Hypotension may be due to stress or change of position — specifically, rising abruptly from a supine or sitting position to a standing position (orthostatic hypotension).
Normal blood pressure varies considerably; what qualifies as low blood pressure for one person may be normal for another. Consequently, every blood pressure reading must be compared against the patient’s baseline and clinical status. Typically, a reading below 90/60 mm Hg, or a drop of 30 mm Hg from the baseline, is considered low blood pressure.
Low blood pressure can reflect an expanded intravascular space (as in severe infections, allergic reactions, or adrenal insufficiency), reduced intravascular volume (as in dehydration and hemorrhage), or decreased cardiac output (as in impaired cardiac muscle contractility). Because the body’s pressure-regulating mechanisms are complex and interrelated, a combination of these factors usually contributes to low blood pressure.
Act Now: If the patient’s systolic pressure is less than 80 mm Hg, or 30 mm Hg below his baseline, suspect shock immediately. Quickly evaluate the patient for a decreased LOC. Check his apical pulse for tachycardia and respirations for tachypnea. Also, inspect him for cool, clammy skin. Elevate the patient’s legs above the level of his heart, or place him in Trendelenburg’s position if the bed can be adjusted. Then start an I.V. line using a large-bore needle to replace fluids and blood or to administer drugs. Prepare to administer oxygen with mechanical ventilation, if necessary. Monitor the patient’s intake and output and insert an indwelling urinary catheter to accurately measure urine output. The patient may also need a central venous line or a pulmonary artery catheter to facilitate monitoring of fluid status. Prepare the patient for cardiac monitoring to evaluate cardiac rhythm. Be ready to insert a nasogastric tube to prevent aspiration in the comatose patient. Throughout emergency interventions, keep the patient’s spinal column immobile until spinal cord trauma is ruled out.
History
Obtain the patient’s history from the patient or his family, paying particular attention to associated symptoms, such as weakness, fatigue, dizziness, fainting, blurred vision, nausea or vomiting, blood in stool, unsteady gait, palpitations, chest or abdominal pain, difficulty breathing, or generalized pain. Determine if symptoms appear when the patient changes positions suddenly.
Physical examination
Obtain blood pressure measurements with the patient lying down, sitting, and then standing, and compare readings. A drop in systolic or diastolic pressure of 10 mm Hg or more and an increase in heart rate of more than 15 beats/minute between position changes suggest orthostatic hypotension. (See Ensuring accurate blood pressure measurement.)
Obtain the patient’s other vital signs. Inspect the skin for pallor, sweating, and clamminess. Palpate peripheral pulses. Note paradoxical pulse — an accentuated fall in systolic pressure during inspiration — which suggests pericardial tamponade. Then auscultate for abnormal heart sounds (gallops, murmurs), rate (bradycardia, tachycardia), or rhythm. Auscultate the lungs for abnormal breath sounds (diminished sounds, crackles, wheezing), rate (bradypnea, tachypnea), or rhythm (agonal or Cheyne-Stokes respirations). Look for signs of hemorrhage, including visible bleeding and palpable masses, bruising, tenderness, or a positive stool occult blood test. Assess the patient for abdominal rigidity and rebound tenderness; auscultate for abnormal bowel sounds. Also, carefully asses
Pediatric pointers
Normal blood pressure in children is lower than that of adults. (See Normal pediatric blood pressure.)Because accidents occur frequently in children, suspect trauma or shock first as a possible cause of low blood pressure. Remember that even though low blood pressure typically doesn’t accompany head injury in adults (because intracranial hemorrhage is insufficient to cause hypovolemia), it does accompany head injury in infants and young children; their expandable cranial vaults allow significant blood loss into the cranial space, resulting in hypovolemia.
Another common cause of low blood pressure in children is dehydration, which results from failure to thrive or from persistent diarrhea and vomiting for as little as 24 hours.
Geriatric pointers
In elderly patients, low blood pressure commonly results from the use of multiple drugs that potentiate this adverse effect. Orthostatic hypotension due to autonomic dysfunction is another common cause of low blood pressure.Medical causes
Acute adrenal insufficiency
Orthostatic hypotension is characteristic with acute adrenal insufficiency, accompanied by fatigue, weakness, nausea, vomiting, abdominal discomfort, weight loss, fever, and tachycardia. The patient may also have hyperpigmentation of fingers, nails, nipples, scars, and body folds; pale, cool, clammy skin; restlessness; decreased urine output; tachypnea; and coma.Alcohol toxicity
Low blood pressure occurs infrequently; more commonly, alcohol toxicity produces distinct alcohol breath odor, tachycardia, bradypnea, hypothermia, decreased LOC, seizures, staggering gait, nausea, vomiting, diuresis, and slow, stertorous breathing.Anaphylactic shock
Following exposure to an allergen, such as penicillin or insect venom, a dramatic fall in blood pressure and narrowed pulse pressure signal anaphylactic shock, a severe allergic reaction. Initially, it causes anxiety, restlessness, a feeling of doom, intense itching (especially of the hands and feet), and pounding headache. Later, it may also produce weakness, sweating, nasal congestion, coughing, difficulty breathing, nausea, abdominal cramps, involuntary defecation, seizures, flushing, change or loss of voice due to laryngeal edema, urinary incontinence, and tachycardia.Anthrax (inhalation)
Anthrax is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI form. Inhalation anthrax is caused by inhaling aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.Cardiac arrhythmias
With an arrhythmia, blood pressure may fluctuate between normal and low readings. Dizziness, chest pain, difficulty breathing, light-headedness, weakness, fatigue, and palpitations may also occur. Auscultation typically reveals an irregular rhythm and a pulse rate greater than 100 beats/minute or less than 60 beats/minute.Cardiac contusion
With cardiac contusion, low blood pressure occurs along with tachycardia and, at times, anginal pain and dyspnea.Cardiac tamponade
An accentuated fall in systolic pressure (more than 10 mm Hg) during inspiration, known as paradoxical pulse, is characteristic in patients with cardiac tamponade. This disorder also causes restlessness, cyanosis, tachycardia, jugular vein distention, muffled heart sounds, dyspnea, and Kussmaul’s sign (increased venous distention with inspiration).Cardiogenic shock
A fall in systolic pressure to less than 80 mm Hg or to 30 mm Hg less than the patient’s baseline, because of decreased cardiac contractility, is characteristic in patients with cardiogenic shock. Accompanying low blood pressure are tachycardia, narrowed pulse pressure, diminished Korotkoff sounds, peripheral cyanosis, and pale, cool, clammy skin. Cardiogenic shock also causes restlessness and anxiety, which may progress to disorientation and confusion. Associated signs and symptoms include angina, dyspnea, jugular vein distention, oliguria, ventricular gallop, tachypnea, and weak, rapid pulse.Cholera
Cholera is an acute infection caused by the bacterium Vibrio cholerae that may be mild with uncomplicated diarrhea or severe and life threatening. Cholera is spread by ingestion of contaminated water or food, especially shellfish. Signs include abrupt watery diarrhea and vomiting. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.Diabetic ketoacidosis (DKA)
Hypovolemia triggered by osmotic diuresis in hyperglycemia is responsible for the low blood pressure associated with DKA, which is usually present in patients with type 1 diabetes mellitus. It also commonly produces polydipsia, polyuria, polyphagia, dehydration, weight loss, abdominal pain, nausea, vomiting, fruity breath odor, Kussmaul’s respirations, tachycardia, seizures, confusion, and stupor that may progress to coma.Heart failure
With heart failure, blood pressure may fluctuate between normal and low readings. However, a precipitous drop in blood pressure may signal cardiogenic shock. Other signs and symptoms of heart failure include exertional dyspnea, dyspnea of abrupt or gradual onset, paroxysmal nocturnal dyspnea or difficulty breathing in the supine position (orthopnea), fatigue, weight gain, pallor or cyanosis, sweating, and anxiety. Auscultation reveals ventricular gallop, tachycardia, bilateral crackles, and tachypnea. Dependent edema, jugular vein distention, increased capillary refill time, and hepatomegaly may also occur.Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
HHNS, which is common in people with type 2 diabetes mellitus, decreases blood pressure — at times dramatically, if the patient loses significant fluid from diuresis due to severe hyperglycemia and hyperosmolarity. It also produces dry mouth, poor skin turgor, tachycardia, confusion progressing to coma and, occasionally, generalized tonic-clonic seizure.Hypovolemic shock
A fall in systolic pressure to less than 80 mm Hg or 30 mm Hg less than the patient’s baseline, secondary to acute blood loss or dehydration, is characteristic in patients with hypovolemic shock. Accompanying it are diminished Korotkoff sounds, narrowed pulse pressure, and rapid, weak, and irregular pulse. Peripheral vasoconstriction causes cyanosis of the extremities and pale, cool, clammy skin. Other signs and symptoms include oliguria, confusion, disorientation, restlessness, and anxiety.Hypoxemia
Initially, blood pressure may be normal or slightly elevated, but as hypoxemia becomes more pronounced, blood pressure drops. The patient may also display tachycardia, tachypnea, dyspnea, and confusion, and may progress from stupor to coma.Myocardial infarction (MI)
With MI — a life-threatening disorder — blood pressure may be low or high. However, a precipitous drop in blood pressure may signal cardiogenic shock. Associated signs and symptoms include chest pain that may radiate to the jaw, shoulder, arm, back, or epigastrium; dyspnea; anxiety; nausea or vomiting; sweating; and cool, pale, or cyanotic skin. Auscultation may reveal an atrial gallop, a murmur and, occasionally, an irregular pulse.Neurogenic shock
. The result of sympathetic denervation due to cervical injury or anesthesia, neurogenic shock produces low blood pressure and bradycardia. However, the patient’s skin remains warm and dry because of cutaneous vasodilation and sweat gland denervation. Depending on the cause of shock, there may also be motor weakness of the limbs or diaphragm.Pulmonary embolism
Pulmonary embolism causes sudden, sharp chest pain and dyspnea accompanied by cough and, occasionally, low-grade fever. Low blood pressure occurs with narrowed pulse pressure and diminished Korotkoff sounds. Associated signs include tachycardia, tachypnea, paradoxical pulse, jugular vein distention, and hemoptysis.Septic shock
Initially, septic shock produces fever and chills. Low blood pressure, tachycardia, and tachypnea may also develop early, but the patient’s skin remains warm. Later, low blood pressure becomes increasingly severe — less than 80 mm Hg, or 30 mm Hg less than the patient’s baseline — and is accompanied by narrowed pulse pressure. Other late signs and symptoms include pale skin, cyanotic extremities, apprehension, thirst, oliguria, and coma.Vasovagal syncope
Vasovagal syncope is a transient attack of loss or near-loss of consciousness that’s characterized by low blood pressure, pallor, cold sweats, nausea, palpitations or slowed heart rate, and weakness following stressful, painful, or claustrophobic experiences.Other causes
Diagnostic tests
These include the gastric acid stimulation test using histamine and X-ray studies using contrast media. The latter may trigger an allergic reaction, which causes low blood pressure.Drugs
Calcium channel blockers, diuretics, vasodilators, alpha- and beta-adrenergic blockers, general anesthetics, opioid analgesics, monoamine oxidase inhibitors, anxiolytics (such as benzodiazepines), tranquilizers, and most I.V. antiarrhythmics can cause low blood pressure.Nursing considerations
Check the patient’s vital signs frequently to determine if low blood pressure is constant or intermittent. If blood pressure is extremely low, an arterial catheter may be inserted to allow close monitoring of pressures. Alternatively, a Doppler flowmeter may be used.Place the patient on bed rest. Keep the side rails of the bed up. If the patient is ambulatory, assist him as necessary. To avoid falls, don’t leave a dizzy patient unattended when he’s sitting or walking.
Prepare the patient for laboratory tests, which may include bedside glucose check, urinalysis, routine blood studies, an electrocardiogram, and chest, cervical, and abdominal X-rays.
Patient teaching
If the patient has orthostatic hypotension, instruct him to stand up slowly. Advise the patient with vasovagal syncope to avoid situations that trigger the episodes. Evaluate the patient’s need for a cane or walker. Explain all procedures and tests.Read more at http://www.wrongdiagnosis.com/b/blood/book-diseases-13a.htm?ktrack=kcplink
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