Dizzy on Standing After the Morning Diuretic
Mrs. Alvarez is 78 and takes a diuretic every morning for heart failure. At 0615 she calls you to help her to the bathroom, and she walks there without difficulty. On the way back she says the room is spinning and grips your arm. You seat her on the edge of the bed. Her blood pressure lying down is 118/70 with a pulse of 78. After three minutes sitting upright it is 96/58 with a pulse of 104, and she is pale and damp around her forehead. She asks you not to 'make a fuss' and says she only needs a minute. The medication aide is due to pass morning pills at 0700.
1. What do you do in the first five minutes, and in what order?
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Order of actions
- Stay with her and do not let her stand or walk, even the two steps to the bed.
- Lower the bed, put the call light in her hand, and get the nurse - use the call light or call a coworker in the hall. Do not leave the room to find the nurse yourself.
- Help her lie back with her head flat, loosen anything tight at her waist or neck, and keep her warm.
- Recheck blood pressure and pulse in a few minutes and note the time.
- Stay until the nurse arrives.
Reasoning: a falling systolic pressure with a rising pulse, plus dizziness and pallor, means she is close to fainting. The realistic next event is a fall. A CNA does not diagnose the cause, but keeping her horizontal and safe while getting the nurse is squarely within scope. Leaving her seated upright on the bed edge, or walking her back to the bathroom because she asked, are the wrong choices.
2. Which of these numbers do you report, and how do you present them so the nurse can act?
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Report every number with its position, time and symptom, not just the abnormal one: 'Lying 118/70, pulse 78. Sitting three minutes: 96/58, pulse 104. She was dizzy and pale and is now lying down.'
Reasoning: the meaning is in the comparison. A 22 mmHg systolic drop, a 12 mmHg diastolic drop and a pulse rise of 26 beats per minute, in a resident who is symptomatic, is a pattern that suggests orthostatic hypotension - plausibly worsened by the morning diuretic and possible volume loss. A single reading of 96/58 would say much less. Mention the diuretic, the time, and any recent fluid intake or output you know of; the nurse uses that to decide about holding the dose, fluids, or calling the provider.
3. She says, 'Don't tell the nurse, I don't want a fuss.' How do you respond, and what goes in the record?
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Acknowledge the feeling without agreeing to secrecy: 'I understand you don't want a fuss. I can't keep this between us because it isn't safe - if you faint you could break something. I'm going to tell the nurse, and I'll stay with you.'
Reasoning: a CNA cannot promise to withhold information that affects safety. Agreeing, then reporting anyway, damages trust; refusing to report risks a fall. Refusing to report and honoring the request are both wrong.
Documentation: objective facts only - times, positions, readings, what she said, what you did, who you notified. Not 'resident was noncompliant' or 'probably dehydrated.'
4. When the nurse is tied up for ten minutes, she asks you to bring her water and her pills. What do you do?
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Do not give the pills. The nurse is assessing whether the blood pressure medication should be held, and giving a diuretic or an antihypertensive to a symptomatic, hypotensive resident could make her worse.
Water is different, but do not hand it over unasked either - ask the nurse whether fluids are appropriate and whether she has a restriction, then give what is cleared and record the amount.
Reasoning: this task separates 'helpful' from 'in scope.' Passing a scheduled medication is never a CNA task, and 'the aide already gave it' removes the nurse's chance to make a clinical decision based on the readings.