Drug Store News TechEd Program
This lesson is supported by an educational grant from
Helping patients navigate at-home
blood pressure monitoring
Introduction
The number of patients needing at-home
monitoring of blood pressure has been in-
creasing in recent years and is expected to
continue to increase.1,2 The overall rate of
hypertension in the U.S. adult population is
32% (1999 to 2004).2 Additionally, the num-
ber of adults with hypertension worldwide
is predicted to increase by 60% in the next
15 years.3 The number of patients in the
United States who own at-home blood pres-
sure monitors also is steadily increasing,
jumping from 49% in 2000 to 64% in 2005.1
The number of patients who report using
their blood pressure monitors is lower but
is nonetheless on the rise, from 38% in 2000
to 55% in 2005. Patients that own monitors
may not regularly use them, or may incor-
rectly use them. Pharmacy technicians often
are the first people patients see when they
visit their community pharmacies. Techni-
cians can play an important role in helping
to identify patients who may be in need of
home blood pressure monitoring and refer-
ring them to the pharmacist for counseling.
Goals of treatment
Current guidelines for goals of treatment
Megan Friedrich,
PharmD, assistant
professor of clinical
sciences at Drake
University College
of Pharmacy &
Health Sciences
Author disclosures: Megan Friedrich does not
have any actual or potential conflicts of interest in
relation to this lesson.
Universal Program Number: 401-000-10-204-H01-T
Initial release date: Oct. 1, 2010
Planned expiration date: Oct. 1, 2013
This program is worth one contact hour (0.1 CEU).
Target Audience: Pharmacy technicians in
community-based practice.
Drug Store News CEdrugstorenews.com/40100010204H01 September/October 2010
LEARN TOGETHER
CARE TOGETHER
were established in 2003 in the seventh report
by the Joint National Committee on Preven-
tion, Detection, Evaluation and Treatment of
Blood Pressure, or JNC 7, through the Nation-
al Institutes of Health.4 The ultimate goal of
therapy is to reduce death and complications
from heart and kidney disease. The primary
goal should be to achieve a systolic blood
pressure of <140 mmHg, followed by the goal
of a diastolic blood pressure of <90 mmHg.
The systolic blood pressure is the top number
of a measurement and represents the pressure
the body experiences when the heart is beat-
ing. It is the pressure the heart has to push
against to push blood throughout the body.
The diastolic blood pressure is the bottom
number of the measurement and represents
the pressure the body experiences in between
heartbeats. It is the lowest pressure the body
experiences. A high systolic blood pressure
is directly correlated to heart disease because
the heart has to work harder to push blood in
the body. A high diastolic blood pressure also
is dangerous if the body always is under con-
stant high pressure, and it puts the patient at
significant risk for complications. If a patient
has diabetes or chronic kidney disease, the
goal should be reduced to <130 mmHg/<80
Program Goal
To enable technicians to assist the pharmacist in
identifying patients in need of self-monitoring of
blood pressure, as well as referring patients in
need of consultation to the pharmacist.
Learning Objectives
Upon completion of this lesson, the pharmacy
technician should be able to:
1. Identify patients that should monitor their blood
pressure at home.
2. Compare how taking a measurement at the wrist
versus arm differs and how the size of the cuff
affects the accuracy of the result.
3. List the steps involved in taking a proper blood
pressure measurement with an at-home blood
pressure monitor.
4. Inform the pharmacist of identified patient-specific
factors that may affect blood pressure.
5. Educate patients on availability of at-home blood
pressure monitoring and refer patients in need of
monitoring to the pharmacist for consultation.
mmHg. These goals are based on clinic mea-
surements. Since at-home measurements are
consistently lower than clinic measurements
in most patients, the guidelines set a goal
for at-home measurements of <135 mmHg
/<85 mmHg. The guidelines also stress the
importance of recognizing and detecting hy-
pertension, stating that “individuals who are
normotensive (<120 mmHg/<80 mmHg) at
age 55 have a 90% lifetime risk of developing
hypertension” and that “the relationship be-
tween blood pressure, or BP, and cardiovascu-
lar disease, or CVD, events is continuous, con-
sistent and independent of other risk factors.”
Steps to home blood
pressure monitoring
1. Identify if the patient needs
a blood pressure monitor
Patients are recommended to monitor
their blood pressure at home in addition
to clinic visits if they have been diagnosed
with hypertension (systolic >140 mmHg,
or diastolic >90 mmHg), prehypertension
(systolic 120 mmHg to 139 mmHg, or dia-
stolic 80 mmHg to 89 mmHg) or have risk
factors for hypertension.5 Risk factors for
hypertension include advancing age, family
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other customer service issues should be directed to
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macy technicians and has been developed to meet
requirements for PTCB and ICPT recertification.
Drug Store News is accredited by the Accreditation
Council on Pharmacy Education as a provider of
continuing pharmacy education.
Copyright ©2010 by Lebhar-Friedman Inc.
All rights reserved.
 Drug Store News TechEd Program

history, poor diet, excessive alcohol use (i.e., may play a role. Men are more likely to de- mendous outcomes on a patient’s overall
more than one drink a day for women and velop hypertension before age 45. Risk for health. Barriers are individual to each pa-
more than two drinks a day for men), lack developing hypertension is equal between tient. Barriers that have been identified in
of physical activity and being overweight ages 45 and 64. Women are more likely to the literature include expense of monitor,
(i.e., body mass index of 25 kg/m2 to 30 kg/ develop hypertension after age 64. low education level and low income.1,6 Oth-
m2) or obese (i.e., >30 kg/m2). Gender also Pharmacists and technicians have op- er barriers may include physical disability,
portunities to ensure that patients at risk are cultural beliefs, lack of self-efficacy or con-
identified and educated about the need for fidence that one can control his or her blood
T a b le 1 monitoring and about the resources avail- pressure, or other reasons. There are several
able to them. Pharmacists may offer blood communication tools available that can help
Common blood pressure health screenings at the pharmacy, guide pharmacists and technicians to ensure
pressure medications which include a screening of the risk factors successful interactions with patients.7,8,9,10
Generic Brand for hypertension. If a patient has a prehy- Finally, both pharmacists and technicians
name name(s) pertensive or hypertensive reading, or risk may interact with patients that are resistant
factors are identified, the patient may be to changing. When this occurs, the pharma-
amlodipine Norvasc® educated on the benefits of home monitor- cist or technician should show respect for
ing, if appropriate. Screenings are much the patient’s choice rather than trying to con-
atenolol Tenormin®
more successful if all staff members help to vince him or her of the benefits of monitor-
benazepril Lotensin® market the event and recruit patients. Tech- ing. Pushing patients before they are ready
nicians also have a key role in identifying forces them into further resistant behaviors,
bumetanide Bumex® patients in need of at-home monitoring. If a as well as forces them to explain why they
candesartan Atacand® technician notices a prescription for a blood don’t want to monitor. If patients are uncer-
pressure medication at the in-window or tain about whether or not to get a monitor,
captopril Capoten® out-window, new or refill, the technician technicians should refer the patient to the
carvedilol Coreg® may ask the patient if he or she has a moni- pharmacist for further consultation.
tor at home, and refer him or her to the phar-
clonidine Catapres® macist if the patient is interested in getting 3. Determining the appropriate monitor
diltiazem Cardizem , Dila­
® a blood pressure monitor. Refer to Table 1 There are a wide variety of at-home
for a list of common blood pressure medica- electronic monitors available that measure
cor XR®, Tiazac® tions. If a patient has just been discharged blood pressure from the upper arm or wrist.
doxazosin Cardura® from the hospital, technicians could alert the Patients or physicians may ask pharmacists
pharmacist so they can review the doses of and technicians if the monitors are validat-
enalapril Vasotec® blood pressure medications to see if any- ed. All blood pressure monitors sold within
furosemide Lasix® thing has changed and remind the patient the United States are approved by the Food
about monitoring. Any staff member should and Drug Administration and must be in
hydralazine Apresoline® take action if he or she notices a patient look- compliance with the Association for the
hydrochlo­ HydroDiuril, ing at blood pressure monitors in the aisle Advancement of Medical Instrumentation/
and work with other staff members to get American National Standards Institute SP10
rothiazide Microzide®
that patient a consult with the pharmacist. testing standard. More information regard-
irbesartan Avapro® ing this testing standard may be found at
2. Identify any barriers www.fda.gov/MedicalDevices/Device-
lisinopril Prinivil®, Zestril® to self-monitoring RegulationandGuidance/GuidanceDocu-
losartan Cozaar® While many patients are unaware they ments/ucm080219.htm. Refer patients with
are candidates for self-monitoring, others questions to the pharmacist for counseling.
methyldopa Aldomet choose not to monitor their blood pressure Monitors also may be validated for accu-
metoprolol Lopressor®, for other reasons. Identifying barriers to racy and reliability according to voluntary
self-monitoring and helping a patient work standard international testing protocols by
Toprol XL®
through his or her barriers may have tre- the Association for the British Hyperten-
nifedipine Adalat® CC,
Procardia® Patient Scenario 1
olmesartan Benicar®
JS is a 74-year-old female who regularly visits you at the pharmacy. She was
prazosin Minipress® diagnosed with high blood pressure five years ago. She gets her blood pressure
propranolol Inderal® LA checked by the pharmacist once a month. Recently, JS told you that she knows
she needs to check her blood pressure more often, but she cannot afford a blood
ramipril Altace® pressure cuff and is not sure what to do. She also mentioned that her son, who
spirono­ Aldactone® also has high blood pressure, could get a monitor for free through his insurance at
lactone the U.S. Department of Veterans Affairs. What should you recommend?

terazosin Hytrin® Discussion

valsartan Diovan® JS should be referred to the pharmacist. An encouraging referral from the techni­
cian in this scenario would play a vital role in ensuring the interaction with the
verapamil Calan®, Covera- pharmacist is beneficial for this patient due to the fact that JS trusts the techni­
HS®, Isoptin® SR, cian. The pharmacist can then find out additional information in order to better
Verelan® assist and educate JS.

September/October 2010 CEdrugstorenews.com/40100010204H01 Drug Store News


sion Society, and the European Society of
Hypertension.1,5 There also is an Interna-
tional Protocol for the Validation of Auto-
mated BP Measuring Devices.1,5
When correctly used, electronic monitors
correlate well with the auscultatory method.4
Most studies on the effects of hypertension
and its consequences have been done using
the brachial artery as the site of measure-
ment.1 Therefore, monitors that measure
blood pressure in the brachial artery on the
upper arm have been recommended by
the American Heart Association and other
groups.1,11 Wrist monitors are accurate when
correctly used; the patient must hold the
device very still at heart level, which is an
important counseling point for pharmacists.
In obese patients, wrist monitors may be the
only practical option. Also, patient preference
may play a large role in determining if an arm
or wrist monitor is selected. Finger monitors
are not accurate and should not be used.
Once it has been determined whether an
arm or wrist monitor is most appropriate, the
next step for arm monitors is to determine
the appropriate cuff size. Most monitors will
come with a regular adult cuff. Many manu-
facturers will include an order form for alter-
native cuff sizes, which can be ordered for an
additional charge. Other sizes may be avail-
able, depending on the manufacturer. Correct
cuff size is important to ensure accurate re-
sults. A cuff should cover 80% of the circum-
ference of the upper arm and at least 40% of
the width from the shoulder to the elbow.11
When a cuff is too small, it will lead to false
high readings and vice versa.
Once the patient determines the proper
cuff size, he or she must choose between
manual and automatic inflation. Both types
are accurate, and this choice is based on
patient preference. Automatic monitors
generally are more expensive than manual
monitors. Monitors with automatic infla-
tion will electronically sense the pulse and
blood pressure and automatically inflate
and deflate. With automatic cuffs, some
patients do not like the sensation or will
complain that these monitors inflate the
cuff too tightly. However, many patients
prefer automatic cuffs for their ease of use.
Manual cuffs still electronically sense the
pulse and blood pressure, but they require
the patient to manually inflate the cuff. For
manual cuffs, it is important for the patient
to rapidly inflate the cuff to about 30 mmHg
above their usual systolic blood pressure, or
as directed in product-specific instructions.
Under-inflating the cuff is a common cause
for error. It also is important to note that if
a patient has an arrhythmia, or irregular
heartbeat, he or she may prefer a manual
cuff since it sometimes is more difficult for
machines to sense the pulse.
In general, monitors that cost more tend to
have more features. As previously stated, au-
tomatic monitors usually are more expensive
Drug Store News CEdrugstorenews.com/40100010204H01 September/October 2010
Drug Store News TechEd Program
than manual monitors. Additionally, moni-
tors may have different features, including
the ability to record readings for more than
one user, larger memory capacity, talking
functions, the ability to detect irregular heart-
beats, multiple cuff sizes, AC adapter cords
and the ability to download readings and/
or sync to an online personal health record.
Some monitors also measure other values,
such as body fat percentage, BMI or blood
glucose. The most important factor should be
choosing a monitor that has been validated
and then helping the patient decide what
other features are important to him or her.
4. Refer to pharmacist for
counseling on proper use
After the patient has chosen a monitor to
match his or her specific needs, it is impor-
tant to learn the best technique for an accu-
rate blood pressure reading. The pharmacist
should be the one to counsel the patient
on proper use of the monitor. The patient
should be resting for at least five minutes
prior to measurement. The patient should
be seated with both feet flat on the ground,
back supported and the arm supported on a
flat surface at heart level.1,4,12,13
General counseling information will be
outlined, however individual blood pressure
monitors may vary, so pharmacists and pa-
tients also should refer to product-specific in-
structions. The arm cuff should be placed on
the bare arm, which is free from clothing and
positioned so the middle of the cuff lies over
the brachial artery.1 The wrist cuff should
be snugly placed around the wrist, and the
elbow should be securely held or anchored
so that the wrist may be held still at heart
level. Patients should refrain from drinking
caffeinated beverages, smoking or exercising
30 minutes prior to measurement.4 Patients
should take two or three readings per sit-
ting, one minute apart.1,12 The best time to
test is either first thing in the morning be-
fore taking medication or at bedtime before
taking medication. Most monitors will au-
tomatically store results; however, not all
monitors have this capability. Other moni-
tors will erase the memory when the batter-
ies are replaced. Therefore, it might be ben-
eficial to recommend that patients keep an
additional electronic or paper log.
Most monitors will have two steps to
measurement. It is best to prepare to mea-
sure, including placing the cuff on the arm
or wrist as described above, before turning
the monitor on. First, press the “Power” or
“On/Off” button to turn the monitor on.
Then press it again or press “Start” to start
the measurement for automatic monitors,
or start inflating the cuff for manual moni-
tors. For some automatic monitors, patients
just need to press the “Power” button once
to turn the device on and start the measure-
ment. Most monitors have a separate but-
ton for obtaining stored readings from the
memory. Most manual monitors are inflat-
ed using a bulb and deflated automatically
by the device. If time allows, have the phar-
macist fit the patient for the proper cuff and
show the patient how to use the monitor
before leaving the store. If the pharmacy
has limited brands, consider having one or
two demonstration monitors with a large
and regular cuff for training purposes.
Once the patient begins monitoring, it
is recommended that he or she bring the
monitor to the doctor’s office to verify the
monitor’s accuracy, as well as have his or
her technique verified.1 This should be done
yearly. This also may be done at the pharma-
cy if the pharmacist has the proper equip-
ment to measure blood pressure by auscul-
tation. It should be noted that two separate
readings, whether taken by manual monitor,
automatic monitor or auscultation method,
likely would not match exactly.
5. Additional education by the pharmacist
Technicians also may help raise aware-
ness that pharmacists are a good source of
information regarding the management of
blood pressure. It is important for patients to
be aware of other potential factors that can
contribute to hypertension. Disease states
or abnormalities may cause hypertension,
which the pharmacist may review with the
patient. The pharmacist also may check that
the proper lab work has been done to rule
out other diseases that might cause hyper-
tension. The pharmacist can review the pa-
tient’s medications to see if any medications
are causing hypertension. Pharmacists may
help patients by educating them on the im-
portance of adherence, encouraging lifestyle
change and, when appropriate, intervene on
their behalf to initiate change in therapy.
6. Follow-up with the patient
Follow-up with patients is challenging
in the community setting. It is an important
step, however, in making a lasting impact
on whether or not patients follow through
on what was recommended. Pharmacists
and technicians are encouraged to devise a
follow-up system in their current workflow
in order to call patients to verify that their
monitors are working and check on their
blood pressure within the first month of use
and periodically thereafter.
Conclusion
It has been demonstrated that patients
who monitor their blood pressure at home
are more likely to achieve their blood pres-
sure goals.14 At-home monitoring also em-
powers patients to take an active part in
managing their hypertension. Technicians
can assist the pharmacist by identifying pa-
tients who may benefit from at-home moni-
toring or who have questions regarding
blood pressure, and referring them to the
pharmacist for counseling.
 Drug Store News TechEd Program

Helping patients navigate at-home

blood pressure monitoring
Successful completion of “Helping patients
navigate at-home blood pressure monitoring”
(lesson 401-000-10-204-H01-T) is worth one
contact hour of credit. Mail completed answer
sheet to DSN/Pharmacy Practice, 3922 Coconut
Palm Dr., Tampa, FL 33619. For faster service,
fax to (813) 626-7203. For fastest service, visit
our website at CEdrugstorenews.com.
1. Which of the following patients should
monitor her blood pressure at home?
a. A 37-year-old patient with diabetes
and a one-time office reading of
122/82 mmHg.
b. A 45-year-old patient with a family
history of hypertension who is
overweight and has poor lifestyle habits.
c. A 72-year-old patient recently
diagnosed with prehypertension by
her physician.
d. B and C
e. All of the above
Learning Assessment
4. An arm blood pressure cuff should cover
80% of the circumference of the upper
arm and at least 40% of the width from
the shoulder to the elbow.
a. True
b. False
5. Technicians may be involved in
encouraging use of at-home blood
pressure monitors by:
a. Identifying patients that are in need
of monitoring by watching for anti-
hypertensive medication prescriptions
at the in-window and out-window
b. Notifying the pharmacist when a
patient is looking at blood pressure
monitors in the aisle
c. Being familiar with the products
available at the pharmacy
d. Alert pharmacists to changes in anti-
hypertensive therapy after receiving
hospital discharge orders
e. All of the above
8. Why is it important for patients to bring
their monitors to the doctor’s office?
a. Monitors need to be verified for
accuracy.
b. To ensure the monitor has not been
damaged
c. To ensure the patient is correctly using
the monitor
d. All of the above
e. None of the above
9. The variation in prices of blood pressure
monitors is primarily due to:
a. Whether or not the monitors have
been validated
b. The amount of features on the monitor,
such as memory capacity
c. Whether or not the monitor has
automatic inflation and deflation
capabilities
d. B and C
e. All of the above

2. At-home monitoring is the preferred 10. Why is it important for patients to

method for evaluating a patient’s clinical
response to treatment because at-home
monitors:
a. Cost less than ambulatory blood
pressure monitors
b. Are more accurate than ambulatory
blood pressure monitors
c. Are not dependent on user technique
d. Can account for external factors, such
as caffeine and nicotine
e. All of the above
3. According to the JNC 7 guidelines, what
are the goal(s) of anti-hypertensive
treatment?
a. Reduce complications of kidney and
heart disease
b. Blood pressure goal of <135/<85
mmHg for at-home monitoring
c. Reduce systolic blood pressure to goal,
followed by the diastolic
d. A and B
e. All of the above
6. Which of the following is correct
monitor their blood pressure at home?
regarding proper blood pressure
a. It is more accurate than clinic
technique?
measurements or ambulatory blood
a. The patient should have his or her arm
pressure monitors.
supported on a pillow at heart level.
b. Patients are more likely to achieve
b. Both feet should be placed flat on the
their blood pressure goals.
ground.
c. It is a good way to track symptoms of
c. The patient should take two to three
hypertension and hypotension.
readings, five minutes apart.
d. A and B
d. The patient should refrain from
e. All of the above
smoking or consuming caffeine for
four hours prior to measurement.
e. All of the above
7. Which of the following new medication
pickups should include pharmacist
counseling on blood pressure
monitoring?
a. Glucophage
b. Niaspan
c. Zestril
d. Cipro
e. Xopenex HFA

September/October 2010 CEdrugstorenews.com/40100010204H01 Drug Store News