FUNDAMENTAL OF NURSING PROCEDURE MANUAL for PCL ...

48
Fundamental of Nursing Procedure Manual
Care Action Rationale
9. (B)
3) Close the screw clamp on the bulb and inflate the
cuff to a pressure30 mmHg above the point
where the pulse had disappeared
4) Open the clamp and allow the aneroid dial to fall
at rate of 2 to 3 mmHg per second.
5) Note the point on the dial when first clear sound
is heard. The sound will slowly increase in
intensity.
6) Continue deflating the cuff and note the point
where the sound disappears. Listen for 10 to 20
mmHg after the last sound.
7) Release any remaining air quickly in the cuff and
remove it.
8) If you must recheck the reading for any reason,
allow a 1 minute interval before taking blood
pressure again.
10. Assist the client to a comfortable position.
Advise the client of the reading.
Ensure that the systolic reading is not
underestimated.
If deflation occurs too rapidly, reading may be
inaccurate.
This first sound heard represents the systolic
pressure or the point where the heart is able to
force blood into the brachial artery.
This is the adult diastolic pressure. It represents
the pressure that the artery walls exert on the
blood at rest.
Continuous cuff inflation causes arterial
occlusion, resulting in numbness and tingling of
client’s arm.
The interval eases any venous congestion and
provides for an accurate reading when you repeat
the measurement.
Indicate your interest in the client's well-being
and allow him/her to participate in care.
11. Wash your hands. Handwashing prevents the spread of infection.
12. Record blood pressure on the client’s chart. Sign
on the chart. Report any findings to senior staffs.
13. Replace the instruments to proper place and
discard.
Fig. 35 Care Action 9. (A) 3) : Palpatory method
Inflating the cuff while checking brachial artery
Documentation provides ongoing data collection.
Giving signature maintains professional
acountability
To prepare for the next procedure.
Fig. 36 Care Action 9. (B) 2) :Auscultation
Placing the diaphragm without touching the cuff