Vital Signs, Height, and Weight 367 28. Listen carefully while the cuff is deflating. Note the dial reading when you hear the first sound (beat). This is the systolic blood pressure. 29. Continue deflating the cuff slowly and evenly. Note the dial reading when the sound (beat) disappears. This is the diastolic blood pressure. 30. Remove the stethoscope earpieces from your ears. Completely deflate the cuff and remove it from the arm. 31. Document the blood pressure on a pad, on a form, or in the electronic record. 32. Report abnormal results to the appropriate licensed nursing staff member immediately. 33. Return the cuff to its case or wall mount. 34. Clean the earpieces and diaphragm of the stethoscope with antiseptic wipes. Discard the disposable cover, if used. 35. Return the stethoscope and cuff case (if appropriate) to their storage locations. 36. If the resident is in bed, check to be sure the bed wheels are locked. Then reposition the resident and lower the bed. 37. Follow the plan of care to determine if the side rails should be raised or lowered. The Procedure: Electronic Device 38. Provide privacy by closing the curtains, using a screen, or closing the door to the room. 39. Bring the electronic blood pressure unit near the resident and plug it into a source of electricity. 40. Clean the cuff with an antiseptic wipe or cover it with a disposable paper cover. 41. Have the resident rest quietly and lie comfortably on the bed or sit in a chair. 42. If the resident is in bed, lock the bed wheels and then raise the bed to hip level. If he is on an examining table, stand next to him or sit in a chair in front of him so you can get a clear view of the digital display. 43. Remove any restrictive clothing from the resident’s arm. Ask the resident which arm he would prefer, if appropriate. 44. Locate the Power switch and turn on the machine. 45. Squeeze any excess air out of the blood pressure cuff. 46. Connect the cuff to the connector hose. 47. Wrap the cuff smoothly and snugly around the resident’s exposed arm. Do not wrap the cuff around clothing. Make sure the cuff is not too snug. 48. Make sure the arrow marked on the outside of the cuff is correctly placed over the brachial artery. 49. Make sure the connector hose between the cuff and the machine is not kinked. 50. Press the Start button. The cuff should begin to inflate and then deflate as the reading is being taken. 51. You will see or hear a signal when the reading is complete. 52. If you are taking periodic, automatic measurements, set the machine for the designated frequency of blood pressure measurements. The upper and lower alarm limits for systolic, diastolic, and mean blood pressure readings are set according to facility policy. 53. Document the blood pressure on a pad, on a form, or in the electronic record. 54. Report abnormal results to the licensed nursing staff immediately. 55. Clean the tubing and cuff with an antiseptic wipe. Discard the disposable cover, if used. 56. Remove the machine and place it in its appropriate storage location. 57. If the cuff is to remain on the arm between blood pressure readings, loosen it. Remove the cuff at least every two hours and rotate to the other arm, if possible. Evaluate the skin for redness or irritation. Report any abnormal observations to the licensed nursing staff. 58. If the resident is in bed, check to be sure the bed wheels are locked. Then reposition the resident and lower the bed. 59. Follow the plan of care to determine if the side rails should be raised or lowered. Follow-Up 60. Wash your hands to ensure infection control. 61. Make sure the resident is comfortable and place the call light and personal items within reach. 62. Conduct a safety check before leaving the room. The room should be clean and free from clutter or spills. 63. Wash your hands or use hand sanitizer before leaving the room. Reporting and Documentation 64. Report any specific observations, complications, or unusual responses to the licensed nursing staff. Figure 16.22 Wards Forest Media, LLC Figure 16.23 Wards Forest Media, LLC Figure 16.24 Wards Forest Media, LLC Figure 16.25 © Tori Soper Photography Figure 16.26 © Tori Soper Photography Figure 16.27 Wards Forest Media, LLC Copyright Goodheart-Willcox Co., Inc.