Clinical Findings

Neuro: Anxiety, restlessness, dizziness, light-headedness, decreased LOC, faintness, syncope.

Resp: SOB, respiratory distress.

CV: SBP <90 mm Hg, or SBP 40 mm Hg below Pt’s normal baseline BP, tachycardia, bradycardia, CP, arrhythmia.

Skin: Coolness, pallor, diaphoresis.

GI/GU: Nausea and vomiting, UO <30 mL/hr.

MS: Weakness, fatigue.

Collaborative Management

• Lay Pt flat, unless contraindicated by respiratory or airway compromise.
• Elevate foot of bed 10° to 15°.
• Assess LOC and orientation.
• Assess for and control any bleeding with direct pressure.
• Anticipate and prepare for return to surgery if Pt is postoperative.
• Assess for associated symptoms (CP, respiratory distress, AMS).
• Review medical record (medication, recent labs, treatments) for possible causes of drop in BP.
• Obtain IV access and administer fluid bolus as ordered.
• Administer STAT medications as ordered.
• Notify HCP of change in Pt status.
• Transfer to ICU if condition continues or worsens.