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 SBP >220 or DBP >140 mm Hg, notify physician STAT.
• Elevate Pt's 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.