A nurse is preparing to palpate a client’s systolic blood pressure using the brachial artery. After applying the blood pressure cuff to the client’s arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)
A.
Palpate the brachial pulse site.
B.
Discontinue palpation of the brachial pulse.
C.
Inflate the blood pressure cuff to 30 mm Hg beyond where the brachial pulse was last felt.
D.
Deflate the blood pressure cuff slowly until the brachial pulse is detected.
The Correct Answer and Explanation is:
To correctly palpate a client’s systolic blood pressure using the brachial artery, the nurse should follow these steps in the specified order:
- Palpate the brachial pulse site.
The nurse begins by palpating the brachial pulse, which is located on the inside of the arm, just above the elbow. This step is essential to locate the pulse and ensure proper positioning of the blood pressure cuff. - Inflate the blood pressure cuff to 30 mm Hg beyond where the brachial pulse was last felt.
After locating the pulse, the nurse should inflate the blood pressure cuff. The cuff should be inflated to a level that is 30 mm Hg above the point where the brachial pulse is no longer palpable. This ensures that the cuff pressure is high enough to temporarily occlude the brachial artery, which is necessary to detect the systolic pressure accurately. - Discontinue palpation of the brachial pulse.
Once the cuff is inflated to the desired level, the nurse should stop palpating the brachial pulse. At this point, the pulse should not be felt due to the pressure from the cuff. - Deflate the blood pressure cuff slowly until the brachial pulse is detected.
Finally, the nurse should slowly deflate the cuff while observing the point at which the brachial pulse becomes palpable again. The pressure reading at the moment the pulse is first detected is the systolic blood pressure.
Explanation:
Palpating a client’s systolic blood pressure without a stethoscope is a skill used when the auscultatory method (using a stethoscope to listen to the Korotkoff sounds) is not possible or practical. This method allows the nurse to estimate the systolic blood pressure by feeling the return of the pulse as the cuff is slowly deflated.
The sequence of steps is crucial to ensure accurate measurement. First, the nurse must palpate the brachial pulse to establish where the pulse is felt. This ensures that the cuff is in the correct position and that the measurement will be accurate. Inflating the cuff to 30 mm Hg beyond the point where the pulse disappears ensures that the artery is completely occluded, which is necessary to measure the systolic pressure. Discontinuing palpation is necessary to allow the nurse to focus on detecting the pulse’s return during cuff deflation. Finally, slowly deflating the cuff allows for the precise detection of the systolic pressure as the pulse returns.
This method, though less precise than the auscultatory method, is useful in certain clinical situations, such as in noisy environments or when a stethoscope is unavailable. It is also an essential skill for nurses to develop an understanding of blood pressure assessment and to ensure the accuracy of readings in various situations.