Clinical Findings

Neuro: Dizziness, light-headedness, vertigo, faintness, HA, anxiety, AMS, restlessness, visual disturbances, seizures.

Resp: SOB, hyperventilation.

CV: Tachycardia, bradycardia, CP, palpitations, arrhythmias, dependent edema, symptoms of CHF.

Skin: Coolness and moisture, warmth and flushing, tingling sensation.

GI/GU: Nausea and vomiting, oliguria if kidneys affected.

MS: Weakness, fatigue.

Collaborative Management

• Note: If SPB >220 or DPB >140 mm Hg, notify HCP STAT.
• Elevate Pt’s head of bed to 30° to 45°.
• Assess LOC and orientation.
• Obtain VS and record BP readings in both arms.
• Assess ECG (if monitored) and treat arrhythmias per order as indicated.
• Assess for neurological deficits such as slurred speech, unequal pupils, facial droop, or weakness or numbness on one side of body and other associated fi ndings (CP; respiratory distress; rapid, thready pulse; or AMS).
• Auscultate carotid, abdominal, and femoral arteries for bruits.
• Palpate lower extremities for edema and pulses.
• Monitor labs for indications of TOD (proteinuria, ↑ BUN/creatinine, ↑ Na^–, ↑ K⁺, ↑ TSH, fasting glucose >100 mm/dL, ↓ LDL/triglycerides, ↓ HDL, ↓ Hct).
• Administer or assist with antihypertensive medication as ordered (e.g., beta blockers, Ca⁺⁺ channel blockers, ACE inhibitors, diuretics).
• Transfer to ICU if condition continues or worsens.