A nurse is obtaining a client’s manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?
A.
Apply the largest cuff available.
B.
Use the palpatory method to determine blood pressure.
C.
Place the arm above the level of the client’s heart.
D.
Deflate the cuff quickly.
The Correct answer and Explanation is:
Correct Answer: B. Use the palpatory method to determine blood pressure.
When a nurse is having difficulty auscultating (hearing) the sounds during manual blood pressure measurement, using the palpatory method can be an effective alternative. The palpatory method involves palpating the brachial or radial artery while inflating the cuff until the pulse is no longer felt, then slowly deflating the cuff until the pulse reappears. The pressure at which the pulse reappears is considered the systolic blood pressure. This method does not provide diastolic pressure but can be useful in situations where auscultation is challenging.
Explanation:
Manual blood pressure measurement is a fundamental nursing skill, requiring the use of a sphygmomanometer and a stethoscope to listen to Korotkoff sounds, which indicate the systolic and diastolic pressures. However, certain factors can make it difficult to auscultate these sounds. Common issues include improper cuff size, noisy environments, incorrect stethoscope placement, or patient-related factors such as low blood pressure or weak pulse.
Option B is the correct action because the palpatory method is a reliable alternative when auscultation is difficult. This technique is particularly useful in cases of weak Korotkoff sounds or in noisy environments. Although it does not provide a diastolic reading, it still gives valuable information about the systolic pressure.
Option A (applying the largest cuff available) is incorrect because using an improperly sized cuff can lead to inaccurate readings. The cuff should be appropriate for the patient’s arm size; a cuff that is too large can underestimate the blood pressure, while one that is too small can overestimate it.
Option C (placing the arm above the level of the heart) is also incorrect. The correct positioning for accurate blood pressure measurement is to have the client’s arm at heart level. Elevating the arm above heart level can result in falsely low readings.
Option D (deflating the cuff quickly) is not advisable. Deflating the cuff too quickly can cause the nurse to miss the Korotkoff sounds, leading to an inaccurate measurement. The cuff should be deflated slowly and steadily, at a rate of about 2-3 mmHg per second, to accurately capture the systolic and diastolic pressures.
In conclusion, when encountering difficulty in auscultating blood pressure, the palpatory method (Option B) is a practical and effective alternative. It helps ensure that the nurse obtains at least the systolic blood pressure reading, which is critical for assessing the client’s cardiovascular status.