Blood Pressure Measurement Education - CE/NCPD

ALERT

Discuss with the patient and family the importance of notifying the practitioner and withholding medications when blood pressure (BP) values are abnormal.

OVERVIEW

Patients with a variety of illnesses such as cardiac, kidney, or vascular diseases are susceptible to wide variations in their 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#ref4">4} 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 acceptable 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.

Research demonstrates that HBPM can be an effective tool in managing hypertension.³ Furthermore, the combination of self-management and office-based monitoring of BP helps practitioners establish baseline data about their patients and analyze trends related to the use of medications, exercise, or rehabilitation programs. Patients should be taught how to monitor their BP regularly and how to interpret readings that are outside of individualized normal values. Self-monitoring should be a collaborative effort. Factors that affect the accuracy of BP readings, such as cuff placement, movement of the tubing, and position of the patient, should be addressed in patient teaching.

Aneroid sphygmomanometers for BP monitoring in the home are commercially available. Measuring BP with an aneroid sphygmomanometer requires a stethoscope and a skilled operator.

Newer devices such as electronic digital sphygmomanometers are safe, lightweight, compact, and portable. Many patients who receive home care choose to use electronic BP devices, which are commercially available. These devices, which often 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. Although electronic monitors are easier to use, they often provide systolic readings that are a little lower than the reading obtained by a health care team member, and their diastolic readings are often a little higher than that of a health care team member. Therefore, BP readings obtained by a health care team member and BP readings obtained by the electronic monitor should be compared to assess the accuracy of the home monitor.

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. Not all electronic home BP monitors come with interchangeable cuff sizes, further complicating the monitoring of BP at home. The nurse should help patients and families resolve issues about cuff size, calibration, and accuracy of the electronic equipment before they determine which type of BP monitor to purchase.

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 and family the risks for hypertension and the symptoms that indicate the need to monitor BP.
• Begin education as soon as the need for BP monitoring at home is determined. Instruct the patient to monitor BP even if it remains in the normal range.
• Perform multiple demonstrations and ensure that the patient or family perform return demonstrations.
• Ensure that the patient and family understand the practitioner’s recommendations for the treatment regimen, including the potential adverse effects and interactions of medication therapies, and the monitoring frequency.
• Ensure that the patient understands that BP changes throughout the day and 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 arm, the arm with the higher readings should be used for HBPM.
• 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.
• Instruct the patient to reduce environmental noise before taking BP, especially when using a stethoscope.
• Encourage a patient who is on a long-term monitoring plan to perform BP monitoring on a routine schedule.
• Instruct the patient to avoid exercise, caffeine, and smoking for 30 minutes before monitoring BP to avoid an inaccurate reading.¹
• Involve the family in an explanation and demonstration of proper BP monitoring technique.
• Instruct the patient to call the practitioner if BP readings are low and accompanied by symptoms such as dizziness because the patient should be evaluated as soon as possible.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. 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. Assess the patient’s and family member’s visual and auditory acuities as well as their abilities to use BP monitoring equipment properly.
5. Assess the patient’s overall health literacy to provide appropriate written and verbal instructions for HBPM.
6. Assess the patient’s knowledge of normal BP ranges and symptoms and common causes of high or low readings.
7. Assess the patient’s knowledge of what a BP reading measures, which specific medical issues affect BP readings, and why an awareness of variations in BP readings is important to the patient’s well-being.
8. Assess the patient’s previous knowledge of or experience with measuring BP. Have the patient or family member perform a return demonstration if the patient or family member indicates an ability to monitor BP.

Preparation

1. Assist the patient in obtaining appropriate equipment. Older patients or those with limited dexterity may be unable to use a traditional cuff and stethoscope and may need to use an electronic device.
2. Instruct the patient to be still and sit correctly: back straight and supported, feet on floor, and legs straight and uncrossed.¹

PROCEDURE

Using a Sphygmomanometer and Stethoscope

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Discuss with the patient the best sites for monitoring BP. Demonstrate palpation of the pulse.
   1. Explain that for self-monitoring, the brachial artery is almost always used.
   2. Explain that the cuff should not be applied to an arm with an IV catheter with or without fluids infusing; an arteriovenous (AV) shunt, an AV graft, or a fistula; trauma, inflammation, or disease; or a cast or bulky bandage.
   3. 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 extremity that already has impaired circulation.

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

5. Demonstrate the steps for measuring BP.

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

6. Demonstrate palpation of an artery, positioning of the cuff, wrapping of the cuff, placement of the stethoscope, inflation and release of the cuff, and listening for sounds.
7. Describe the sounds of monitoring and their relationship to observation of the gauge during a BP reading.
   1. Observe the point on the manometer where the first clear sound is heard. Explain that it reflects systolic pressure.
   2. Deflate the cuff gradually and observe the point on the manometer where the sound is no longer heard. Explain that it reflects diastolic pressure.
8. Teach the patient to clean the diaphragm of the stethoscope with rubbing alcohol or a damp cloth routinely.
9. Have the patient attempt each step of the skill on you or a family member.

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

10. Observe the patient demonstrate the technique for BP monitoring on self (if able).
    1. Do not allow multiple BP attempts on any one limb.

       Rationale: Making repeated BP attempts restricts circulation.

    2. If the patient is having difficulty hearing BP, ensure that the patient is applying the cuff appropriately and using the correct cuff size.
    3. Ensure the correct use of equipment (e.g., the cuff may have been deflated too quickly or too slowly; the cuff may not have been pumped high enough for systolic readings).
11. 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.
12. Give the patient a logbook or piece of paper to record BP measurement and the time it is taken.
    1. Instruct the patient to record whether medications that affect the BP or pulse were taken.
    2. Instruct the patient to use the written record or logbook to report readings to the practitioner.

       Rationale: Keeping an organized record of BP readings and medications empowers the patient and provides accurate information to the practitioner.

13. Instruct the patient in the proper care of the equipment (e.g., storage and cleaning).
14. Remove PPE and perform hand hygiene.
15. Document the procedure in the patient’s record.

Using an Electronic BP Monitor

1. Perform hand hygiene and don gloves. Don additional 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. Discuss with the patient the best sites for monitoring BP. Demonstrate palpation of the pulse.
   1. Explain that for self-monitoring, the brachial artery is almost always used.
   2. Explain that the cuff should not be applied to an arm with an IV catheter with or without fluids infusing; an AV shunt, an AV graft, or a fistula; trauma, inflammation, or disease; or a cast or bulky bandage.
   3. 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 extremity that already has impaired circulation.

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

6. Demonstrate the steps for measuring BP.

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

7. 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.
8. Have the patient attempt each step of the skill on you or a family member.

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

9. Observe the patient demonstrate the technique for BP monitoring on self (if able).
   1. Do not allow multiple BP attempts on any one limb.

      Rationale: Making repeated BP attempts restricts circulation.

   2. Ensure the correct use of equipment (e.g., the cuff may have been deflated too quickly or too slowly; the cuff may not have been pumped high enough for systolic readings).
   3. 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.

      Rationale: Printed and audiovisual references promote confidence for independent performance.

10. Give the patient a logbook or piece of paper to record BP measurement and the time it is taken.
    1. Instruct the patient to record whether medications that affect the BP or pulse were taken.
    2. Instruct the patient to use the written record or logbook to report readings to the practitioner.

       Rationale: Keeping an organized record of BP readings and medications empowers the patient and provides accurate information to the practitioner.

11. Instruct the patient in the proper care of the equipment (e.g., storage, cleaning, and battery care).
12. Remove PPE and perform hand hygiene.
13. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Observe the patient demonstrate the technique for BP monitoring on at least three different occasions and verify that the patient adds information to the logbook correctly.
2. Ask the patient if readings are within the desired range and inform the patient when abnormal readings should be reported to the practitioner.
3. 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).
4. Have the patient demonstrate proper care of the equipment.
5. Ensure that the patient has a logbook or reliable method for recording at-home readings.

EXPECTED OUTCOMES

• Patient or family member accurately monitors BP.
• Patient explains the importance of monitoring BP, the best time for monitoring, and the circumstances that warrant a call to the practitioner for an evaluation.

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

• Education
• BP
• Patient’s ability to demonstrate procedure
• Patient’s understanding of the procedure
• Unexpected outcomes and related interventions

PEDIATRIC CONSIDERATIONS

• BP readings are often inaccurate and are not typically assessed as a routine physical indicator in children.
• Developmentally appropriate strategies should be used. Young children are more likely to cooperate if they are allowed to touch or play with equipment before the procedure. It may be helpful to perform the procedure first on a family member or another person who is significant to the child. This allows the child 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 a limb comfortably or perform the fine motor skills that are required to monitor BP.
• HBPM is not a replacement for BP monitoring by a health care team member in older adults, but it does reduce the number of required office visits if the older adult patient is able to use the equipment accurately and if the equipment is accurate.
• Age-related changes such as hearing loss may limit the choices of BP monitoring devices.

HOME CARE CONSIDERATIONS

• Patients who frequently monitor their BP at home experience better BP control and have decreased health care costs.
• Patients should be taught to monitor their BP regularly and to interpret readings that are outside of individualized normal values. For example, patients should learn about factors that affect the accuracy of BP readings, such as cuff placement, movement of the tubing, and position of the patient.
• Many patients who receive home care choose to use electronic BP devices.
• The home environment should be assessed for a favorable place to monitor BP (e.g., a quiet room with a comfortable place to sit).

REFERENCES

1. American Heart Association (AHA). (2023). The facts about high blood pressure. Retrieved June 27, 2023, from https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure (Level VII) (classic reference)*
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. McManus, R.J. and others. (2021). Home and online management and evaluation of blood pressure (HOME BP) using a digital intervention in poorly controlled hypertension: Randomised controlled trial. British Medical Journal, 372. doi:10.1136/bmj.m4858 Retrieved June 27, 2023, from https://www.bmj.com/content/bmj/372/bmj.m4858.full.pdf (Level II)
4. 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.

Adapted from Perry, A.G. and others (Eds.). (2022). Clinical nursing skills and techniques (10th ed.). St. Louis: Elsevier.

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