Christian University of Thailand

College of Nursing
INUR3302: Nursing Process and Basic Health Assessment
Monitoring Blood Pressure
! I" No! ####!!!! Name! ###############$core ##!!!
2 % Performed satisfactoril& % Needs 'ractice 0 % No Performance
Procedure Rationale Evaluation
! Chec( 'h&sician)s order or
nursing care 'lan for fre*uenc&
and route! More fre*uent
tem'erature measurement ma& +e
a''ro'riate +ased on nursing
,udgment!
Provides for patient’s safety
2! Identif& the 'atient! Identifying the patient ensures
safety.
3! -.'lain the 'rocedure to the
'atient!
Explanation reduces
apprehension and encourages
cooperation.
/! Perform hand h&giene and 'ut
on glo0es if a''ro'riate or
indicated!
Hand hygiene deters the spread of
microorganisms. Gloves prevent
contact with blood and body
fluids.
1! Close curtains around the +ed
and close door to room if
'ossi+le!
Provides for patient privacy.
2! $elect the a''ro'riate arm for
a''lication of cuff!
Measurement of blood pressure
may temporarily impeded
circulation to the extremity.
3! Ha0e the 'atient assume a
comforta+le l&ing or sitting
'osition 4ith forearm su''orted
at the le0el of the heart and the
'alm of the hand u'4ard!
his position places the brachial
artery on the inner aspect of the
elbow so that the bell or
diaphragm of the stethoscope can
rest on it easily.
5! -.'ose the +rachial arter& +&
remo0ing garments or mo0e a
slee0e6 if it is not too tight7 a+o0e
the area 4here the cuff 4ill +e
'laced!
!lothing over the artery interferes
with the ability to hear sounds and
may cause inaccurate blood
pressure readings. " tight sleeve
would cause congestion of blood
and possibly inaccurate readings.
8! Pal'ate the location of the
+rachial arter&! Center the +ladder
of the cuff o0er the +rachial
arter&7 a+out mid4a& on the arm7
so that the lo4er edge of the cuff
is a+out 2!1 to 1 cm 9:;2:< a+o0e
the inner as'ect of the el+o4! =ine
the arter& mar(ing on the cuff
4ith the 'atient)s +rachial arter&!
>he tu+ing should e.tend from
the edge of the cuff nearer the
'atient)s el+o4!
Pressure in the cuff applied
directly to the artery provides the
most accurate readings. If the cuff
gets in the way of the stethoscope#
readings are li$ely to be
inaccurate. " cuff placed upside
down with the tubing toward the
patient’s head may give a false
reading.
0! ?ra' the cuff around the arm
smoothl& and snugl&7 and fasten
it! "o not allo4 an& clothing to
interfere 4ith the 'ro'er
'lacement of the cuff!
" smooth cuff and snug wrapping
produce e%ual pressure and help
promote an accurate
measurements. " cuff too loosely
wrapped results in an inaccurate
reading.
! Chec( that the needle on the
aneroid gauge is 4ithin the @ero
mar(! If using a mercur&
manometer7 chec( to see that the
manometer is in the 0ertical
'osition and the mercur& is 4ithin
the @ero le0el 4ith the gauge at
e&e le0el!
If needle is not in the &ero area#
the blood pressure may not be
accurate. ilting a mercury
manometer# inaccurate
calibration# or improper height for
reading the gauge can lead to
errors in determining the pressure
measurements.
2! Pal'ate the 'ulse at the
+rachial arter& +& 'ressing gentl&
4ith the fingerti's!
Palpation allows for
measurement of the approximate
systolic reading.
3! >ighten the scre4 0al0e on the
air 'um'!
he bladder within the cuff will
not inflate with valve open.
/! Inflate the cuff 4hile
continuing to 'al'ate the arter&!
Note the 'oint on the guage 4here
the 'ulse disa''ears!
he point where the pulse
disappears provides an estimate of
the systolic pressure. o identify
the first 'orot$off sound
accurately# the cuff must be
inflated to a pressure above the
point at which the pulse can no
lober be felt.
1! "eflate the cuff and 4ait 1
seconds!
"llowing a brief pause before
continuing permits the blood to
refill and circulate through the
arm.
Obtaining blood pressure
measurement
2! Assume a 'osition that is no
more than 3 feet a4a& from the
gauge!
" distance of more than about (
feet can interfere with accurate
readings of the numbers on the
gauge.
3! Place the stethosco'e
ear'ieces in &our ears! "irect the
ear'ieces for4ard into the canal
and not against the ear itself!
Proper placement bloc$s
exrtraneous noise and allows
sound to travel more clearly.
5! Place the +ell or dia'hragm of
the stethosco'e firml& +ut 4ith as
little 'ressure as 'ossi+le o0er the
+rachial arter&! "o not allo4 the
stethosco'e to touch the clothing
or the cuff!
Having the bell or diaphragm
directly over the artery allows
more accurate readings. Heavy
pressure on the brachial artery
distorts the shape of the artery and
the sound.Placing the bell or
diaphragm away from clothing
and the cuff prevents noise# which
would distract from the sounds
made by blood flowing through the
artery.
8! Pum' the 'ressure 30 mmHg
a+o0e the 'oint at 4hich the
s&stolic 'ressure 4as 'al'ated and
estimated! A'en the 0al0e on the
manometer and allo4 air to
esca'e slo4l& 9allo4ing the gauge
to dro' 2;3 mm 'er heart +eat<!
Increasing the pressure above the
point where the pulse disappeared
ensures a period before hearing
the first sound that corresponds
with the systolic pressure. It
prevents misinterpreting phase Ii
sounds as phase I.
20! Note the 'oint on the gauge at
4hich the first faint7 +ut clear7
sound a''ears that slo4l&
increases in intensit&! Note this
num+er as the s&stolic 'ressure!
)ystolic pressure is the point at
which the blood in the artery is
first able to force its way through
the vessel at a similar pressure
exerted by the air bladder in the
cuff. he first sound is phase I of
'orot$off sounds.
2! Read the 'ressure of the
closest e0en num+er!
It is common to practice to read
blood pressure to the closest even
number.
22! "o not reinflate the cuff once
the air is +eing released to
rechec( the s&stolic 'ressure
reading!
*einflating the cuff while
obtaining the blood pressure is
uncomfortable for the patient and
may cause an inaccurate
reading.*einflating the cuff causes
congestion of blood in the lower
arm# which lessen the loudness in
the lower arm.
23! Note the 'ressure at 4hich the
sound first +ecomes muffled! Also
o+ser0e the 'oint at 4hich the
sound com'letel& disa''ears!
>hese ma& occur se'aratel& or at
the same 'oint!
he point at which the sound
changes correspond to phase I+
'orot$off sounds and is
considered the first diastolic
pressure reading.
2/! Allo4 the running air to
esca'e *uic(l&! Re'eat an&
sus'icious reading7 +ut 4ait 30 to
20 seconds +et4een readings to
,alse readings are li$ely to occur
if there is congestion of blood in
the limb while obtaining repeated
readings.
allo4 normal circulation to return
in the lim+! "eflate the cuff
com'letel& +et4een attem'ts to
chec( the +lood 'ressure!
21! Remo0e the cuff7 and clean
and store the e*ui'ment!
E%uipment should be left ready for
use.
22! Remo0e glo0es if 4orn!
Perform hand h&giene!
-eters the spread of
microorganisms.
23! "ocument the 'rocedure and
data!
-ocumentation prevents clinical
errors during the practice
Recommendations: ##########################!!
Instructor######!!
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