While assessing for orthostatic hypotension, the nurse follows which steps when taking the blood pressure? Select all that apply
A) Check and record blood pressure taken while the client is in the bed.
B) Assist client to a sitting position with feet dangling off the floor.
C) Assist client to standing position and wait 2 minutes before taking his blood pressure.
D) Record measurements and report a drop of 25 mmHg systolic and 10 mmHg diastolic.
E) Keep the blood pressure cuff attached the whole time.
Ans: A, C, D, E
Feedback:
In adults, moving from a flat, horizontal position to a vertical position results in pooling of blood in the lower extremities. People with healthy, intact autonomic nervous systems reflexively compensate for the volume shift by increasing the rate and force of myocardial contraction and by vasoconstriction, thus maintaining adequate blood pressure. Even with normal compensation, however, a position change usually results in a drop in systolic blood pressure and an increase in heart rate, but these changes are temporary.
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