Silleza, Angelica Jayne V

BSN 1-1

Lyceum of the Philippines University- Batangas

College of Nursing

NCM 103- Fundamentals of Nursing- Skills Lab

Assessment Test
Equipment:
 1 Aneroid sphygmomanometer
 2. Cloth or disposable vinyl pressure cuff of appropriate size for
patients extremity
 Alcohol wipe
 3 Stethoscope
 Paper and pen for recording

Measuring Blood Pressure S U NP Remark

s
1. Identify patient using two identifiers.
a. Determine need to assess 4. Patients
BP Identify risk factor.
b. Observe for signs and symptoms of BP
alterations.

3. Explain to patient that you will assess BP.

Have patient rest at least 5. 5 minutes
before measuring BP sitting or lying down,
wait 1 minute if patient is standing.
4. Perform hand hygiene and clean
6.stethoscope earpieces and 7. diaphragm
with alcohol swab.
5. Position patient:
a. Arm: Position patient 8. Sitting or lying
position; position forearm at heart level.
Turn palm up. If sitting instruct patient to
keep feet flat on floor without 9.
Crossing legs
b. Thigh: Position patient lying with thigh
flat. Have knee 10. Slightly flexed
6. Expose extremity (arm or leg) fully by
removing 11. Constricying clothing
7. Palpate 12.brachial artery or popliteal artery
(leg). With cuff fully deflated, apply bladder
of cuff above artery by centering arrows
marked on cuff over artery. Position cuff 13.
2. Cm (1 inch) above site of pulsation. Wrap
cuff evenly and snugly around extremity.
8. Position manometer gauge vertically at eye
level and no farther than 1 m away.
9. Relocate brachial or popliteal pulse. Palpate
artery distal to cuff with fingertips of
nondominant hand while inflating cuff rapidly
to pressure 14.30 mmHg above point at
which pulse disappears. Slowly deflate cuff
and note point when pulse reappears.
Deflate cuff fully and wait 30 seconds.
10. Place stethoscope earpieces in ears and be
sure that sounds are clear, not muffled.
11. Relocate brachial or popliteal artery and
place bell or diaphragm chest piece of
stethoscope over it.
12. Close valve of pressure bulb 15. clockwise
until tight.
13. Quickly inflate cuff to 30 mm Hg above
palpated systolic pressure.
14. Slowly release pressure bulb valve and
allow needle of manometer gauge to fall at
rate of 2-3 mm Hg/sec. Make sure there are
no 16.extraneus sounds
15. Note point on manometer when you hear
first clear sound. Sound slowly increases in
intensity.
16. Continue to 17. Deflate cuff noting point at
which muffled or dampened sound appears.
17. Continue to deflate cuff gradually, noting
point at which sound disappears in adults
Listen for 10-20 mm Hg after last sound and
allow remaining arm to escape quickly.
18. !8,American Heart Association recommends
average of two sets of BP measurement19.
2 minutes apart. Use second set of BP
 measurement as baseline.
19. Remove cuff from extremity unless you need
to repeat measurement.
20. Help patient return to comfortable position
and cover upper arm.
21. Discuss findings with patient.
22. Perform hand hygiene.
23. Record BP in nurses' notes.
24. Record any signs or symptoms of BP
alternations in nurses' notes.
25. 20 document measurements of BP after
administration of specific therapies in
nurses' notes.
26. Report abnormal findings to nurse in charge
or health care provider.