Question

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement?

a. Advise the UAP to document the last blood pressure obtained in the client's graphic sheet
b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed
c. Document why the blood pressure cannot be accurately measured at the present time
d. Estimate the blood pressure by assessing the pulse volume of the clients' radial pulses

Answer 1

The nurse should demonstrate to the UAP how to palpate the popliteal pulse and document why the blood pressure can't be measured in the standard manner. Estimating blood pressure by radial pulse volume is not accurate or advisable.

Step-by-step explanation:

Action for Measuring Blood Pressure with Both Arms in Casts

When a patient has casts on both arms and is unable to be turned to the prone position, measuring blood pressure can be challenging. If the blood pressure cannot be measured by the usual arm method due to casts, and the patient cannot be turned prone to measure from the legs, the nurse should take a different approach. In this specific case, the nurse should:

• Explain and demonstrate to the unlicensed assistive personnel (UAP) how to palpate the popliteal pulse and measure the blood pressure with the patient in the supine position with the knee flexed.
• Document the reason why the blood pressure cannot be accurately measured using the standard method at this time.

It is not practical to estimate blood pressure by assessing the pulse volume of the radial pulses as this method does not provide an accurate measure of arterial pressure. Blood pressure should be measured and documented accurately using the appropriate method and equipment to ensure patient safety and proper care management.