Count for one full minute and note the pulserhythm and volume.
Place the client’s
arm across the chest andobserve the chest movements while supposedlytaking radial pulse.
Count the respiratory rate for 1 full minute. Aninhalation and an exhalation is counted as onerespiration. Observe the depth, rhythm, andcharacter or respiration.
ASSESSING BLOOD PRESSURE1.
The elbow should be slightly fixed with thepalm of the hand facing up and the forearmsupported at heart level.
Expose the upper arm
Wrap the deflated cuff evenly around the upperarm. Locate the brachial artery. Apply thecenter of the bladder directly over the artery.
For an adult, place the lower border of the cuff appropriately 2.5 cm (1 inch) above theantecubital space.
If this is the client’s initial examination,
perform a preliminary palpatory determinationof systolic pressure.
Palpate the brachial artery with fingertips.
Close the valve on the pump by turning theknob clockwise.
Pump the cuff until you no longer feel thebrachial pulse. At that pressure, the bloodcannot flow through the artery. Note thepressure on the sphygmomanometer at whichpulse is no longer felt.
Release the pressure completely in the cuff, andwait for one to two minutes before makingfurther measurements.
Position the stethoscope appropriately
Clean the earpieces of the stethoscope withalcohol.
Warm the amplifier by rubbing it with the palmof your hand.
Insert the ear attachments of the stethoscope inyour ears so that they tilt slightly forward.
Ensure that the stethoscope hands freely fromthe ears to the diaphragm.
Place the bell of the amplifier of thestethoscope over the brachial pulse. Hold thediaphragm with thumb and index finger.
Auscultate the client’s blood pressure.
Pump the cuff until the sphygmomanometerreads 30 mm Hg above the point where thebrachial pulse disappeared.
Release the valve of the cuff carefully so thatthe pressure decreases at the rate of 2-3 mm Hgper second.
As the pressure falls, identify the mamometerreading at each of five phases, if possible.
Deflate the cuff rapidly.
Wait one or two minutes before making furtherdeterminations.
Repeat the above steps once or twice asnecessary to confirm the accuracy of thereading.
If this is the client initially examination, repeat
the procedure on the client’s other arm.