Clinical Findings

Neuro: Dizziness, light-headedness, faintness, anxiety, syncope.

Resp: SOB, hyperventilation.

CV: Hypotension, tachycardia, bradycardia, CP, chest tightness or pressure, palpitations, arrhythmias.

Skin: Coolness, pallor, diaphoresis.

GI/GU: Nausea and vomiting.

MS: Weakness, fatigue.

Collaborative Management

• Stay with Pt until you can assist to chair or back to bed (if, during assist, Pt has syncopal episode, assist Pt to floor, call for help, then assess ABCs).
• Lay Pt flat and elevate foot of bed 10° to 15°.
• If Pt is hyperventilating, encourage slow, deep breathing.
• Assess for neurological deficits (e.g., slurred speech, unequal pupils, facial droop, or weakness or numbness on one side of body).
• Assess for associated symptoms (CP, respiratory distress, or hypotension).
• Assess ECG (if monitored) and treat arrhythmias per order as indicated.
• Review MAR and labs for causes of dizziness or syncope.
• Obtain STAT bedside blood glucose level.
• Obtain and document orthostatic VS (each set, 1 min apart) from supine, sitting, and standing positions—Use extreme caution (Pt may pass out) and extra staff or specialty equipment (e.g., standing platform) as needed based on Pt’s presentation and tolerance to test. Note: An increase in HR or decrease in SBP by 20 points from baseline is positive for orthostatic hypotension.