Managing and preventing Orthostatic Hypotension

Introduction

Orthostatic hypotension is a form of low blood pressure that happens when standing up from a sitting or lying position. Many people occasionally feel dizzy or lightheaded after standing and it is usually not a cause for concern. Orthostatic hypotension is often mild, lasting a few seconds to minutes after standing. However, longstanding orthostatic hypotension can be a more serious sign. It occurs when something interrupts the body’s natural process of counteracting blood pressure variations. In elderly individuals, it can cause fall accidents.

Common Causes

• Dehydration/hypovolemia. Standing up too quickly.
• Side effects of certain medications such as antidepressants, muscle relaxants and narcotics.
• Patients on diuretic therapy, antihypertensive medications such as alpha blockers, beta blockers and calcium channel blockers.
• Peripheral neuropathy.
• Old age (over 74 years) due to decreased baroreceptor sensitivity, decreased cerebral blood flow and various drug therapy.
• Medications causing vasodilation.
• Fluid-electrolyte imbalance.
• Parkinson’s disease causing autonomic nervous system failure.
• Diabetes causes impaired lower limb vasoconstriction.
• Staying in bed for longer time following surgical procedures and stressful events such as difficult delivery.

Symptoms of Orthostatic Hypotension

• Feeling dizzy or lightheaded when standing up. In some cases, fainting occurs.
• Blurred vision.
• Nausea.
• Disorientation or confusion.
• Feeling weak.
• Falling.
• Chest pain.

These symptoms usually clear up when the person sits up or lie down for a few minutes.

Pathophysiology

• Pathophysiological changes related to positional drop in blood pressure are associated with dependent pooling of blood in the veins of liver intestines legs, feet, and other organs.
• Venous return and stroke volume decreases as a result of pooled blood that causes compromised cardiac output and drop in arterial blood pressure. Gravity causes pooling of blood in the legs when the person stands up.
• This further leads to a decrease in blood pressure as there is less blood circulating back to the heart for pumping.
• Normally the baroreceptors near the heart and neck arteries sense the lowered blood pressure and send signal to brain.
• The heart beats faster and pumps more blood to stabilize blood pressure based on the signals sent back to heart by centers in brain.
• The baroreceptors also cause the blood vessels to constrict, which increases resistance to blood flow leading to an increase in blood pressure.
• Normal changes that occur when a person stands up and goes from a lying to sitting position include:
  • Increase in heart rate
  • Decrease in systolic blood pressure up to 15 mmHg and decrease in diastolic blood pressure up to 10 mmHg

There is intravascular volume depletion, for example lying down BP may be 120/70 mmHg, heart rate 70 per minute standing BP 98/52 mmHg, heart rate 94/minute.

Preventive Measures

Non-pharmacological

• Avoid sudden postural change.
• Avoid hot environment that can cause dehydration.
• Avoid motionless standing.
• Have an adequate intake of water.
• Adequate intake of salt.
• Take maneuverers to improve blood pressure by increasing venous return such as leg-crossing, squatting, and bending forward.
• Assume standing position slowly rather than quickly.
• Perform dangling of feet by sitting on the side of bed for about a minute so that sudden occurrence of dizziness can be avoided.
• If due to medication, then an adjustment of the dose or change in the type of medicine may be taken with physician’s advice. Compression stocking may prevent blood from pooling in the legs when the person is sitting or lying down and allows for more blood to be available to the brain.
• Using caffeine containing drinks, such as coffee.

Pharmacological Treatment

• For patients getting repeated occurrences of postural hypotension due to medications they take or the disease they suffer following medications may be used.
• Fludrocortisone (Florinef) to increase the volume of blood in the blood vessels. This is an adrenaline-mimicking drug which stimulates the sympathetic nervous system and does not have significant side effects.
• Midodrine (Pro Anatine) works by constricting the blood vessels and increasing blood pressure and thus used to treat low blood pressure(hypotension).
• Droxidopa used to treat postural hypotension associated with Parkinson’s disease.

Complications

Falling is the most important complication of orthostatic hypotension. Most often the symptoms are self-limiting, giving the patient a chance to sit down. Most often it is the trauma sustained in the fall that causes the damage.

Special Considerations

1. Patient education on ways to decrease postural hypotension is a valuable tool to potentially save lives.
2. Teach patients to rise slowly from lying to standing and to dangle feet first while flexing and wiggling feet and toes which allow time for blood to push upward from periphery and legs.
3. Care of patient with postural hypotension includes assessing blood pressure while lying and standing positions regularly.
4. Its recording and reporting to concerned physicians and explaining to patients are important.
5. Evaluation of orthostatic hypotension should be done along with symptom.
6. Review of high-risk medications should be done.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
8. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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