Format-for-Blood Pressure-Procedures

NURSING CARE MANAGEMENT 101
HEALTH ASSESSMENT
TITLE OF THE PROCEDURE
NAME OF STUDENT: ____________________ SECTION & GROUP NUMBER: _______________________

DATE OF RETURN DEMONSTRATION: ________________ CLINICAL INSTRUCTOR: ___________________
Definition or Blood pressure reflects the pressure exerted on the walls of the arteries. This
Purpose pressure varies with the cardiac cycle, reaching a high point with systole and low
point with diastole. Therefore, blood pressure is a measurement of the pressure of
the blood in the arteries when the ventricles are relaxed (systolic blood pressure) and
when the ventricles are relaxed (diastolic blood pressure).
Preparing the Before measuring the blood pressure, consider the

Client and following behavioral and environmental conditions that
Physical
can affect the reading:
Assessment
1. Room temperature too hot or cold
2. Recent exercise
3. Alcohol intake
4. Nicotine use
5. Muscle tension
6. Bladder distension
7. Background noise
8. Talking (either client or nurse)
9. Arm position
Equipment Gather Equipment:

1. Aneroid Sphygmomanometer
2. Stethoscope
ASSESSMENT PROCEDURE
(this can be typewrite based on the sequence of parts to be SCORES
examined and techniques)
STEPS RATIONALE 0 1 2 REMARKS

NOT DONE MASTE
DONE R
1 Assemble your equipment so
that the sphygmomanometer,
stethoscope, and your pen
and recording sheet are
within easy reach. Assist the
client into a comfortable,
quiet, restful position for 5-10
minutes. Client may lie down
or sit.
2 Remove client's clothing from
the arm and palpate the
pulsations of the brachial
artery. (If the client's sleeve
can be pushed up to make
room for the cuff, make sure
that the clothing is not so
constrictive that it would alter
a correct pressure reading.)
3 Place the blood pressure cuff
so that the midline of the
bladder is over the arterial
pulsation and wrap the
appropriate-sized cuff
smoothly and snugly around
the upper arm, 1 in. above
the antecubital area so that
there is enough room to place
the bell of the stethoscope.
The bladder inside the cuff
should encircle 80% of the
arm circumference in adults
and 100% of the arm
circumference in children
younger than age 13.
A cuff that is too small may
give a false or abnormally
high blood pressure reading.
An aneroid or mercury
sphygmomanometer can be
used; how-ever, many areas
have prohibited the use of
mercury-containing devices
and instead use electronic
blood pressure cuffs.
4 Support the client's arm
slightly flexed at heart level
with the palm up.
5 Put the earpieces of the
stethoscope in your ears,
palpate the brachial pulse
again, and place the
stethoscope lightly over this
area. Position the mercury
gauge on the manometer at
eye level.
6 Adjust the screw above the
bulb to tighten the valve on
the air pump, and make sure
that the tubing is not kinked
or obstructed.
7 Inflate the cuff by pumping
the bulb to about 30 mmHg
above the point at which the
radial pulse disappears. This
will help you avoid missing an
auscultatory gap.
8 Deflate the cuff slowly—
about 2 mm per second—by
turning the valve in the
opposite direction while
listening for the first of
Korotkoff sounds. Read the
point, closest to an even
number, on the mercury
gauge at which you hear the
first faint but clearer sound.
Record this number as the
systolic blood pressure. This is
phase I of Korotkoff sounds.
9 Next, note point, closest to an
even number, on the mercury
gauge at which the sound
becomes muffled (phase IV of
Korotkoff sounds). sounds).
Finally, note the point at
which the sound subsides
completely (phase V of
Korotkoff sounds). When both
a change in sounds and a
cessation of the sounds are
heard, record the numbers at
which you heat phase 1, IV,
and V sounds. Otherwise,
record the first and last
sounds.
10 Deflate the cuff at least
another 10 mmHg to make
sure you hear no more
sounds. Then deflate
completely and
remove.
11 Record readings to the
nearest 2 mmHg.
GIVEN SCORES / TOTAL NUMBER OF SCORES * 50+50 =
_______________________________
Signature of Clinical Instructor/Date

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NURSING CARE MANAGEMENT 101

TITLE OF THE PROCEDURE

NAME OF STUDENT: SECTION & GROUP NUMBER: ___

Preparing the Before measuring the blood pressure, consider the

Equipment Gather Equipment:

STEPS RATIONALE 0 1 2 REMARKS

GIVEN SCORES / TOTAL NUMBER OF SCORES * 50+50 =

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