Question

a. Identify situations when a blood pressure would not be measured on a client’s arm or leg.

b. State the rationale for the following nursing actions:

1. place client’s arm at heart level, palm up
2. palpate the brachial artery. Position cuff 2.5 cm above the brachial pulse. Center cuff above artery
3. after inflating the cuff to find point at which brachial pulse disappears, wait 30 seconds before re-inflating the cuff
4. inflate cuff to 30 mm Hg above palpated systolic pressure

c. Discuss some common errors in blood pressure readings; for each factor, identify the effect on blood pressure reading and the rationale.

d. When might you, as a nurse, decide to take blood pressure on the client’s thigh? How do blood pressure readings taken on the thigh vary from those taken on the arm?

e. Define the following terms: systolic pressure; diastolic pressure; pulse pressure; Korotkoff’s sounds; antecubital space; hypotension, hypertension, orthostatic hypotension, postural hypotension.

Answer 1

1. The situations when the blood pressure is not measured on arms and legs are very rare conditions.

• When the patient is handicapped and without 4 limbs.
• When the patients is paraplegic after a stroke or head injury.
• When the patient is hemiplegic with an IV line in the unaffected hand and a shunt in unaffected leg
• Lymphaedema on the extremities
• Bilateral mastectomy with lymphedema of extremity

2. Rationales:

1. place client’s arm at heart level, palm up   : The measuring should be done at heart level, otherwise there will be variation in the reading. If the hand is placed below heart level, then increased reading will be shown , and if hand is above heart level, decreased reading will be shown. Keeping the palm up helps to do pulse check of radial and brachial arteries easy.

2. palpate the brachial artery. Position cuff 2.5 cm above the brachial pulse. Center cuff above artery:

Brachial artery is palpated to assure presence of pulse as well as location. Brachial artery is along groove at antecubital fossa. Placing the bladder of the cuff directly over the artery ensures that proper pressure is applied on inflation.

3. after inflating the cuff to find point at which brachial pulse disappears, wait 30 seconds before re-inflating the cuff

Continuous cuff inflation cause arterial occlusion and repeating measurements too soon creates venous congestion, making sounds difficult to hear.

4. inflate cuff to 30 mm Hg above palpated systolic pressure

Inflation above systolic level ensures accurate measurement of systolic BP.

3. Errors of BP monitoring:

Checking the BP soon after the patient enters the clinician’s office: Not allowing the patient to relax may show increased BP readings.

Having no support for the patient back and feet: Dangling the feet when sitting can increase the reading value. Make the patient sit straight or allow to take supine position.

Unsupported arm: if the patient’s arm is not supported, the heart level of arm position can not be maintained and this cause increase or decrease in the measurement. Also don’t clunch the fist.

Wrapping the cuff over the clothing: this can increase the reading and more thicker the cloth, more the value of BP will be.

Using wrong sized cuff: using small sized cuff may increase the reading, so always use correct sized cuffs.

Having a full bladder: if the patient is having full bladder, that can be discomfortable to the patient and show an increased BP reading. Empty the bladder before checking BP.

4. The nurse checks the BP on thighs when the hand measurement as well as ankle measurement of BP is contra indicated. This is a very rare condition.

• The patient with a arterovenous shunt on radial arm of one hand and a venous cannula on the other hand plus a cellulitis on foot can be a hint for checking Bp on the thighs.
• bilateral mastectomy.
• patient with edema of extremity.
• Also when the manual measurement readings on other sites are not measurable, the nurse may go for a thigh BP measurement.

Normally, the systolic blood pressure in the legs is usually 10% to 20% higher than the brachial artery pressure.

e)

systolic pressure:The highest pressure on the walls of arteries as the heart contracts

diastolic pressure: The lowest pressure on the areteries as the heart relaxes.

pulse pressure: the difference between systolic and diastolic readings is the pulse pressure.

Korotkoff’s sounds: are the sounds of blood flow heard while checking the BP with a sphygmomanometer and stethoscope.

antecubital space: or the elbow pit is a triangular depression formed between the humerus and ulna and radius.

hypotension: a systolic BP of less than 90 mm of Hg or diastolic BP of less than 60 mm of Hg is considered as hypotension.

hypertension: hypertension is increased blood pressure than normal and usually SBP will be above 140 mm of Hg and DBP will be more than 90 mm of Hg

orthostatic hypotension: is the condition where Blood pressure falls suddenly as the patient changes position from lying down or sitting to standing up.

postural hypotension: is same as orthostatic hypotension.