blood pressure taking vital signs health assessment

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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.

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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:

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Poor : 74 and below