Blood Pressure, Measuring - HumanGood



|Blood Pressure, Measuring H5MAPR0034 |Level II |

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|Purpose |The purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls |

| |of the arteries, veins and chambers of the heart. |

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|Preparation |Review the resident’s care plan to assess for any special needs of the resident. |

| |Assemble the equipment and supplies as needed. |

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|General Guidelines |A blood pressure reading is represented as a ratio or fraction. The top number (the systolic pressure) measures |

| |the blood pressure during the contractions of the heart (systole). The bottom number (the diastolic pressure) |

| |measures the pressure of the blood while the heart is at rest (diastole). |

| |The blood pressure is generally defined as Normal when the systolic pressure is in the range of 101 to 129 mm/Hg |

| |and the diastolic pressure is in the range of 61 to 84 mm/Hg. |

| |Borderline hypertension is typically defined as a systolic pressure of 130 to 139 mm/Hg and a diastolic pressure |

| |of 85 to 89 mm/Hg. |

| |Hypertension is usually defined as blood pressure over 140/90 mm/Hg (although the elderly often have persistent |

| |systolic readings from 140 to 160 mm/Hg. |

| |Hypertension should be reported to the physician. If a resident has a hypertensive reading, staff should record |

| |several readings taken at different times of the day. Staff should note any pertinent medications and/or recent |

| |changes of condition when reporting to the physician. |

| |Hypotension is defined as blood pressure less than 100/60 mm/Hg. |

| |Orthostatic (postural) hypotension is defined as a 20 mm/Hg (or greater) decline in systolic blood pressure or a |

| |10 mm/Hg (or greater) decline in diastolic blood pressure upon standing. |

| |Post-prandial hypotension is defined as a 20 mm/Hg decline in systolic blood pressure (or a 10 mm/Hg drop if the |

| |baseline is less than 100 mm/Hg) within two (2) hours after eating a meal. |

| |Hypotension should be reported to the physician. Staff should record several readings throughout the day, |

| |including before and after meals. |

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|Equipment and Supplies |The following equipment and supplies will be necessary when performing this procedure: |

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| |Sphygmomanometer; |

| |Stethoscope; |

| |Antiseptic swabs; |

| |Paper and pencil or pen; and |

| |Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). |

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|Steps in the Procedure |Wash and dry your hands thoroughly before beginning the procedure. |

| |Place the equipment on the bedside stand or overbed table. Arrange the supplies so that they can be easily |

| |reached. |

| |If the resident is standing, instruct the resident to sit in a chair or lie down on the bed. |

| |Expose the resident’s arm by rolling the sleeve up about 5 inches above the elbow. |

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|Steps in the Procedure (continued)| |

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| |Wrap the blood pressure cuff evenly around the upper arm, approximately one (1) inch from the elbow. (Note: The |

| |cuff should fit snugly, but not so tightly that the resident is uncomfortable. If the cuff is placed too loosely, |

| |you will get a false high blood pressure reading.) |

| |Be sure the manometer is positioned so that you can see the numbers clearly. |

| |Wipe the earplugs and diaphragm of the stethoscope with an antiseptic swab. Discard the swab into the designated |

| |container. Place the earplugs of the stethoscope into your ears. |

| |Close the valve on the air pump. (Note: Turn the thumbscrew clockwise. However, do not tighten it too much or it |

| |will be difficult to open when you try to release the pressure from the cuff.) |

| |With your second and third finger of one hand, locate the brachial pulse at the bend in the elbow. |

| |When you locate the pulsation, place the diaphragm of the stethoscope firmly against the skin. Hold the diaphragm |

| |in place with your hand. |

| |With your free hand, pump air into the cuff by squeezing the bulb until you can no longer hear the pulsation. |

| |(Note: You must be watching the mercury level on the manometer while you are pumping the air in the cuff.) |

| |When you hear the last pulsation sound, loosen the thumbscrew slowly to let the air out. Watch the mercury reading|

| |on the manometer. Listen for the first sound. Note the number. This will be the top (systolic) reading. |

| |Continue to listen for the pulsation sound and watch the mercury reading on the manometer. When you hear the last |

| |sound, note the number. This will be the lower (diastolic) reading. |

| |Record the blood pressure on the paper. |

| |To measure orthostatic blood pressure, repeat steps eight (8) through fourteen (14) immediately after helping the |

| |resident to a standing position. Note the changes in both the systolic and diastolic measurements compared to the |

| |reading taken while the resident was in a seated position. |

| |To measure post-prandial blood pressure, perform steps one (1) through fourteen (14) before meals and repeat one |

| |(1) to two (2) hours after meals. |

| |Deflate the cuff completely and remove it from the resident’s arm. |

| |Roll up the blood pressure cuff. (Note: If using a mercury apparatus, place the cuff in the case.) |

| |Wipe the earplugs and diaphragm of the stethoscope with an antiseptic swab. Discard the swab into the designated |

| |container. |

| |Reposition the bed covers. Make the resident comfortable. |

| |Place the call light within easy reach of the resident. |

| |If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them |

| |they may now enter the room. |

| |Wash and dry your hands thoroughly. |

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|Documentation |The following information should be recorded in the resident’s medical record: |

| |The date and time the blood pressure was measured. |

| |The name and title of the individual(s) who measured the blood pressure. |

| |The blood pressure reading. |

| |If the resident refused the treatment, the reason(s) why and the intervention taken. |

| |The signature and title of the person recording the data. |

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|Reporting |Notify the supervisor if the resident refuses the treatment. |

| |Report other information in accordance with facility policy and professional standards of practice. |

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|References |

|MDS (CAAs) |Section I; Section J |

|Survey Tag Numbers |n/a |

|Related Documents |Vital Signs and Weight Record (See CD-ROM) |

|Risk of Exposure |Blood–Body Fluids–Infectious Diseases–Air Contaminants–Hazardous Chemicals |

|Procedure |Date:________________ By:__________________ |

|Revised |Date:________________ By:__________________ |

| |Date:________________ By:__________________ |

| |Date:________________ By:__________________ |

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