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Sep.24.2020

Blood Pressure (Systolic): Palpation (Home Health Care) - CE

OVERVIEW

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. The peak pressure occurs when the heart’s ventricular contraction, or systole, forces blood under high pressure into the aorta. When the ventricles relax, the blood remaining in the arteries exerts a trough, or diastolic, pressure against the arterial wall. 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 methods for measuring BP are auscultation using a sphygmomanometer and a stethoscope or measurement using an electronic BP monitor. Palpation may be used to obtain an estimate of systolic BP before using the auscultation method, or if unable to obtain a BP by auscultation.

During auscultation, as the sphygmomanometer cuff is deflated, five different sounds, called Korotkoff sounds, are heard over the artery. Each sound has a distinct characteristic (Figure 1)Figure 1. BP is recorded with the first Korotkoff sound (systolic pressure reading) at the beginning of the fifth Korotkoff sound (diastolic pressure reading). The difference between systolic pressure and diastolic pressure is the pulse pressure. For a BP of 120/80 mm Hg, the pulse pressure is 40 mm Hg, the difference between 120 mm Hg and 80 mm Hg.

Cuff size should be proportionate to the limb circumference. Most adults require a large adult cuff. An improper-size cuff produces inaccurate BP measurements. Studies show that using a cuff that is too narrow results in an overestimation of BP and using a cuff that is too wide results in an underestimation of BP.undefined#ref1">1

When measuring BP in the upper arm is not possible—for example, when the available BP cuffs do not fit the upper arm properly—BP may be measured in the forearm. To obtain the most accurate reading, the proper size BP cuff must be used for the forearm, which typically has a smaller circumference than the upper arm. BP measurements in the forearm and upper arm are not interchangeable. Forearm measurements tend to be higher than upper-arm measurements with the greater variability in systolic BPs.6 The thigh or calf can be used if measurement of the upper arms and forearms is not possible.1 A bariatric cuff may be needed for larger adults. The thigh BP is not interchangeable with an ankle or upper extremity BP.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain how the equipment works as well as the procedure to the patient, family, and caregivers.
  • Instruct the patient, family, and caregivers about ambulatory BP threshold guidelines. In adults, normal BP is less than 120/80 mm Hg3 (Table 1)Table 1.
  • Educate the patient, family, and caregivers about the signs and symptoms of hypotension (in adults, hypotension is considered a BP less than 90/60, although low BP without signs or symptoms is usually not treated):5
    • Dizziness or light-headedness
    • Fainting (syncope)
    • Blurred vision
    • Nausea
    • Fatigue
    • Lack of concentration
  • Educate the patient, family, and caregivers about the risk factors for hypertension:
    • Family history of hypertension, premature heart disease, lipidemia, or renal disease
    • Obesity
    • Cigarette smoking
    • Vaping
    • Heavy alcohol consumption
    • High blood cholesterol and triglyceride levels
    • Prolonged stress from psychosocial and environmental factors
    • Sedentary lifestyle
  • Educate the patient, family, and caregivers regarding the primary strategies for preventing hypertension:
    • Weight management
    • Daily exercise
    • Diet low in sodium and saturated fat
    • Adequate intake of dietary potassium and calcium
    • Avoidance of tobacco and nicotine products (e.g., cigars, cigarette, vaping)
  • Instruct the patient, family, and caregivers to ensure that the patient has adequate rest before BP measurements and that BP measurements are performed at the same time each day using the same limb with the patient in the same position, either sitting or lying down.
  • Explain to the family and caregivers that the patient must remain still and quiet during the procedure.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
  5. Prepare an area in a clean, convenient location and assemble the necessary supplies.
  6. Review the patient’s medical record for a history of cardiovascular disease, renal disease, diabetes, chronic pain, and other factors that influence BP (e.g., weight, smoking, medications).
  7. Evaluate the patient for signs and symptoms of BP alterations.
    1. Observe a patient at risk for high BP for:
      1. Headache (usually occipital)
      2. Facial flushing
      3. Nosebleed
    2. Observe a patient at risk for low BP for:
      1. Dizziness
      2. Mental confusion
      3. Restlessness
      4. Pale, dusky, or cyanotic skin and mucous membranes
      5. Cool, mottled skin over the extremities
  8. Determine the best site for BP measurement. Consider using the lower extremity if the brachial arteries are inaccessible. Avoid applying the cuff to an extremity in these situations:
    1. A peripherally inserted central catheter is present.
    2. An arteriovenous shunt or fistula is present.
    3. Ipsilateral (same-side) breast or axillary surgery has been performed.
    4. The extremity has been traumatized or injured.
    5. The extremity has known infections or medical conditions (e.g., those causing vasoconstriction or a tumor pressing on the vascular supply).
    6. The extremity has a cast or bulky bandage.
  9. Determine the previous baseline BP and site, if available, from the patient’s record.
  10. Make sure the patient has not exercised, ingested caffeine, or smoked immediately before obtaining the BP measurement.2 Make sure the patient does not have to void.
    Rationale: The urge to void can significantly increase BP. 4
  11. Make sure the room is warm.
    Rationale: Exposure to cold can significantly increase systolic BP. 4
  12. Measure the extremity circumference and select the appropriate-size cuff (Figure 2)Figure 2 (Table 2)Table 2.
    Rationale: Proper cuff size is necessary for an accurate reading. The cuff must be wide and long enough to allow for the size of the arm or thigh. Narrow cuffs cause false-high readings.
  13. Tell the patient that BP is going to be taken and that the cuff will squeeze the arm or leg.
  14. Have the patient sit or lie down. If the patient is sitting, ensure that his or her back is supported.4
  15. If using the upper arm or forearm:
    1. Position the patient’s arm, supported, at heart level with the palm facing up (Figure 3)Figure 3.
    2. If the patient is sitting, instruct him or her to keep the feet flat on the floor with the legs uncrossed.
      Rationale: If the patient’s arm is not supported at the heart level, a lower BP will be recorded when the arm is above heart level, and a higher BP will be recorded when the arm is below heart level. 1 Leg crossing can falsely increase systolic and diastolic BP.
    3. If the patient is supine, ensure that his or her legs are not crossed.
      Rationale: Leg crossing can falsely increase systolic and diastolic BP.
  16. If using the leg:
    1. Assist the patient to a prone position.
    2. If the patient is unable to assume a prone position, assist him or her to a supine position with the knee slightly flexed.
      Rationale: The prone position provides the best access to the popliteal artery. Leg crossing can falsely increase systolic and diastolic BP.
    3. Ask the patient not to cross his or her legs.
      Rationale: Leg crossing can result in a false reading of increased systolic and diastolic BP.
  17. Expose the patient’s arm or leg fully by removing any constricting clothing. Do not place the BP cuff over clothing.
    Rationale: Placing the cuff over clothing may affect the BP measurement.
  18. Apply the BP cuff to the patient’s arm or leg.
    1. Upper arm
      1. Palpate the brachial artery for a pulse (Figure 4)Figure 4.
      2. Apply the cuff above the artery by centering the arrows marked on the cuff over the artery so that the lower edge of the cuff is 2 to 3 cm (0.8 to 1.2 in) above the antecubital fossa to allow room for palpation.1 If the cuff has no center arrows, estimate the center of the bladder and place it over the artery.
        Rationale: Positioning the cuff bladder directly over the brachial artery ensures that proper pressure is applied during inflation.
      3. Wrap the fully deflated cuff evenly and snugly around the patient’s upper arm.
        Rationale: A loose-fitting cuff causes false-high readings.
    2. Forearm
      1. Palpate the radial artery for a pulse.
      2. Position the cuff above the styloid process.
      3. Apply the cuff above the artery by centering arrows marked on the cuff over the radial artery with the lower edge of the cuff positioned about 2.5 cm (1 in) above the styloid process.6 If the cuff has no center arrows, estimate the center of the bladder and place it over the artery.
        Rationale: Positioning the cuff bladder directly over the radial artery ensures that proper pressure is applied during inflation.
      4. Wrap the fully deflated cuff evenly and snugly around the patient’s forearm.
        Rationale: A loose-fitting cuff causes false-high readings.
    3. Thigh
      1. Palpate the popliteal artery for a pulse.
      2. Position the cuff over the lower third of the patient’s thigh.1
      3. Apply the cuff above the artery by centering the arrows marked on the cuff over the artery so that its lower edge is 2 to 3 cm (0.8 to 1.2 in) above the popliteal fossa to allow room for palpation.1 If the cuff has no center arrows, estimate the center of the bladder and place it over the artery.
        Rationale: Positioning the cuff bladder directly over the popliteal artery ensures that proper pressure is applied during inflation.
      4. Wrap the fully deflated cuff evenly and snugly around the patient’s thigh.
        Rationale: A loose-fitting cuff causes false-high readings.
    4. Calf
      1. Palpate the dorsalis pedis or posterior tibial artery for a pulse.
      2. Position the cuff over the lower half of the patient’s calf.1
      3. Apply the cuff so that its lower edge is about 2.5 cm (1 in) above the malleoli.1
      4. Wrap the fully deflated cuff evenly and snugly around the patient’s calf.
        Rationale: A loose-fitting cuff causes false-high readings.
  19. Position the manometer vertically at eye level.
    Rationale: Looking up or down at the scale can result in distorted incorrect readings.
  20. Ask the patient not to speak while BP is being measured.
  21. Locate and continually palpate the brachial artery (upper arm BP), radial artery (forearm BP), popliteal artery (thigh BP), or dorsalis pedis or posterior tibial artery (calf BP) with the fingertips of one hand (Figure 4)Figure 4.
  22. Palpate the artery distal to the cuff with the fingertips of the nondominant hand while inflating the cuff rapidly to a pressure level above the point at which the pulse disappears.
  23. Slowly release the pressure bulb valve, allowing the manometer needle to fall slowly and continuously at a rate of 2 to 3 mm Hg per second.4
  24. Note the point on the manometer at which the pulse reappears. This point is the palpated estimate of systolic BP.
    Rationale: Too rapid a decline in the mercury level causes inaccurate readings. Too slow a decline in the mercury level causes discomfort.
  25. Deflate the cuff fully and wait a short time.
    Rationale: The estimate of systolic BP determines the maximal inflation point for accurate reading by palpation. Completely deflating the cuff prevents venous congestion and false-high readings.
  26. Remove the cuff from the patient’s arm or leg unless a repeat measurement is needed (after a brief pause).
    Rationale: Continuous cuff inflation causes arterial occlusion, resulting in numbness and tingling of the arm or leg.
  27. If this is the patient’s first BP measurement, repeat the procedure on the other arm or leg. If there is a consistent difference between the BP in the patient’s arms or between the BP in the patient’s legs, use the arm or leg with the higher pressure.1
    Rationale: Comparison of BP in both arms or legs helps detect cardiovascular, neurologic, and musculoskeletal abnormalities. A normal difference of up to 10 mm Hg may exist between arms. 1
  28. Help the patient resume a comfortable position and return any removed clothing. Inform the patient of the BP reading, as appropriate.
  29. Record abnormal values and report them to the practitioner (Table 1)Table 1.
  30. Clean the BP cuff per the manufacturer’s instructions and the organization’s practice.
  31. If obtaining a patient’s BP measurement for the first time, establish the BP reading as the baseline if it is within the acceptable range per the organization’s practice.
  32. Compare the BP reading with the patient’s previous baseline, if available, and the usual BP for the patient’s age.
  33. Discard or store supplies, remove gloves, and perform hand hygiene.
  34. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • BP is within acceptable range.
  • Patient tolerates procedure.
  • Able to obtain palpable pulses.

UNEXPECTED OUTCOMES

  • BP is above acceptable range.
  • BP is below acceptable range or insufficient for adequate perfusion and oxygenation of tissues.
  • Unable to obtain palpable pulses.
  • BP reading cannot be obtained.
  • A significant difference exists between upper extremity BP readings or between lower extremity BP readings.

DOCUMENTATION

  • BP measurement
  • Method used to obtain BP
  • Site of BP measurement and patient’s position
  • Abnormal findings
  • Signs and symptoms of BP alterations
  • Education
  • Patient’s progress toward goals
  • Unexpected outcomes and related interventions
  • Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

  • Older adults, especially frail older adults, typically have lost upper arm mass, requiring special attention to BP cuff size.
  • Older adults’ skin is more fragile and susceptible to damage from cuff pressure when BP measurements are frequent. More frequent evaluation of the skin under the cuff or rotation of BP sites is recommended.
  • Older adults have increased systolic pressure because of decreased vessel elasticity.
  • Older adults often experience a fall in BP after eating.
  • Older adults need to change position slowly and to wait after each change to avoid postural hypotension and prevent injuries.

REFERENCES

  1. American Association of Critical-Care Nurses (AACN). (2016). AACN practice alert: Obtaining accurate noninvasive blood pressure measurements in adults. Critical Care Nurse, 36(3), e12-e16. doi:10.4037/ccn2016590 (Level VII)
  2. American Heart Association (AHA). (2017). Monitoring your blood pressure at home. Retrieved August 2, 2020, from https://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/Monitoring-Your-Blood-Pressure-at-Home_UCM_301874_Article.jsp#.Wuct7ExFwy9
  3. American Heart Association (AHA). (2017). Understanding blood pressure readings. Retrieved August 2, 2020, from https://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.Wucr9UxFwy9
  4. Kallioinen, N. and others. (2017). Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: A systematic review. Journal of Hypertension, 35(3), 421-441. doi:10.1097/HJH.0000000000001197 (Level I)
  5. National Heart, Lung, and Blood Institute (NHLBI). (n.d.). Low blood pressure. (Hypotension). Retrieved August 2, 2020, from https://www.nhlbi.nih.gov/health-topics/hypotension (Level VII)
  6. Schimanski, K. and others. (2014). Comparison study of upper arm and forearm non-invasive blood pressures in adult emergency department patients. International Journal of Nursing Studies, 51(12), 1575-1584. doi:10.1016/j.ijnurstu.2014.03.008 (classic reference)* (Level VI)

ADDITIONAL READINGS

Daskalopoulou, S.S. and others. (2015). The 2015 Canadian hypertension education program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Canadian Journal of Cardiology, 31(5), 549-568. doi:10.1016/j.cjca.2015.02.016

*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

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