Monday, January 30, 2012

Informed Consent for Orthostatics: To Be or Not to Be

Orthostatic Blood Pressures, or "Orthostatics" are familiar to many of us.

What are 'Orthostatics'? 
What is the proper way to perform 'Orthostatics'?
First, the patient's Blood Pressure (BP) and Heart Rate (HR) are noted (**NOT just the BP).

Then, the patient is placed in 3 positions, one after the other.

***** SPECIAL NOTE: If the patient feels dizzy at any time, abort the procedure. There is no textbook 'rule' that the patient has to stay standing for 5 minutes before taking the #3 BP/HR data...the patient may be passed out on the floor by then. Remain vigilant to watch for falls and syncope.*****

For now, we want to emphasize that if the patient is dizzy, light-headed, weak, nauseated, or 'feels like fainting', one must consider aborting the procedure to avoid complications. These symptoms are exactly what leads the Cardiologist or other health care provider to consider doing the Tilt Table Test in order to better delineate, in a controlled and safer environment, what happens to the patient upon changes in position.

Complications of 'Orthostatics' include but are not limited to:

General: Light-headedness, dizziness, nausea, vomiting, syncope, seizure, falls.
Neurologic: Altered mental status, confusion, irritability, agitation, seizure.
Cardiac: Tachycardia, decreased cardiac output, palpitations, arrhythmias.
Respiratory: Tachypnea, shortness of breath, aspiration if full stomach and/or vomiting occurs.
GI: Vomiting, loss of bowel or bladder function.

Patients are generally compelled to follow instructions and cooperate with procedures, especially if the patient is presenting with a Complaint and the procedure is ordered in order to allow the Complaint to be further elucidated. But the Patient should be encouraged not to stretch the limits on tolerating this procedure. Specifically, the Nurse, Physician Assistant, or Nurse Practitioner should anticipate the possible scenarios that are possible.

The Health Care Provider should expect that this procedure could cause the Patient to pass out. 

Attention to the environment should consider: the availability of a nearby vomiting receptacle; a need to support a patient who is passing out; a slid-free standing area; fainting protocol procedure already in place; prevention of falls and/or head injury; supportive interventions for recovery.

Finally, one must ask whether or not an Informed Consent should be obtained prior to doing "Orthostatics". The benefit:risk ratio must be considered, and the ancillary Staff should be aware that adverse events can occur. Proper provisions should be made to ensure that if unstable, the patient does not drive her/himself home.

Now you are ready to know the details.



Wait 5 minutes after having the patient placed in the lying position (supine). Then,

#1. Supine.       Do BP and HR.
#2. Sitting.        Do BP and HR.
#3. Standing.    Do BP and HR.

The physician then assesses all three positions and all 6 numbers. More on this later. 

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