CONTENTS GLOSSARY MENU

STUDENT : ________________________________________________________ DATE: ______________

INSTRUCTOR : _____________________________________________________ DATE: ______________

PROCEDURE PERFORMANCE CHECKLIST

Skill 31-5 Measuring Blood Pressure (BP)

S U NP Comments
Measuring Blood Pressure (BP)
1. Determine need to assess client’s BP. _____ _____ _____ ______________________
2. Determine best site for BP assessment and cuff _____ _____ _____ ______________________
size.
3. Determine previous baseline BP (if available) _____ _____ _____ ______________________
from client’s record.
4. Encourage client to avoid exercise and smoking _____ _____ _____ ______________________
for 30 minutes before assessment of BP.
5. Assist client to sitting or lying position. Make _____ _____ _____ ______________________
sure room is warm, quiet, and relaxing.
6. Explain to client that BP is to be assessed and _____ _____ _____ ______________________
have client rest at least 5 minutes before meas-
urement is taken. Ask client not to speak while
BP is being measured.
7. Wash hands. _____ _____ _____ ______________________
8. With client sitting or lying, position client’s fore- _____ _____ _____ ______________________
arm or thigh and provide support if needed.
9. Expose extremity by removing constricting _____ _____ _____ ______________________
clothing.
10. Palpate brachial artery or popliteal artery. _____ _____ _____ ______________________
Position cuff 2.5 cm above site of pulsation.
Center bladder of cuff above artery. With cuff
fully deflated, wrap cuff evenly and snugly
around upper arm.
11. Position manometer vertically at eye level, no _____ _____ _____ ______________________
more than 1 m away from client.
12. To determine baseline BP, palpate brachial or _____ _____ _____ ______________________
radial artery with fingertips of one hand while
inflating cuff rapidly to pressure 30 mm Hg
above point at which pulse disappears. Slowly
deflate cuff and note point when pulse reappears.
13. Deflate cuff fully and wait 30 seconds. _____ _____ _____ ______________________
14. Using a stethoscope, make sure that sounds are _____ _____ _____ ______________________
clear, not muffled.
15. Relocate brachial or popliteal artery and place _____ _____ _____ ______________________
bell or diaphragm chestpiece of stethoscope over
it.
16. Close valve of pressure bulb clockwise until _____ _____ _____ ______________________
tight.
17. Inflate cuff to 30 mm Hg above palpate systolic _____ _____ _____ ______________________
pressure.

Continued

12 Potter/Perry: Fundamentals of Nursing, ed 5. Copyright © 2001 Mosby, Inc. All rights reserved.
 CONTENTS GLOSSARY MENU

S U NP Comments
18. Slowly release valve and allow mercury to fall at _____ _____ _____ ______________________
rate of 2 to 3 mm Hg/sec.
19. Note point on manometer when first clear sound _____ _____ _____ ______________________
is heard.
20. Continue to deflate cuff, noting point at which _____ _____ _____ ______________________
muffled or dampened sound appears.
21. Continue to deflate cuff gradually, noting point _____ _____ _____ ______________________
at which sound disappears. Note pressure to
nearest 2 mm Hg.
22. Deflate cuff rapidly and completely. Remove _____ _____ _____ ______________________
cuff from client’s arm unless measurement must
be repeated.
23. If this is the first assessment of the client, repeat _____ _____ _____ ______________________
procedure on other arm.
24. Assist client in returning to a comfortable posi- _____ _____ _____ ______________________
tion and cover upper arm if previously clothed.
25. Discuss findings with client as needed. _____ _____ _____ ______________________
26. Wash hands. _____ _____ _____ ______________________
27. Compare reading with previous baseline and/or _____ _____ _____ ______________________
acceptable BP for client’s age group.
28. Compare BP in both of client’s arms or legs. _____ _____ _____ ______________________
29. Correlate BP with data obtained from pulse _____ _____ _____ ______________________
assessment and related cardiovascular signs and
symptoms.
30. Inform client of value of and need for periodic _____ _____ _____ ______________________
reassessment of BP.
31. Record BP and report abnormal findings. _____ _____ _____ ______________________

Potter/Perry: Fundamentals of Nursing, ed 5. Copyright © 2001 Mosby, Inc. All rights reserved. 13