St.

Michael’s College
College of Nursing
Iligan City

Name: __________________________________________________ Group: ______________

Clinical Instructor: _________________________________________ Date: _______________

Assessing a Blood Pressure

Concept:__________________________________________________________________________________
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Purpose:
:_________________________________________________________________________________________
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Equipments:______________________________________________________________________________
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Oral
Performed
Rationale
Procedure Written Rationale
Not
Yes No Done
Done
1. Assessment:
 Signs and symptoms of
hypertension and hypotension
 Factors affecting blood pressure.

2. Planning:
Gather all the necessary equipment
needed for the procedure.
 ________________________
 ________________________
 ________________________

3. Implementation:
 Identify the patient.
 Explain the procedure to the
patient.
 Perform hand hygiene.
 Delay obtaining the blood
pressure if the patient is
 emotionally upset, is in pain, has
just exercised, or just taken
meals, unless it is urgent to
obtain blood pressure.
 Select the appropriate arm for the
application of the cuff (consider
the circulation not compromised
due to some reasons).
 Have the patient assume a
comfortable lying or sitting
position with the forearm
supported at the level of the heart
and with the palm upward.
 Expose the area of the brachial
artery by removing garments or
moving the sleeve, if it is not too
tight, above the area where the
cuff will be placed.
 Center the bladder of the cuff
over the brachial artery
approximately midway on arm, so
the cuff’s lower edge is about 2.5
to 5 cm (1 to 2 inches) inches
above the inner aspect of the
elbow. Tubing should extend
from the cuff edge nearer the
patient’s elbow.
 Wrap the cuff smoothly and
snugly around the arm. Fasten it
securely or tuck the end of the
cuff well under the preceding
wrapping. Do not allow any
clothing to interfere with the
proper placement of the cuff
 Check that the needle on the
aneroid gauge is within the zero
mark. If using a mercury
manometer, check to see that the
manometer is in a vertical
position and that the mercury is
within the zero level with the
gauge at eye level.
 Palpate the pulse at the brachial
or radial artery by pressing gently
with your fingertips.
 Tighten the screw valve on the
air pump.
 Inflate the cuff while continuing to
palpate the artery. Note the point
on the gauge where the pulse
disappears.
 Deflate the cuff and wait 15
seconds.
 Assume a position that is no
more than 3 feet away from the
gauge.
 Place the stethoscope earpieces
in the ears. Direct the ear tips
forward into the canal, not
against the ear itself.
 Place the stethoscope bell or
diaphragm firmly but with as little
pressure as possible over the
brachial artery. Do not allow the
stethoscope to touch clothing or
cuff.
 Pump the pressure 30 mm Hg
above the point at which the
systolic pressure was palpated
and estimated. Open the
manometer valve and allow air to
escape slowly (allowing the
gauge to drop 2 to 3 mm per
heartbeat)
 Note the point on the gauge at
which the first faint, but clear, the
sound appears and slowly
increases in intensity. Note this
number as the systolic pressure.
 Read pressure to the closest
even number.
 Do not re-inflate the cuff once the
air is being released to recheck
the systolic pressure reading
 Note the pressure at which the
sound first becomes muffled.
Also, observe the point at which
sound completely disappears.
Note this number as diastolic
pressure. These may occur
separately or at the same point.
 Allow remaining air to escape
quickly repeat any suspicious
reading but wait 30 to 60
 seconds between readings to
allow normal circulation to return
to the limb. Be sure to deflate the
cuff completely between attempts
to check blood pressure
 Remove the cuff. Clean and store
equipment
 Perform hand hygiene. If gloves
are worn, discard them in the
proper receptacle.

4. Evaluation:
 Record the findings on a paper
flow sheet or computerized
record.
 Report abnormal findings to the
appropriate person.
 Identify the arm used and site of
assessment if other than
brachial.