Elsevier Logo

ContenidodeClinicalSkills

Procedimientos estandarizados para UN CUIDADO CONSISTENTE

¡Conozca más acercade Clinical Skills! Formación estandarizada en competencias y gestión de las competencias en enfermería y otros profesionales de la salud para garantizar que los conocimientos y las habilidades estén actualizados y reflejen las mejores prácticas y las últimas pautas clínicas.

Apr.29.2021

Blood Pressure Measurement (Pediatric) - CE

ALERT

To obtain an accurate blood pressure (BP) measurement, use the proper cuff size for the patient.

OVERVIEW

BP measurement is taken for a variety of diagnostic and therapeutic decisions; therefore, measurements must be correct and reproducible. Values that fall outside the expected range warrant further physical examination, investigation, and practitioner notification. BP evaluation should be part of a complete physical assessment of the patient.

Intraarterial measurement with an invasive catheter is the gold standard for obtaining an arterial BP. Because the intraarterial method is not practical for most pediatric patients, noninvasive blood pressure (NIBP) measurements are used. The standard of care is to obtain NIBP measurements via auscultation using a sphygmomanometer. This standard requires the health care team member to take the BP measurement in the right upper arm with the stethoscope placed over the brachial artery.undefined#ref2">2 This proven and consistent method for measuring BP yields reliable and reproducible results.2 Although the standard of care is to obtain an NIBP measurement in the upper right arm, obtaining a secondary BP measurement from the calf in a pediatric patient is an alternative if a BP reading cannot be obtained in the upper arm.

When using sphygmomanometry, the health care team member determines the pressure necessary to collapse the artery in the arm by inflating the cuff. As the cuff is deflated, the team member notes the pressure as sounds produced by the arterial pulse waves (Korotkoff sounds).

NIBP can also be measured using oscillometry or palpation. BP values obtained from oscillometric (automated) devices differ from values obtained by auscultation. Oscillometric devices are useful when auscultation is difficult or frequent BP measurements are necessary. Oscillometric devices measure BP by detecting oscillations on the walls of the occluded artery as the cuff is deflated, calculating systolic blood pressure (SBP) and diastolic blood pressure (DBP) values from measurements of the mean arterial BP. Elevated BP readings obtained using an oscillometric device should be remeasured with a sphygmomanometer if possible.

Whichever NIBP method is chosen, the cuff size (inner inflatable bladder) of the measuring device is an important factor in the accuracy of the BP measurement. For a child, the bladder cuff width should be approximately 40% of the circumference6 of the arm (Figure 1)Figure 1, measuring at a point midway between the olecranon (elbow) and acromion (bony projection of the shoulder blade)3,7 (Figure 2)Figure 2, and the bladder cuff length should cover 80% to 100% of the arm circumference.6 The American Heart Association’s recommendations (Table 1)Table 16 help the health care team member select an appropriate size cuff for the child, which directly reflects the radial arterial pressure when used on the upper arm.3 Extremity circumference should be used when measuring for cuff size as well as when determining placement. For a neonate or infant, the cuff bladder width should be approximately 50% of the mid-arm circumference.1

Standard BP tables used to determine hypertension status are based on auscultatory measurements. However, BP values obtained with oscillometric methods can be reliable and consistent if recorded in standardized conditions with a well-functioning measurement device.

Normal BP is defined as SBP and DBP less than the 90th percentile for age, height, and gender.5 Prehypertensive BP is defined as average SBP or DBP greater than or equal to the 90th percentile but less than the 95th percentile.5 Hypertension is defined as average SBP or DBP greater than or equal to the 95th percentile for age, height, and gender measured on at least three separate occasions.5

Current charts for BP values in children are based on gender, age, and height. Current national BP standards for children are based on BP values obtained with a mercury sphygmomanometer and do not apply to values obtained with oscillometric devices, which tend to overestimate BP and hypertension (Table 2)Table 2.5

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • 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. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to body fluids.
  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. Review the diagnosis and reason for obtaining the BP measurement.
  6. Assess the patient’s anxiety level.
  7. Assess the patient’s and family’s understanding of the reasons for and risks and benefits of the procedure.

Preparation

  1. Provide a quiet examination area. Calm and reassure the patient before measuring his or her BP. Allow time to recover from recent activity or apprehension.

PROCEDURE

Obtaining a BP Value Using Auscultation

  1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to body fluids.
  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. Select the best site for measuring BP. Do not apply the cuff 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. Select the appropriate size BP cuff. Estimate the size using inspection or measure the circumference of the extremity.
    Do not use a cuff that is smaller than appropriate; doing so can lead to false high BP readings. Do not use a cuff that is wider or larger than appropriate; doing so may produce false low readings.
    1. For a child, ensure that the bladder cuff width is approximately 40% of the circumference6 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.4 For children through adolescence, available cuffs should include pediatric cuffs of varying sizes, a standard adult cuff, a large adult cuff, and a thigh cuff.
    2. For a neonate or infant, ensure that the cuff bladder width is approximately 50% of the mid-arm circumference; cuffs are available in a variety of sizes.1
  6. Place a child in a sitting position; place an infant in the supine position. Keep a patient who is unable to sit up for BP measurement recumbent.
    Rationale: Sitting upright is the optimal position for BP measurement. The sitting position ensures that the midpoint of the arm is at the level of the heart (right atrium). The BP may be falsely elevated if the patient actively holds his or her arm at the level of the heart.
    Keep a patient who is critically ill in a position that maintains hemodynamic stability. When taking a BP measurement in a patient who is supine, support the arm on a pillow to ensure that it is at the level of the heart.
  7. Palpate the brachial artery and place the cuff so the midline of the bladder is over the arterial pulsation (Figure 1)Figure 1. Wrap and secure the cuff snugly around the bare upper arm.
    Rationale: Proper cuff application improves the accuracy of the measurement.
    Remove clothing with sleeves; rolling up a sleeve may cause a tourniquet effect around the upper arm.
  8. Clean the stethoscope with an alcohol wipe and warm the bell and diaphragm of the stethoscope.
    Rationale: Korotkoff sounds are heard more easily with the bell of the stethoscope in younger children.
  9. Place the earpieces of the stethoscope in the ears angled forward.
    Rationale: Proper positioning of the earpieces allows the best sound transmission.
    Ensure that the room is quiet so Korotkoff sounds are audible.
  10. Gently place the bell of the stethoscope over the brachial artery pulsation just above the antecubital fossa but below the lower edge of the cuff (Figure 1)Figure 1.
    Avoid placing excessive pressure on the brachial artery because doing so may affect Korotkoff sounds.
  11. Stabilize the patient’s extremity to limit movement.
  12. Avoid overinflating the BP cuff. If necessary, estimate SBP using palpation before obtaining SBP by auscultation.
    Overinflating the cuff may cause discomfort to the patient.
  13. Partially open the valve, deflate the bladder at 2 to 3 mm Hg per second4 and listen to the brachial pulsation.
    Avoid deflating the cuff too rapidly; doing so may cause inaccurate BP measurements.
  14. As pressure in the cuff decreases, note the pressure reading on the manometer for the first occurrence of Korotkoff sounds (K1).
    Rationale: K1 indicates SBP.
  15. Note the pressure reading when the Korotkoff sounds are muffled (K4) and when the sounds disappear (K5).
    Rationale: Korotkoff sounds can often be heard through the entire period of cuff deflation; absence of sounds (K5) denotes DBP.
  16. After the last Korotkoff sounds are heard, continue to deflate the cuff slowly.4
  17. If sounds are heard until the BP cuff is fully deflated, repeat the BP measurement with less pressure on the head of the stethoscope. If a very low K5 continues, record muffling of sounds (K4) as the DBP.
    Rationale: Continuing to deflate the cuff slowly ensures that no further sounds are audible.
  18. Record measurements for the SBP, DBP, and the mean arterial BP.
  19. If the values are abnormal, repeat the measurement after a brief rest period.
    Rationale: BP values vary widely because of physiologic variables, and further evaluation may be necessary.
  20. Remove PPE and perform hand hygiene.
  21. Document the procedure in the patient’s record.

Obtaining a BP Value with an Oscillometric Device

  1. Perform hand hygiene. Don appropriate PPE based on the patient’s need for isolation precautions or risk of exposure to body fluids.
  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. Select the best site for measuring BP. Do not apply the cuff 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. Select the appropriate size BP cuff. Estimate the size using inspection or measure the circumference of the extremity.
    Do not use a cuff that is smaller than appropriate; doing so can lead to false high BP readings. Do not use a cuff that is wider or larger than appropriate; doing so may produce false low readings.
    1. Ensure that the bladder cuff width is approximately 40% of the circumference6 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.4 For children through adolescence, available cuffs should include pediatric cuffs of varying sizes, a standard adult cuff, a large adult cuff, and a thigh cuff.
    2. For a neonate or infant, ensure that the cuff bladder width is approximately 50% of the mid-arm circumference; cuffs are available in a variety of sizes.1
  6. Place a child in a sitting position; place an infant in the supine position. Keep a patient who is unable to sit up for BP measurement recumbent.
    Rationale: Sitting upright is the optimal position for BP measurement. The sitting position ensures that the midpoint of the arm is at the level of the heart (right atrium). The BP may be falsely elevated if the patient actively holds his or her arm at the level of the heart.
    Keep a patient who is critically ill in a position that maintains hemodynamic stability. When taking a BP measurement in a patient who is supine, support the arm on a pillow to ensure that it is at the level of the heart.
  7. If the oscillometric device allows, adjust the settings to a mode that is appropriate for the patient’s size and the type of cuff.
    Rationale: Adjusting the settings helps ensure accurate readings and prevents unnecessarily high inflation of the cuff, which causes excessive discomfort for the patient.
  8. Palpate the appropriate artery (brachial or radial in the arm; popliteal, dorsalis pedis, or posterior tibial in the leg) and place the cuff so the midline of the bladder is over the arterial pulsation (Figure 1)Figure 1. Wrap and secure the cuff snugly around the bare extremity.
    Remove clothing with sleeves; rolling up a sleeve may cause a tourniquet effect around the upper arm.
  9. Activate the oscillometric device to initiate the BP measurement.
  10. Stabilize the patient’s extremity to limit movement.
  11. Record measurements for the SBP, DBP, and the mean arterial BP.
    If the BP measurement is elevated, measure BP using the auscultatory method.
  12. If the oscillometric device is used for ongoing BP monitoring, setup and activate the appropriate alarms.
  13. Remove PPE and perform hand hygiene.
  14. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Monitor the patient’s ability to tolerate the procedure.
    Reportable conditions: Inability to obtain BP values because of agitation or other factors, BP values that remain higher or lower than expected or vary significantly from the patient’s baseline values, significant differences between BP values in the upper and lower extremities
  2. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

  • Accurate values for BP are obtained and recorded.
  • Patient tolerates the procedure with minimal discomfort.

UNEXPECTED OUTCOMES

  • Korotkoff sounds are not auscultated.
  • BP measurement is not obtained using oscillometric device because of the patient’s agitation or movement.
  • Patient is unable to tolerate the procedure.

DOCUMENTATION

  • BP measurement, date and time, patient’s position, extremity used, cuff size, and patient’s activity status
  • Patient’s response to the procedure
  • Notification of the practitioner regarding unexpected or abnormal BP value and related treatment
  • 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 VI)
  2. 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 (Level VII)
  3. Foote, J.M. (2019). Chapter 4: Communication, physical, and developmental assessment of the child and family. In M.J. Hockenberry, D. Wilson, C.C. Rodgers (Eds.), Wong’s nursing care of infants and children (11th ed., pp. 80-136). St. Louis: Elsevier.
  4. Lough, M.E. (2018). Chapter 12: Cardiovascular clinical assessment. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (8th ed., pp. 184-198). Maryland Heights, MO: Elsevier.
  5. 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 March 2, 2021, from https://www.nhlbi.nih.gov/files/docs/guidelines/peds_guidelines_full.pdf (classic reference)* (Level VII)
  6. 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, 142-161. doi:10.1161/01.HYP.0000150859.47929.8e (classic reference)* (Level VII)
  7. Steinmann, R.A. (2020). Chapter 6: Initial assessment. In Emergency nursing pediatric course: Provider manual (5th ed., pp. 45-58). Burlington, MA: Jones and Bartlett Learning.

*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
;