OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF NURSING - PAMPANGA

PROGRAM Bachelor of Science in Nursing Student Name

Year and Section
COURSE HEALTH ASSESSMENT Instructor
Date

PROCEDURE​ ​ ​ : Taking the Blood Pressure

EXPECTED OUTCOME​​ : The student should be able to perform taking blood pressure
ASESSMENT TASK​ ​ : Return demonstration

Exceptional Good Average Poor

Assessment Dimension SCORE
(3) (2) (1) (0)
1. Assess factors that Assessed factors Assessed two (2) Assessed one (1) Failed to assess
affect blood pressure that affect blood factors affecting factor affecting blood the factors that
pressure blood pressure pressure affect blood
pressure
2. Wash hands before Observed Hand washing was Hand washing was Hand washing
starting the procedure principles of done with minimal done with maximal was not done
medical hand error error
washing
3. Determine client’s Performed the Performed the Performed the Failed to
baseline blood pressure procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
4. Determine which Performed the Performed the Performed the Failed to
procedures with procedures with procedures with perform the
extremity is most
ease minimal maximum supervision procedure
appropriate for reading
supervision
5. Prepare materials. Gathered materials Gathered materials Gathered materials Failed to gather
Select a cuff size that needed with little time with more time all the materials
completely encircles preparation preparation needed
client’s upper arm
without overlapping ends

6. Identify the patient and Greeted and Performed the two Performed the one (1) Failed to
explain the procedure identified client by (2) ways of ways of identifying the identify the
asking his/her identifying the the the client client
name and checking client
his or her ID band
politely
7. Explain the procedure Explained Explained the Explained the Failed to explain
procedure and its procedure but lack procedure but in an procedure and
purpose to the some details. unclear manner. its purpose.
client clearly and
completely with
client’s consent
8. Place the client in an Properly and Placed the client Placed client Failed to
appropriate position skillfully positioned comfortably and in comfortably and in any positioned
the client any preferable preferable position client properly
comfortably position with less with maximum and comfortably
supervision supervision
9. Move client’s clothing Performed the Performed the Performed the Failed to
away from upper aspect procedures with procedures with procedures with perform the
of the arm ease minimal maximum supervision procedure
supervision
10. Position client’s arm Performed the Performed the Performed the Failed to
at heart level, extending procedures with procedures with procedures with perform the
elbow with palm turned ease minimal maximum supervision procedure
supervision
upward. Have client relax
arm and not overly
tighten elbow.

11. Wrap deflated cuff Performed the Performed the Performed the Failed to
evenly around the upper procedures with procedures with procedures with perform the
arm. For an adult, place ease minimal maximum supervision procedure
lower border of the cuff supervision
approximately 2.5cm
(1inch) above the
antecubital space

12. Apply cuff snugly Performed the Performed the Performed the Failed to
smoothly over upper arm procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
13. insert earpieces of Performed the Performed the Performed the Failed to
stethoscope into ears procedures with procedures with procedures with perform the
with a forward tilt ease minimal maximum supervision procedure
supervision
14. Relocate brachial Performed the Performed the Performed the Failed to
pulse and place the bell procedures with procedures with procedures with perform the
or diapraghm directly ease minimal maximum supervision procedure
supervision
over brachial pulse. Hold
the diaphragm with the
thumb and index finger

15. Close the valve of the Performed the Performed the Performed the Failed to
pump by turning the procedures with procedures with procedures with perform the
knob clockwise ease minimal maximum supervision procedure
supervision
16. Inflate cuff to Performed the Performed the Performed the Failed to
30mmHg above the procedures with procedures with procedures with perform the
normal systolic reading of ease minimal maximum supervision procedure
supervision
the client

17. Release the valve of Performed the Performed the Performed the Failed to
the cuff carefully so that procedures with procedures with procedures with perform the
the pressure decreases at ease minimal maximum supervision procedure
supervision
the rate of 2-3mmHg per
second. As the pressure
falls, identify the
manometer reading by
listening for the
korotkoff’s sounds

18. Mark the first audible Performed the Performed the Performed the Failed to
sound as the systolic procedures with procedures with procedures with perform the
pressure reading and the ease minimal maximum supervision procedure
supervision
last audible sound as the
diastolic pressure reading

19. After final sound has Performed the Performed the Performed the Failed to
disappeared, deflate cuff procedures with procedures with procedures with perform the
rapidly and completely ease minimal maximum supervision procedure
supervision
20. Remove cuff or wait Performed the Performed the Performed the Failed to
for 2 minutes before procedures with procedures with procedures with perform the
taking a second reading ease minimal maximum supervision procedure
supervision
21. Inform the client of Performed the Performed the Performed the Failed to
reading procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
22. Position client Properly and Placed the client Placed client Failed to
comfortably. skillfully positioned comfortably and in comfortably and in any positioned
the client any preferable preferable position client properly
comfortably position with less with maximum and comfortably
supervision supervision
23. Put all equipment in Performed the Performed the Performed the Failed to
proper place. procedures with procedures with procedures with perform the
ease minimal maximum supervision procedure
supervision
24. Wash hands and Washed hands and Washed hands and Washed hands but Washed hands
document pertinent data documented the some of the details most of the details of but
information about of procedure were the procedure were documentation
the procedure not documented not documented was not done
 properly and
completely

OVERALL SCORE: ________________

Target raw score is 54 out of 72. If raw score is less than 54, repeat the return demonstration.

_____________________________________
FACULTY SIGNATURE OVER PRINTED NAME