A nurse is reviewing the documentation of a client’s blood pressure by a newly licensed nurse.
The documentation states, “Blood pressure 102/58 mm Hg, client sitting up in a chair.”. Which of the following information should the nurse clarify?
A.
Systolic blood pressure.
B.
Position of the client.
C.
Unit of measurement.
D.
Location of blood pressure cuff.
The Correct Answer and Explanation is:
The correct answer is B. Position of the client.
Explanation:
When reviewing blood pressure documentation, it is crucial to ensure that all pertinent details are accurately recorded. The documentation provided states, “Blood pressure 102/58 mm Hg, client sitting up in a chair.” This entry includes the systolic and diastolic pressures, which are correctly noted with the unit of measurement (mm Hg), and the position of the client (sitting up in a chair). However, the position of the client is an area that may require clarification.
Blood pressure readings can vary based on the client’s position at the time of measurement. Common positions for taking blood pressure include sitting, lying down, or standing. Each of these positions can affect the measurement due to changes in blood volume distribution and gravitational effects. Therefore, documenting the client’s position is essential for interpreting the accuracy and relevance of the blood pressure reading.
The sitting position, while noted in the documentation, should be clarified with more specifics if needed, such as whether the client’s back was supported, their feet were flat on the floor, and if their arm was at heart level. These factors can influence the accuracy of the reading. The recommended practice for measuring blood pressure is to ensure the client is seated with their back supported, feet flat on the floor, and the arm at heart level to obtain a standardized and reliable measurement.
On the other hand, the systolic blood pressure (102 mm Hg) and diastolic blood pressure (58 mm Hg) are documented correctly and clearly, as is the unit of measurement (mm Hg). The location of the blood pressure cuff is also not specified here but is typically less crucial in affecting the measurement compared to the client’s position. Thus, the most critical aspect to clarify in this documentation is the position of the client, ensuring that it aligns with recommended practices for accurate blood pressure measurement.