Question

Skill name:: Two step BP method

All questions must be answered based on the skill listed above:

what is the Description of this skill?

what are the indicators?

what are the nursing interventions (pre, intra, post)?

what are the outcomes/evaluation?

what is the client education for this skill?

what are the potential complications?

what are the nursing interventions?

Answer 1

In two step BP method the BP needs to be measured twice for more accurate readings. In first step the BP needs to be measured by palpating brachial artery. In second step BP is again measured by using stethoscope.

The skill includes following steps :

1. Wrap the arm cuff around the arm, one inch above cubital fossa. Palpate the brachial artery. Then Inflate the cuff. Note when the pulse disappears. Inflate 30mmhg more. Then deflate. Note when pulse reappears. This is systolic BP. Now let the patient rest for 1-2 min. Now take the BP using stethoscope. Place stethoscope on the brachial artery. Inflate cuff. Note when the pulse disappears. Keep inflating 30mm hg more. Now deflate. Note when the pulse reappears. This is systolic BP. Slowly keep deflating the cuff. Note when the pulse again disappears. This is diastolic BP. Completely deflate the cuff.

Two step BP method is used when more accurate readings are required.

The pre procedure nursing interventions : explain the procedure to the patient, make patient comfortable, position the patient in lying or sitting position.

Intra procedural nursing intervention: place the arm comfortably and in supported position, arm cuff should not be very tight, note the readings accurately and clearly, arm should not move during procedure, stethoscope should be placed correctly on brachial artery

Post procedural nursing intervention: let the patient rest for few minutes after the procedure

The outcomes of two step BP method are measurement of more accurate BP readings.

The patient needs to be educated about the procedure clearly. Patient should be kept calm and comfortable. Patient should be instructed not to move his arm during procedure and report any discomfort immediately during procedure.

Complications : complocations are minimal. Very tight arm cuff can cause discomfort, tingling and numbness in arm. Petechiae may occur in few patients.

Nursing interventions include patient education about the procedure, comfortably positioning patient in lying or seating position, keeping patient calm and allowing patient to rest for a few minutes before and after procedure.