NUR 111: SKILL 5-5: ASSESSING ARTERIAL

BLOOD PRESSUREASSESSING A BLOOD PRESSURE: I FEEL THIS IS ONE OF THE MOST IMPORTANT SKILLS, AS A NURSE, THAT YOU WILL EVER LEARN. IT IS VITAL

THAT YOU LEARN THIS SKILL CORRECTLY. A SINGLE BLOOD PRESSURE READING CAN SAY SO MUCH ABOUT A PATIENT’S HEALTH & WELL BEING.

ASSESSING ARTERIAL BLOOD PRESSURE

Blood pressure is the force exerted by blood against the vessel walls.

The standard unit for measuring blood pressure is millimeters of mercury (mm Hg).

The most common technique of measuring blood pressure is auscultation with a sphygmomanometer & stethoscope.

As the sphygmomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases.

HYPERTENSION & HYPOTENSION

Hypertension Hypertension is a major factor

underlying death from heart attach & stroke in the U.S. & Canada.

Hypertension is defined as systolic blood pressure (SBP) of 140 mm Hg, or greater, diastolic blood pressure (DBP) of 90 mm Hg or greater or taking antihypertensive medication.

The diagnosis of hypertension in adults requires the average of two or more readings taken at each of two or more visits after an initial screening.

Hypotension Hypotension occurs when the

systolic blood pressure falls to 90 mm Hg or below.

Although some adults normally have a low blood pressure, for most people a low blood is an abnormal finding associated with illness.

Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness or dizziness) and low blood pressure when rising to an upright position.

Classification of Blood Pressure for Adults Ages 18 Years & Older

Category Systolic (mm Hg) Diastolic (mm Hg)

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage I 140-159 or 90-99

Stage II >160 or >100

JUST A QUICK REMINDER: ALSO, PLEASE FEEL FREE TO PRINT THIS PAGE & KEEP IT WITH YOU

PERFORMING A BLOOD PRESSURE

This skill needs to be practiced, practiced & practiced in the nursing skills lab!

There is no video provided for this in the skills book, but even if there was, this skill cannot be passed without going to the skills lab and Practicing!

I will talk briefly about this skill, but you know what I’m going to say…if you don’t practice this skill, as with most other skills, you won’t pass it!

PERFORMING A BLOOD PRESSURE

Expected outcome following completion of procedure:

Blood pressure is within acceptable range for patient’s age.

Explain to patient that you will assess their blood pressure.

Have them rest for at least 5 minutes before measuring, lying or sitting blood pressure & 1 minute before measuring a standing blood pressure.

Ask patient not to speak while you are measuring their blood pressure.

Be sure that patient has not exercised, ingested caffeine, or smoked for 30 minutes before assessment of blood pressure.

Have patient assume sitting or lying position. Be sure that the room is warm, quiet & relaxing.

Perform hand hygiene

PERFORMING A BLOOD PRESSURE – CONT’D Implementation:

Assess blood pressure by auscultation:

A: Upper extremity: With patient sitting or lying, position their forearm at heart level with palm turned up.

B: Lower Extremity: With patient prone, position patient so knee is slightly flexed.

Leg crossing can falsely increase blood pressure.

Expose extremity

Palpate brachial artery or popliteal artery.

With cuff fully deflated, apply bladder or cuff above artery by centering arrows marked on cuff over artery.

Position cuff 2.5 cm (1 inch) above site of pulsation (antecubital or popliteal space).

With cuff fully deflated, wrap it evenly and snugly around upper arm.

Position manometer gauge vertically at eye level – you should be no farther than 1 meter

Measure blood pressure

PERFORMING A BLOOD PRESSURE – CONT’D Again, I’m not going to discuss this skill in detail.

The only way to learn this skill is to PRACTICE in the nursing skills lab!

One of the last things I’m going to discuss is the Korotkoff Phases

Again: As the sphygomomanometer cuff is deflated, the five different sounds heard over an artery are called Korotkoff phases. The sound in each phase has unique characteristics.

Blood pressure is recorded with the systolic reading, before the diastolic (beginning of the fifth Korotkoff sound).

The difference between systolic and diastolic pressure is the pulse pressure.

For a blood pressure of 120/80, the pulse pressure is 40.

KOROTKOFF PHASES

SYSTOLIC & DIASTOLIC PRESSURE

END OF THE SKILL

If you practice, in the nursing skills lab, with a study partner, you should have no trouble passing this skill!

Again, my other power-point presentations have more detail, but for this particular skill, I need you to read the book & PRACTICE!

This skill requires practice and patience. A nursing instructor will be listening when

you count the blood pressure on “a patient”, so your numbers need to be accurate!

Practice, Practice, Practice & Good Luck!