Basic Nursing Skills - Vital Signs
Accurately measure and record blood pressure using an automated (electronic) blood pressure monitor.
Critical steps are identified only where the CareFlow study checklist marks them.
Perform hand hygiene
Critical step
Address resident by name and explain the procedure
Ensure resident has been resting for at least 5 minutes
Position resident comfortably with arm supported at heart level
Critical step
Expose upper arm - do not take BP over clothing
Critical step
Select appropriate size cuff (bladder should encircle 80% of arm)
Critical step
Locate brachial artery on inner arm above elbow
Apply cuff snugly with center of bladder over brachial artery, 1-2 inches above elbow
Critical step
Ensure cuff tubing is not kinked and is connected properly to monitor
Position resident's arm with palm facing upward, arm relaxed
Press start button on automated monitor
Instruct resident to remain still and not talk during measurement
Wait for monitor to complete measurement and display reading
Record blood pressure reading accurately (systolic/diastolic) within plus or minus 8 mmHg
Critical step
Remove cuff and reposition resident's clothing
Report any abnormal findings to nurse (systolic above 140 or below 90, diastolic above 90 or below 60)
Perform hand hygiene
Critical step
Requirements and evaluator wording can vary by state and testing program. Compare this study checklist with your current candidate handbook and instructor guidance.