Question

Mr. Charles Lamont is a 64-year-old patient who is visiting his primary care physician with complaints of vomiting x 3 days and inability to keep anything down. His wife is waiting for him in the lobby. She is hoping that Mr. Lamont will tell the physician about his recent bout of coughing and shortness of breath. He smokes 1½ packs of cigarettes per day. His wife has been encouraging him to stop, but he has not shown any interest in quitting. Laura, the registered nurse, takes Mr. Lamont into an examination room. Laura asks him about his overall health and he tells her about a nagging cough and feeling of dizziness when he tries to get up. Laura examined Mr. Lamont and observed dry, scaly skin, an inflamed hemorrhoid, and tremors to his fingers and toes. The patient also vomits after drinking a cup of apple juice. He also reports pain in his feet. Laura instructed the UAP to takes Mr. Lamont’s vital signs with the following results: blood pressure, 156/94 mm Hg sitting; temperature, 98.8° F orally; radial pulse, 52 beats/min and irregular; respirations, 25 breaths/min and regular; and pulse oximetry 87%. Laura retakes the pulse prior to documenting and reporting the findings to the physician. She also documents the vital signs in the computerized medical record.

Mr. Lamont calls Laura, the nurse, and tells Laura that as he attempted to get up and go to the bathroom he felt dizzy and had to sit down. Laura also observed that Mr. Lamont was tachypneic. Laura takes Mr. Lamont’s blood pressure and gets the following results: B/P lying 150/90 mm hg, sitting 130/80 and standing 110/70. His pulse increased to 104 beats per minute; resp 28 bpm. Laura called the physician to report the findings using SBAR communication technique before documenting them in the electronic health record. The patient’s wife overheard the nurse reporting to the physician that Mr. Lamont has orthostatic hypotension, is tachycardic, and tachypneic. The wife asked the nurse what those terminologies mean?

a. What is the definition of orthostatic hypotension

b. What may be some causes of orthostatic hypotension?

c. What are clinical signs and symptoms of orthostatic hypotension

d. How is orthostatic hypotension assessed?

e. What is the nurse’s priority intervention for patient with orthostatic hypotension?

f. What is a nursing diagnosis for patient with orthostatic hypotension?

g. How should the nurse describe to the patient’s wife the following:

i. What is tachycardia?

ii. What is tachypnea

iii. What is the purpose of measuring pulse oximetry?

iiii. What can affect the accuracy of pulse oximetry

Answer 1

Ans) a. Orthostatic hypotension is a physical finding defined by the American Autonomic Society and the American Academy of Neurology as a systolic blood pressure decrease of at least 20 mm Hg or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing.

b. Orthostatic hypotension can have causes that aren't due to underlying disease. Examples include dehydration, standing up too quickly, medication side effects or ageing.

c. Orthostatic hypotension signs and symptoms include:

• Feeling lightheaded or dizzy after standing up.
• Blurry vision.
• Weakness.
• Fainting (syncope)
• Confusion.
• Nausea.

d. Orthostatic hypotension is assessed:

1. Have the patient lie supine for 10 minutes and obtain blood pressure and HR.
2. Take blood pressure and HR immediately after the patient arises and ask about dizziness.
3. After the patient maintains an upright posture for 3 minutes, obtain blood pressure and HR again.