Orthostatic Blood Pressures: November 2025 Competency

Orthostatic (postural) vital signs help identify hemodynamic instability related to volume depletion, medication effects, autonomic dysfunction, or acute illness. Accurate technique protects patient safety (falls/syncope prevention) and informs timely clinical decisions.

Preparation & Patient Safety

• Explain the process; assess for dizziness, weakness, recent falls, or high fall risk.
• Use the correct cuff size: bladder length ≈ 80% of arm circumference and width ≈ 40%; place on bare upper arm at heart level.
• Use the same arm for all readings; ensure patient is hydrated/warm and the room is safe for standing.
• If the patient develops marked dizziness, pallor, diaphoresis, or presyncope at any stage, stop, assist to sit/lie, and follow the concern/escalation steps below.

Standard Procedure & Required Wait Times

• Supine (lying): Have the patient lie flat, resting quietly for at least 5 minutes. Record BP and heart rate.
• Sitting: Assist to sit with feet on the floor. Wait 1–3 minutes (2 minutes preferred for consistency). Record BP and heart rate.
• Standing: If not positive in sitting (see criteria below) and the patient is stable, assist to stand. Wait 1–3 minutes (measure as close to 3 minutes as tolerated). Record BP and heart rate.

When to Stop Early

If orthostatic hypotension criteria are met between lying → sitting or the patient becomes symptomatic, you do not have to continue to standing. Prioritize safety, document findings, and escalate per protocol.

What Counts as a Positive Orthostatic Test?

• Systolic BP drop ≥ 20 mmHg or Diastolic BP drop ≥ 10 mmHg within 3 minutes of a position change (usually lying → standing; lying → sitting also applies if symptomatic/unstable).
• Supportive findings: Heart rate increase ≥ 20–30 bpm with symptoms (dizziness, lightheadedness, presyncope), depending on agency guidance.

Why We Test Orthostatics

• Evaluate dizziness, syncope, falls, generalized weakness, or new confusion.
• Assess suspected dehydration/volume loss (poor intake, diuretics, GI loss, bleeding).
• Monitor effects of medications (antihypertensives, diuretics, opioids, psychoactives).
• Screen for autonomic dysfunction (e.g., diabetes, Parkinson’s, neuropathy) or acute illness.

Documentation Expectations

• Position, time intervals, BP and HR for each position (supine, sitting, standing).
• Cuff size used, arm/location, patient tolerance/symptoms (dizziness, nausea, diaphoresis).
• Interpretation (positive/negative) and actions taken (fluids, safety measures, provider notification).

If Positive or Symptomatic: Clinical Concerns & Next Steps

• Institute fall precautions; assist the patient to sit/lie; reassess.
• Evaluate likely causes: dehydration, bleeding, infection, medication effects, autonomic dysfunction.
• Notify the ordering provider per protocol; report readings, symptoms, and suspected contributors.
• Review medication timing/doses (e.g., recent changes to antihypertensives/diuretics); encourage oral fluids if appropriate and not contraindicated.
• Consider same-day escalation if severe, persistent, or associated with syncope, chest pain, dyspnea, melena/hematemesis, or acute neuro changes.

Supplies at the Station

• Validated automated BP device or calibrated manual sphygmomanometer and stethoscope.
• Multiple cuff sizes (small adult through large adult/thigh) to ensure correct fit.
• Chair with arm support; reclinable surface or exam table for supine reading.
• Disinfectant wipes for equipment; hand hygiene supplies.

Validation process: Demonstrate correct positioning, wait times, measurement technique with the right cuff size, safety monitoring, interpretation, and documentation. If the first attempt is not satisfactory, you’ll review guidance and return for a second attempt during your session (as time allows). If still not satisfactory, 1:1 remediation will be scheduled per standard process.