Health Care Module Divine Colleges of Malolos City

ASSESING BLOOD PRESSURE

Definition : Blood pressure is the pressure exerted by blood against the inner walls
of the arteries. Measuring a client’s blood pressure gives you
information about health of the cardio vascular, circulations and renal
system. (Hogan)

Purposes : (Kozier)

• To obtain a baseline measure of arterial blood pressure for subsequent

evaluation
• To determine the client’s hemodynamic status (e.g). stroke
volume of the heart and the blood vessels resistance)
• To identify and monitor changes in blood pressure resulting from a disease
process and the medical therapy (i.e. presence or history of cardiovascular
disease, renal disease, circulatory shock, or acute pain, rapid infusion of fluids
or blood products)

Equipment and materials :

• Stethoscope
• Blood pressure
• Sphygmomanometer
• Alcohol swab
• Pen, pencil, vital sign, flow sheet or record form

Implementation
ACTION RATIONALE
Explain the procedure to client. This is done to alleviate anxiety and to
ensure maximal cooperation.

Gather equipment It reduces transmission of

microorganisms.
3. Wash your hands. Select a blood
pressure cuff that is the appropriate Improper cuff size results in inaccurate
size for the client. readings, if cuff is too small, it results in

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false-high readings and tends to come

loose as it is inflated, if the cuff is to
large, false-low readings may be
recorded.
Select appropriate arm for application of cuff
(no intravenous infusion, breast or axilla Inappropriate site selection may result
surgery on that side, csts, arterio-venous in poor application of sounds., causing
shunt, or injured or disease limb.) inaccurate readings. Application of
pressure from inflated bladder
temporarily impairs blood flow and can
further compromise circulation
extremity that already has impairments.
(Potter)

If you can’t use one of the client’s arms

Expose the area or brachial artery by to take a blood pressure reading,
removing garments or move a sleeve if it is measure blood pressure at the popliteal
not to tight, above the area where the cuff artery. (Hogan)
will be placed.
It ensures proper cuff application. Tight
Center the bladder cuff of the cuff over the clothing causes congestion of blood and
brachial artery, approximately midway on the can falsely elevate BP readings. (Potter)
arm, so that the lower edge of the cuff is
about 2.5 cm to 5 cm (1 to 2 inches) above
the inner aspect of the elbow. The tubing Inflating the bladder cuff directly over
should extend fro the end of the cuff nearer brachial artery ensures that proper
the client’s elbow. pressure is applied during inflation.
Loose fitting cuff causes flase-high
Wrap the cuff around the arm smoothly and readings. (Potter)
smugly and fasten it securely or tuck the end
of the cuff well under the preceding
wrapping. Do not allow any clothing to
interfere with the proper placement of the
cuff. This ensures uniform and complete
compression of the brachial artery. A
Check that the mercury manometer is in a cuff that is too loose will result in a

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vertical position. The mercury must be within false-high reading. (Hogan)

zero area with the gauge at the eye level. If
an aneroid is used, the needle should be
within the zero mark.
Positioning the manometer above eye
Palpate the brachial or radical pulse by level result in false high reading.
pressing gently with fingertips. Positioning it below eye level result in
false low reading. (Hogan)

Tighten the screw valve on the air pump.

Inflate the cuff while continuing to palpate Inflating bladder directly over artery
the artery. Note the point in the gauge where ensures proper pressure is applied
the pulse disappears. during inflation. (Hogan)

It prevents air leak during inflation.

(Hogan)

Estimating prevents false-low readings,

which may result from the presence of
an auscultatory gap (inaudible sounds
below the actual systolic pressure). This
phenomenon occurs in about 5% of
adults and is prevalent in individuals
with hypertension. (Potter)

Blood pressure measurements should be

Deflate the cuff and wait for 15 seconds. performed on each client whose blood
pressure is being read for the first time.
It ensures that the cuff is sufficiently
Place the stethoscope in the ear properly. inflated to you in an accurate systolic
reading by auscultation. It also provides
information about an auscultatory gap.
Place the bell or diaphragm of the Failure to identify such a gap results in a
stethoscope over the artery where the pulse false low systolic reading. (Hogan)
is felt. Do not allow the stethoscope to touch

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clothing or the cuff. Deflating cuff prevents venous

congestion and false-high reading.
(Potter)

Each earpiece should follow angle of ear

canal to facilitate hearing. (Potter)

Proper stethoscope placement ensures

optimal sound reception. Stethoscope
improperly positioned causes muffled
Pump the pressure 30mmHg above the point sounds that often result in false-low
at which the pulse disappers. Open the valve systolic and false-high readings. (Potter)
of the manometer and allow air to escape
slowly (allowing the gauge to drop 2 to 3
mmHg per heartbeat).

The blood pressure is low-frequency

sound, it is best heard with the bell-
shaped diaphragm. (Kozier)

Note the point on the gauge at which there is The auscultatory systolic blood pressure
an appearance of the first faint, but clear should be slightly higher thatn the
sounds that slowly increase intensity. Note palpatory reading. Slow inflation can
this number as the systolic pressure. result in inaccurate reading. (Hogan)

Read the pressure to the closest even

number. Too rapid or slow decline in pressure can
cause inaccurate readings. Noise
Do not re-inflate the cuff once the air is being interferes with precise hearing of
released to recheck the systolic pressure Korotkoff phases (Potter)
reading.
First korotkoff phase reflects systolic BP.
Note the pressure at which the sound (Potter)
becomes muffled. Also observe the point at
which the sound completely disappears. This
may occur separately or the same point.

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 Health Care Module
Allow the remaining air to escape quickly.
Repeat any suspicious readings, but wait for
30 to 60 seconds between reading to allow
normal circulation to return to the limb. Be
sure to deflate the cuff completely between
attempts to check the blood pressure.
If it is difficult to hear sounds when checking
the blood pressure, raise the client’s arm
over his head for 15 seconds just before
rechecking the blood pressure.
Inflate the cuff while the arm is elevated and
then gently lower the arm while continuing to
support it.
Position the stethoscope and deflate the cuff
at the usual rate while listening to Korotkoff
sounds.
Remove the cuff, clean and store
equipment Wash your hands.
Record blood pressure.
1.
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Divine Colleges of Malolos City
Continuous cuff inflation causes arterial
occlusion, resulting in numbness and
tingling of client’s arm. (Potter)
Beginning of the 5th Korotkoff phase is
an indication of diastolic pressure with
adults. The 4th Korotkoff phase involves
distinct muffling sounds, and in children
it is recorded as the diastolic pressure.
(Potter).
If you attempt to obtain the blood
pressure reading too soon after
obtaining previous reading you will
receive a false-high reading. (Hogan)
the
If an arm is unsupported, client performs
isometric exercises that can increase
diastolic pressure 10%. Placement of the
arm above the level of the heart causes
low reading. (Potter)
Rapid inflation ensures accurate
reading. (Potter)
Too rapid or too slow a decline can
cause inaccurate readings (Potter)
Health Care Module Divine Colleges of Malolos City

Cuff can become significantly

contaminated. (Kozier)

It reduces transmission of
microorganism. (Potter)

It serves as baseline for comparison and

evaluation for change in condition and
alterations. (Potter)

ASSISTING A CLIENT TO TRANSFER FROM BED TO

CHAIR

Purposes : (Kozier)
 To enable the nurse to change the client’s surroundings as well
as position.
 To increse opportunities for socialization

Equipment and Materials :

 Robe or appropriate clothing
 Slippers or shoes with nonskid soles
 Transfer belt
 Chair, commode, wheelchair as appropriate to client need
 Sliding board

Implementation

ACTION RATIONALE
1. Explain the procedure to the It increases client participation and reduces

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client. Offer a bedpan and wash transmission of microorganism. (Potter)

your hands.
It determines client’s ability to assist as
2. Assess the client’s ability to much possible to promote independence
assist in transferring. Move and a sense of control over situation.
equipment as necessary to make (Potter)
room for the chair. Close the
door or curtain.
Having the bed in the lowest position is
3. Position the bed in a low safest in case the client falls. (Hogan)
position.
Non-skid soles decreases risk of slipping
during transfer. Always have the client wear
4. Assist the patient to put on a shoes during transfer; bare feet increases
robe and slippers with non-skid risk of fall. (Potter)
soles.

4.1 Position the chair of at Position chair within easy access for
the bedside.: transfer. (Potter)
a. For a client with
unimpaired mobility: bring
chair close to the bedside
facing the foot of the bed
and if possible, brace the Having them get out of bed on the strong
back of the against a side helps prevent loss of balance and
bedside table. possible falls.
b. For a client with impaired
mobility : position the
chair facing the head or
foot of the bed. When
sitting on the side of the
bed, the client should be
able to stead self by using
the hand on the affected
side to grasp the arm of This is done to avoid accidental moving of
the chair. (Figure 14) the chair and the bed while transferring the

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Health Care Module Divine Colleges of Malolos City

patient. (kozier)
5. Lock the wheel of the chair and
bed; if appropriate , raise the
foot pedals on the wheelchair to The client can sit up move easily if the head
the upward position. of bed is up. (Hogan)

6. Raise the head part of the bed to Moving their legs reduces friction or
the highest position. shearing from the sheets while increasing
the force of the movements;; supporting
7. Assist the client to get to the side their upper body keeps them from falling
of the bed by supporting the backward. Moving from lying position to
patient’s head and neck while sitting position can cause postural
moving the patient’s legs to hypotension, which can lead to dizziness
dangle on the edge of the bed. and a subsequent fall unless the client has
(Figure 14.1) time gather equilibrium. (Hogan)

When you help clients stand, they can assist

you by balancing against your shoulder
while using their leg muscle to stand or by
8. Assist the client to rise to a pushing off the mattress with their hands.
standing position. Keeping your knees against the client’s
a. For the client with knees prevents them from buckling, thus
unimpaired mobility : reducing the risk of a fall. (Hogan)
face the patient and brace
your feet and knees
against the patient. Place
your hand around the
patient’s waist while the
client holds onto you
between the shoulder and
the waist. Use your legs Ability to stand can be maintained in
to help you raise the paralyzed or weak limb with support of the
patient to the standing knee. (Potter)
position.

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Health Care Module Divine Colleges of Malolos City

b. For the client with

impaired mobility : face
the patient and brace
your feet and knees
against the patient. Place
your hands around the
patient, especially against
the affected extremity.
Place your hands around
the patient’s wrist.
Pivot prevent twisting your spine and
The patient may place the causing injury. (Hogan)
unaffected arm to reach
for the arm of the chair
and to push up while
rising to the standing It increases client’s stability and prevents
position. (Figure 14.3) injury to the nurse from poor body
mechanics (Potter)
9. Pivot the patient (on the Moving slowly helps prevent dizziness or
affected limb if applicable) into other discomforts. (Hogan)
the position in front of the chair
with legs position against the
chair.

10. The patient may use one arm

(the unaffected limb if
applicable) and place on the arm
of the chair and steady self while It prevents injury to client from poor body
slowly lowering to sitting alignment (Potter)
position. Continue to brace the
patients’s knees and flex your
own hips and knees when
seating the client. Increased activity may result in symptoms
associated with activity intolerance. These
clients may find transfer very fatiguing and
will need post transfer interventions to

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restore their level of comfort. (Potter)

11. Adjust the patient’s position
using pillows where necessary.
Position the call bell so it is
available for use wash your
hands.

12. Document any observation on

the patient’s response to the
procedure and length of time in
the chair.

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Health Care Module Divine Colleges of Malolos City

MOVING A PATIENT UP IN BED : TWO OR THREE

PERSON – ASSIST

Implementation
ACTION RATIONALE
1. Assess the client’s need and It provides a baseline to determine ability
ability to participate. to assist caregivers and assess the client’s
progress toward improved activity
tolerance and muscle endurance (Potter)

2. Identify the client. This is done to make sure that you are
performing the procedure to the right
client. (Kozier)

3. Explain to the patient the

rationale for the procedure. It decreases anxiety and increases client
cooperation. (Potter)
4. Raise bed to the height at the
center of the gravity. It provides greater stability for the nurse
during working. (Potter)
5. Put bed in flat position.
Repositioning from a flat position
decreases friction and possible shear on
the client’s skin. (Potter)
6. Remove the pillow and place at
the head of the bed.
It reduces interference from bedding
7. Move the client to one side of during positioning procedure. (Potter)
the bed.
It ensures proper body mechanics and
prevents muscle and back strain for the
8. Have the client bend the knee nurse (Potter)
and place the sole of the feet

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Health Care Module Divine Colleges of Malolos City

firmly on the surface of the

bed. (Figure 16) It positions client to exert effort when
mobbing up in the bed. (Potter)
9. Nurse 1 slides his or her arm
under the client’s head and
shoulders. This nurse faces the It prevents trauma to the client’s
foot of the bed. musculoskeletal system by supporting
shoulders and hip joints and every
10. Nurse 2 slides his or her arm distributing weight. (Potter)
under client’s hips from the
same side of the bed. This
nurse also faces the foot of the
bed.

11. The nurse with the heavier

burden (usually nurse 2) counts Counting coordinates movement of both
and both pull the client up in nurses. (Potter)
bed at the same time)

12. On the count, client pulls with Client’s assistance reduces friction and
the arms and pushes with the work load. (Potter)
feet as you pull. From your
position you will pull the
patient up in the bed. In pulling
you use your strong muscles
effectively.
It maintains client’s comfort and body
13. Position client comfortably. alignment. (Potter)

It protects client from falling out of bed.

14. Make sure safety devices are in (Potter)
place.

15. Wash your hands. It reduces transmission of microorganism.

(Potter)
16. Evaluate the client for

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Health Care Module Divine Colleges of Malolos City

alignment and comfort. Prompt identification of poor alignment

reduces risk to client’s skin and
musculoskeletal system.

MOVING A PATIENT CLOSER TO ONE SIDE

Purposes : (Kozier)
To facilitate proper body mechanics when performing essentials
nursing procedure.

Implementation
ACTION RATIONALE

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Health Care Module Divine Colleges of Malolos City

1. Assess client’s needs and It provides a baseline to determine ability

ability to participate. to assist caregivers and assess the client’s
progress toward improved activity
tolerance and muscle endurance (Potter)

2. Identify the client.
3. Explain to the patient
rationale for the procedure.
4. Raise bed to the height at the
center of the gravity.
5. Put bed in flat position.
6. Slide your arms under client’s
head and shoulders and pull
that section of the
towards you. Be sure to bend
your hips and knees, keeping
your back straight. (Figure 17)
7. Move your hands and arms
down to the client’s hips and
pull that section of the body.
Keep you back straight and
your hips and knees flexed.
(Figure 17.1)
This is done to make sure that you are
performing the procedure to right client.
(Kozier)
the
It decreases anxiety and increases client
cooperation (Potter)
It provides greater stability for the nurse
during working. (Potter)
Repositioning from a flat position
decreases friction and possible shear on
client’s skin. (Potter)
body
It maintains proper body alignment. It
brings you closer to the object to be
moved. It lowers center of gravity. It uses
thigh muscle rather that back muscle.
(Potter)

8. Move your hand and arms

under the client’s legs and pull Facing the direction of the movement
towards you. (Figure 17.2) ensures proper balance. Flexing the knees
lowers your center of gravity and uses
thigh muscles rather then your back

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Health Care Module Divine Colleges of Malolos City

9. Repeat in sequence until the muscles.

client is in correct position to
the bed.

10. Make sure safety devices are in

place. It protects clients from falling out of bed.
(Potter)
11. Wash your hands.

12. Evaluate the client for It reduces transmission of microorganisms.

alignment and comfort. (Potter)

Prompt identification of poor alignment

reduces risk to client’s skin and
musculoskeletal. System (Potter)

TRANSFERRING A CLIENT FROM BED TO STRETCHER

(THREE-CARRIER LIFT)

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Health Care Module Divine Colleges of Malolos City

Purposes : (Kozier)
A stretcher or gurney is used to transfer supine clients from one location to
another. Whenever the client is capable of accomplishing the tansfer from bed to
stretcher independently, either by lifting onto it or by rolling onto it, the client should
be encourae to do. If the client cannot move on the stretcher independently, at least
two nurses if client is totally helpless or is heavy.

Equipment :
• Stretcher
• Linen
• Sliding board (optional)
I
Implementation

ACTION RATIONALE
1. Explain the procedure to the This is done to alleviate anxiety and to
client. ensure maximal cooperation. (Kozier)
2. Place the stretcher at the right
angle to the foot of the bed. Lock It is done to align stretcher and bed for
the wheels of the bed and wheels safety transfer. (Potter)
of the stretcher. Raise the bed to
the height of the stretcher. (Figure It is easier to the client to move down a
18) slant. (Kozier)
3. Decide on the responsibility for
the lift. Each person must support In this procedure, each nurse bears only
the section of the body. a third of the client’s weight. (Hogan)
a. head, shoulders and chest.
b. Hips The wider the base of support and lower
c. Thigh and legs center of gravity, the grate stability when
4. lifting .(Kozier)

It distributes client’s weight over

forearms of lifter. (Potter)

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Health Care Module Divine Colleges of Malolos City

It moves work load over lifter’s to work

together and safely lift the client. (Potter)

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