The nurse is preparing to measure a patient for orthostatic hypotension. Which action should the nurse take to obtain this information? (Select all that apply.)
a. Use the correct size blood pressure cuff for the patient.
b. Instruct the patient not to eat or drink for 30 minutes prior to the test.
c. Have the patient refrain from smoking for at least 4 hours prior to the test.
d. Take pulse and blood pressure readings immediately upon assisting the patient to stand.
e. Assist the patient to a sitting position, wait 3 minutes, and take the pulse and blood pressure.
f. Obtain supine reading with patient lying with head of bed elevated 30 degrees for 30 minutes.
ANS: A, B, D, E
To detect orthostatic hypotension: Use correct size blood pressure cuff. Explain procedure to patient; determine if patient can safely stand. Have patient lie flat in bed at least 5 minutes prior to readings. Patient should not eat or smoke 30 minutes before readings; patient should not talk during readings and should sit up with legs uncrossed while sitting. Take patient's lying blood pressure and heart rate. Assist patient to sitting position. Ask if dizzy or light-headed with each position change. Wait 3 minutes, and then take patient's sitting blood pressure and heart rate. If patient is dizzy or light-headed, continue sitting position for 5 minutes, if tolerated. Do not attempt to bring the patient to standing. Repeat sitting blood pressure. If blood pressure has increased and patient is no longer dizzy, assist patient to stand. Assist patient to stand and take blood pressure and pulse immediately. Then take again in 3 minutes. If blood pressure drops and patient is dizzy or light-headed, do not attempt to ambulate the patient. Document all heart rate and blood pressure measurements. B. F. These actions are not a part of the procedure to assess for orthostatic hypotension.
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