Blood Pressure

Question 1

List the steps in the Blood Pressure procedure

Answer 1

1. Do initial steps procedure.
2. Clean the earpieces and diaphragm of the stethoscope with an antiseptic wipe.
3. Uncover the resident’s arm to the shoulder.
4. Rest the resident’s arm level with the heart with palm upward on a comfortable surface.
5. Wrap a proper sized sphygmomanometer cuff around the upper unaffected arm approximately 1-2 inches above the elbow.
6. Put the earpieces of stethoscope in your ears.
7. Place the diaphragm of stethoscope over the brachial artery at the elbow.
8. Close the valve on the bulb. If blood pressure is known, inflate the cuff to 20 mm/hg above the usual reading. If blood pressure is unknown, inflate the cuff to 160 mm/hg.
9. Slowly open the valve on the bulb.
10. Watch the gauge and listen for the sound of a pulse.
11. Note the gauge reading at the first pulse sound.
12. Note the gauge reading when the pulse sound disappears.
13. Completely deflate and remove the cuff.
14. Accurately record systolic and diastolic readings.
15. Do final steps procedure.
16. Report any unusual findings to the nurse.

Question 2

What is the rationale for step “2. Clean the earpieces and diaphragm of the stethoscope with an antiseptic wipe.”?

Answer 2

Reduces pathogens and prevents the spread of infection.

Question 3

What is the rationale for step “4. Rest the resident’s arm level with the heart with palm upward on a comfortable surface.”?

Answer 3

A false low reading is possible, if heart is above heart level.

Question 4

What is the rationale for step “5. Wrap a proper sized sphygmomanometer cuff around the upper unaffected arm approximately 1-2 inches above the elbow.”?

Answer 4

The cuff must be proper size and placed on arm correctly so the amount of pressure on the artery is correct. If not, the reading will be falsely high or low.

Question 5

What is the rationale for step “6. Put the earpieces of stethoscope in your ears.”?

Answer 5

The earpieces should fit into your ears snugly to make hearing easier.

Question 6

What is the rationale for step “8. Close the valve on the bulb. If blood pressure is known, inflate the cuff to 20 mm/hg above the usual reading. If blood pressure is unknown, inflate the cuff to 160 mm/hg.”?

Answer 6

Inflating the cuff too high is painful and may damage small blood vessels.

Question 7

What is the rationale for step “9. Slowly open the valve on the bulb.”?

Answer 7

Releasing the valve slowly allows you to hear the beats accurately.

Question 8

What is the rationale for step “11. Note the gauge reading at the first pulse sound.”?

Answer 8

The first sound is the systolic pressure.

Question 9

What is the rationale for step “12. Note the gauge reading when the pulse sound disappears.”?

Answer 9

The last sound is the diastolic pressure.

Question 10

What is the rationale for step “13. Completely deflate and remove the cuff.”?

Answer 10

An inflated cuff left on a resident’s arm can cause numbness and tingling. If you must take their blood pressure again, completely deflate the cuff and wait 30 seconds. Never partially deflate a cuff and then pump it up again. The blood vessels will be damaged and the reading will be falsely high or low.

Question 11

What is the rationale for step “14. Accurately record systolic and diastolic readings.”?

Answer 11

Record the readings immediately so you won’t forget. Accuracy is necessary because decisions regarding the resident’s care may be based on your report. What you write is a legal record of what you did. If you don’t document it, legally, it didn’t happen.

Question 12

What is the rationale for step “16. Report any unusual findings to the nurse.”?

Answer 12

Provides the nurse with the information to properly assess the resident’s condition.