While being tested for orthostatic hypotension, the patient stands up and begins to feel light-headed and feels faint. The nurse should do which of the following? (Select all that apply.)
a. Have the patient lie down.
b. Report findings to the health care provid-er.
c. Have the nursing assistive personnel (NAP) check orthostatic blood pressure.
d. Instruct the patient not to get out of bed without assistance.
e. Take the BP in each arm and use the arm with the lowest systolic reading.
A, B, D
Orthostatic hypotension occurs when patients with normal blood pressure experience a drop in blood pressure upon rising to an upright position and is associated with symptoms of lighthea-dedness or dizziness. If orthostatic signs or symptoms such as dizziness, weakness, lightheaded-ness, feeling faint, or sudden pallor occur, stop BP measurement and return patient to a supine position. Report the findings of orthostatic hypotension or orthostatic signs or symptoms to the nurse in charge or the health care provider. Instruct the patient to ask for assistance when getting out of bed if orthostatic hypotension is present or orthostatic signs or symptoms occur. The skill of measuring orthostatic blood pressure (BP) cannot be delegated to nursing assistive personnel (NAP) in an unstable patient. With the patient supine, take a BP reading in each arm. Select the arm with the highest systolic reading for subsequent measurements.
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