Obtaining Blood Pressure

Blood pressure refers to the force of the blood against arterial walls. Systolic pressure is the highest point of pressure on arterial walls when the ventricles contract. The lowest pressure present on arterial walls during diastole is the diastolic pressure.

Equipment: Stethoscope Sphygmomanometer Blood pressure cuff of appropriate size Pen, paper or Alcohol swab

Assessment Assess the brachial pulse, or pulse appropriate for site being used. Assess for an intravenous infusion, and breast or axilla surgery on the side of the body corresponding to the arm used. Assess for the presence of a cast, arteriovenous shunt, or injured or diseased limb. If any of these conditions are present, do not use the affected arm to monitor blood pressure. Assess for factors for factors that could affect blood pressure reading, such as the patients age, exercise, position, weight, fluid balance, smoking, and medications. Note baseline or previous blood pressure measurements.

Nursing Diagnosis; - Determine the related factors for the nursing diagnoses based on the patients current status. Appropriate nursing diagnoses include: Decreased cardiac output Ineffective Health Maintenance Effective Therapeutic Regimen Management Risk for falls

Implementation

Action

Rationale

1.

Perform hand hygiene.

Hand hygiene deters the spread of microorganisms.

2.

Explain procedure to patient.

Explanation reduces apprehension and encourages cooperation

This position places the brachial artery on 3. Assist patient to comfortable the inner aspect of the elbow so that the position with forearm support at heart level bell or diaphragm of the stethoscope can and palm up. rest on it easily. 4. Expose the brachial artery by Clothing over the artery interferes with the removing garments, or move a sleeve, if it ability to hear sounds and may cause is not too tight, above the area where the inaccurate blood pressure readings. A cuff will be placed. tight sleeve would cause congestion of blood and possible inaccurate readings. 5. Palpate the location of the brachial artery. Center the bladder of the cuff over the brachial artery, about midway on the arm, so that the lower edge of the cuff is about 2.5 to 5 cm above the inner aspect Pressure in the cuff applied directly to the of the elbow. Line the artery marking on the artery provides the most accurate cuff with the patients brachial artery. The readings. tubing should extend from the edge of the cuff nearer the patients elbow. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. If the needle is not in the zero area, the blood pressure may not be accurate. Tilting a mercury manometer, inaccurate calibration, or improper height for reading the gauge can lead to errors in determining the pressure measurements. Palpation allows for approximate systolic reading.

6. Wrap the cuff around the arm smoothly and snugly, and fasten it.

7. Check that the needle on the aneroid gauge is within the zero mark. If using mercury manometer, check to see that the manometer is in the vertical position and that the mercury is within the zero level with the gauge at eye level. 8. Palpate the pulse at the brachial radial artery by pressing gently with fingertips.

9. Tighten the screw valve on the air pump. The bladder within the cuff will not inflate with the valve open. 10. Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears. The point where the pulse disappears provides an estimate of the systolic pressure. Allowing a brief pause before continuing permits the blood to refill and circulate through the arm.

11. Deflate the cuff and wait 15 seconds.

12. Place the stethoscope earpieces in Proper placement blocks extraneous noise your ears. Direct the earpieces forward and allows sound to travel more clearly. into the canal and not against the ear itself.

13. Repalpate the brachial artery and place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery.

Heavy pressure on the brachial artery distorts the shape of the artery and the sound.

14. Pump the pressure 30 mm Hg above the point at which the systolic pressure was palpated and estimated.

Increasing the pressure above the point where the pulse disappeared ensures a period before hearing the first sound that corresponds with the systolic pressure.

15. Open the valve on the manometer and ). It prevents misinterpreting phase 11 allow air to escape slowly (allowing the sounds as phase 1. gauge to drop 2-3 mm per heartbeat. 16. Note the point on the gauge at which the first faint but clear, sound appears that slowly increases in intensity. Note this number as the systolic pressure. 17. Do not inflate the cuff once the air is being released to recheck the systolic pressure reading. 18. Note the pressure at which the sound first become muffled. Also observe the point at which the sound completely disappears. These may occur separately or at the same point. 19. Allow the remaining air to escape quickly. Repeat any suspicious reading, but wait 30 to 60 seconds between readings to allow normal circulation to return in the limb. 20. Remove the cuff, and clean and store the equipment. Systolic pressure is the point at which the blood in the artery is first able to force its way through the vessel at a similar pressure exerted by the air bladder in the cuff. The first sound is phase 1 of Korotkoff sounds Reinflating the cuff causes congestion of blood in lower arm, which lessens the loudness of Korotkoff sounds. The point at which the sound changes correspond to phase IV korotkoff sounds and is considered the first diastolic pressure reading. The last sound heard is the beginning of phase V and is the second diastolic measurement in adults.

False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated results

Equipment should be left ready for use.

21. Perform hand hygiene. This deters the spread of microorganisms 22. Record blood pressure. Record systolic and diastolic in form 130/80. Identify arm used and site of assessment if other than brachial.