11 Assessing Arterial Blood Pressure
Assessment
- Identified factors that normally influence blood pressure.
- Determined client baseline blood pressure from client record.
Nursing Diagnosis
- Identified the purpose and risks associated with assessing arterial blood pressure.
Planning
- Identified expected outcomes.
- Explained procedure to client.
- Selected appropriate cuff size.
Evaluation
- Established client’s baseline blood pressure. Compared blood pressure with client’s baseline and normal range.
- Identified unexpected outcomes.
- Reported and recorded blood pressure correctly.
Assessing Arterial Blood Pressure – Implementation
- Performed hand hygiene.
- Provided privacy.
- Positioned client forearm at heart level with palm of hand turned up. Feet or legs not crossed.
- Removed constricting clothing from around upper arm.
- Palpated brachial artery, positioned cuff 2.5 cm (1 in) above brachial artery, and wrapped cuff evenly and snugly around upper arm.
- Positioned manometer at eye level.
- Measured blood pressure.
- Two-step method:
- Located radial pulse. Palpated the artery distal to the cuff while inflating the cuff rapidly to 30 mm Hg above point where pulse disappeared. Noted point when pulse appeared while deflating cuff slowly. Wait 30 seconds after deflating cuff before auscultation.
- Checked stethoscope.
- Applied stethoscope over brachial artery.
- Tightened valve of bulb. Quickly inflated cuff to 30 mm Hg above palpated systolic pressure.
- Allowed mercury/needle to fall evenly at rate of 2 to 3 mm Hg/sec during auscultation.
- Noted point on manometer when first clear sound is heard.
- Continued to deflate cuff gradually, noting point at which sound disappeared. Deflate cuff quickly.
- One-step method:
- Placed stethoscope pieces in ears and ensured sounds were clear.
- Placed diaphragm of stethoscope over brachial artery.
- Closed valve of bulb. Quickly inflated cuff to 30 mmHg above client usual systolic blood pressure.
- Slowly released bulb valve and allowed mercury needle to fall at a rate of 2 to 3 mm Hg/sec. noted point on manometer when first clear sound is heard.
- Continued to deflate cuff gradually, noted point at which sound disappeared. Deflated cuff quickly.
- Removed cuff.
- Repeated procedure on other arm if first assessment.
- Assisted client in comfort measures.
- Informed client of blood pressure reading.
- Cleaned earpieces and diaphragm of stethoscope with alcohol swab.
Faculty Comments
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