently assist Pt to floor, call for help, and then assess ABCs). ■ Lay Pt flat and elevate foot of bed 10–15 degrees. ■ If Pt is hyperventilating, encourage slow, deep breathing. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Assess for neuro deficits such as slurred speech, unequal pupils, facial droop, or weakness or numbness on one side of the body and other associated findings such as chest pain; respiratory distress; rapid, thready pulse; or hypotension. ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Review medical record (medication, recent labs, and treatments) for possible causes of dizziness or syncope. ■ Obtain STAT bedside blood glucose level if Pt is diabetic. ■ Obtain and document orthostatic vital signs (each set, 1 minute apart) from supine, sitting, and standing positions. Note: An increase in HR or decrease in SBP by 20 points from baseline is positive for orthostatic hypotension. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including 12-lead ECG, labs (CBC, electrolytes) pharmacologic therapy, diagnostic studies, and/or transfer to ICU. ■ Document assessments, any interventions, and outcome. ■ Note: If vasovagal/syncopal episode is reasonably anticipated in relation to Pt’s clinical status (e.g., anxiety related to an overt fear of needles), it is not immediately necessary to notify physician, unless there exists a need to order (or clarify an order for) medication or additional treatment, or, if you suspect underlying cause such as dysrhythmia.