Dizzy on the Edge of the Bed: Orthostatic Symptoms and a Red Heel
Mrs. Okonkwo, 82, has been in bed for two days with vomiting and diarrhea. She takes furosemide daily and has been drinking very little. At 2 p.m. she wants to walk to the toilet. The aide raises the head of the bed and helps her sit on the edge. Within a few seconds she says, 'The room is spinning,' and her face looks pale. She is wearing a gait belt. Her radial pulse, taken by the aide, is 92 and regular. She insists, 'Just get me up, I'll be fine, I don't want to wet the bed.' The wheelchair and the call light are both across the room, and the aide is alone.
1. What does the aide do in the next two minutes - and what must she not do?
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Do not stand her up, and do not let her pull herself up on the aide. Dizziness with pallor on sitting is a warning that she may faint; a standing transfer could end with both of them on the floor.
- Stay beside her, keep a hand on the gait belt and one on her shoulder, and ask her to stay still.
- Lower her: either ease her back down and raise the foot of the bed, or have her lean forward with her head down between her knees while the aide supports her.
- Do not leave her alone to fetch the wheelchair or the call light - she could slide off the bed. Call out for help, use the wall call light if it is within reach, or use the phone if there is one at the bedside.
- Keep talking to her calmly and watch her colour, breathing and whether she stays responsive.
- Recheck the pulse once she is settled, and ask if she feels sick, has chest pain, or feels like she might pass out.
- If she becomes unresponsive, stops breathing normally, or has chest pain, that is an emergency - call for the nurse and emergency help immediately.
Afterwards, do not try the walk again on your own initiative. Toileting gets planned with the nurse, likely with a bedpan or commode at the bedside.
2. What does the aide report, and what makes this different from ordinary tiredness?
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Report at once to the nurse, not at the end of the shift.
Facts to give:
- Dizziness and spinning on sitting, pale colour, pulse 92 and regular.
- Two days of vomiting and diarrhea with poor fluid intake, on furosemide - a diuretic that pulls fluid off on top of losses from being sick.
- That she has been flat in bed for two days, which is exactly the setup for blood pressure dropping on standing.
- That she is insistent about getting up, so the nurse can decide how she is toileted.
Why this is not just tiredness:
- It came on within seconds of a position change and is new for her.
- It comes with pallor and a symptom (spinning) rather than just 'I'm sleepy.'
- It fits a pattern - dehydration plus a diuretic plus two days of bed rest - that the nurse can check by taking blood pressure lying, sitting and standing and by looking at hydration.
Document what she said, the pulse, the position she was in, what the aide did, and who was told and when. The aide does not decide 'she's dehydrated'; she reports the picture so the nurse can.
3. That afternoon, while helping her turn, the aide sees a palm-sized red area over the sacrum that does not lighten when pressed. What does the aide do, and what does she not do?
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Treat it as an early pressure injury until the nurse says otherwise. Redness that does not blanch is not 'just from lying on it.'
- Do not massage it. Rubbing a non-blanching area damages tissue that is already compromised.
- Do not put lotion, powder or ointment on it on the aide's own initiative.
- Keep her off it: turn and reposition on the schedule (generally at least every two hours), and use a pillow or wedge so she is truly off the spot, not just tilted back onto it.
- Float the heels with a pillow under the calves so they hang free, and check the heels, ankles and ears as well.
- Keep the skin clean and dry after each incontinence episode; wash gently and pat rather than rub.
- Avoid dragging her across the sheets - use a lift sheet, and use a mechanical lift or two-person assist for transfers now, since she is dizzy anyway.
- Report the same shift: exactly where it is, roughly how big, the colour, that it did not blanch, and when it was first seen.
Document the description and the care given. Nurses stage and treat pressure injuries; the aide's value is finding it early and keeping weight off it.