Question

Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, what should the nurse do?

a. Subtract one third of the diastolic BP from the systolic BP.
b. Auscultate for a pericardial friction rub that increases in volume during inspiration.
c. Evaluate the rhythm of the pulse in relation to the patient's inspiration and expiration.
d. Note the first Korotkoff sound occurring during both inspiration and expiration while deflating the blood pressure cuff.

Answer 1

To assess for pulsus paradoxus in a patient with suspected cardiac tamponade, the nurse should note the first Korotkoff sound occurring during both inspiration and expiration while deflating the blood pressure cuff option (d).

Step-by-step explanation:

To assess for the presence of pulsus paradoxus in a patient suspected of having cardiac tamponade, the nurse should follow a specific protocol when measuring blood pressure. This protocol involves noting the difference in blood pressure readings during inspiration and expiration. The correct procedure is:

1. The clinician wraps an inflatable cuff tightly around the patient's arm at about the level of the heart.
2. The clinician raises pressure around the artery, temporarily cutting off blood flow into the patient's arm by injecting air into the cuff.
3. While gradually allowing air within the cuff to escape, the clinician places the stethoscope on the patient's antecubital region and listens for the Korotkoff sounds.
4. The answer to the student's question is then d. Note the first Korotkoff sound occurring during both inspiration and expiration while deflating the blood pressure cuff.

This method allows the clinician to detect the variation in systolic blood pressure between breaths that is characteristic of pulsus paradoxus.