NUR 111: SKILL 5-5: ASSESSING ARTERIAL BLOOD PRESSURE ASSESSING 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 or  Stage I or  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!