The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
A.
Document the absence of the radial pulse.
B.
Release the manometer valve immediately.
C.
Inflate blood pressure cuff to 120 mm Hg.
D.
Record a palpable systolic pressure of 90 mm Hg.
The Correct Answer and Explanation is:
The correct answer is C. Inflate blood pressure cuff to 120 mm Hg.
Explanation
When obtaining a systolic blood pressure by palpation, the primary goal is to determine the point at which the radial pulse is no longer palpable. This point indicates the approximate systolic pressure, but it is important to ensure accurate measurement by considering the full range of the pressure.
1. Understanding Palpation of Systolic Blood Pressure: Palpation of blood pressure is often used when the auscultatory method is not feasible, such as in situations with noisy environments or when the client has irregular heartbeats. In palpation, the nurse inflates the cuff until the radial pulse is no longer palpable. The pressure at which this occurs is noted as an estimate of systolic blood pressure.
2. Reason for Inflating the Cuff Further: After the radial pulse disappears at 90 mm Hg, it indicates that the systolic pressure is higher than 90 mm Hg. To accurately measure the systolic blood pressure, the cuff should be inflated further to ensure that the true systolic pressure is captured. Inflating the cuff to 120 mm Hg allows the nurse to measure the pressure more accurately. If the nurse were to stop at 90 mm Hg, the reading would be inaccurate because it is below the actual systolic pressure.
3. Incorrect Actions:
- A. Documenting the Absence of the Radial Pulse: This does not address the need to accurately measure the systolic blood pressure. Documentation should include the accurate systolic measurement obtained by further inflating the cuff.
- B. Releasing the Manometer Valve Immediately: This would prevent obtaining a correct measurement. Releasing the valve before ensuring the cuff has reached a sufficient pressure may lead to inaccurate readings.
- D. Recording a Palpable Systolic Pressure of 90 mm Hg: Since 90 mm Hg is below the actual systolic pressure, recording this value would not be accurate.
In summary, inflating the cuff to 120 mm Hg ensures that the actual systolic pressure is measured accurately and provides reliable data for assessing the client’s blood pressure.