Nursing Procedure

Nursing Procedure : Measuring Blood Pressure

Theorical Note

Blood pressure (BP) is the pressure that the blood exerts on the walls of arteries. The source of the blood pressure is the heart, pumping the blood into the aorta. The blood pressure rises and falls during the cardiac cycle. This is caused by the heart, which has two basic phases – systole and diastole. Systole is the contraction (i.e. contraction of the atrium or a chamber during which the blood is expelled from the appropriated section). Diastole is the period of the cardiac cycle between the two systoles, when the heart muscle is relaxed and filled with blood. Depending on the heart’s activity, the further distinguishing systolic blood pressure -induced by contraction of the chambers and diastolic blood pressure where the heart chambers are resting. The highest value of blood pressure is achieved in the systole phase; the lowest at the end of diastole phase

Blood pressure values

According to the WHO definition, the optimal value of the blood pressure is around 120/80 mmHg, (mmHg stands for the measured values of mercury in the mercury column).

Objective
After studying this chapter, you should be able to:
• List the most common places for measuring blood pressure;
• Demonstrate this procedure using a model or simulator in the laboratory and later in clinical practice;
• Assess the risks of potential complications;
• Explain the terms related to the measurement of blood pressure;
• Evaluate the significance of changes in the measured values of blood pressure;
• Implement selected methods for measuring blood pressure
Purpose
• To collect information on the patient’s condition;
• To assess the patient’s condition;
• Incidence of pathological values in the monitored physiological function;
• Prevention of heart disease and blood vessels disease;
• Measuring blood pressure before and after surgery;
• Measuring blood pressure as part of preventive examinations.
Patient preparation
• The patient is informed of the reason, method and frequency of measuring the blood pressure.
• The patient is informed about cooperation when measuring the blood pressure.
• The patient is informed of the measured blood pressure value.
• The patient is informed of the physiological blood pressure values.
• The patient is informed of the potential treatment.
• The patient must not smoke or drink black coffee before measuring BP.
• The patient must rest for at least 5 minutes before measuring.
• It is important to obtain all information from the patient regarding other treatments (possibility of influencing BP).
• BP is always measured in the same position of the patient, and if permitted by their condition, also on the same limb.
• Patient, who is concerned about the procedure or is nervous and unstable, need to be fully reassured; wait a while then repeat the BP measuring after about 30 minutes.
• The patient is put into an appropriate position, usually sitting or lying down on the left arm.
Preparation of aids
• A functional tonometer is selected for measuring BP.
• Prepare a suitable, disposable PVC pad which is put under the cuff.
• Select the appropriate cuff size to measure BP.
• Stethoscope – if measuring BP with a mercury tonometer.
Auscultation method of BP measurement with mercury tonometer
• When measuring BP on the upper arm, the arm is stretched with the palm facing upwards.
• The tonometer must be level with the patient’s chest and the mercury column at eye level of the person measuring.
• Wrap the cuff around the patient’s arm so that the bottom edge is 3 to 4 cm above the cubital fossa.
• The centre of the rubber cuff with the tubing is placed over the centre of the cubital fossa.
• Feel the a.brachialis in the cubital fossa.
• Place the diaphragm of the stethoscope on the point where the pulse is palpated.
• Put the stethoscope eartips in the ears.
• The stethoscope is held by the thumb on the non-dominant hand.
• Close the valve on the balloon and inflate the cuff until the sound of the heart cannot be heard.
• Release the valve on the balloon with the thumb and fingers of the dominant hand.
• Watch the mercury descend and listen carefully to the first, clearly audible beat, which indicates the systolic blood pressure level; the heart sounds begin to get gradually louder, the last clearly audible beat indicates the diastolic blood pressure level.
• If the measured BP was not clearly audible, the air is released from the cuff and the measuring process is repeated.
• The patient is notified of the measured values.
• Pathological changes in the measured values of BP are reported to a doctor.
• The measured values are recorded in the nursing documentation, the daily record as is customary on the ward.
Auscultation method of BP measurement with an aneroid tonometer
The procedure is the same as with the mercury tonometer. In this type of tonometer, watch the
movement of the manometer’s hand, which corresponds to the movement of the mercury in
the mercury column.
Palpation method of blood pressure measurement
The palpation method of blood pressure measurement uses a mercury tonometer. This method is included in order to give a full overview.
• The procedure with this method is identical after attaching the cuff.
• The three middle fingers of the non-dominant hand are placed over the a.radialis and proceed as if measuring the pulse.
• The dominant hand gradually releases the valve on the balloon, draining the air from the cuff.
• Observe the mercury column descending.
• The first felt pulse wave indicates the systolic pressure value.
• The diastolic pressure value cannot be palpated.

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Referensi :

  • Jirkovský, D. e. (2014). Nursing Procedure and Interventions. Prague: Česká republika. doi:ISBN: 978-80-87347-16-4
  • FAIX, Pavol. B Braun Echo [online]. 2002 [cit. 2011-04-06]. Intravenous cannula. Available from <http://www.bbraun.sk/bbecho/r2002/bbe_mar2002b.htm>.

Ns. Satya Putra Lencana BSN, RN
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Ns. Satya Putra Lencana BSN, RN

Occupational Health Nursing (OHN) at Larsen & Toubro (LNT) Saudi Arabia Lcc | CEO & MD of Devisaudia.com | Indonesian Migrant Worker Task Force under Labor Attache of Indonesian Embassy, Riyadh, Saudi Arabia

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