Low / Decreased Blood Pressure (Hypotension)

Also Consider:  Anemia, Dehydration, High Blood Pressure, Weakness (general) 

1. Take Vital Signs

• Temperature:

• Blood Pressure lying:

• Blood Pressure standing (if safe):

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• Acute mental status change

• Not eating or drinking as much as usual

• Fainting, dizziness or lightheadedness when standing up

• Acute decline in ADL abilities

• Thirst, signs of dehydration

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress

• Cardiovascular:  Chest pain, new irregular pulse, cyanosis, mottling, edema

• GI: Nausea, vomiting, diarrhea,, abdominal distention or tenderness, rebound tenderness, bowel sounds

• GU: New or worsened incontinence, pain with urination, blood in urine, urinary retention / bladder scan

• Neurologic  changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)

• Very low urinary output (<30cc/hr)

• Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, cellulitis, wound infection

• Fingerstick glucose (patients with diabetes)

3. Take Action using SBAR Report:

• Immediately notify the medical staff & resident representative

  • BP systolic less than 100 and more than 20 points below baseline; OR 

  • Accompanied by chest pain, mental status change, fever, falling, dizziness, diaphoresis, tachycardia, hypoxia, tachypnea

• Notify medical staff & resident representative within the next 16 hours. 

  • BP less than 100 systolic and less than 20 points below baseline in a patient on antihypertensive therapy

• Notify medical staff on the next business day 

  •  BP  less than 100 systolic and less than 20 points below baseline

• Notify medical staff at the next regular rounds 

  • Change in blood pressure from baseline

4. Implement Management Plan

• Monitor vital signs every 4-8 hrs for 2-3 days

• Offer fluids frequently

• Oral, IV, or subcutaneous fluids if needed for hydration

• Place on Intake & Output monitoring

• Monitor meal acceptance

• Place on 24-hour report for 2-3 days

• Obtain lab results (if ordered), and notify medical as needed of:

  • Significantly abnormal values in lab tests (refer to appropriate Situation)

  • WBC > 12,000 or neutrophils > 90%

  • Infiltrate or pneumonia on chest x-ray

  • Positive C. Diff

  • Urine results suggest infection and symptoms or signs present (Refer to “UTI” Situation)

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative daily or with any changes

• Update advance directives if appropriate

2025-04-26