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Hypotension, General information - Coggle Diagram
Hypotension
PLAN: Client BP will return to normal (SBP >90)
STABILIZE: lay flat wiht legs elevated 30 degrees
Maintain bedrest (prevent falls)
Monitor V/S frequently (freq vary based on acutiy)
Stop fluid loss
Hold medications that will lower BP
Increase fluids (IV and PO)
Monitor I&O
elderly lose the sensation of thirst
Assessment
Obtain accurate medication list
Diuretics
Opioids
Sedatives
Anti-hypertension (-pril, -sartan,-lol)
Proper technique when obtaining BP
Assess for volume loss: bleeding, dehydration, fluid loss (n/v/d), diuretics, diaphoresis
S&S of low perfusion (cardiovascular)
Cool skin
Clamminess
Pallor
Sweating
Thready/absent pulses
Orthostatic hypotension
Obtain BP & HR: laying, sitting, & standing
Positive orthostatic: Drop in SBP >10 and increase HR >10
HUGE safety issues-increase risk for falls
Dizzy
Poor fluid intake
Dry skin
Weakness
PLAN: Client will understand education
Fall prevention
Maintain adequate hydration
Orthostatic hypotension: change position slowly
Monitor BP and keep log
S&S when to call provider
Excessive fluid loss
Syncope
SBP <90
Medication education
Dose, route, frequency
Side effect and adverse events
Diagnosis
Medical (prove): SBP <90 (does not require serial readings)
Nursing diagnosis
Risk for unstable blood pressure
Deficient fluid volume
Decreased cardiac output
EVALUATION: Is the PLAN met??
General information
Common causes
Expanded intravascular space
LOW volume
Medications
Definition
BP <90/60
drop on BP 30 mmHg
EMERGENCY!! low perfusion = NO BP & NO Oxygen = Death
No peripheral perfusion SBP <80