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Lecture: Ns. Sri Padma Sari, S.Kep, MNS.

Design by:
Sayekti Dwi Cahyani Sang Ayuning Jati Wijayanti
Sri Wahyuti Nuri Mawarni Restu Ayu Sarawati
Lika Hanifa Seli Monita Wardani
Febria Rizky Aulia Mirza Hielmy Muthohar
Iga Ayu Saputri Irfan Ardani

Class of A.16.2


A. Preparation and Equipment Blood Pressure
 The nurse should explain to the patient that their blood pressure (BP)
needs to be measured. The nurse should gain their informed consent.
 The nurse should ensure that the appropriate equipment is available
and in good working condition.
 Equipment:
 A sphygmomanometer (working andcalibrated).
 A stethoscope.
 An appropriate-size BP cuff.
 The nurse should know how to feel for the radial and brachial pulses
before undertaking the procedure.
B. Procedure
1) Ask the patient or visually check if they have had any trauma or
surgery to their arm or have an intravenous infusion in progress. If
they have, or if there are any contraindications, use the other arm. If it
is not possible to use either arm, the thigh can be used by applying a
thigh cuff to the mid-thigh area.
2) Ensure the patient is relaxed and seated comfortably, with their back
supported and feet uncrossed and flat on the floor.
3) Ensure the BP cuff is the correct size for the arm.
4) Check that the patient’s arm is not restricted by any tight clothing.
Support the arm with apillow, ensuring that it is level with the
person’sheart (midsternal level).
5) Wrap the BP cuff aroundarm is not restrictedby any tight clothing.
6) Ask the patient not to talk during the procedure.
7) Locate the radial pulse. Inflate theBP cuff by pumping the cuff bulb,
until theradial pulse can no longer be felt. Note thereading on the dial.
This figure is the estimatedsystolic pressure.
8) Deflate the BP cuff completely and wait for 15-30 seconds.
9) Palpate the brachial artery to ensure the correctplacement of the
stethoscope. Place the centre of the stethoscope bell over the brachial
10) Inflate the cuff again to 20-30mmHg above thepredicted systolic BP.
11) As you deflate the cuff, note when theloud thudding occurs; this is the
systolic BP.
12) Deflate the cuff fully once no further sounds canbe heard and remove
it from the patient’s arm.
13) Inform the patient that the procedure is finished.


Mr. I felt himself so dizzy then he decided go to the Harapan

independent nurse's self-care for a blood pressure check.

N : good morning sir, let me introduce myself. My name is Ners

Hielmy. I’m the nurse for this session. Before that, what’s your
name ?

P : good morning, i'm irfan.

N : oh yes dad Irfan how old are you ?

P : i'm 35 years old

N : where do you live mr. irfan?

P : i live in semarang, jalan sari raya no 1

N : well sir, what do you feel?

P : I’m lately feel dizzy, and my head feels heavy.

N : do you have a history of disease?

Q : previously I had hypertension.

N : what do you consume before this?

P : oh yeah, yesterday i ate satay of goat meat during eid al-adha.

N : oh so, can i check your blood pressure?

P : yes please.
N : what is your blood pressure normally?

P : i remember 120/90

N : okay please lie here.

P : yes.

N : is your position comfortable?

P : yes i am.

N : excuse me sir, i will raise your arm and roll up your clothes to put
the cuff.

P : yes please.

N : ok, i have finished checking the blood pressure, thanks for the

P : yes your welcome, if possible, may I know how the result?

N : your blood pressure is 150/100 mmhg, mr.

P : Is that normal ?

N : actually, the normal scale is 120/80mmHg, so your blood pressure

on scale of hipertention.

P : then what should I do to control my blood pressure?

N : i should of you to reduce high-sodium foods such as reducing

salt-rich foods, reducing goat meat consumption as well. You can
consume cucumbers that will help lower your blood pressure.

P : oh well. Thank you

N : yes sir , get well soon sir.