Med Sur Lab

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BloodPressureTwoStepMethod-checklist.pdf

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Mosby: Mosby's Nursing Video Skills Student _________________________________________ Date ___________________ Instructor _______________________________________ Date ___________________ PERFORMANCE CHECKLIST FOR OBTAINING BLOOD PRESSURE BY THE ONE-STEP METHOD S U NP Comments

1. Verified health care provider’s orders.

2. Gathered necessary equipment and supplies.

3. Performed hand hygiene.

4. Provided for patient’s privacy.

5. Checked patient’s baseline reading, determined

best site for use.

6. Introduced self to patient and family, identified

patient using two identifiers, compared

identifiers with information on patient’s ID

bracelet.

7. Positioned patient and patient’s arm

appropriately.

8. Exposed upper arm fully.

9. Ensured blood pressure cuff is appropriate the

appropriate size.

10. Palpated patient’s brachial artery in the

anticubital space.

11. Positioned cuff properly above artery,

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

wrapped fully deflated cuff properly around

upper arm.

12. Positioned manometer properly, stood no

more than one yard away from it.

13. Palpated brachial artery distal to cuff while

inflating cuff with other hand.

14. Noted point at which pulse disappeared,

inflate cuff appropriately past that point,

slowly deflated cuff.

15. Noted point at which pulse disappeared.

16. Fully deflated cuff, waited 30 seconds.

17. Cleaned earpieces, diaphragm, and bell of

stethoscope with alcohol swabs.

18. Placed earpieces in ears, ensured sounds were

clear and not muffled.

19. Placed bell or diaphragm over stethoscope,

did not let chestpiece touch cuff or patient’s

clothing.

20. Closed valve on pressure bulb properly, quick

inflated cuff to the proper pressure.

21. Released valve on pressure bulb, let

manomemter fall properly, noted point at

which the first clear sound is heard.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

22. Continued to deflate cuff slowly, noted

pressure at which sound disappears.

23. Listened after last sound, let remaining air

escape quickly, discussed findings with

patient, removed cuff.

24. Took patient’s BP again after 2 minutes, used

second set of measurements as baseline.

25. Removed cuff from patient’s arm, repeated

process on other arm if necessary.

26. Helped patient into a comfortable position,

covered upper arm, discussed findings.

27. Cleaned earpiece, diaphragm, and bell of

stethoscope with alcohol swabs.

28. Compared findings with the appropriate

classification of blood pressure.

29. Compared BP measurement to patient’s

baseline.

30. Helped patient into a comfortable position,

placed personal items within reach.

31. Placed call light within easy reach, ensured

patient knew how to use it.

32. Raised top side rails and lowered bed to

ensure patient’s safety.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.

33. Disposed of used supplies and equipment, left

patient’s room tidy.

34. Removed and disposed of gloves if worn,

performed hand hygiene.

35. Documented and reported patient’s response

and outcomes.