A practical nurse (PN) is collecting orthostatic vital signs for an adult client who reports experiencing dizziness and lightheadedness when getting out of bed. In what order should the PN perform the steps for this data collection technique? Arrange the actions in the correct chronological sequence.
- 1Place the client in a supine position to rest for 5 to 10 minutes.
- 2Obtain and record the baseline blood pressure and pulse rate.
- 3Assist the client to a standing position.
- 4Wait for 1 to 3 minutes while the client remains in the upright position.
- 5Measure and record the blood pressure and pulse rate in the standing position.
Answer
The correct sequence is to first rest the client supine for 5 to 10 minutes, measure baseline vital signs, assist the client to stand, wait 1 to 3 minutes, and finally measure the standing vital signs.
To accurately collect orthostatic vital signs, the practical nurse must first establish a resting baseline by having the client lie supine for 5 to 10 minutes, followed by taking the baseline blood pressure and pulse. Next, the PN assists the client to a standing position (or sitting if standing is unsafe) and waits 1 to 3 minutes to allow the cardiovascular system to react to the gravitational shift. Finally, the PN measures the vital signs again to assess for significant changes, such as a drop in systolic blood pressure of at least 20 mm Hg or diastolic of 10 mm Hg, which indicates orthostatic hypotension.
Step-by-Step Solution
Key Concept
Orthostatic Vital Signs Data Collection