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Orthostatic Hypotension 2 The Physiology of Blood Pressure Regulation
Orthostatic Hypotension 2 The Physiology of Blood Pressure Regulation
Regulation of the blood pressure is a vital physiological process enabling the body
to respond to immediately changing demands such as ‘fight or flight’, or resting
I
ever, as blood flows into the arterial system does not adjust
n healthy people, each heartbeat forms it meets resistance (in the form of friction) quickly enough
a pressure wave that travels down the from contact with blood vessel walls. The after a sudden
arterial system. The peak of the wave main resistance to blood flow occurs in the change in posture
occurs during systole when blood is arterioles, which are smaller vessels
under pressure from cardiac formed from the branching of arteries;
contraction making the arterial they are referred to as resistance vessels
wall expand. During diastole – when the (Tortora and Derrickson, 2014). Resistance
heart is briefly relaxing – the arterial walls from all blood vessels in the systemic cir-
recoil, delivering a pulse (Lowry and cuit combines to produce the SVR, which
Ashelford, 2015). increases BP in the systemic arterial
Systemic circulation (Fig 1) provides system. These two factors together – CO
oxygenated blood to all organs in the body. and the SVR – generate actual BP in the sys-
It is essential that this blood supply is temic arterial system.
maintained at all times. After perfusing
the organs, blood is returned to the right Role of autonomic nervous system
atrium of the heart through the systemic CO and SVR are adjusted on a moment-by-
venous system. moment basis to ensure BP meets the
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Dilated Vasoconstriction
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minute
● Diastole – period in the cardiac cycle Increased stroke Increased pulse
volume pressure
when the heart refills with blood
● Orthostatic (postural) hypotension
– sudden drop in blood pressure that Characterised by a sudden drop in BP and/ exhalation with a closed mouth, nose or
occurs after posture change, such as or pulse (ventricular pauses of >3 seconds glottis occurs, which increases pressure in
from lying down to standing and/or fall in systolic BP of >50mmHg), the chest cavity. This increase in thoracic
● Vasovagal syncope – fainting caused typical triggers include shaving, turning pressure decreases venous return, which
by a sudden drop in heart rate and BP the head, extending the neck and wearing can decrease the heart rate and therefore
● Stroke volume – volume of blood tight collars. BP, leading to collapse.
ejected by the left ventricle with each Analysis of a random sample of 200 falls
contraction Postprandial hypotension reported to the National Reporting and
● Sympathetic and parasympathetic Postprandial hypotension (PH) or low BP Learning System showed that 15% occurred
nervous systems – the two branches after a meal is commonly defined as a while the patient was using the toilet or
of the autonomic nervous system decrease in systolic BP of 20mmHg or more, commode (National Patient Safety Agency,
● Syncope – loss of consciousness and observed within two hours after meal 2007). Although it is reasonable to assume
caused by a fall in blood pressure ingestion. This can occur because eating that most of these falls occurred while the
● Systemic circulation – circulation diverts blood to the stomach and intestines patient was trying to attend to personal
from the left ventricle of the heart to help with digestion, which, in turn, hygiene, nurses need to be mindful of the
into the aorta and systemic arteries reduces venous return (as well as stroke potential for vasovagal episodes in these
● Systemic vascular resistance – total volume and CO) and lowers BP. A compro- circumstances.
resistance opposing blood flow mised baroreceptor reflex may not be quick
within the systemic circulation enough to counter this drop in BP, so Conclusion
● Systole – period in the cardiac patients must be advised to take care when BP is a vital bodily function and nurses
cycle when blood is pumped out getting up after a large meal, especially if need to understand its anatomy and physi-
of the heart they have been immobile for long periods. ology to assess the risks of blood pressure
● Valsalva reflex – sudden rise and Along with orthostatic hypotension, PH becoming too high or too low and to then
drop in blood pressure occurring can often occur in healthy people – usually take the necessary precautions to reduce
when a person strains, for example there are very modest drops in BP and no risk of harm to the patient. NT
when opening one’s bowels symptoms. In older adults, especially those
● Venous return – veins return blood with reduced autonomic and baroreceptor References
Jansen RW et al (1995) Postprandial hypotension
from the systemic circulation to the responses, this may cause falls, syncope, in elderly patients with unexplained syncope.
right atrium of the heart dizziness and fatigue (Jansen et al, 1995). Archives of Internal Medicine; 155: 9, 945-952.
Patients with confirmed PH should eat Lowry M, Ashelford S (2015) Assessing the pulse
rate in adult patients. Nursing Times; 111: 36-37, 18-20.
small, frequent meals that are light in car- National Patient Safety Agency (2007) Slips, Trips
Reduced blood volume bohydrates. These patients may also need and Falls in Hospital. Bit.ly/SlipsTrips2007
Blood loss (haemorrhage) leads to lowered extra support after meals to ensure they Tortora GJ, Derrickson BH (2014) Principles of
blood volume, which, in turn, reduces mobilise safely. Given the potential preva- Anatomy and Physiology. Hoboken, NJ: Wiley.
venous return and pressure, leading to lence of this condition among hospital
hypotension. Dehydration due to reduced inpatients, nurses should review and take
fluid intake, increased fluid output or into account the timing of routine obser-
Articles in the series
infections and medication such as diu- vation rounds, which typically occur ● Part 1: effect of orthostatic
retics will also reduce blood volume. within two hours of mealtimes. hypotension on falls risk, 9 November
(nursingtimes.net/Hypotension1Nov9)
Carotid sinus hypersensitivity Valsalva reflex
Carotid sinus hypersensitivity is an exag- The Valsalva reflex or manoeuvre is a For more on this topic go online...
gerated response to carotid sinus barore- sudden rise then drop in BP occurring Assessing and managing primary
ceptor stimulation in the neck, resulting when a person strains to open their bowels hypertension
in dizziness, falls and/or syncope from and can, in some cases, lead to vasovagal
B
it.ly/NTHypertension
transient diminished cerebral perfusion. syncope (fainting). While straining,