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Manual Reading

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Electronic Reading

Prior to Treatment: (Critical Thinking)

• Gather appropriate physical assessment equipment: stethoscope and blood pressure cuff.
• Consider age and physical size related variations for exam.
• Evaluate baseline and factors influencing vital signs.

Prior to Treatment: (Critical Thinking)

• Gather appropriate physical assessment equipment: blood pressure cuff.
• Consider age and physical size related variations for exam.
• Evaluate baseline and factors influencing vital signs.

Patient Interaction: (Safety)

• Patient identifiers.
• Create appropriate physical environment.
• Provide privacy.
• Explain procedure.
• Clean equipment prior to use.
• Wash hands.
• Assessment for best limb (avoid injured or painful extremity or one with condition contraindicating use).

Patient Interaction: (Safety)

• Patient identifiers.
• Create appropriate physical environment.
• Provide privacy.
• Explain procedure.
• Clean equipment prior to use.
• Wash hands.
• Assessment for best limb (avoid injured or painful extremity or one with condition contraindicating use).

Steps of Procedure: Manual Reading (Patient Centered Care)

1. Evaluate appropriate cuff size.
1. Width: 40-50% of limb circumference.
2. Length: Bladder of cuff to completely encircle the arm without overlap.
2. Position client.
1. Sitting or recumbent with forearm supinated and slightly flexed at the heart level.
3. Remove clothing as necessary to expose extremity.
4. Place cuff around the upper arm with the center of the bladder over the artery. The lower edge of the cuff should be about 3 am above the antecubital fossa.
5. Palpate the artery.
6. Palpate the brachial or radial pulse, distal to the cuff. Close air valve and rapidly inflate the cuff to 30 mm Hg above when the pulse is no longer felt.
7. Place stethoscope gently over the artery.
8. Slowly open the valve and release the air, allowing the pressure to drop 2-3 mm Hg per heart beat.
9. Auscultate for BP sounds without re-inflating the cuff.
10. Note the first sound heard (systolic blood pressure).
11. Note when sound becomes inaudible (diastolic blood pressure).
12. Fully deflate cuff rapidly and remove from arm.
13. Wait 2 minutes before taking another blood pressure.

Steps of Procedure: Electronic Reading (Patient Centered Care)

1. Plug in machine.
2. Connect dual air hose to back of monitor.
3. Evaluate appropriate cuff size.
1. Width: 40-50% of limb circumference.
2. Length: Bladder of cuff to completely encircle the arm without overlap.
4. Position client.
1. Sitting or recumbent with forearm supinated and slightly flexed at the heart level.
5. Remove clothing as necessary to expose extremity.
6. Place cuff around the upper arm with the center of the bladder over the artery. The lower edge of the cuff should be about 3 am above the antecubital fossa.
7. Turn on machine and follow manufacturer"s instructions.
8. Obtain reading.
9. Remove cuff.

After Procedure (Patient Centered Care, Safety)

• Provide appropriate nursing management for abnormal findings.

After Procedure (Patient Centered Care, Safety)

• Provide appropriate nursing management for abnormal findings.

Documentation (Informatics, Communication)

• Outcome of assessment.
• Interventions used for nursing management of care.
• Patient"s response to interventions.

Documentation (Informatics, Communication)

• Outcome of assessment.
• Interventions used for nursing management of care.
• Patient"s response to interventions.