Blood Pressure Flashcards
(17 cards)
Definition
To take systolic, diastolic, and pulse pressure.
To determine certain physiologic changes that may occur.
To determine the pumping action of the heart.
To aid in diagnosis.
To evaluate the general condition of the patient.
Special Considerations
- Keep patient physically and emotionally rested before taking the blood pressure.
- For required repeated take blood pressure in the same arm, in the same position and time.
- Take blood pressure reading as quickly as possible to prevent venous congestion.
- Allow 20-30 seconds for venous circulation to return to normal if repeated reading is necessary.
- Report promptly to the physician or head nurse any significant change in blood pressure.
- Size of cuff should be appropriate to the size of the patient’s arm
Equipment
Sphygmomanometer
Appropriate sized blood pressure cuff
Stethoscope
Step 1 + rationale
Place patient in a comfortable position with the arm supported and palm upward.
- This position places the brachial artery so that the stethoscope csn rest on it conveniently in the antecubital area.
Step 2
Roll patientcs gown above the elbows; Choose proper BP cuff size; place the cuff so that the inflatable bag is centered over the brachial artery. The lower edge of cuff is 2cm above the antecubital fossa.
Step 2 rationale
Most measurement errors occur by not taking the time to choose the proper cuff size. Proper placement of the cuff pressure applied directly over the artery will yield most accurate reading.
Step 3 + rationale
Wrap the cuff smoothly around the arm and tuck end of cuff securely under preceeding wrapping.
- A twisted cuff and wrapping could produce unequal pressure and an inacurrate reading.
Step 4 + rationale
Place yourself so that aneroid gauge can be read at eye level, and no more than 3 feet away.
- If the eye level is above or below aneroid gauge, parallax will give an inaccurate reading.
Step 5 + rationale
Use the fingertips to feel for a strong pulsation in the antecubital space
- Accurate blood pressure readings are possible when the stethoscope is directly over the artery.
Step 6 + rationale
Place the bell of the stethoscope on the brachial artery in the antecubital space where the pulse was noted without causing too much pressure.
- Sound transmission can be distorted when source and reception are misaligned.
Step 7 + rationale
Pump the bulb of manometer until the mercury rises to approximately 20-30 mmHg above the anticipated systolic pressure.
- Pressure in the cuff prevents blood from flowing through the brachial artery.
Step 7 + rationale
Pump the bulb of manometer until the mercury rises to approximately 20-30 mmHg above the anticipated systolic pressure.
- Pressure in the cuff prevents blood from flowing through the brachial artery.
Step 8
Using the valve on the bulb, release 2-3 mm per heartbeat and note on the manometer the point at which the first sound is heard, record this figure as the systolic pressure.
Step 8 rationale
Systolic pressure is that point at which the blood in the brachial artery is first able to force its way through, against the pressure exerted on the vessel by the cuff of the manometer.
Step 9 + rationale
Continue to release the air in the cuff evenly and gradually. Sounds may become a bit “muffled”.
- The artery is open, but still partly occluded.
Step 10
Note the reading on the manometer when the last distinct loud sound is heard. Record this figure as the diastolic pressure.
Step 11 + rationale
Allow the remaining air to escape quickly, remove the cuff and cleanse the equipment.
- Parallax is the apparent changebof position of an object when seen from two different points.
