During the assessment of an adult client's blood pressure, the nurse notes the following on the sphygmomanometer:
first faint tapping sounds at 136, swishing sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at 76. This nurse would document this client's blood pressure as _____________.
Record your answer as a fraction.
Correct Answer: 136/76
The sounds above are the five phases of Korotkoff's sounds. The first sound heard (Phase 1) is recorded as the systolic blood pressure. This is when the blood pressure cuff has been released just enough to allow the first spurts of blood to pass through the artery. Phase 2 is marked by the period in which the sounds change from tapping to swishing; blood flows turbulently through the artery. Phase 3 is when blood flows through the artery during systole but collapses during diastole; the sounds are crisp and tapping. During Phase 4, the sounds become muffled and have a soft blowing quality. The pressure in the cuff does not completely collapse the artery in any part of the cardiac cycle. The diastolic blood pressure is marked by the beginning of silence (Phase 5). This is when the cuff no longer collapses the artery, and blood is free flowing through the artery.
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