Proc7 measure vs_bp
- 1. Page 1 of 3 Republic of the Philippines NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY General Tinio, Cabanatuan City, Nueva Ecija ClinicalLearningSkillsLaboratory HEALTH ASSESSMENT (NCM 101) CHECKLIST: vital signs: Blood Pressure Name: ______________________________________________________________ Score: Block: ________________________ Date:____________________________ PROCEDURE Assessing Blood Pressure Performed Comments YES NO ASSESSMENT 1. Assess: Signs and symptoms of hypertension / hypotension Factors affecting blood pressure 2. Determine: The policies and procedures for the facility The client’s record for medications that may increase or decrease the Blood Pressure PLANNING 1. Assembleequipmentandsupplies: Stethoscope Blood pressure cuff of the appropriate size Sphygmomanometer IMPLEMENTATION 1. Priorto performingtheprocedure,introduceselfand verifythe client’sidentityusingagencyprotocol. Explain to the client what youare going to do, why it is necessary, and how he or she can participate. 2. Wash handsand observeother appropriateinfection control procedures. 3. Provideforclientprivacy. 4. Place the client in the appropriate position. The adult client should be sitting unless otherwise specified. Both feet should be flat on floor. The elbow should be slightly flexed with the palm of the hand facing up and the forearm supported at the heart level. Expose the upper arm. 5. Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the center ofthe bladder directly over the artery.
- 2. Page 2 of 3 Remarks: _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ RatingScale: Excellent : 96 – 100% _______________________________________________ Very Satisfactory : 90 – 95% Student’sPrintedName and Signature Very Good : 85 – 89% Good : 80 – 84% ___________________________________ Fair : 75 – 79% Skill LaboratoryInstructor For an adult, place the lower border of the cuff approximately 2.5 cm (1 inch) above the antecubital space. 6. If this is the client’s initial examination, perform a preliminary palpatory determination ofsystolic pressure. Palpate the brachial artery with the fingertips. Close the valve on the pump by turning the knob clockwise. Pump up the cuff until you no longer feel the brachial pulse. At that pressure,the blood cannot flow through the artery. Note the pressure on the sphygmomanometer at which pulse is no longer felt. Release the pressure completely in the cuff, and wait one to two minutes before making further measurements. 7. Position the stethoscope appropriately. Cleanse the earpiece with alcohol or recommended disinfectant. Insert the ear attachment of the stethoscope in your ears so that they tilt slightly forward. Ensure that the stethoscope hangs freely from the ears to the diaphragm. Place the bell side of the amplifier of the stethoscope over the brachial pulse. Hold the diaphragm with the thumb and index finger. 8. Auscultate the client’s blood pressure Pump up the cuff until the sphygmomanometer reads 30 mm Hg above the point where the brachial pulse disappeared. Release the valve on the cuff carefully so that the pressure decreases at the rate of 2-3 mm Hg per second. As the pressure falls, identify the manometer reading. Deflate the cuff rapidly and completely. 9. When the device has determined the blood pressure reading, note the digital results. 10. Remove the cuff. 11. Wipe the cuff with an approved disinfectant. EVALUATION AND DOCUMENTATION 12. Document the Blood Pressure in Vital Signs Record sheet 13. Report abnormal results to the primary care provider. 14. Document the procedure in the Client’s record. TOTAL:
- 3. Page 3 of 3 Poor : 74 and below