ENW-Masthead2.gif (25553 bytes)

bar_Turquoise_and_Gray.jpg (1480 bytes)

Research Applied to Clinical Practiceimgtchr1.gif (1235 bytes)
by Robert C. Knies, RN MSN CEN
Section Editor

bar_Turquoise_and_Gray.jpg (1480 bytes)
Orthostatic Measurement
bar_Turquoise_and_Gray.jpg (1480 bytes)

Definition:

        Orthostatic, tilt or postural vital signs (VS) are serial measurements of blood pressure (B/P) and pulse that are taken with the patient in the supine, sitting, and standing positions, results are used to assess possible volume depletion. This test is commonly performed on patients who complain of; nausea, vomiting, diarrhea, GI bleed, and syncope. The results can help the practitioner decide if the patient needs fluid replacement, more extensive testing or treatment.

Possible Causes:

Diseases

Medications

Addison’s disease Anemia Diuretics
Autonomic disorders Diabetes Mellitus Calcium Channel blockers
Hyponatremia Mitral valve prolapse Alpha-adrenergic blockers
Nephrotic syndrome Neurologic diseases Ganglionic blocking drugs
Recent brain attack Pheochromocytoma Tricyclic antidepressants
Toxic shock syndrome Prolonged bed rest MAO inhibitors
Alcohol consumption Post partal bleeding  
Chronic Fatigue Syndrome    

Normal Pathophysiology:

        When a patient stands, gravity causes blood to pool in the large vessels of the legs and lower trunk (up to 500ml). Normally, baroreceptors in the aortic arch and carotids sense this change in blood pressure/volume and stimulate an endocrine, catecholamine, renin/aldosterone response. This response causes the peripheral blood vessels to constrict, the heart rate and contractility to increase, and the kidneys to hold fluids. This action pulls blood into the core circulation to supply the primary organs (heart, lungs, kidneys, liver and brain).

        In patients who are volume depleted (hypovolemic), there is not enough circulating blood to be pushed into core circulation, especially when the patient moves from the supine to sitting or standing. That is why clinicians think a positive tilt is indicative of volume depletion, and institute replacement while awaiting other test results.

        There is little agreement as to what indicates a significant orthostatic change and what is considered a positive tilt test. The "20-10-20" rule may be used as a guide for this. The rule refers to the expected decrease in systolic B/P (up to 20 mm Hg), a rise in diastolic B/P of 10 mm HG and an increase in heart rate by 20 beats per minute.

Measurement Techniques:

        1. There is controversy as to length of wait between moving to a new position and taking VS. Most studies and experts agree that a one minute wait between movement is satisfactory.

        2. For consistency the same arm with the same cuff and same location of pulse measurement should be used. This is easily accomplished by using electronic measuring devices.

Supine- The patient needs to lie supine, without pillows, for two to three minutes before measuring VS. * If supine position compromises patient’s breathing status or comfort level, assist them to a position as flat as possible. It is a good technique to obtain two sets of measurement while the patient is supine and use the second set as the baseline. This is done due to the normal sympathetic response (alerting reaction) which can cause false positives by initially raising the systolic B/P.

Sitting- Taking measurements with the patient in this position is controversial, some say the elevation is not significant enough to cause a change, other say that this in-between position causes false negatives by providing a chance for the body to adjust before changing to the standing position. * If the patient is not able to stand this is the next position after supine. Whenever measuring at this position the patient should be sitting upright, with their legs dangling at the side of the bed.

Standing- If the patient ambulated to the treatment area, and there are no signs of syncope, the sitting position can be avoided

Documentation:

        Using symbols i.e., o-<--< =lying;  o|_=sitting;  =standing, or writing out the name of the position and the results at each position are necessary. You should also indicate whether the pulse was regular and if on a monitor, document rhythm. Also include any symptoms the patient reports as well as your clinical observations, but do not pose leading questions like, "are you dizzy?" Lastly, if fluid replacement is ordered, after infusion is completed, repeat orthostatic assessment should be performed to evaluate and document effectiveness.


References:

Halpern, JS (1987). Clinical notebook: Assessment of orthostatic hypotension. Journal of Emergency Nursing, 13 (3), 170-171.
Roper, M (1996). Back to basics; Assessing orthostatic vital signs. American Journal of Nursing, 96 (8), 43-46.


"Research Applied to Clinical Practice: Orthostatic Measurement"
[http://ENW.org/Research-Orthostatic.htm]
is a webarticle by  Robert C. Knies, RN MSN CEN
[bknies@stevenshealthcare.org]
©Robert C. Knies, RN MSN CEN
presented by Emergency Nursing World ! [http://ENW.org]
Tom Trimble, RN [Tom@ENW.org] ENW Webmaster
ENW
name, logos, and layout ©Tom Trimble, RN


 

 
 

Clinical Articles Special Articles

Links

2003 ASA
"Difficult Airway Practice Guidelines"

Airway 10 Commandments
Action Plan for Airway Hell!

Using Anesthesia Bags
Optimizing Mask Ventilation
Sedation Guidelines
Sedation Principles
Sedation Checklist

Aphorisms, Maxims, and Pearls
Discharge Instructions
I.V. Starts -Improving Your Odds!
Pediatric Hints -An ABC
Tips & Tricks -from Other Nurses
Manipulative Behaviors by Patients

Heat Emergencies
End Tidal CO2 Monitoring
in CPR: A Predictor of Outcome

Fix This Airway!
Crises in Airway Management

Bioterrorism References
Electrolytes
Headache & Stroke
Outsize Patients
--a big nursing challenge!

The Poisoned Patient
Respiratory Encounters (I Can't BREATHE! Part I)

Respiratory Encounters (I Can't BREATHE! Part II)

 

Internet Starter Set
Quick Subject Guide
Basic Desktop References
Medical Links
-  (Addiction Medicine to Gerontology)
Medical Links
- (Gov't to Medical Organizations)
Medical Links
- (Medical Records to Primary Care)
Medical Links
- [Psych. to Wilderness]
Nursing Links
[General]
Emergency Nursing Links
Pre-Hospital Links

- [Ambulance to EMS Web Pages]

Pre-Hospital Links
[Fire to Special Purpose Care Organizations]
Just for Fun Links
 
ENW !  urges help to
victims of recent disasters
American Red Cross  
donate page
 



supports and recommends

FREE EMERGENCY MEDICINE TALKS

   Emergency Medicine education for everyone.
 

MP3 files provided by: Joe Lex, MD
 


Fabulous Places!  --  Fabulous Conferences!
Check frequently for updates

   

Plan for the Year Ahead!  
Meetings & Symposia

                   Meetings of 2013

 
 
Clinical Research Behind the Scenes at ENW! The World of Emergency Nursing
Meet the Editor
Temperature Management
Gastric Decontamination

Thermometry in Acute Care
Latest Research in Resuscitation

Septic Children
ACT
INR
Carbon Monoxide
Malignant Hyperthermia
Geriatric Thermoregulation
SSRI's
"
Orthostatics"
NG Tubes
RSV
Defibrillation
Disclaimer  Applies to all portions of this site!

Policies of this Website

Information for Authors

The Emergency Nursing
& Emergency Nursing World ! FAQ


ENW is Listed@

What's This All About?

Tom Trimble's Tale
Library of Resources & Solutions
CPEN Review - Putting
 It All Together

Bedlam Among the Bedpans
Veinlite EMS
Body Piercing Removal Kit
& Training Program

Emergency Nursing 5-Tier
Triage Protocols
Emergency Newborn Care
Quick Reference to Triage
Quick-E Guides
The Emergency Nursing "Cool Web-Find!"
Honor Gallery of Previous Winners
An 1895 Look At Nursing
Beatitudes For Leaders
E-Mail Lists & Usenet Groups

Emergency Nursing WebLinks
Emergi-Lexicon
Em-Nsg-L: The Emergency Nursing List
Humor
Night-Shift Survival Tips
Old-Aid -Archaic & Obsolete
University-Level Emergency Nursing Education
Words & Thoughts
 
California ENA Website ENW! Supports ENA  

is now
http://www.CalENA.US

We Support

Use this button to
go to ENA's sit
e

Emergency
Nursing World !
is an independent entity and
NOT a component

of
ENA

 

 

 
Google


WWW ENW.org

Emergency

Nursing World !