Hypotension is low blood pressure. Normal blood pressure (BP) for most adults is 120/80 mmHg. Blood pressure of less than 90/60 mmHg is considered hypotensive. Anything above 120/80 mmHg is considered elevated, and stage 1 hypertension is diagnosed at 130/80 mmHg.
Hypotension is categorized according to the following:
- Systolic blood pressure < 90 mmHg
- Mean arterial pressure < 65 mmHg
- Diastolic blood pressure < 60 mmHg
Poor cardiac output due to untreated hypotension can have serious adverse effects. Hypotensive shock is a complication that can result in multi-organ failure and death. Early detection and treatment are important to prevent complications.
In this article:
- Symtoms and Causes
- Nursing Process
- Nursing Care Plans
- Impaired Gas Exchange
- Ineffective Tissue Perfusion
- Risk for Shock
- Risk for Unstable Blood Pressure
Symtoms and Causes
Hypotension is often asymptomatic and does not always require intervention. It only becomes a concern if the pressure is not able to supply oxygen-rich blood to the body’s vital organs. When symptoms appear, the patient may experience lightheadedness, fainting, and weakness.
Resistance in the blood vessels and cardiac output affects BP. Hypotension can be caused by the following underlying conditions:
- Blood loss (most common cause)
- Hypoventilation
- Changes in posture
- Electrolyte imbalances
Nursing Process
Asymptomatic hypotension likely does not require investigation or management. If hypotension is occurring as a symptom of a larger issue and continues to worsen, identifying the cause and preventing complications is necessary.
The nurse’s role is to closely monitor blood pressure changes and other vital signs, administer medications and fluids to improve blood pressure, and educate patients on preventing hypotension.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for hypotension, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for hypotension.
Decreased Cardiac Output
Decreased cardiac output associated with hypotension can occur when the body does not receive enough blood from the heart for adequate perfusion.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Reduced cardiac output
- Decreased peripheral vascular resistance
- Diminished blood volume
- Lessened blood viscosity
- Decreased vessel wall flexibility
As evidenced by:
- Decreased blood pressure; less than normal limits
- Bradycardia
- Decreased blood volume
- Blurred vision
- Dizziness or lightheadedness
- Fainting
- Fatigue
- Trouble concentrating
- Low urine output
Expected outcomes:
- Patient will maintain blood pressure within normal limits.
- Patient will verbalize the relationship between cardiac output and blood pressure.
- Patient will participate in preventive activities that decrease the workload of the heart and hypotension.
Assessment:
1. Determine the patient’s risk and causative factors.
Hypotension is a symptom of an underlying condition. There is a higher risk in individuals with a history of heart and renal problems.
2. Assess for indications of poor cardiac function and impending heart failure.
The following symptoms may signal poor cardiac function, decreased blood pressure, and impending heart failure:
- Excessive fatigue
- Activity intolerance
- Sudden or increasing weight gain
- Edema of the extremities
- Dyspnea
3. Monitor the patient’s vital signs and hemodynamic parameters.
Hemodynamic monitoring through vital sign assessments, ECGs, central venous pressure, etc., ensure that perfusion is sufficient throughout the body. Monitoring is used to compare, track trends, and gauge the effectiveness of interventions.
4. Review lab values and cardiac diagnostic results.
Review complete blood counts, electrolytes, BUN and creatinine levels, echocardiograms, stress tests, and more to help identify patients who are at risk for cardiac complications and hypotension.
Interventions:
1. Position the patient comfortably.
A semi-Fowler’s position is recommended to aid cardiac compensation and reduce oxygen consumption.
2. Administer oxygen as ordered.
Oxygen administration increases the oxygen available for heart function and tissue perfusion.
3. Administer medications as ordered.
Inotropic medications increase cardiac contractions to help systemic and cardiac circulation.
4. Monitor intake and output.
If blood pressure is low, there may not be enough blood to support kidney function. Low urine output can signal issues with perfusion.
5. Administer IV fluids and/or blood.
Low circulating blood volumes are a major contributor to hypotension. Ensure adequate volume by administering IV fluids and replacing blood or plasma.
Impaired Gas Exchange
Impaired gas exchange associated with hypotension can be caused by inadequate blood supply to the heart and lungs.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Low hemoglobin
- Incomplete filling of the heart during heart contraction
- Hypovolemia
- Hypoventilation
- Blood loss
- Inadequate blood flow
- Ventilation-perfusion imbalance
As evidenced by:
- Difficulty of breathing
- Fatigue
- Use of accessory muscles
- Nasal flaring
- Headache
- Alteration in the level of consciousness
- Pale skin color
- Cyanosis
- Tachycardia
- Palpitations
- Visual disturbances
- Anxiety
- Hypoxemia
Expected outcomes:
- Patient will demonstrate ABGs within normal limits.
- Patient will maintain oxygen saturation and breathing pattern within normal limits.
- Patient will verbalize no complaints of difficulty breathing, nasal flaring, or restlessness.
Assessment:
1. Determine respiratory status.
Severe hypotension can lower the body’s oxygen levels, compromising the gas exchange and production of oxygenated blood to the brain and heart. The patient may present with symptoms of obvious respiratory distress, altered ABGs, restlessness, and irritability.
2. Note any change in the level of consciousness.
Change in mentation is among the early symptoms of inadequate gas exchange. Late signs of impaired gas exchange include lethargy and somnolence.
3. Record the changes in vital signs.
Assess for changes in oxygen saturation, heart rate, blood pressure, respiratory rate, and cardiac rhythm. Hypoxemia can lead to alterations in blood pressure, heart rate, and arrhythmias.
4. Review hemoglobin results.
Inadequate alveolar gas exchange occurs due to a lack of blood supply and insufficient blood pressure, which is evident through a decreased hemoglobin level.
Interventions:
1. Perform continuous telemetry and spo2 monitoring.
The body is at risk of not obtaining enough oxygen to perform its function if the blood pressure falls dangerously low. Reduced oxygen levels can affect the gas exchange in the heart and lungs.
2. Prevent hypotensive shock.
A significant drop in blood pressure (shock) can be fatal, including those brought on by uncontrolled bleeding, severe infections, or allergic responses. Prevent this by ensuring adequate volume expansion through IV fluids, blood products, and medications.
3. Promote coughing and breathing techniques.
Show the patient how to breathe and cough therapeutically. Coughing and deep breathing increase air exchange and oxygenation. Deep diaphragmatic breathing aids blood flow into the heart and the lungs for gas exchange.
4. Check ABGs within an hour after starting oxygen therapy.
ABGs should be checked 30-60 minutes after starting oxygen to ensure oxygenation without CO2 retention.
Ineffective Tissue Perfusion
Ineffective tissue perfusion associated with hypotension can be caused by the inadequate blood supply and compromised blood flow to the tissues from decreased blood pressure.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Inadequate blood pressure
- Poorly oxygenated blood
- Decreased hemoglobin
- Incomplete filling of the heart during heart contraction
- Poor blood supply
- Inadequate blood flow
As evidenced by:
- Decreased blood pressure (hypotension)
- Weak peripheral pulses
- Increased central venous pressure (CVP)
- Tachycardia
- Dysrhythmias
- Decreased oxygen saturation
- Chest pain (angina)
- Rapid breathing (tachypnea)
- Alteration in the level of consciousness
- Restlessness
- Fatigue
- Intolerance in activities
- Cold and clammy skin
- Prolonged capillary refill time
- Pale or cyanotic color of the membranes
- Nausea
- Complaints of claudication
- Numbness
- Oliguria
Expected outcomes:
- Patient will maintain peripheral pulses and capillary refill time within acceptable limits.
- Patient will present an alert, conscious, and coherent level of consciousness.
- Patient will verbalize no complaints of dizziness or fainting.
Assessment:
1. Assess the cardiovascular status.
Failure to produce enough cardiac output while maintaining complete peripheral resistance is known as cardiogenic shock. Besides hypotension, it can present as a weak pulse, tachypnea, tachycardia, and loss of consciousness.
2. Assess the patient’s skin color and capillary refill.
Central cyanosis occurs from seriously impaired pulmonary function. Peripheral cyanosis indicates vasoconstriction or obstructed blood flow.
3. Monitor intake and output.
A lack of blood pressure and blood flow can affect kidney function resulting in reduced urine output. Closely monitor and document intake and output.
Interventions:
1. Improve blood flow.
Fludrocortisone and midodrine improve blood pressure and tissue perfusion. Fludrocortisone increases blood volume to increase tissue perfusion, while midodrine raises the blood pressure with chronic orthostatic hypotension.
2. Encourage the patient to wear anti-embolic stockings.
Antiembolic or compression stockings lower varicose vein discomfort and edema to improve blood flow of the lower extremities.
3. Promote salt intake.
Promote salt (sodium) in the patient’s diet, which can significantly increase blood pressure and tissue perfusion. Sodium intake can be beneficial for those with low blood pressure.
4. Assist the patient in position changes.
Encourage the patient to gently rise to a standing position from a supine or sitting position. When getting out of bed, advise the patient to dangle on the side of the bed before standing to prevent orthostatic hypotension.
5. Prepare the patient for a tilt table test.
A tilt table test can gauge how the body responds to positional changes. Throughout the exam, blood pressure and heart rate are tracked.
Risk for Shock
Risk for shock associated with hypotension can be caused by not having enough blood volume to perfuse the brain and other organs.
Nursing Diagnosis: Risk for Shock
Related to:
- Decreased blood pressure; less than normal limits
- Decreased blood volume (hypovolemia)
- Decreased oxygen level in the blood (hypoxemia)
- Decreased oxygen level in the tissue (hypoxia)
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.
Expected outcomes:
- Patient will be able to demonstrate hemodynamic balance as evidenced by vital signs within normal limits.
Assessment:
1. Assess the patient’s risk factors.
Risk factors that can lead to hypotension and shock include the following:
- Trauma
- Surgery
- Poor coagulation
- Anticoagulant medication
- Organ bleeding
- Persistent vomiting
- Diarrhea
- Diabetes insipidus
- Improper use of diuretics
- Sepsis
- Burns
2. Monitor the patient’s blood pressure.
Severe hypotension is considered a hallmark sign of shock. Note the presence of the following:
- Low blood pressure (hypotension)
- Narrowing range between systolic and diastolic BP (narrow pulse pressure)
3. Review laboratory and diagnostic studies results.
Assess for the presence of bleeding through coagulation results and diagnostic scans to determine the cause of shock.
Interventions:
1. Collaborate with the healthcare team.
Collaborate with the healthcare team for immediate management of bleeding causing hypotension and shock. Managing shock is an emergency that requires a team to administer fluids, blood products, medications, and oxygenation.
2. Administer vasopressors.
Vasopressors such as epinephrine or vasopressin constrict blood vessels to raise blood pressure.
3. Note for bleeding signs and symptoms.
Recognize the following signs and symptoms of bleeding that can lead to hypotension and shock:
- Pain that is not relieved by pain medications
- Unresolved bleeding
- Excessive fluid loss
- Persistent fever and chills
- Skin pallor
- Faintness, dizziness, or confusion
4. Place in Trendelenburg position.
Positioning the patient with their head lower than their feet can raise blood pressure and aid in perfusion to the brain and vital organs.
Risk for Unstable Blood Pressure
Risk for unstable blood pressure can be caused by autonomic response changes which are responsible for controlling internal functions such as heart rate, body temperature, and blood pressure. If blood pressure is too low, it can result in life-threatening shock.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Medication side effects
- Orthostatic hypotension
- Pregnancy
- Parkinson’s disease
- Autoimmune disorders
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain blood pressure within normal limits.
- Patient will not experience hypotensive side effects from medications.
- Patient will verbalize strategies to ensure safety related to orthostatic hypotension.
Assessment:
1. Review the patient’s current medication regimen.
Tricyclic antidepressants, vasodilators, antihypertensives, and diuretics can directly affect blood pressure.
2. Note changes and trends in the patient’s blood pressure readings.
The nurse must accurately assess blood pressure. Incorrect readings can result in delayed treatment or worsening hypotension if being overtreated with antihypertensives.
3. Note the patient’s signs and symptoms of hypotension.
Take note of signs and symptoms such as dizziness or syncope. Early recognition of symptoms can prevent possible complications.
4. Assess the patient’s and caregiver’s knowledge of hypotension.
Low blood pressure may be a sign of an underlying health problem. Inquire about the patient’s and/or caregiver’s understanding of how to prevent or manage hypotension.
Interventions:
1. Manage the underlying condition.
Patients who are pregnant, have autoimmune diseases, or Parkinson’s disease are at risk for hypotension. Ensure the proper management of other comorbidities.
2. Encourage the patient to position from supine to standing slowly.
Instruct the patient to change from a supine/ sitting to a standing position slowly. Orthostatic hypotension occurs when blood pressure drops when standing, decreasing blood supply to the brain. This can increase the risk of falling or fainting and can be avoided by changing positions slowly.
3. Ask the patient to demonstrate the proper checking of blood pressure.
Ensure the patient’s equipment is calibrated correctly. Have them demonstrate to ensure accuracy. Advise the patient to keep a journal throughout the day and note any symptoms, patterns, and causative factors.
4. Have the patient teach back the causes of hypotension and how it can be prevented and treated.
The following behavior and lifestyle modifications should be taught to the patient to improve blood pressure:
- Eating habits
- Exercise
- Smoking cessation
- Stress management
- Substance abuse programs
5. Ensure adequate hydration.
Dehydration often causes hypotension. Encourage the patient (if not contraindicated) to drink plenty of fluids, especially in the event of vomiting or diarrhea.
References
- Dewit, S. C., Stromberg, H., & Dallred, C. (2017). Care of Patients With Diabetes and Hypoglycemia. In Medical-surgical nursing: Concepts & practice (3rd ed., pp. 1823). Elsevier Health Sciences.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing (13th ed., p. 971). Wolters Kluwer India Pvt.
- Mayo Clinic. (2022, May 14). Low blood pressure (hypotension) – Symptoms and causes. Retrieved February 2023, from https://www.mayoclinic.org/diseases-conditions/low-blood-pressure/symptoms-causes/syc-20355465
- National Center for Biotechnology Information. (2022, February 16). Hypotension – StatPearls – NCBI bookshelf. Retrieved February 2023, from https://www.ncbi.nlm.nih.gov/books/NBK499961/
- Sharma, S., Hashmi, M. F., & Bhattacharya, P. T. (2022, February 16). Hypotension – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK499961/
- UK National Health Service. (2017, October 23). Low blood pressure (hypotension). nhs.uk. Retrieved February 2023, from https://www.nhs.uk/conditions/low-blood-pressure-hypotension/
- WebMD. (2002, November 1). The basics of low blood pressure. Retrieved February 2023, from https://www.webmd.com/heart/understanding-low-blood-pressure-basics
