Clinical Findings

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

Resp: SOB, hyperventilation.

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

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°-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 the body).
• Assess for associated symptoms (CP, respiratory distress, or hypotension).
• Review MAR and labs for causes of dizziness or syncope.
• Obtain STAT bedside blood glucose level.
• Obtain and document orthostatic vital signs (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 fororthostatic hypotension.