Clinical Findings
Neuro: Dizziness, light-headedness, vertigo, faintness, HA, anxiety, AMS, restlessness, visual disturbances, seizures.
Resp: SOB, hyperventilation.
CV: Tachycardia, bradycardia, CP, palpitations, dysrhythmias, dependent edema, symptoms of CHF.
Skin: Coolness and moisture, warmth and flushing, tingling sensation.
GI/GU: Nausea and vomiting.
MS: Weakness, fatigue.
Collaborative Management
- Note: If SPB >220 or DPB >140 mm Hg, notify physician STAT.
- Elevate Pts head of bed to 30°45°.
- Assess LOC and orientation.
- Palpate pulse for rate and rhythm. If Pt is monitored, assess ECG.
- Assess for neurological deficits such as slurred speech, unequal pupils, facial droop, or weakness or numbness on one side of body and other associated findings (chest pain; respiratory distress; rapid, thready pulse; or AMS).
- Obtain and record BP readings in both arms.
- Administer or assist with antihypertensive medication as ordered.