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Oct.28.2020

Blood Pressure Measurement Education (Pediatric) - CE

ALERT

Discuss the importance of notifying the practitioner and withholding medications when abnormal values in blood pressure (BP) or pulse occur (e.g., in the case of hypotension).

OVERVIEW

Families should learn to measure BP accurately to assess the effectiveness of their child’s medication regimens or to monitor their child’s rehabilitation or exercise program. Nurses teach families the skill of measuring their child’s BP and the important issues regarding unusual readings. Nurses also teach families about factors that can affect BP readings, such as cuff placement, movement of the tubing, and the patient’s position.

In the home, many families use commercially available electronic BP reading devices (Figure 1AFigure 1A, Figure 1B)Figure 1B, which produce a BP measurement without the use of a stethoscope. A cuff around an extremity (preferably the right arm) is used, and a reading is displayed electronically. Although easy to use, electronic monitors are not always accurate.undefined#ref3">3

Cuff size is a major factor that affects the accuracy of BP monitoring (Figure 2)Figure 2. A BP cuff that is too small provides a false high BP, whereas a cuff that is too large tends to provide a false low BP. The nurse should help the family select the appropriate cuff size for their child by measuring the arm circumference at the midpoint between the elbow (olecranon) and shoulder (acromion). For a child, the bladder cuff width should be approximately 40% of this circumference, and the bladder cuff length should cover 80% to 100% of the arm circumference.2,4 For a neonate or infant, the cuff bladder width should be approximately 50% of the mid-arm circumference.1 Cuff size can also be determined using the American Heart Association’s recommendations (Table 1)Table 1.4 Not all electronic home BP monitors come with interchangeable cuff sizes, further compounding the problem of monitoring BP at home. In addition, as a pediatric patient grows, the required BP cuff size changes.

BP varies by body size; the BP for a child or adolescent should be assessed with respect to height, sex, and age.2

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Instruct the patient and family to report abnormal readings to the practitioner.
  • Educate the patient and family about the risks for hypertension and hypotension.
  • Instruct the patient and family about the specifics of the treatment regimen, including the potential adverse reactions and interactions of medications.
  • Explain the reason for obtaining BP values to the family and the patient, if developmentally appropriate.
  • Explain how the patient can help during the BP measurement (e.g., quietly sitting still), if developmentally appropriate.
  • Inform the patient that the cuff squeezes or hugs the arm and that this sensation lasts only a short time.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the patient and family.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient’s developmental level and ability to interact.
  5. Assess the patient’s anxiety level.
  6. Review the diagnosis and reason for obtaining the BP measurement.
  7. Assess the patient’s and family’s visual and auditory acuity as well as their ability to manipulate and properly use BP monitoring equipment.
  8. Assess the patient’s and family’s knowledge of the normal BP range and the symptoms and common causes of hypotension and hypertension.
  9. Assess the patient’s and family’s knowledge of which medical issues affect BP and why an awareness of BP variations is important for the child’s well-being.
  10. Assess the patient’s and family’s knowledge of and experience with measuring BP.
  11. Discuss with the patient and family the best setting in the home for measuring BP (e.g., quiet room with a comfortable place to sit).

Preparation

  1. Encourage the patient and family to take BP measurements on a routine schedule to promote a long-term monitoring plan.
  2. If the patient is taking an antihypertensive medication, teach the patient or family that it should be taken at the same time each day.
  3. Teach the patient or family to measure BP at the same time each day and to ensure that the patient does not consume caffeine or smoke before the measurement.
    For an adolescent who smokes or vapes, discuss the harmful effects of smoking or vaping, emphasizing its effects on BP.
  4. Explain that BP should be measured with the patient in a comfortable position, with his or her feet flat on the floor, and in a warm and quiet environment if performing a manual measurement.
  5. Allow a young patient to manipulate or play with the equipment before the procedure.
    Rationale: Young pediatric patients are more likely to cooperate if allowed to manipulate or play with the equipment before the procedure.
  6. Prepare the patient for the squeezing sensation of the inflated BP cuff by comparing the sensation to an elastic band on the finger or a tight hug on the arm. If necessary, perform the procedure first on a family member or doll.
    Rationale: Performing the procedure first on a family member or doll allows the patient to see that the procedure is safe and may enhance cooperation.
  7. Describe the symptoms that indicate the need to perform a BP measurement.

PROCEDURE

  1. Perform hand hygiene.
  2. Verify the correct patient using two identifiers.
  3. Explain the procedure to the patient and family and ensure that they agree to treatment.
  4. Discuss the best sites for measuring BP. Explain that the cuff should not be applied to an extremity that has an IV catheter; an arteriovenous shunt; trauma, inflammation, or disease; or a cast or a bulky bandage.
    Rationale: Avoiding extremities that have wounds, IV lines, vascular compromise, fragile bones, or injuries helps prevent injury to the extremity. Pressure created by the inflated bladder of the BP device can temporarily impair blood flow and compromise circulation in an extremity that already has impaired circulation.
  5. Demonstrate the steps for measuring BP cuff size (Figure 2)Figure 2 and for measuring BP.
    1. Teach the family how to ensure that the bladder cuff width for a child is approximately 40% of the circumference of the arm measured at a point midway between the olecranon and acromion and that the bladder cuff length covers 80% to 100% of the arm circumference.2,4 For a neonate or infant, the cuff bladder width should be approximately 50% of the mid-arm circumference.1
    2. If using a sphygmomanometer and stethoscope:
      1. Teach the family how to palpate the different arteries (brachial or radial in the arm; popliteal, dorsalis pedis, or posterior tibial in the leg), position the cuff, wrap the cuff, place the stethoscope, inflate and release the cuff, and listen for Korotkoff sounds. Explain that Korotkoff sounds are easier to hear with the bell of the stethoscope in younger children.
      2. Describe the sounds heard during the measurement and their relationship to the gauge during the BP reading. Caution the family about the level and length of time appropriate for cuff inflation.
      3. Provide instruction on how to clean the bell and diaphragm of the stethoscope with isopropyl alcohol or a damp cloth.
      4. Use a double-headed teaching stethoscope to verify the accuracy of the reading, or perform a BP measurement soon after the family’s attempt to verify the accuracy.
    3. If using an electronic BP monitor, explain the correct placement of the cuff and the use of electronic equipment for proper cuff inflation.
  6. Explain that all equipment except the stethoscope bell and the cuff should be moved away from the extremity and that BP should be measured with the cubital fossa at the level of the heart.
  7. Have the family members attempt to perform each step of the skill on an assistant or another family member. Correct any errors in technique as they occur.
  8. Have the family members demonstrate the techniques on the patient. Do not allow multiple repetitive attempts on any one extremity.
    Rationale: Repeated attempts may affect the measurement because of anxiety and the repeated circulatory restriction.
  9. Acknowledge that developing competence in measuring BP may take time; have the family members attempt to perform each step of the skill at different times until they gain comfort.
  10. Observe the family members performing the skill and recording the readings.
  11. Provide printed instructions with a written or pictorial guide or access to an electronic source demonstrating the procedure, if possible.
  12. Discuss the desired BP range based on the patient’s sex and age. Also, discuss when BP should be monitored and when the practitioner should be notified.
    Discuss the importance of withholding antihypertensive medications when the patient’s BP is low and notifying the practitioner when the BP reading is out of the desired range and when medications are not taken.
  13. Provide a logbook or designated piece of paper for recording the BP readings.
    1. Instruct the family to record the site where the BP was taken and the time the BP was taken.
    2. Instruct the family to record whether medications that affect BP were taken.
    3. Instruct the family to use this written record to report BP readings to the practitioner.
  14. Instruct the family on the proper care of the BP equipment (e.g., storage, cleaning, battery care).
  15. Perform hand hygiene.
  16. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Observe the family demonstrate the correct technique for BP measurement on several occasions and verify that the family adds information to the logbook accurately. If possible, have the family demonstrate with the BP cuff that they will be using at home.
    Rationale: Providing feedback through a return demonstration of psychomotor learning is the best means to evaluate learning and ensures that the family is using the appropriate size BP cuff.
  2. Ask the family to state the BP readings that are within the desired range. Also, ask family members to indicate when they should report abnormal readings to the practitioner.
  3. Ask the family to describe the reason for BP monitoring and any related medications (e.g., antihypertensives) or treatments (e.g., diet, exercise).
  4. Have the family demonstrate proper care of the BP equipment.
  5. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • BP is accurately monitored.
  • BP is within range expected for patient’s age and condition.
  • Family explains purpose and implications of therapies.
  • Family describes which alterations in BP require communication with practitioner to evaluate changes in treatment regimen.

UNEXPECTED OUTCOMES

  • Family is unable to measure BP because of inability to manipulate equipment, inability to hear or palpate BP accurately, or inability to see numbers on equipment.
  • Family has difficulty explaining purposes or implications of therapy.
  • BP is inaudible or difficult to obtain with stethoscope.

DOCUMENTATION

  • Patient’s and family’s demonstration of BP measurement
  • Patient’s and family’s demonstration of recording BP in logbook
  • Unexpected outcomes and related interventions
  • Education

REFERENCES

  1. Dionne, J.M. and others. (2020). Method of blood pressure measurement in neonates and infants: A systematic review and analysis. The Journal of Pediatrics, 221, 23-31. doi:10.1016/j.jpeds.2020.02.072 (Level I)
  2. Foote, J.M. (2017). Chapter 4: Communication and physical assessment of the child and family. In M.J. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong’s essentials of pediatric nursing (10th ed., pp. 57-113). St. Louis: Elsevier.
  3. National Heart, Lung, and Blood Institute (NHLBI), U.S. Department of Health and Human Services. (2012). Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Full report. Retrieved June 15, 2020, from https://www.nhlbi.nih.gov/files/docs/guidelines/peds_guidelines_full.pdf (classic reference)* (Level VII)
  4. Pickering, T.G. and others. (2005). Recommendations for blood pressure measurement in humans and experimental animals: Part 1: Blood pressure measurement in humans: A statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension, 45(1), 142-161. doi:10.1161/01.HYP.0000150859.47929.8e (classic reference)* (Level VII)

ADDITIONAL READINGS

Flynn, J.T. and others. (2017). Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics, 140(3), e20171904 doi:10.1542/peds.2017-1904

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports