Obtaining blood pressure steps and process PDF

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Steps on how to obtain blood pressure, using the AHA guidelines....

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9/4/2021

Elsevier

Skills Obtaining Blood Pressure by the Two-Step Method Quick Sheet ALERT

1. Verify the health care provider’s orders. 2. Gather the necessary equipment and supplies. 3. Provide for the patient’s privacy. 4. Perform hand hygiene. 5. Check the patient’s baseline reading, and determine the best site to use. For example, if the patient is receiving intravenous fluids in the left arm, use the right arm to take the blood pressure. 6. Introduce yourself to the patient and family, if present. 7. Identify the patient using two identifiers, such as name and date of birth or name and account number. Compare these identifiers with the information on the patient’s identification bracelet. 8. Explain the procedure to the patient and ensure that he or she agrees to treatment. 9. Position the patient’s forearm, supported if needed, at heart level with the palm facing up. If the patient is sitting, instruct him or her to keep the feet flat on the floor with the legs uncrossed and back supported. If the patient is supine, ensure the legs are not crossed. Placement of the arm above heart level causes a falsely low reading of about 2 mm Hg for each inch (2.5 cm) above heart level. 10. Expose the upper arm fully by removing any constricting clothing. Do not place the BP cuff over clothing. 11. Ensure that you have the appropriate size blood pressure cuff for the patient. The cuff ’s width should be 40% of the circumference of the midpoint of the limb on which it will be used. The cuff ’s bladder should encircle at least 80% of the upper arm. 12. Palpate the patient’s brachial artery in the antecubital space. 13. Apply the BP cuff. Position the cuff in the antecubital space. Apply the cuff above the artery by centering the arrows marked on the cuff over the artery so that the end of the cuff is 2 to 3 cm above the antecubital fossa to allow room for placement of the stethoscope. If the cuff has no center arrows, estimate the center of the bladder and place it over the artery. Wrap the fully deflated cuff evenly and snugly around the patient’s upper arm. 14. Position the manometer vertically at eye level, and stand no more than 1 yard away from it. 15. Ask the patient not to speak while BP is being measured. 16. Using the fingertips of your nondominant hand, palpate or auscultate the brachial artery distal to the cuff while inflating the cuff with your other hand. 17. Note the point at which the pulse disappears, and continue to inflate the cuff 30 mm Hg higher. Note that point, and then slowly deflate the cuff. 18. Note the point at which the pulse reappears. This is the palpated systolic pressure. The measurement is expressed in millimeters of mercury (mm Hg). 19. Fully deflate the cuff and wait 30 seconds. 20. Clean the earpieces, diaphragm and bell of the stethoscope with alcohol swabs. 21. Place the stethoscope earpieces in the ears and make sure sounds are clear, not muffled. 22. Locate the brachial or radial artery as appropriate and place the diaphragm of the stethoscope over it below the bottom of the cuff. Do not let the chest piece touch the cuff or clothing. Do not place the diaphragm under the cuff or place excessive pressure on the stethoscope head. If unable to palpate the artery because of weakened pulse, use an ultrasonic stethoscope. 23. Turn the valve of the pressure bulb clockwise until tight. Quickly inflate the cuff above the patient’s estimated palpated systolic pressure, the patient’s previously documented systolic pressure, or the point at which Korotkoff sounds cease. 24. Slowly release the pressure bulb valve, allowing the manometer needle to fall slowly and continuously at a rate of 2 to 3 mm Hg per second. Observe the point on the manometer at which the first Korotkoff sound is heard, indicating the systolic BP. The sound will slowly increase in intensity. 25. Continue to deflate the cuff gradually; note the point on the manometer at which all Korotkoff sounds disappear, indicating the diastolic BP. 26. When the sounds disappear, quickly deflate the cuff completely. Discuss the findings with the patient, as needed. Remove the cuff. 27. For greater accuracy, take the patient’s blood pressure again in 2 minutes. Use the second set of measurements as the baseline. 28. If this is the patient’s first BP assessment, repeat the procedure on the other arm. If there is a consistent difference between the blood pressure in the patient’s arms, use the arm with the higher pressure. 29. To complete the procedure, help the patient return to a comfortable position and return any removed clothing, inform the patient of the blood pressure reading, as appropriate, and report abnormal values to the practitioner. 30. Perform hand hygiene. 31. Clean the BP cuff per the manufacturer’s instructions and the organization’s practice. Clean the earpieces and diaphragm of the stethoscope, if applicable, per the organization’s practice. 32. Compare your findings with the classification of blood pressure for adults: , a. Normally, the systolic pressure is less than 120 mm Hg, and the diastolic pressure is less than 80 mm Hg. b. With elevated blood pressure, the systolic pressure is 120 to 129 mm Hg, and the diastolic pressure is less than 80 mm Hg. c. In stage 1 hypertension, the systolic pressure is 130 to 139 mm Hg, or the diastolic pressure is 80 to 89 mm Hg. d. In stage 2 hypertension, the systolic pressure is at least 140 mm Hg, or the diastolic pressure is at least 90 mm Hg. 33. As part of your follow-up care, compare this BP measurement to the patient’s baseline readings.

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34. Help the patient into a comfortable position, and place toiletries and personal items within reach. 35. Place the call light within easy reach, and make sure the patient knows how to use it to summon assistance. 36. To ensure the patient’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. 37. Dispose of used supplies and equipment. Leave the patient’s room tidy. 38. Remove and dispose of gloves, if used. Perform hand hygiene. 39. Document and report the patient’s response and expected or unexpected outcomes.

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