Hypotension

Hypotension

Clinical Findings

Neuro: Anxiety, restlessness, dizziness, lightheadedness, decreased LOC, faintness, syncope. Resp: Shortness of breath, respiratory distress. CV: SBP <90 mm Hg, or SBP 40 mm Hg below Pt’s normal baseline BP, tachycardia, bradycardia, chest pain, dysrhythmia. Skin: Cool, pale, diaphoretic. GI/GU: Nausea and vomiting, UO <30 mL/hour. MS:Weakness, fatigue.

Nursing Interventions

■ Lay Pt flat, unless contraindicated by respiratory or airway compromise, and elevate foot of bed 10–15 degrees. ■ Assess LOC and orientation. ■ Assess for and control any bleeding with direct pressure. ■ Anticipate and prepare for return to surgery if Pt is postop. ■ Assess for associated symptoms (chest pain, respiratory distress, cyanosis, decreased LOC). ■ Assess apical pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Administer supplemental oxygen titrated to SpO2 >90% and be prepared to ventilate Pt manually if RR <8 breaths/minute. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Obtain IV access, if not already in place, and titrate to SBP >90 mm Hg. Caution: Keep IV at TKO if hypotension is secondary to heart failure or cardiogenic shock. ■ Review medical record (medication, recent labs, and treatments) for possible causes of drop in BP. ■ 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, Hgb and Hct, electrolytes, BUN and creatinine, urine specific gravity), additional pharmacologic therapy (fluids, blood products, vasopressors), chest x-ray, and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.