Assessment: Blood Pressure

Medical Equipments:

• Alcohol swabs
• Stethoscope
• Sphygmomanometer

Nursing Procedures:

1. Identify the extremity that is most appropriate for reading. Furthermore do not take blood pressure reading on an injured or painful extremity or on in which an intravenous line is running
2. Select a cuff size to completely encircle upper without overlapping
3. Move clothing away from upper arm
4. Position arm at heart level, extend elbow with palm turned upward
5. Make sure bladder cuff is fully deflated and pump valve move freely
6. Identify brachial artery in the antecubital space
7. Apply cuff snugly and smoothly over upper arm about 2.5 cm (1 inch) above antecubital space with center of cuff over brachial artery
8. Connect bladder rubbing to manometer tubing or if a portable mercury-filled manometer is used, position vertically at eye level
9. Palpate brachial artery, then turn valve clockwise to close and compress bulb to inflate cuff to 30 mg Hg above point where palpated pulse disappears.
10. Slowly deflate cuff and noting reading when pulse is felt again.
11. Insert earpiece of stethoscope in ears with a forward tilt and ensure that the diaphragm hangs freely
12. Relocate brachial pulse with your non-dominant hand and place bell or diaphragm chestpiece directly over pulse. The chestpiece of stethoscope should be in direct contact with skin and not touch cuff. see picture
    
13. Close the valve with dominant hand by turning it clockwise then compress pump to inflate cuff until manometer reach 30 mm Hg above diminished pulse point
14. Turn valve counterclockwise slowly so the mercury falls at 2-3 mm Hg per second. Listen for five phase of Korotkoff's sounds while noting manometer reading. A fain, clear tapping sound appear and increase in intensity (phase I), sound swishes (phase II), sound intense (phase III), abrupt and distinctive muffled sounds (phase IV), and sound disappears (phase V)
15. Deflate cuff rapidly and completely
16. Remove cuff or wait 2 minutes before taking a second reading
17. Record and inform patient about result
18. Put all equipment and store in proper place
19. Wash hands
20. Document the result in patient's medical record and compare with patient's baseline data and normal range for age group
21. If there are abnormal result, measure again and report abnormal result to instructor or nurse in charge