Treatment

Treating low blood pressure If you have low blood pressure, but do not have any symptoms, you do not require treatment. Only a small number of people who have low blood pressure are prescribed medication to treat the condition. For example, some elderly people may experience symptoms when changing posture, and are sometimes given medication to constrict (narrow) their arteries. Medications that cause low blood pressure If you are taking medication and your GP suspects that it may be causing low blood pressure, s/he will probably advise a change of medication or alter the dose. If you are taking a blood pressure lowering medicine, such as the alpha blocker, doxazosin, and you feel dizzy or faint when you stand up, you should have your blood pressure measured to see if it drops. If it does, you might need to have your medicine changed. You should discuss this with your GP or practice nurse. Underlying illnesses or conditions If your GP suspects that a disorder, such as a heart condition, adrenal gland failure, or a nerve condition, is causing your low blood pressure, you may be referred to hospital for further tests and treatment. If adrenal gland failure is the cause of your low blood pressure, replacing the missing hormone, aldosterone, will rectify the problem. If a nerve condition is causing low blood pressure, it can be more difficult to treat. You might be given medicines in order to stimulate your nervous system. Salt and fluids While people who have high blood pressure are usually advised to restrict their salt intake, if you have low blood pressure, you may be advised to include more salt in your diet. If you have postural (orthostatic) hypotension, you may be advised to increase your salt intake, either by adding more salt to your food, or by using salt tablets. Your GP will be able to advise you about how much additional salt you require. Also, if you are dehydrated, ensuring that you drink enough fluid (at least eight glasses a day) will help. Other treatments If you have low blood pressure, your GP may recommend wearing support stockings to help stimulate your circulation, or using several pillows to raise your head while sleeping.

Prevention
Preventing low blood pressure

If you have low blood pressure, and it is part of your genetic make up, you are lucky because it means that, to a certain degree you have some natural protection against the factors that cause high blood pressure (hypertension). Older people, particularly those with diabetes, may have a tendency for their blood pressure to fall when standing, and blood pressure lowering drugs may make this worse. However, getting up slowly will help you to avoid sudden falls in your blood pressure. When getting out of bed, you should sit up slowly first, before standing up slowly.

Cardiac Output, Decreased Meg Gulanick, RN, PhD

NANDA: A state in which the blood pumped by an individual's heart is sufficiently reduced that it is inadequate to meet the needs of the body's tissues
Common causes of reduced cardiac output include myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. Geriatric patients are especially at risk, because the aging process causes reduced compliance of the ventricles, which further reduces contractility and cardiac output. Patients may have acute, temporary problems or experience chronic, debilitating effects of decreased cardiac output. Patients may be managed in an acute, ambulatory care, or home care setting. This care plan focuses on the acute management. Related Factors

Increased or decreased ventricular filling (preload) Alteration in afterload Impaired contractility Alteration in heart rate, rhythm, and conduction Decreased oxygenation Cardiac muscle disease

Defining Characteristics

Variations in hemodynamic parameters (blood pressure [BP], heart rate, cardiovascular pressure [CVP], pulmonary artery pressures, venous oxygen saturation [S VO2], cardiac output) Arrhythmias, electrocardiogram (ECG) changes Rales, tachypnea, dyspnea, orthopnea, cough, abnormal arterial blood gases (ABGs), frothy sputum Weight gain, edema, decreased urine output Anxiety, restlessness Syncope, dizziness Weakness, fatigue Abnormal heart sounds Decreased peripheral pulses, cold clammy skin

Confusion, change in mental status Angina Ejection fraction less than 40% Pulsus alternans

Expected Outcome Patient maintains BP within normal limits; warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses.

Ongoing Assessment
Actions/Interventions/Rationale Key: (i) independent (c) collaborative (i) Assess mentation. Restlessness is noted in the early stages; severe anxiety and confusion are seen in later stages. (i) Assess heart rate and blood pressure. Sinus tachycardia and increased arterial blood pressure are seen in the early stages; BP drops as the condition deteriorates. Elderly patients have reduced response to catecholamines, thus their response to reduced cardiac output may be blunted, with less rise in heart rate. Pulsus alternans (alternating strong-then-weak pulse) if often seen in heart failure patients. (i) Assess skin color and temperature. Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation. (i) Assess peripheral pulses. Pulses are weak with reduced cardiac output. (i) Assess fluid balance and weight gain. Compromised regulatory mechanisms may result in fluid and sodium retention. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output. (i) Assess heart sounds, noting gallops, S3, S4. S3 denotes reduced left ventricular ejection and is a classic sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filling.

(i) Assess lung sounds. Determine any occurrence of paroxysmal nocturnal dyspnea (PND) or orthopnea. Crackles reflect accumulation of fluid secondary to impaired left ventricular emptying. They are more evident in the dependent areas of the lung. Orthopnea is difficulty breathing when supine. PND is difficulty breathing that occurs at night. (c) If hemodynamic monitoring is in place:

Monitor central venous, right arterial pressure [RAP], pulmonary arterial pressure (PAP) (systolic, diastolic, and mean), and pulmonary capillary wedge pressure (PCWP). o Hemodynamic parameters provide information aiding in differentiation of decreased cardiac output secondary to fluid overload versus fluid deficit. Monitor SVO2 continuously. o Change in oxygen saturation of mixed venous blood is one of the earliest indicators of reduced cardiac output. Perform cardiac output determination. o Provides objective number to guide therapy.

(i) Monitor continuous ECG as appropriate. (i) Monitor ECG for rate, rhythm, ectopy, and change in PR, QRS, and QT intervals. Tachycardia, bradycardia, and ectopic beats can compromise cardiac output. Elderly patients are especially sensitive to the loss of atrial kick in atrial fibrillation. (i) Assess response to increased activity. Physical activity increases the demands placed on the heart; fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of patient's response serves as a guide for optimal progression of activity. (i) Assess urine output. Determine how often the patient urinates. Oliguria can reflect decreased renal perfusion. Diuresis is expected with diuretic therapy. (i) Assess for chest pain. Indicates an imbalance between oxygen supply and demand. (i) Assess contributing factors so appropriate plan of care can be initiated.

Therapeutic Interventions
Actions/Interventions/Rationale Key:

(i) independent (c) collaborative (c) Administer medication as prescribed, noting response and watching for side effects and toxicity. Clarify with physician parameters for withholding medications. Depending on etiologic factors, common medications include digitalis therapy, diuretics, vasodilator therapy, antidysrhythmics, ace inhibitors, and inotropic agents. (c) Maintain optimal fluid balance. For patients with decreased preload, administer fluid challenge as prescribed, closely monitoring effects. Administration of fluid increases extracellular fluid volume to raise cardiac output. (c) Maintain hemodynamic parameters at prescribed levels. For patients in the acute setting, close monitoring of these parameters guides titration of fluids and medications. (c) For patients with increased preload, restrict fluids and sodium as ordered. To decrease extracellular fluid volume. (c) Maintain adequate ventilation and perfusion, as in the following:

Place patient in semi- to high-Fowler's position o To reduce preload and ventricular filling. Place in supine position o To increase venous return, promote diuresis. Administer humidified O2 as ordered. o The failing heart may not be able to respond to increased O2 demands.

(c) Maintain physical and emotional rest, as in the following:

Restrict activity o To reduce O2 demands. Provide quiet, relaxed environment. o Emotional stress increases cardiac demands. Organize nursing and medical care o To allow rest periods. Monitor progressive activity within limits of cardiac function.

(c) Administer stool softeners as needed. Straining for a bowel movement further impairs cardiac output. (c) Monitor sleep patterns; administer sedative. Rest is important for conserving energy.

(c) If arrhythmia occurs, determine patient response, document, and report if significant or symptomatic. Both tachyarrhythmias and bradyarrhythmias can reduce cardiac output and myocardial tissue perfusion.

Have antiarrhythmic drugs readily available. Treat arrhythmias according to medical orders or protocol and evaluate response.

(c) If invasive adjunct therapies are indicated (e.g., intra-aortic balloon pump, pacemaker), maintain within prescribed protocol.

Education/Continuity of Care
Actions/Interventions Key: (i) independent (c) collaborative (i) Explain symptoms and interventions for decreased cardiac output related to etiologic factors. (i) Explain drug regimen, purpose, dose, and side effects. (i) Explain progressive activity schedule and signs of overexertion. (i) Explain diet restrictions (fluid, sodium).

rendelenburg Position for the Hypotensive Patient

May 14, 2010 by Kane Guthrie 6 Comments A 28 year-old female has hypovolaemic shock from a ruptured ectopic pregnancy. Her blood pressure is 68/35, pulse 124, and GCS 13/15. She has received 2 litres of Normal Saline with minimal response. The senior registrar in the emergency department requests the patient be given 0.5mg IV metaraminol, and asks you to tilt the bed into the Trendelenburg position as a temporising measure untill blood products arrives and the patient is taken to the operating theatre. As the patient is then rushed off to theatre, you wonder what does the Trendelenburg position actually do, and what is the evidence for it.

"Trendelenburg Position" (Source: nurseweb.ucsf.edu) History of the Trendelenburg position The Trendelenburg position involves placing the patient head down and elevating the feet. It is named after German surgeon Friedrich Trendelenburg, who created the position to improve surgical exposure of the pelvic organs during surgery. In World War 1 , Walter Cannon, the famous American physiologist, popularized the use of Trendelenburg position as a treatment for shock. It was promoted as a way to increase venous return to the heart, increase cardiac output and improve organ perfusion. A decade later, Cannon reversed his opinion on the benefits of the Trendelenburg position but that did not deter its widespread use. Today, the Trendelenburg position remains a time honoured tradition in the early management of the hypotensive patient. As we shall see, this is despite a flimsy evidence base.

Friedrich Trendelenburg 1844-1924 What the Literature tells us about the Trendelenburg position Shammas & Clark (2007) summarised the state-of-play regarding the use of the Trendelenburg position to treat acute hypotension as follows:

Trendelenburg position is widely used by nurses and other healthcare providers as a first-line intervention in the treatment of acute hypotension and/or shock. A review of the results of 5 research studies did not provide overwhelming support for its use as a treatment of hypotension. When Trendelenburg positioning improved cardiac parameters, it was brief and was followed by haemodynamics deterioration that led to negative consequences. Adverse consequences were found in certain patient populations who were obese, had compromised right ventricular ejection fraction, a pulmonary disorder, or a head injury. The Trendelenburg position should be avoided as a treatment of acute hypotension/shock until definitive research with larger sample sizes is conducted that support its use as safe and effective.

Ostrows 1997 study of critical care nurses beliefs about the Trendelenburg position showed 99% of respondents had used the position, 28% believed it was always beneficial and 61% believed it was somewhat beneficial although they also recognised the complications from it. Studies that have demonstrated an increase blood pressure and cardiac output are limited. When observed, the increase is generally short lived, lasting less than 10 minutes. Summary: Current data to support the use of the Trendelenburg position during shock are limited and do not reveal any beneficial or sustained changes in systolic blood pressure or cardiac output.

Complications of the Trendelenburg position in the hypotensive patient

Anxiety and restlessness Progressive dyspnea Hypoventilation and atelectasis caused by reduced respiratory expansion Altered ventilation/perfusion ratios from gravitation of blood to the poorly ventilated lung apices Increasing venous congestion within and outside the cranium leading to increased intracranial pressure Pressure from abdominal organs is transmitted into the thoracic cavity, which can impair venous return to the heart, leading to a further decreased cardiac output and hypotension Increase risk of aspirating gastric contents

When the Trendelenberg position should, and should not, be used The Trendelenburg position is clinically useful for:

Insertion or removal of central venous catheters Certain spinal anaesthetic techniques

The Trendelenburg position is probably not indicated or may have harmful effects in:

Resuscitation of patients who are hypotensive Patients in whom mechanical ventilation is difficult, or patients with decreased vital capacity Patients who have increased intracranial pressure Patients who have cerebral oedema Patients who have increased intraocular pressure Patients with ischaemia of the lower limbs

What does the future hold for the Trendelenburg position? Until further large randomised control studies show a benefit from the use of the Trendelenburg position, it should not be a part of routine practice. When confronted with a hypotensive patient your time and attention may be better spent thinknig about evidence limited, time honoured practices and dilemmas like whether to resuscitate the patient with crystalloid or colloid, or whether dopamine or noradrenaline should be used as a vasopressor It is the mark of an educated mind to be able to entertain a thought without accepting it. Aristotle