TRINITY VALLEY COMMUNITY COLLEGE



TRINITY VALLEY COMMUNITY COLLEGE

ASSOCIATE DEGREE NURSING

RNSG 1216

PROCEDURE GUIDE AND CHECK-OFF SHEET

ASSESSING BLOOD PRESSURE

Blood pressure provides two numbers. The first number is the systolic pressure which is the amount of pressure the heart must exert to pump blood into the periphery; the second number is the diastolic pressure which is the amount of pressure the heart is exerting during rest. The nurse documents systolic/diastolic (120/80) when reporting a patient’s blood pressure.

Delegation: This procedure can be delegated to unlicensed assistive personnel with proper training. The nurse retains the responsibility for knowing the patient’s blood pressure and taking the appropriate nursing interventions based on that knowledge.

Note: There may be times when it is inappropriate to delegate this procedure.

| Procedure | Scientific Rationale |

| The following equipment is needed for this skill: | |

|sphygmomanometer with cuff of correct size |a. Correct cuff size ensures accurate blood pressure. |

|b. stethoscope. | |

| Select a cuff that fits completely around the patient’s arm and |If a cuff is too wide, a false low reading may occur. If the cuff is |

|is about two-thirds the length of the patient’s upper arm. The |too narrow, a false high reading may occur. |

|bladder of the cuff should be approximately 60 to 80 % of the | |

|circumference of the extremity. | |

| Encourage patient to avoid exercise, smoking, and ingestion of |Can cause false elevations of blood pressure. |

|caffeine for 30 minutes before assessing blood pressure. | |

|Place the patient’s arm level with the heart, palm up, and in a |A false high reading will result if the arm is below the heart level. |

|relaxed, comfortable position. Have patient relax at least 5 |A false low reading will result if the arm is above the heart level. |

|minutes before measurement. |Relaxing avoids falsely elevated readings. The brachial artery is |

| |exposed when the palm is in the upright position. |

|The nurse must be careful in taking the blood pressure in an arm |Blood pressures should not be taken in arms with shunts for |

|that may be injured when pressure is applied. |hemodialysis, intravenous lines, breast surgery, or traumatic injury. A|

| |leg blood pressure can be obtained by using the popliteal artery. |

|Place the bottom edge of the blood pressure cuff 1 inch above the|Ensures that the blood pressure cuff is in the correct position before |

|patient’s antecubital area with arrow pointing directly over the |inflating cuff. |

|brachial artery. | |

|Wrap the cuff snugly allowing space to put the |A snug fit is required to obtain a correct blood pressure reading. |

|stethoscope over the brachial artery. Place the cuff directly |There must be complete and equal compression of the brachial artery. |

|over the skin not over any type of clothing. | |

|Position the sphygmomanometer so that the nurse can see the |With a mercury manometer, eye level above mercury results in a false |

|pressure gauge without any problems. A mercury gauge should be |high reading and eye level below mercury results in false low reading. |

|at eye level and the needle of an aneroid gauge should be at |If needle is not at zero on an aneroid manometer, the blood pressure |

|zero. |reading will be inaccurate. |

| Palpate the brachial artery then inflate the cuff until the |Remember this number because when taking the blood pressure the nurse |

|nurse can no longer feel the pulse. Release the cuff and observe |should inflate the cuff to 30mmHg above this number when obtaining the |

|the reading when the nurse can feel the pulse again. This is |systolic pressure. It ensures that the cuff will be inflated |

|called the palpable pulse. |sufficiently to obtain an accurate systolic reading. Overinflation of |

| |the cuff can be painful and may damage small blood vessels. |

| Wait 30 to 60 seconds to obtain the patient’s blood pressure |A false high reading will be obtained if the blood pressure is |

|after taking the palpable pulse. |auscultated too soon after obtaining the palpable pulse. |

| Place the diaphragm of the stethoscope lightly over the brachial|The bell of the stethoscope may be used if difficulty is encountered |

|artery. |hearing low-pitched sounds. |

| Quickly inflate the cuff by tightening the screw clamp and |Inflating the cuff quickly will ensure accurate reading; inflating |

|pumping the cuff up to 30 mm Hg above the palpable pulse. |slowly may result in inaccurate reading. The auscultated reading should|

| |be slightly higher than the palpable pulse reading. |

|Deflate the cuff slowly and steadily (2 mm Hg/second). Listen for|A rapid deflation results in a false low systolic reading, while a slow|

|a soft, tapping sound. This is the patient’s systolic blood |deflation results in a false high reading. This sound is known as the |

|pressure. |first Korotkoff sound. |

| Continue deflating the cuff slowly. The nurse may hear a murmur,|Murmurs (Korotkoff II), tapping (Korotkoff III), muffled (Korotkoff |

|a swishing sound, a clear tapping or a muffled sound but the |IV), and end of diastole (Korotkoff V) sound correlates with the |

|nurse must wait to hear the last sound when determining the |beginning and end of diastole. Muffling sounds is best indicator of |

|diastolic blood pressure reading. |diastole in children. Korotkoff V sounds may continue all the way to |

| |zero in children and athletes. |

| Quickly deflate the cuff completely. Wait 1-2 minutes if the |Waiting will allow the circulation to return to the hand and prevents |

|nurse must recheck the blood pressure. |decreased circulation to the hand causing discomfort. |

|Document the patient’s blood pressure in the patient record. |Newborn S: 60-90 D: 20-60 |

| |Infant to 1 yr S: 85-105 D: 50-65 |

|Normal blood pressure: |Age 1-3 S: 95-105 D: 50-65 |

| |Age 3-6 S: 95-100 D: 55-60 |

| |Age 6-12 S: 100-110 D: 60-70 |

| |Age 12-18 S: 110-130 D: 60-80 |

| |Adult S: 110-140 D: 60-90 |

| |Older Adult S: 120-140 D: 70-90 |

| Report an abnormal blood pressure to the appropriate personnel |Any abnormalities in blood pressure readings may indicate cardiac |

|along with other pertinent cardiovascular assessment. |problems which must be addressed immediately. Any abnormal finding |

| |must have a corresponding nursing action. |

| Note: If the patient is going from a lying to a sitting |Waiting will allow the body’s compensatory mechanisms to stabilize the |

|position, wait at least 2 minutes before taking the blood |blood pressure. |

|pressure. | |

N:ADN/ADN Syllabus/CBC Curriculum/Level I/1216/Performance Checklist for Basic Skills - Assessing Blood Pressure Reviewed 04/16

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download