STANDARD OPERATING
PROCEDURE
NURSING
MEASURING BLOOD PRESSURE
Understanding
Take measurements
of blood pressure in patients with a monitoring or observation of the general
state of the patient in treatment.
Aim
To launch an
action with the aim of supporting imperfect health services provided in the
accuracy Assessment of patients.
1. Knowing the patient's general condition.
2. Knowing early heart function.
3. Following the development of the course of
the disease.
4. Helps determine one supporting diagnosis.
Policy
Measures of blood
pressure measurement is based on guidelines and rules defined, in order to
support the recovery of patients in care services were excellent.
Procedure
1.
Stage of pre interactions:
a. Verification of the patients nursing
services program
b. Prepare tools
c. Keep the privacy of the client; if necessary,
close the doors and windows / drapery
d. Prepare yourself officers in interacting
with patients
e. Make sure the contract time for action on
patient has been done
2. Stage orientation:
a. Give greetings
b. Clarification time contract
c. Explain the purpose and procedure
d. Give the patient the opportunity to ask
e. Ask consent and patient readiness
f. Preparation tool brought closer to
patients
3. The work phase.
a. Washing hands.
b. Let the patient is lying down or sitting
quietly on the bed.
c. Holding the patient's hand, and then
attach (wrap) tensimeter cuff on the upper arm above the elbow
d. Limit the bottom cuff of about 2-3 cm from
the elbow crease
e. May be in the left or right arm, making
sure not at arm attached infusion or there are injuries or paralysis of motion.
Fitting the cuff on this part because this was where the blood vessels called
the brachial artery
f. Sphygmomanometer cuff should be level or
level of the heart, the patient in a state of lying down or sitting. His
condition should be relaxed / relaxed, hands should not be strained
g. Attach a stethoscope in his ears, put the
diaphragm at the bottom winding cuff in the folds of the elbow where the
brachial artery is located
h. Starting at pumping blood pressure, Cup
Turn the wheel to the right (clockwise) of the existing air regulator valve on
the pump rubber cuff to shut it down, so that when pumping cuff later that no air
is leaking out.
i.
Knead
the rubber to pump air into the cuff, pumping stops until a knock audible and
added 40mmHg.
j.
After
that rotate to the left a little bit of air regulator valve to allow air in the
cuff out bit by bit with the speed of 2-3 mmHg / sec.
k. Blood flow in the brachial artery to flow
again. Watch and listen to the sound arising from the stethoscope when the
valve is open cuff. When the sound of arterial pulse (... thump ... thump ...
thump ... thump ...) for the first time, then that sounds called Korotkoff
sound at a time marker systolic pressure.
l.
Then
the throbbing sound was getting louder and louder, and then turned into a
noisy, then heard clearly, then began to weaken and then disappeared. Well, the
point in time of the sound of knocking / arterial pulse disappeared which was
used as a marker of diastolic blood pressure
4.
Stage termination:
a. Thank you for the cooperation with patient
b. Document the results of the investigation
c. Evaluation of client response
d. Conclude the activity
e. Giving a message
f. The contract period further activities
g. Adjust the position of the clients as
comfortable as possible
h. Clear up the tools and return it to its
place
5.
Document:
a. name of client
b. Date and time
c. Action taken
d. client response
e. name of officer
Related
unit
All personnel Doctor, Nursing and
Midwife, .....................HOSPITAL
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