Blood Pressure Education (Ambulatory) - CE/NCPD

OVERVIEW

Patients with a variety of illnesses such as cardiac, kidney, or vascular diseases are susceptible to wide variations in blood pressure (BP). In general, a sustained systolic BP reading of 130 mm Hg or higher and a sustained diastolic reading of 80 mm Hg indicate hypertension.^{undefined#ref3">3} Unmanaged hypertension increases the risks associated with cardiovascular disease or heart failure, stroke, and kidney disease.

Patients benefit from knowing how to monitor their own BP and pulse because it enables them to seek medical attention early when readings are outside the normal range. Home blood pressure monitoring (HBPM) allows patients to participate in their own health care. Also, HBPM helps to reduce health care costs and can improve the quality and outcome of overall management of patients with hypertension.

Examples of patients who need to know these skills include those with heart disease and those involved in cardiac rehabilitation programs. In addition, healthy people who exercise should learn how their body responds to exercise and should be able to determine appropriate exercise plans based on knowing their BP before, during, and after exercise.

HBPM can be an effective tool in managing hypertension. Furthermore, the combination of self-management and office-based monitoring of BP helps health care team members establish baseline data about their patients and analyze trends related to the use of medications, exercise, or rehabilitation programs. Factors that affect the accuracy of BP readings, such as cuff placement, tubing movement, and the patient’s position, should be addressed in patient teaching.

Electronic digital sphygmomanometers are safe, lightweight, compact, and portable. These devices, many of which also measure pulse rate, produce a BP measurement without the use of a stethoscope. A cuff is placed around the arm or wrist or attached to the fingertip, and a reading is displayed electronically for the patient. Therefore, BP readings obtained by a health care team member and BP readings obtained by the electronic monitor should be compared to determine the home monitor’s accuracy. Patients with atrial fibrillation or other arrhythmias may not be good candidates for HBPM with an electronic device because accuracy of the measurement can be affected by an irregular heart rhythm.¹

Electronic BP monitors are easy to use, but the health care team member should teach the patient that they may provide lower systolic readings and higher diastolic readings than aneroid monitors, which may be used in health care facilities. This information may spare the patient from undue alarm when different numbers are obtained during HBPM.

One factor that affects the accuracy of BP monitoring is cuff size (Box 1). BP cuffs that are too small tend to overestimate BP, whereas cuffs that are too large tend to underestimate BP. Thus, choosing the correct cuff size, one in which the bladder completely encircles the arm without overlapping, is important. Not all electronic home BP monitors come with interchangeable cuff sizes, further complicating the monitoring of BP at home.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain to the patient the risks for hypertension and the symptoms that indicate the need to monitor BP.
• Ensure that the patient understands the recommendations for the treatment regimen, including the potential side effects and interactions of medication therapies, and the monitoring frequency.
• Ensure that the patient understands that BP changes throughout the day and that excessive monitoring can cause undue anxiety and concern.
• Inform the patient that HBPM is most easily done on the nondominant arm; however, left-arm and right-arm readings may differ.
  • Explain that first-time BP readings should be taken in both arms and that if one arm has consistently higher readings than the other, the arm with the higher readings should be used for HBPM.
  • Explain that any difference of 10 mm Hg or less is considered normal and no cause for concern.¹
• Instruct the patient to perform BP monitoring in a comfortable position with the arm supported and the feet flat on the floor and in a warm, quiet environment.
• Encourage the patient to perform BP monitoring on a routine schedule, measuring it at the same time every day unless otherwise directed by the health care team member.¹
• Instruct the patient to avoid exercise, caffeine, and smoking for 30 minutes before monitoring BP to avoid an inaccurate reading.¹
• Instruct the patient to empty the bladder and to maintain at least 5 minutes of quiet rest before taking a measurement.¹
• Instruct the patient to monitor BP if readings are low and accompanied by symptoms such as dizziness because the patient should seek additional care.
• Instruct the patient to monitor if BP readings are slightly or moderately higher than normal or are suddenly higher than 180/120 mm Hg and when to seek additional care.¹
• Teach the patient the signs and symptoms of an acute myocardial infarction (e.g., chest pain, shortness of breath, back pain, numbness or weakness, change in vision, difficulty speaking) and provide instructions on when to seek additional care.¹
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Explain the procedure and ensure that the patient agrees to treatment.
5. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
6. Evaluate the patient’s overall health literacy to provide appropriate written and verbal instructions for HBPM.
7. Provide the patient with printed instructions with a written or pictorial guide appropriate to the patient’s health literacy level. If applicable, provide the patient with a videotape or website address that demonstrates the procedure.
8. Determine the patient’s knowledge of what a BP reading measures, normal BP ranges, which specific medical issues affect BP readings, and why an awareness of variations in BP readings is important to the patient’s well-being.
9. Evaluate the patient’s previous knowledge of or experience with measuring BP. Have the patient perform a return demonstration if the patient indicates an ability to monitor BP.
10. Explain that the cuff should not be applied to an arm with an arteriovenous (AV) shunt, fistula, or graft; decreased blood flow; trauma; or a cast or bulky bandage. Explain that if the patient has had breast or axillary surgery, the patient should apply the cuff to the arm on the other side.

    The postsurgical side may be used if other sites are not available or practical.²

    Rationale: Appropriate site selection promotes accuracy in reading and minimizes the potential for trauma. The application of pressure from an inflated bladder temporarily impairs blood flow and compromises circulation in the arm or leg that already has impaired circulation.

    Rationale: The risk of developing lymphedema from occasional BP measurement following breast or lymph surgery is low.²

11. Explain that the cuff should not be applied over clothes.¹
12. Explain how to measure for the correct cuff size for the patient’s arm or thigh.
13. Demonstrate palpation of the brachial artery pulse.
14. Demonstrate the steps for measuring BP.

    Rationale: Demonstration is the best technique for teaching a psychomotor skill.

15. Demonstrate the correct placement of the cuff, the use of electronic equipment for proper cuff inflation, and the procedure for changing batteries following the manufacturer’s instructions for use.
16. Have the patient attempt each step of the skill on a health care team member.

    Rationale: Errors in technique can be corrected as they occur.

17. Observe the patient demonstrating the technique for BP monitoring on self.
    1. Ensure the correct use of equipment.
    2. Instruct the patient to take two or three readings 1 minute apart.¹
18. Instruct the patient to record BP measurement and the time it is taken.
19. Instruct the patient in the proper care of the equipment (e.g., storage, cleaning, and battery care).
20. Ask the patient if readings are within the desired range and confirm that the patient knows when to seek additional care for abnormal readings.
21. Ask the patient to describe the reason for BP monitoring and any related medications (e.g., antihypertensives, antiarrhythmics) or treatment (e.g., diet and exercise).
22. Have the patient demonstrate proper care of the equipment.
23. Discard supplies, remove PPE, and perform hand hygiene.
24. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Patient accurately monitors BP.
• Patient explains the importance of monitoring BP and the best time for monitoring.

UNEXPECTED OUTCOMES

• Patient is unable to monitor BP because of cognitive or sensory problems (e.g., inability to manipulate the equipment or see numbers on the equipment).
• Patient has difficulty explaining the purposes of monitoring or the implications of therapy.

DOCUMENTATION

• BP
• Patient’s ability to demonstrate procedure
• Patient’s understanding of the procedure
• Education
• Unexpected outcomes and related interventions
• Evaluation findings communicated to the clinical team leader per the organization’s practice

PEDIATRIC CONSIDERATIONS

• Developmentally appropriate strategies should be used. Young children are more likely to cooperate if they can touch or play with equipment before the procedure.
• Performing the procedure first on a family member may be helpful. This allows the patient to observe that the procedure is safe.

OLDER ADULT CONSIDERATIONS

• Musculoskeletal changes such as arthritis or other joint conditions may impair an older adult’s ability to position an arm comfortably or perform the fine motor skills that are required to monitor BP.

REFERENCES

1. American Heart Association (AHA). (2017, reviewed 2023). Monitoring your blood pressure at home. Retrieved June 27, 2023, from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home (Level VII)
2. McLaughlin, S.A. and others. (2017). Considerations for clinicians in the diagnosis, prevention, and treatment of breast cancer-related lymphedema, recommendations from an expert panel: part 2: preventive and therapeutic options. Annals of Surgical Oncology, 24(10), 2827-2835. doi:10.1245/s10434-017-5964-6 (classic reference)* (Level VII)
3. Whelton, P.K. and others. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), 2199-2269. doi:10.1016/j.jacc.2017.11.005 (Level VII)

ADDITIONAL READINGS

American Heart Association (AHA). (2020). How to accurately measure blood pressure at home. Retrieved June 27, 2023, from https://www.heart.org/en/news/2020/05/22/how-to-accurately-measure-blood-pressure-at-home

*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

Clinical Review: Martha Beck, MA, BSN, RN, CNOR

Published: August 2023