#bscn

Syncope is a brief loss of consciousness resulting from reduction in cerebral blood flow.  You might also be exposed to the term “presyncope” in your experience, which is a reduction to cerebral blood flow that leads to a sensation of impending loss of consciousness. If a patient experiences syncope or is admitted with syncope, the priority is to determine the cause of the syncopal episode(s).  Questions to Consider: Did the patient actually lose consciousness? Was the episode syncopic or presyncopic? Is the patient still unconscious? This requires immediate nursing assessment and intervention to support the airway. What position was the patient in during the episode? A syncopal episode that occurs while a patient is in a recumbent position (lying down) is almost always due to a cardiac problem. Was syncope the admitting diagnosis? An admitting diagnosis that is not syncope may help determine the cause of a syncopal episode (seizure disorder, TIA, cardiac disease, etc.) Was any seizure-like activity witnessed or experienced. The experience of an aura, biting of the tongue, or incontinence of stool or urine is suggestive of seizure activity. Headache, mental confusion, drowsiness are common sequelae of seizures, these are less common in cardiac causes of syncope. Priority Interventions Following A Syncopal Episode: If unconscious: Rotate the patient to the left side. This prevents the tongue from falling to the back of the throat and obstructing the airway. This also reduces the risk for aspiration if emesis occurs. Ensure an IV is in place. An IV fluid will likely be ordered TKVO in preparation for anticipated medications. STAT 12-lead ECG and rhythm strip. A cardiac dysrhythmia may be easier to document early on, while the patient is still symptomatic.  If conscious: Assess vital signs. Vital signs may be ordered q15 min while the physician is assessing for an underlying cause. Frequent assessment of VS is crucial, especially if the origin of syncope is cardiac or neurological. Assess for evidence of head or neck injury Return the patient to the bed, with slow transitions during positioning. This is done IF the vital signs are stable and there is no evidence of a head or neck injury. Maintain the patient on bedrest while the problem is being assessed. A patient experiencing syncope is at risk for recurrent episodes. This patient is a high fall risk and the priority is to maintain the patient’s safety while determining the underlying cause.

Order an ECG and rhythm strip.  Most patients will regain consciousness within a few minutes after experiencing a syncopal episode.

Some Points to Consider: 1. Syncope occurring while changing position (from supine to sitting or standing), suggests orthostatic hypotension 2. An aura experienced by the patient suggests seizure activity in an unwitnessed episode 3. Palpitations experienced by the patient prior to the episode suggest cardiac dysrhythmia 4. Syncope after turning the head to one side, or if an individual is wearing a tight collar, may represent carotid sinus syncope - typically seen in elderly males 5. Numbness or tingling in hands or feet before the syncopic episode is common in patients experiencing hyperventilation or anxiety 6. Patients with a history of stroke may also have coronary atherosclerosis and be at risk for cardiac dysrhythmias. Atherosclerosis is a diffuse process. Origin of syncope in these patients may be cardiac or neurological. 7. Note any medications that may be contributing to underlying causes of syncope

Does the patient appear comfortable, uncomfortable/distressed, or critical?

A patient suffering from severe colic or hemorrhage is often restless, whereas a patient suffering from peritonitis lies immobile, preventing any movement that could further exacerbate their pain. Peritonitis might also make a patient draw their knees up to reduce pain.

What is the patient’s blood pressure?

Significantly decreased BP with complaints of abdominal pain may indicate impending hypovolemic, hemorrhagic, or septic shock. A decrease in BP with an increase in HR when assessing postural vital signs suggests volume depletion.

Is the pain localized?

During assessment, assess for a location of maximum intensity of pain. This may indicate a site of origin. Even if a patient complains of generalized pain, further assessment may reveal a localized source and make diagnosis more efficient. Assessing for pain in common areas of referred pain may also help this process.

What are the characteristics of the pain?

Pain associated with a peptic ulcer is often described as burning, whereas pain associated with a perforated ulcer is sudden onset and severe. Biliary colic is often described as sharp and constricting, takes one’s breath away. An obstructed bowel will cause pain that is gripping but intermittent. Acute pancreatitis is often describes as deep and agonizing.

Is the development of pain gradual or rapid?

Severe pain of colic (renal, biliary, intestinal) develops gradually, within hours. Pain of acute onset or that is paired with fainting is seen with perforation of viscus, ruptured ectopic pregnancy, gut strangulation, torsion of a cyst or colic. Are there any aggravating factors? Pain that is exacerbated during meals, and/or relieved with a bowel movement, suggests that the origin of pain is hollow gut. Pain that increases with inspiration is associated with pleuritis and peritonitis. Pain that is exacerbated by micturition suggests a urogenital cause. Is there associated nausea or vomiting? Vomiting with the onset of pain: acute peritoneal irritation, perforation of viscus, acute pancreatitis Pain relieved by vomiting: hollow gut origin Vomiting long after onset of pain: intestinal obstruction, paralytic ileus What does associated emesis look like? Brown, feculent: bowel obstruction Frank blood: upper GI bleed

Is there any associated diarrhea?