89

SKILL 5-5

Assessing Arterial Blood Pressure

NSO

Basic Skills / Vital Signs / Obtaining Blood Pressure by the One-Step Method and Obtaining Blood Pressure by the Two-Step Method

Vital Signs Module / Lesson 5

HYPERTENSION
Hypertension is a major factor underlying death from heart attack and stroke in the United States and Canada. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (National High Blood Pressure Education Program [NHBPEP], 2003) has set criteria for determining categories of hypertension (Table 5-2). Prehypertension is a designation for patients at high risk for developing hypertension. In these patients, early intervention by adoption of healthy lifestyles reduces
Phase 5 Silence

Phase 4

Blood pressure (BP) is the force exerted by blood against the vessel walls. During a normal cardiac cycle, BP reaches a peak, followed by a trough, or low point, in the cycle. The peak pressure occurs when the hearts ventricular contraction, or systole, forces blood under high pressure into the aorta. When the ventricles relax, the blood remaining in the arteries exerts a minimum or diastolic pressure. Diastolic pressure is the minimal pressure exerted against the arterial wall at all times. The standard unit for measuring BP is millimeters of mercury (mm Hg). The measurement indicates the height to which the BP can sustain the column of mercury. The most common technique of measuring BP is auscultation using a sphygmomanometer and stethoscope. As the sphygmomanometer cuff is deated, the ve different sounds heard over an artery are called Korotkoff phases. The sound in each phase has unique characteristics (Fig. 5-10). Blood pressure is recorded with the systolic reading (rst Korotkoff sound) before the diastolic (beginning of the fth Korotkoff sound). The difference between systolic pressure and diastolic pressure is the pulse pressure. For a BP of 120/80, the pulse pressure is 40.

Korotkoff phases 140 Phase 1 A sharp thump 130 Phase 2 A blowing or whooshing sound

120

A softer thump than phase 1 A softer blowing sound that fades

Phase 3

110

100

90

80

FIG 5-10 The sounds auscultated during blood pressure measurement can be differentiated into ve Korotkoff phases. In this example, the blood pressure is 140/90 mm Hg.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

90
the risk or prevents hypertension. Hypertension is dened as systolic blood pressure (SBP) of 140 mm Hg or greater, diastolic blood pressure (DBP) of 90 mm Hg or greater or taking antihypertensive medication (NHBPEP, 2003). The diagnosis of hypertension in adults requires the average of two or more readings taken at each of two or more visits after an initial screening. One BP recording revealing a high SBP or DBP does not qualify as a diagnosis of hypertension. However, if you assess a high reading (e.g., 150/90 mm Hg), encourage the patient to return for another checkup within 2 months (Table 5-3). Orthostatic changes in vital signs are good indicators of blood volume depletion. Some medications cause orthostatic hypotension if misused, especially in young patients and older adults.

BLOOD PRESSURE EQUIPMENT

You measure arterial blood pressure either directly (invasively) or indirectly (noninvasively). The direct method requires electronic monitoring equipment and the insertion of a thin catheter into an artery. The risks of invasive BP monitoring require use in an intensive care setting. The more common noninvasive method requires use of the sphygmomanometer and stethoscope. A sphygmomanometer includes a pressure manometer, an occlusive cloth or disposable vinyl cuff that encloses an inatable rubber bladder, and a pressure bulb with a release valve that inates the bladder (Fig. 5-11). There are two types of manometers: aneroid and mercury. The aneroid manometer has a glass-enclosed circular gauge containing a needle that registers millimeter calibrations. Metal parts in the aneroid manometer are subject to temperature expansion and contraction and must be recalibrated at least every 6 months to verify their accuracy. Before using the aneroid manometer, make sure the needle is pointing to zero. Mercury manometers, once the gold standard, are less common because they contain mercury, a hazardous substance. Many states have prohibited the sale or use of mercury-containing devices. However, some facilities or nursing units still have mercury manometers. Pressure created by ination of the compression cuff moves the column of mercury up the tube against the force of gravity. Millimeter calibrations mark the height of the mercury column. To ensure accurate readings, the mercury column should fall freely when you release pressure and it should always be at zero when the cuff is deated. Mercury manometers are wall mounted or portable. You obtain accurate readings by looking at the height or meniscus level of the mercury at eye level. Looking up or down at the mercury results in distorted readings. The release valves of both mercury and aneroid sphygmomanometers must be clean and freely movable in either direction. The valve, when closed, holds the pressure constant. A sticky valve makes pressure cuff deation hard to regulate.

HYPOTENSION
Hypotension occurs when the SBP falls to 90 mm Hg or below. Although some adults normally have a low BP, for the majority of people low BP is an abnormal nding associated with illness (e.g., hemorrhage or myocardial infarction). Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness or dizziness) and low BP when rising to an upright position. In severe cases, loss of consciousness may occur. Normally, when a healthy individual changes from a lying to sitting or standing position, the peripheral blood vessels in the legs constrict, the heart rate and contractility increase, and BP remains adequate to perfuse the heart and brain.

TABLE 5-2
Category Normal Prehypertension Stage 1 Stage 2

Classication of Blood Pressure for Adults Age 18 Years and Older*

Systolic (mm Hg) 120 120-139 140-159 160 and or or or Diastolic (mm Hg) 80 80-89 90-99 100

From National High Blood Pressure Education Program; National Heart, Lung, and Blood Institute; National Institutes of Health: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, JAMA 289(19):2560, 2003. *Based on the average of two or more readings taken at each of two or more visits after an initial screening. Patient is not taking antihypertensive drugs and not acutely ill. When systolic and diastolic blood pressures fall into different categories, the higher category should be selected to classify the individuals blood pressure status. For example, 160/92 mm Hg should be classied as stage 2 hypertension.

TABLE 5-3

Recommendations for Blood Pressure Follow-up

Follow-up Recommended* Recheck in 2 years. Recheck in 1 year. Conrm within 2 months. Evaluate or refer to source of care within 1 month. For those with higher pressure (e.g., 180/110 mm Hg), evaluate and treat immediately or within 1 week, depending on clinical situation and complications.

Initial Blood Pressure Normal Prehypertension Stage 1 hypertension Stage 2 hypertension

*Modify the scheduling of follow-up according to reliable information about

past blood pressure measurements, other cardiovascular risk factors, or target organ damage. Provide advice about lifestyle modications.

FIG 5-11

Mercury and aneroid sphygmomanometers.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

91
Cloth or disposable vinyl compression cuffs contain an inatable bladder and come in several different sizes. The size selected is proportional to the circumference of the limb you are assessing (Fig. 5-12). Ideally the width of the cuff should be 40% of the circumference (or 20% wider than the diameter) of the midpoint of the limb on which the cuff is to be used. The bladder enclosed within the cuff should encircle at least 80% of the upper arm (NHBPEP, 2003). Many adults require a large adult cuff. A regular-size cuff holds a bladder in the width of 12 to 13 cm (4.8 to 5.2 inches) and the length of 22 to 23 cm (8.5 to 9 inches). An improperly tting cuff produces inaccurate BP measurements (Box 5-5). Electronic or automatic blood pressure machines consist of an electronic sensor positioned inside a blood pressure cuff attached to an electronic processor. Electronic devices have their limitations but are useful when frequent measurements are necessary (Box 5-6).

Arm leng th

FIG 5-12 Guidelines for proper blood pressure cuff size. Cuff width equals 20% more than upper arm diameter, or 40% of circumference and two thirds of upper arm length.

BOX 5-5
Error

Common Mistakes in Blood Pressure Assessment

Effect
False False False False False False False False False False False False False False low reading high reading high reading high diastolic reading low systolic and false high diastolic reading high reading low reading high reading low systolic and false high diastolic reading low diastolic reading high diastolic reading low systolic reading low systolic reading high systolic and false low diastolic reading

Bladder or cuff too wide Bladder or cuff too narrow or too short Cuff wrapped too loosely or unevenly Deating cuff too slowly Deating cuff too quickly Arm below heart level Arm above heart level Arm not supported Stethoscope that ts poorly or impairment of the examiners hearing, causing sounds to be mufed Stethoscope applied too rmly against antecubital fossa Inating too slowly Repeating assessments too quickly Inaccurate ination level Multiple examiners using different Korotkoff sounds for diastolic readings

BOX 5-6
Advantages

Advantages and Limitations of Electronic Blood Pressure Machines

Sensitive to outside motion interference and cannot be used in patients with seizures, tremors, or shivers or patients unable to cooperate Not accurate for hypotensive patients or in conditions with reduced blood ow (e.g., hypothermia) Accuracy standards for electronic blood pressure machine manufacturers are voluntary Vulnerable to error in clinical circumstances, including irregular heart rates, obese extremity

Ease of use Efcient when frequent repeated measurements are indicated Stethoscope not required. Allows blood pressure to be recorded more frequently, as often as every 15 seconds with accuracy

Limitations
Expensive Requires source of electricity Requires space to position machine

Cuff width

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Arm diam eter

92
Delegation Considerations
You can delegate the skill of blood pressure measurement to NAP unless the patient is considered unstable (i.e., hypotensive). The nurse directs the NAP about: Appropriate limb for BP measurement. Appropriate-size BP cuff for designated extremity. When a patient is at risk for orthostatic hypotension. Frequency of BP measurement for specic patient. Need to report any abnormalities to the nurse.

Equipment
Appropriate thermometer Soft tissue or wipe Alcohol swab Water-soluble lubricant (for rectal measurements only) Pen, pencil, vital sign ow sheet or record form Clean gloves, plastic thermometer sleeve, disposable probe or sensor cover

STEP
ASSESSMENT 1 Determine need to assess patients BP: a Assess risk factors for BP alterations: History of cardiovascular disease Renal disease Diabetes Circulatory shock (hypovolemic, septic, cardiogenic, or neurogenic) Acute or chronic pain Rapid IV infusion of uids or blood products Increased intracranial pressure Postoperative status Toxemia of pregnancy b Assess for signs and symptoms of BP alterations. In patients at risk for high blood pressure (HBP), assess for headache (usually occipital), ushing of face, nosebleed, and fatigue in older adults. Hypotension is associated with dizziness; mental confusion; restlessness; pale, dusky, or cyanotic skin and mucous membranes; cool, mottled skin over extremities. c Assess for factors that inuence BP: (1) Age (2) Gender (3) Daily (diurnal) variation

RATIONALE

Certain conditions place patients at risk for BP alteration.

Physical signs and symptoms indicate alterations in BP. Hypertension is often asymptomatic until pressure is very high.

(4) Position (5) Exercise (6) Weight (7) Sympathetic stimulation (8) Medications

(9) Smoking

(10) Ethnicity

Allows nurse to anticipate factors that will inuence respirations, ensuring a more accurate interpretation. Acceptable values for BP vary throughout life (see Pediatric and Gerontological Considerations). During and after menopause women often have higher BPs than men of same age. BP varies throughout day; pressure is highest during the daytime between 10:00 am and 6:00 pm and lowest in early morning (Redon, 2004). Blood pressure drops 10% to 20% during nighttime sleep (Giles, 2006). BP falls as person moves from lying to sitting or standing position; normally, postural variations are minimal. Increases in oxygen demand by the body for activity increase BP. Obesity is an independent predictor of hypertension. Pain, anxiety, or fear stimulates the sympathetic nervous system, causing BP to rise. Anxiety raises BP as much as 30 mm Hg. Antihypertensives, diuretics, beta-adrenergic blockers, vasodilators, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and antidysrhythmics lower BP; opioids and general anesthetics also cause a drop in BP. Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises acutely and returns to baseline in about 15 minutes after stopping smoking (NHBPEP, 2003). Incidence of hypertension is higher in African Americans than in European Americans. African Americans tend to develop more severe hypertension at an earlier age and have twice the risk for the complications of hypertension (i.e., stroke and heart attack). Hypertension-related deaths are also higher among African Americans.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 5-5

93
RATIONALE

STEP
2 Determine best site for BP assessment. Avoid applying cuff to

extremity when intravenous uids are infusing, an arteriovenous shunt or stula is present, or breast or axillary surgery has been performed on that side. Also, avoid applying the cuff to extremity that has been traumatized, diseased, or requires a cast or bulky bandage. Use the lower extremities when the brachial arteries are inaccessible. 3 Determine previous baseline BP and site (if available) from patients record. Determine any report of latex allergy. NURSING DIAGNOSES Decreased cardiac output Decient uid volume

Inappropriate site selection may result in poor amplication of sounds, causing inaccurate readings. Application of pressure from inated bladder temporarily impairs blood ow and can further compromise circulation in extremity that already has impaired blood ow.

Allows nurse to assess for change in condition. Provides comparison with future BP measurements. If patient has latex allergy, verify that stethoscope and BP cuff are latex free. Excess uid volume Ineffective tissue perfusion

Decient knowledge regarding medication adherence for BP control

Individualize related factors based on patients condition or needs.

PLANNING 1 Expected outcome following completion of procedure: Blood pressure is within acceptable range for patients age. 2 Explain to patient that you will assess BP. Have patient rest at least 5 minutes before measuring lying or sitting BP and rest 1 minute before measuring standing (NHBPEP, 2003). Ask patient not to speak while you are measuring BP (NHBPEP, 2003). 3 Be sure patient has not exercised, ingested caffeine, or smoked for 30 minutes before assessment of BP (NHBPEP, 2003).
4

Cardiovascular status is stable. Reduces anxiety that falsely elevates readings. Exercise causes false elevations in BP. Talking to a patient during BP assessment increases readings 10% to 40%.

Have patient assume sitting or lying position. Be sure room is warm, quiet, and relaxing.

5 Select appropriate cuff size (see Fig. 5-12). 6 Perform hand hygiene.

Caffeine or nicotine causes false elevations in BP. Smoking increases BP immediately and lasts up to 15 minutes. The effects of coffee or caffeine increase BP up to 3 hours. Maintains patients comfort during measurement. The patients perceptions that the physical or interpersonal environment is stressful affect the BP measurement. Use of improper-size cuff causes false low or false high reading (see Box 5-5). Reduces transmission of microorganisms.

IMPLEMENTATION 1 Assess BP by auscultation: upper extremities a With patient sitting or lying, position patients forearm, supported if needed at heart level, with palm turned up (see illustration). If sitting, instruct patient to keep feet at on oor without legs crossed. If supine, patient should not have legs crossed.

If arm is extended and not supported, patient will perform isometric exercise that can increase diastolic pressure (Adiyaman and others, 2006). Placement of arm above the level of the heart causes false low reading. Even in the supported position, a diastolic pressure effort up to 3 to 4 mm Hg can occur for each 5-cm change in heart level. Leg crossing can falsely increase systolic and diastolic BP.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

94
STEP RATIONALE

STEP 1a b c

Patients forearm supported on bed.

Expose upper arm fully by removing constricting clothing. Palpate brachial artery (see illustration A). Position cuff 2.5 cm (1 inch) above site of brachial pulsation (antecubital space). Apply compression cuff above artery by centering arrows marked on cuff over artery (see illustration B). If there are not any center arrows on cuff, estimate the center of the bladder and place this center over artery. With cuff fully deated, wrap cuff evenly and snugly around upper arm (see illustration C).

Ensures proper cuff application. Do not place BP cuff over clothing. Inating bladder directly over brachial artery ensures that you apply proper pressure during ination. Loose-tting cuff causes false high readings.

C
STEP 1c A, Nurse palpating patients brachial artery. B, Center bladder of cuff above artery. C, Blood pressure cuff wrapped around upper arm.
Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 5-5

95
RATIONALE

STEP
d

Position manometer vertically at eye level. Observer should be no farther than 1 meter (approximately 1 yard) away. e Measure BP. (1) Two-step method (a) Relocate brachial pulse. Palpate the artery distal to the cuff with ngertips of nondominant hand while inating cuff rapidly to a pressure 30 mm Hg above point at which pulse disappears. Slowly deate cuff, and note point when pulse reappears. Deate cuff fully and wait 30 seconds. (b) Place stethoscope earpieces in ears, and be sure sounds are clear, not mufed. (c) Relocate brachial artery, and place the bell or diaphragm chestpiece of stethoscope over it. Do not allow chestpiece to touch cuff or clothing (see illustration). Close valve of pressure bulb clockwise until tight. Quickly inate cuff to 30 mm Hg above patients estimated systolic pressure (see illustration). (e) Slowly release pressure bulb valve, and allow manometer needle to fall at rate of 2 to 3 mm Hg/ second. (f) Note point on manometer when you hear rst clear sound. The sound will slowly increase in intensity. (g) Continue to deate cuff gradually, noting point at which sound disappears in adults. Note pressure to nearest 2 mm Hg. Listen for 20 to 30 mm Hg after the last sound, and then allow remaining air to escape quickly. (2) One-step method (a) Place stethoscope earpieces in ears, and be sure sounds are clear, not mufed. (b) Relocate brachial artery, and place bell or diaphragm chestpiece of stethoscope over it. Do not allow chestpiece to touch cuff or clothing. (d)

Looking up or down at the scale can result in distorted readings.

Estimating prevents false low readings. Determine maximal ination point for accurate reading by palpation. If unable to palpate artery because of weakened pulse, use an ultrasonic stethoscope (see Chapter 6). Completely deating cuff prevents venous congestion and false high readings. Each earpiece follows angle of ear canal to facilitate hearing. Proper stethoscope placement ensures best sound reception. Stethoscope improperly positioned causes mufed sounds that often result in false low systolic and false high diastolic readings. The bell provides better sound reproduction, whereas the diaphragm is easier to secure with ngers and covers a larger area. Tightening of valve prevents air leak during ination. Rapid ination ensures accurate measurement of systolic pressure.

Too rapid or slow a decline causes inaccurate readings.

First Korotkoff sound reects systolic BP.

Beginning of the fth Korotkoff sound is an indication of diastolic pressure in adults (NHBPEP, 2003). Fourth Korotkoff sound involves distinct mufing of sounds and is an indication of diastolic pressure in children.

Earpieces should follow angle of ear canal to facilitate hearing. Proper stethoscope placement ensures optimal sound reception. Stethoscope improperly positioned causes mufed sounds that often result in false low systolic and false high diastolic readings. The bell provides better sound reproduction, whereas the diaphragm is easier to secure with ngers and covers a larger area.

STEP 1e(1)(c) pressure.

Stethoscope over brachial artery to measure blood

STEP 1e(1)(d)

Inating blood pressure cuff.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

96
STEP
(c) Close valve of pressure bulb clockwise until tight. Quickly inate cuff to 30 mm Hg above patients usual systolic pressure. (d) Slowly release pressure bulb valve and allow manometer needle to fall at rate of 2 to 3 mm Hg/second. Note point on manometer when you hear rst clear sound. The sound will slowly increase in intensity. (e) Continue to deate cuff gradually, noting point at which sound disappears in adults. Note pressure to nearest 2 mm Hg. Listen for 10 to 20 mm Hg after the last sound, and then allow remaining air to escape quickly. The Joint National Committee (NHBPEP, 2003) recommends the average of two sets of BP measurements, 2 minutes apart. Use the second set of BP measurements as the patients baseline. Remove cuff from patients arm unless you need to repeat measurement. If this is rst assessment of patient, repeat procedure on other arm. Assist patient in returning to comfortable position, and cover upper arm if previously clothed. Discuss ndings with patient as needed. Perform hand hygiene. Clean earpieces and diaphragm of stethoscope with alcohol swab as needed (optional).

RATIONALE
Tightening of valve prevents air leak during ination. Ination above systolic level ensures accurate measurement of systolic pressure. Too rapid or slow a decline in mercury level causes inaccurate readings. The rst Korotkoff sound reects systolic pressure.

Beginning of the fth Korotkoff sound is an indication of diastolic pressure in adults (NHBPEP, 2003). Fourth Korotkoff sound involves distinct mufing of sounds and is an indication of diastolic pressure in children. Two sets of BP measurements help to prevent false positive readings based on a patients sympathetic response (alert reaction). Averaging minimizes the effect of anxiety, which often causes a rst reading to be higher than subsequent measures (NHBPEP, 2003). Continuous cuff ination causes arterial occlusion, resulting in numbness and tingling of patients arm. Comparison of BP in both arms detects circulatory problems. (Normal difference of 5 to 10 mm Hg exists between arms.) Restores comfort and provides sense of well-being. Promotes participation in care and understanding of health status. Makes patient accountable for follow-up assessment. Reduces transmission of microorganisms. Controls transmission of microorganisms when nurses share stethoscope Prone position provides best access to popliteal artery.

g h i j k

2 Assess BP by auscultation: lower extremities a Assist patient to prone position. If patient is unable to assume position, assist patient to supine position with knee slightly exed. b Move aside bed linen and any constrictive clothing from leg. c Locate popliteal artery behind knee.
d

Apply large leg cuff 2.5 cm (1 inch) above popliteal artery around posterior aspect of middle thigh. Center arrows marked on cuff over artery (see illustration).

Ensures proper cuff positioning. Artery palpation site lies just below patients thigh, behind knee, just lateral to the midline in popliteal space. Proper cuff size is necessary for accurate reading. Cuff must be wide and long enough to allow for larger girth of the thigh. Narrow cuff causes false high readings.

STEP 2d

Blood pressure cuff applied around thigh.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 5-5

97
RATIONALE

STEP
e f

g h i

Position manometer vertically at eye level. You should be no farther than 1 meter (approximately 1 yard) away. Using the popliteal artery, follow Step 1e(2)(a) through 1e(2)(e) of one-step method for auscultation of upper extremity. If this is rst assessment of patient, repeat procedure on other leg. Assist patient in returning to comfortable position, and cover leg if previously clothed. Discuss ndings with patient as needed.

Looking up or down at the scale can result in distorted readings.

Comparison of BP in both legs detects circulatory problems. Restores comfort and promotes sense of well-being. Promotes participation in care and understanding of health status. Makes patient accountable for follow-up assessment. Systolic BP in the legs is usually higher by 10 to 40 mm Hg than in the brachial artery, but diastolic BP is the same. Reduces transmission of microorganisms.

Perform hand hygiene. Clean earpieces and diaphragm of stethoscope with alcohol swab as needed. 3 Assess systolic BP by palpation a Follow Steps 1a through 1d of auscultation method for upper extremity or Steps 2a through 2e of auscultation method for lower extremity. b Locate and then continually palpate brachial, radial, or popliteal artery with ngertips of one hand. Inate cuff to a pressure 30 mm Hg above point at which you can no longer palpate pulse.
j

Ensures accurate detection of true systolic pressure once pressure valve is released.

Critical Decision Point If unable to palpate artery because of weakened pulse, use a Doppler ultrasonic stethoscope (see Fig. 5-13).
c

d e f g

Slowly release valve and deate cuff, allowing manometer needle to fall at rate of 2 mm Hg/second. Note point on manometer when pulse is again palpable. Deate cuff rapidly and completely. Remove cuff from patients extremity unless you need to repeat measurement. Assist patient in returning to comfortable position, and cover extremity if previously clothed. Discuss ndings with patient as needed. Perform hand hygiene.

Too rapid or slow a decline results in inaccurate readings. Palpation helps identify the systolic pressure only. Continuous cuff ination causes arterial occlusion, resulting in numbness and tingling of extremity. Restores comfort and promotes sense of well-being. Promotes participation in care and understanding of health status. Reduces transmission of microorganisms.

FIG 5-13 Doppler ultrasonic stethoscope over brachial artery to measure blood pressure.
Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

98
STEP
EVALUATION 1 If assessing BP for the rst time, establish BP as baseline if it is within acceptable range. 2 Compare BP reading with patients previous baseline and usual BP for patients age.

RATIONALE

Used to compare future BP measurements. Allows nurse to assess for change in condition. Provides comparison with future BP measurements.

Unexpected Outcomes
1 Blood pressure is above acceptable range.

Related Interventions
Repeat measurement in other extremity, and compare ndings. Verify correct selection and placement of BP cuff. Have another nurse repeat measurement in 1 to 2 minutes. Observe for related symptoms that are not apparent unless BP is extremely high, including headache, facial ushing, nosebleed, and fatigue in older patient. Report BP to nurse in change or health care provider to initiate appropriate evaluation and treatment. Administer antihypertensive medications as ordered.

2 Blood pressure is not sufcient for adequate perfusion and oxygenation of tissues.

3 Unable to obtain BP reading.

4 Patient experiences orthostatic hypotension. 5 A difference of more than 20 mm Hg systolic or diastolic between BP measurements on upper extremities.

Compare BP value to baseline. Position patient in a supine position to enhance circulation, and restrict activity that decreases BP further. Repeat BP measurement with sphygmomanometer. Electronic BP devices are less accurate in low ow conditions. Assess for signs and symptoms associated with hypotension including tachycardia, weak, thready pulse, weakness, dizziness, confusion, and cool, pale, dusky, or cyanotic skin. Assess for factors that contribute to a low BP, including hemorrhage, dilation of blood vessels resulting from hyperthermia, anesthesia, or medication side effects. Report BP to nurse in charge or health care provider to initiate appropriate evaluation and treatment. Increase rate of IV infusion, or administer vasoconstricting drugs if ordered. Determine that no immediate crisis is present by obtaining pulse and respiratory rate. Assess for signs and symptoms of decreased cardiac output; if present, notify nurse in charge or health care provider immediately. Use alternative sites or procedures to obtain BP: auscultate BP in lower extremity; use a Doppler ultrasonic instrument (see Chapter 6); palpate systolic BP. Maintain patient safety. Return patient to safe position in bed or chair. Restrict activity that may drop BP further. Report abnormal ndings to nurse in charge or health care provider.

Recording and Reporting

Record BP and site assessed on vital sign ow sheet (see Fig. 5-6) or nurses notes. Document measurement of BP after administration of specic therapies in narrative form in nurses notes. Record any signs or symptoms of BP alterations in narrative form in nurses notes. Report abnormal ndings to nurse in charge or health care provider.

Teaching Considerations
Educate patient about risks for hypertension. Persons with family history of hypertension, premature heart disease, lipidemia, or renal disease are at signicant risk. Obesity, cigarette smoking, heavy alcohol consumption, high blood cholesterol and triglyceride levels, and continued exposure to stress from psy-

chosocial and environmental conditions are factors linked to hypertension (NHBPEP, 2003). Primary prevention of hypertension includes lifestyle modications (e.g., lose weight, exercise daily, reduce sodium and saturated fat intake, and maintain adequate intake of dietary potassium and calcium). Cigarette smoking is a powerful risk factor, so encourage patients to avoid tobacco in any form (NHBPEP, 2003). Instruct primary caregiver to take BP at same time each day and after patient has had a brief rest. Take BP sitting or lying down; use same position and arm each time you take pressure. Instruct primary caregiver that if the pressure is difcult to hear, it is probably due to one of the following reasons: the cuff is too loose, not big enough, or too narrow; the stethoscope is not over arterial pulse; cuff deated too quickly or too slowly; or cuff not pumped high enough for systolic readings.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

SKILL 5-5

99

Pediatric Considerations
BP measurement is not a routine part of assessment in children younger than 3 years (Schell, 2006a). The right arm is preferred for BP measurement in children (National High Blood Pressure Education Program Working Group, 2004). Thigh BP is least preferred and most uncomfortable for children (Schell, 2006a). BP measurement can frighten children. Prepare child for squeezing feeling of inated BP cuff by comparing sensation to elastic band on nger or a tight hug on the arm. Obtain BP in child before performing anxiety-producing tests or procedures (Schell, 2006a). When a child reaches adolescence, BP varies by body size. Assess the level of a child or adolescent with respect to body size and age. Heavier and taller children have a higher BP than smaller children of the same age. During adolescence, BP continues to vary according to body size. Normal range for 10- to 17-year-olds at the 90th percentile is 124 to 136/77 to 84 mm Hg for boys and 124 to 127/63 to 74 mm Hg for girls (Hockenberry and others, 2007). Korotkoff sounds are difcult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful.

Gerontological Considerations
Older adults, especially frail older adults, have lost upper arm mass, requiring special attention to selection of BP cuff size. Skin of older adults is more fragile and susceptible to cuff pressure when BP measurements are frequent. More frequent assessment of skin under cuff or rotation of BP sites is recommended. Older adults have an increase in systolic pressure related to decreased vessel elasticity. Older adults often experience a fall in BP after eating. Instruct older adults to change position slowly and wait after each change to avoid postural hypotension and prevent injuries.

Home Care Considerations

Assess home noise level to determine the room that will provide the quietest environment for assessing BP. Instruct patient in the importance of an appropriate-size blood pressure cuff for home use. Assess familys nancial ability to afford a sphygmomanometer for performing BP evaluations on a regular basis. Recommend electronic devices or aneroid sphygmomanometers that have proven to be accurate according to standard testing as well as appropriate-size cuffs. Finger blood pressure monitors are inaccurate (NHBPEP, 2003).

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.