How to Take a Blood Pressure Measurement (Systolic and Diastolic Sounds) Nursing Clinical Skill

Summary

In this video, Sarah from RegisteredNurseRN.com demonstrates how to properly measure blood pressure manually. The process involves preparing the patient, positioning their arm, and using a cuff to estimate systolic pressure. After inflating the cuff, the systolic and diastolic pressures are identified by listening for specific sounds through a stethoscope. Sarah provides step-by-step instructions on how to interpret these sounds, along with tips on cuff placement and ensuring accurate readings. The video concludes with cleaning up and documenting the results, offering helpful insights for nursing professionals.

Takeaways

• 😀 Ensure hand hygiene is performed before starting the blood pressure measurement.
• 😀 Position the patient correctly with their back supported, arm at heart level, and feet uncrossed.
• 😀 Place the cuff about two inches above the elbow bend and align the cuff’s arrow with the brachial artery.
• 😀 Estimate the systolic pressure by palpating the brachial artery and noting the point where the pulse is no longer felt.
• 😀 The estimated systolic pressure should guide the inflation of the cuff by inflating to 30 mmHg above this value.
• 😀 Always confirm the gauge reads zero before starting the measurement.
• 😀 Slowly deflate the cuff at a rate of 2 mmHg per second to listen for the systolic and diastolic sounds.
• 😀 The first sound heard marks the systolic pressure (top number of the reading).
• 😀 The point at which the sound completely stops marks the diastolic pressure (bottom number of the reading).
• 😀 Document the blood pressure reading and note the arm used for the measurement.
• 😀 Clean your supplies and perform hand hygiene after completing the measurement.

Q & A

What is the correct position for a patient when taking a manual blood pressure?

The patient should be seated with their back supported, feet uncrossed, and the arm at heart level with the palm facing up. Support the arm if necessary.

Where should the blood pressure cuff be placed on the arm?

The cuff should be placed about two inches above the elbow crease, with the arrow aligned over the brachial artery.

How do you estimate the systolic pressure before using a stethoscope?

Palpate the brachial artery while inflating the cuff. The point at which the pulse disappears is the estimated systolic pressure.

Why is it important to inflate the cuff 30 mmHg above the estimated systolic pressure?

Inflating above the estimated systolic ensures the cuff pressure fully occludes the artery so that the first Korotkoff sound can be accurately detected.

What is the proper rate of cuff deflation during auscultation?

The cuff should be deflated slowly at approximately 2 millimeters of mercury per second to accurately identify systolic and diastolic sounds.

How is the systolic blood pressure identified during auscultation?

The systolic pressure is recorded at the first appearance of the tapping sound (Korotkoff sound) as the cuff pressure is released.

How is the diastolic blood pressure identified?

The diastolic pressure is recorded at the point where the Korotkoff sounds completely disappear during cuff deflation.

What should you do after taking the blood pressure reading?

Fully deflate the cuff, remove it, clean your supplies, perform hand hygiene, and document the blood pressure along with the arm used.

Why is it important to check that the gauge reads zero before starting?

Ensuring the gauge reads zero prevents inaccurate readings and confirms that the equipment is properly calibrated.

Which part of the stethoscope should be used to listen to the brachial artery?

You can use either the bell or the diaphragm of the stethoscope, placing it over the brachial artery without occluding it.

Why is hand hygiene emphasized before and after measuring blood pressure?

Hand hygiene prevents the spread of infection and maintains patient safety.

What recent guideline change affects how diastolic pressure is determined?

Previously, the last sound heard was recorded as diastolic, but current guidelines recommend recording diastolic at the point when the sound stops completely.