Programs

Measuring Blood Pressure

Written by Hollie Finders, RN
Hollie Finders is a registered nurse with years of experience working in the health care field. She has degrees in both biochemistry and nursing. After working with patients of all ages, Hollie now specializes in pediatric intensive care nursing. Hollie’s LinkedIn

Procedure for Measuring Blood Pressure

Equipment needed: Stethoscope and sphygmomanometer (blood pressure cuff).

  1. Perform hand hygiene.
  2. Explain the procedure to the patient and ask for their assistance in following directions.
  3. Assist the patient into a supine or sitting position. Allow the patient to rest in this position for 5 minutes.
  4. Roll up the patient’s sleeve to expose the patient’s bare arm. Do not attempt to measure blood pressure through clothing.
  5. Grab the blood pressure cuff, open the valve of the pump, and ensure the cuff is completely deflated.
  6. Locate the pulse of the brachial artery, found in the medial aspect of the antecubital fossa (bend of the elbow). Once found, keep your finger on this spot while you align it with the artery marker on the blood pressure cuff.
  7. Secure the blood pressure cuff snugly around the patient’s arm, approximately 2 finger widths (1-1.5 inches) above the elbow. Ensure that the cuff is the proper size, taking up 40% of the upper arm.
  8. Position the arm at the level of the heart with the patient’s palm facing up. If the patient is sitting, make sure the arm is supported.
  9. Fixate the blood pressure gauge where it can be clearly seen.
  10. Put the earpieces of the stethoscope in your ears and place the diaphragm of the stethoscope in the antecubital fossa directly over the brachial artery.
  11. Holding the stethoscope in place with one hand, use your other hand to close the valve of the pump, turning the valve clockwise until it stops. Avoid over-tightening the valve.
  12. Inflate the cuff quickly to approximately 30 mmHg above the estimated systolic pressure.
  13. With your thumb and index finger, open the valve just slightly. Allow the cuff to deflate slowly, at a rate of 2 to 3 mmHg per second.
  14. Watch the gauge closely and note the reading in which the first clear pulse sound is heard. This is the systolic pressure.
  15. Continue deflating the cuff while watching the gauge. Take note of when the pulse can no longer be heard or when the pulse is no longer distinct and sounds muffled. This is the diastolic pressure.
  16. Allow the cuff to deflate 10 to 20 mmHg beyond the diastolic pressure and then open the valve completely to deflate the cuff.
  17. Remove the cuff from the patient’s arm.
  18. If you miss the systolic or diastolic reading, do not reinflate the cuff. Remove the cuff and wait at least one minute before using the same arm to retake the blood pressure.
  19. Perform hand hygiene.
  20. Record the systolic and diastolic pressures, the patient’s position, and which arm was used in the patient’s chart. Notify the nurse of any changes in the patient’s condition.

Important Information about Measuring Blood Pressure

Many factors can interfere with obtaining an accurate blood pressure. The most common mistakes that lead to inaccurate blood pressures are a result of improper technique, including: not supporting the patient’s arm, using the wrong sized cuff, positioning the cuff too low on the patient’s arm, improper positioning of the cuff’s artery marker, and attempting to measure blood pressure through clothing [1]. It is also important to avoid taking a blood pressure in a side that has undergone mastectomy, has paralysis from a stroke, has an IV or dialysis catheter, has had recent trauma, or has severe burns [2,3,4,5].

By: Hollie Finders RN

References

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911816/

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652571/

3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399466/

4. https://www.ncbi.nlm.nih.gov/pubmed/12358628

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053079/

More Resources

Passive Range of Motion Exercises

Range of motion exercises are used to help prevent or decrease contractures, improve flexibility of joints, and improve strength [1]. Bedridden patients as well as those with reduced mobility may greatly benefit from passive range of motion exercises. However, do not perform these exercises without an order to do so, as it may be contraindicated in certain situations.

Handwashing for CNAs

Handwashing is considered the single most important practice to prevent the spread of infection. Even when hands look clean, they could potentially be crawling with dangerous microorganisms and pathogens. Using soap and friction during handwashing helps loosen the oils on the skin, allowing dirt and pathogens to be rinsed away.

Indwelling Catheter Care

Indwelling catheters allow urine to drain from the bladder. They are used when residents are unable to urinate on their own or when the process of cleaning the resident after urination would be difficult for the resident to tolerate (such as during end of life care). Caring for the catheter appropriately is a vital part of preventing infection and skin breakdown.

Measuring the Radial Pulse

The radial artery, located in the wrist, is easy to feel and an efficient location to measure heart rate. Changes to the rhythm or strength of the radial pulse can indicate heart disease, damage to the arm, or body fluid status. It is important to remember to check the radial pulse on both sides as differences between left and right can indicate injury or disease processes.

Measuring the Apical Pulse

The apical pulse rate is the most accurate non-invasive measurement of heart rate because it is measured directly over the apex of the heart. Apical pulse is preferred in cases when the radial pulse is difficult to palpate, when the pulse is irregular, greater than 100 beats per minute, or less than 60 beats per minute when measured by other means (electronic, radial, etc.).

Making an Occupied Bed

If a patient is bedridden or on bedrest, the bed linens will need to be changed while the patient is in the bed. For safety reasons, the nurse’s aid should avoid making an occupied bed if the patient is able to get out of bed. Bed linens should be changed according to the facility’s policy or anytime they are wet or soiled.

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