Fundamentals of Nursing
Quiz 29 :
In the given case, an older client is refusing to get the blood pressure measured. Blood pressure is usually measured to determine the client's hemodynamic status such as cardiac output and for subsequent evaluation. It should be normally less than 120/80 mmHg (millimeters of mercury). Some of the factors that affect the blood pressure include physical activity, stress, medical conditions and temperature. The importance of having the vital signs measured should be discussed with the client. Testing the blood pressure is important as high blood pressure can cause stroke, heart disease and chronic kidney disease or eye problem without showing any symptoms. Thus, taking the blood pressure measurement and treating it early can prevent the client from life-threatening diseases. Also, people who already have these serious medical conditions should check their blood pressure at least every year. If an older client refuses to measure her blood pressure, the source of the client's concern should be determined. The following questions should be asked. 1. Whether she has ever had her blood pressure measured previously. 2. What was her experience and why she does not want to get it measured? 3. What does the client imagine will happen if she is assessed for her blood pressure? 4. Was the last blood pressure reading normal? 5. Is she taking any medication for high blood pressure? 6. If so, when was the last dose taken? 7. Was she physically active right before the appointment? 8. Is she following a healthy diet? 9. What is her physical activity regimen?
The vital signs include body temperature, blood pressure, pulse rate and the respiration rate. Oxygen saturation percentage of the arterial blood is also measured, while measuring the vital signs. These vital signs are checked in order to assess the normal functioning of the body. Any changes in these vital signs reflect some abnormality in the body. It is not an automatic procedure rather it is based upon scientific assessment. When assessing the vital signs of a patient, if the other signs are normal except for the body temperature, one may retake it in few minutes. The nurse should not wait for 15 minutes to take the temperature again. It is an unnecessary step. Retaking the temperature using another thermometer is also unessential. Charting the temperature only after determining it. Hence, the options 1, 3 and 4 are incorrect. The correct intervention at this point would be to check what the previous temperature was. This would also give a comparative parameter. The temperature slightly differs at different times of the day. So, a check of the previous temperature would be beneficial. Hence, the correct answer is option .
After the exploration about checking blood pressure, the client accepts for measuring blood pressure. While measuring, after pumping up the cuff, no sounds are heard during the release of the valve. Initially, the cuff is pumped up until the brachial pulse is no longer heard. The pressure where no sounds are heard is the estimated systolic pressure. After releasing the pressure in the cuff, the diastolic pressure is noted by waiting 2 to 3 minutes. When heard through the stethoscope, a sound is heard when releasing the valve. The sound heard is the blood flowing in the artery of the arm and is the systolic pressure. However, in the given case, there is no sound heard during the release. This may indicate that the client is under shock by hemorrhage or other emergency conditions. Thus, at this stage, the client should be asked to relax and be free of tensions. The pressure should be rechecked after sometime or palpitations can be used rather than auscultation. This would help in establishing the presence of the peripheral pulse. If the nurse is new then she can ask another nurse to measure the blood pressure.