# Situation: A 46-year-old man is admitted to the medical ward after 3 days of profuse watery diarrhea and poor oral intake. He has no history of heart or kidney disease. He weighs 64.8 kg; he weighed 67.0 kg at a clinic visit 1 week ago. His blood pressure is 104/66 mmHg lying and 82/54 mmHg sitting, his pulse is 116/min, his oral mucosa is dry, and he has no edema. An hour after the infusion starts, he says he needs to go to the bathroom right away. Which action by the nurse is BEST?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 46-year-old man is admitted to the medical ward after 3 days of profuse watery diarrhea and poor oral intake. He has no history of heart or kidney disease. He weighs 64.8 kg; he weighed 67.0 kg at a clinic visit 1 week ago. His blood pressure is 104/66 mmHg lying and 82/54 mmHg sitting, his pulse is 116/min, his oral mucosa is dry, and he has no edema.

An hour after the infusion starts, he says he needs to go to the bathroom right away. Which action by the nurse is BEST?

## 보기

1. Open the roller clamp fully for a few minutes before he stands
2. Tell him to use the bedpan until the diarrhea has fully stopped
3. Have him sit on the edge of the bed briefly, then walk with him **✔ 정답**
4. Let him walk alone, keeping the call light cord within his reach

**정답: 3**

## 해설

His blood pressure falls from 104/66 mmHg lying to 82/54 mmHg sitting (a drop of 22/12 mmHg), which is orthostatic hypotension from volume deficit, so he is at high risk of fainting and falling. Letting him sit first and then walking with him keeps him safe while allowing normal toileting. Fall precautions are part of care for volume deficit.

## 심화 해설

Why the blood pressure changes matter
This patient’s lying blood pressure is 104/66 mmHg, but when he sits it drops to 82/54 mmHg. That is a fall of 22 mmHg systolic and 12 mmHg diastolic, which meets the definition of orthostatic hypotension. After 3 days of profuse watery diarrhea and poor oral intake, he has lost about 2.2 kg of body weight, which in an adult with no edema reflects a meaningful extracellular fluid volume deficit. The dry oral mucosa and resting tachycardia of 116/min support the same conclusion: his circulating blood volume is reduced, so venous return and cardiac output drop sharply when he changes position. The orthostatic fall in blood pressure means his brain is not being perfused adequately in the upright position, which creates a high risk of syncope and falling.

Why sitting first and walking with him is the best action
When a patient with volume deficit needs to get to the bathroom urgently, the nurse must balance two goals: preventing a fall and allowing normal toileting. Key point! Moving slowly from lying to sitting, pausing at the edge of the bed, and then ambulating with assistance gives the sympathetic nervous system time to increase peripheral vasoconstriction and heart rate before full standing. This staged approach reduces the magnitude of the orthostatic blood pressure drop and lets the nurse detect early symptoms such as dizziness, blurred vision, or lightheadedness before the patient is fully upright and walking. The nurse’s physical presence during ambulation provides direct support if the patient becomes unsteady.

Why the other options are less safe
Opening the roller clamp fully would rapidly increase IV fluid delivery, but it does not immediately correct the orthostatic response and does nothing to protect the patient while he stands and walks. Telling him to use the bedpan may reduce the risk of walking, but it does not address the urgency of diarrhea and can create unnecessary embarrassment or delay. Letting him walk alone, even with a call light within reach, leaves him unprotected during the highest-risk period—the transition from supine to standing and the first steps—when syncope is most likely to occur. Watch out! A call light is a communication device, not a fall-prevention device. It cannot catch a patient who faints.

How this connects to nursing care for volume deficit
Fall precautions are an essential part of care for any patient with orthostatic hypotension from volume deficit. The nurse should assess orthostatic vital signs before first ambulation, assist the patient to sit at the bedside with legs dangling, and remain with the patient during the first transfer and ambulation. This approach is consistent with the principle that acute orthostatic hypotension commonly occurs during a patient’s first experiences out of bed after a period of illness or immobility, and that supportive nursing care should help the sympathetic reflexes gain maximal control over peripheral vasoconstriction before the patient leaves bed [1]. In this patient, the diarrhea has caused acute volume loss, so the same protective strategy applies.

| Action | Safety rationale | Limitation |
| --- | --- | --- |
| Open roller clamp fully | May increase IV fluid delivery | Does not protect against orthostatic fall while standing |
| Use bedpan | Avoids walking | Delays normal toileting; does not address urgency safely |
| Sit at edge, then walk with nurse | Allows gradual orthostatic adaptation; nurse can support and observe | Requires nurse time but is the safest option |
| Walk alone with call light | Promotes independence | No direct protection during highest-risk transition |

The best nursing action is to have the patient sit on the edge of the bed briefly and then walk with him, because this staged mobilization directly reduces the risk of syncope from orthostatic hypotension while still allowing him to reach the bathroom.References (research sources)

- [1]Acute orthostatic hypotension.Research articleMemmer MK (1988)

## 임상 시나리오

Safe Toileting in Volume DeficitPreventing orthostatic syncope during ambulation
A drop of 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing defines orthostatic hypotension. This patient's BP falls from 104/66 to 82/54 mmHg, placing him at high risk for syncope and falls.

Use staged position changes: have the patient sit on the edge of the bed for 1 to 2 minutes, assess for dizziness or lightheadedness, then stand with assistance before walking. The pause allows sympathetic compensation to increase peripheral vasoconstriction and heart rate.

Always ambulate with the patient when orthostatic hypotension is present. Keep the call light within reach, ensure clear pathways, and use non-slip footwear as part of fall precautions.

CautionDo not let the patient walk alone or rush to the bathroom. Rapid position change or unassisted ambulation can precipitate syncope and injury. Monitor for early warning signs such as blurred vision, weakness, or nausea before full standing.

## 핵심 개념

- **Orthostatic hypotension** — A drop in systolic BP of at least 20 mmHg or diastolic BP of at least 10 mmHg within 3 minutes of standing, indicating inadequate cardiovascular compensation.
- **Volume deficit** — Decreased extracellular fluid volume due to fluid loss or reduced intake, leading to reduced venous return, cardiac output, and tissue perfusion.
- **Syncope** — Transient loss of consciousness caused by inadequate cerebral perfusion, often triggered by orthostatic stress in hypovolemic patients.
- **Fall precautions** — Safety interventions such as assisted ambulation, staged position changes, and environmental modifications to prevent falls in at-risk patients.

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