Question

a nurse is assessing a client with suspected cardiac tamponade. how should the nurse assess the client for pulsus paradoxus?

Answer 1

auscultate systolic BP during slow gradual release of the cuff pressure

Answer 2

To assess for pulsus paradoxus, a clinician measures blood pressure using a cuff and listens for changes in Korotkoff sounds during breathing cycles. A significant drop in systolic blood pressure during inhalation, detected via these sounds, suggests pulsus paradoxus.

Step-by-step explanation:

To assess a client for pulsus paradoxus which is a sign of cardiac tamponade, a nurse or clinician would follow these steps:

• The clinician wraps an inflatable blood pressure cuff tightly around the patient's arm, approximately at the level of the heart.
• Using a rubber pump, the clinician injects air into the cuff, raising pressure and temporarily obstructing blood flow in the patient's arm.
• The clinician then places a stethoscope on the patient's antecubital region.
• While the air from the cuff is gradually released, the clinician listens for Korotkoff sounds, which will change as the cuff deflates.

Pulsus paradoxus is characterized by a drop in systolic blood pressure of more than 10 mm Hg during inspiration. Normally, one would expect to hear the sounds disappear and reappear in compliance with normal breathing cycles, but in pulsus paradoxus, there is a more pronounced drop in blood pressure during inhalation, leading to a greater delay in the reappearance of sounds during this phase. This finding is indicative of the presence of conditions such as cardiac tamponade.