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Nursing 20G - Vital Signs > 16) Measuring Blood Pressure > Flashcards

16) Measuring Blood Pressure Flashcards

1
Q

How can arterial blood pressure be measured?

A
  • Directly (invasively) by inserting catheter into artery
  • Indirectly (noninvasively) using methods like oscillometry or auscultation
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2
Q

When is invasive blood pressure monitoring used?

A
  • Only in critical care settings
  • Due to risk of sudden blood loss from artery
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3
Q

What does Hypertension Canada’s 2020 Guidelines recommend?

A
  • Validated oscillometric upper arm measurements preferred over auscultation
  • AOPB preferred for in-office measurement
  • Out-of-office measurements essential for white coat/masked hypertension
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4
Q

What percentage of Canadian family physicians still use auscultation?

A
  • 52% still use aneroid/mercury devices with auscultation
  • Not following current Canadian guidelines
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5
Q

What does literature say about auscultation vs automated methods?

A
  • Auscultation is more complex, increases human error
  • But automated devices have not eliminated human error completely
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6
Q

What is recommended for nurses?

A
  • Electronic measurement should be encouraged
  • But know proper technique for both auscultation and automated measurement
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7
Q

Can measuring blood pressure be delegated to unregulated care providers (UCPs)?

A
  • In most provinces/territories, yes
  • Nurse is responsible for assessing BP changes
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8
Q

What should the UCP be informed about when delegating BP measurement?

A
  • Appropriate limb for measurement (typically arm, can be leg)
  • Appropriate cuff size for extremity
  • Frequency of measurement for patient
  • Patient’s usual BP values
  • Abnormalities to report to provider
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9
Q

What equipment is needed for BP measurement?

A
  • Aneroid sphygmomanometer
  • Appropriately sized BP cuff
  • Stethoscope
  • Alcohol swab
  • Pen and vital sign flow sheet/documentation form
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10
Q

What is the first step in the procedure?

A
  • Identify patient using at least two identifiers (e.g. name and date of birth)
  • Follows employer policy and improves patient safety
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11
Q

Why determine the need to assess blood pressure?

A
  • Use clinical judgment
  • Certain conditions heighten risk for BP alteration
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12
Q

What conditions increase risk for high blood pressure?

A
  • Cardiovascular disease, renal disease, diabetes
  • Circulatory shock, acute/chronic pain
  • Rapid IV fluids/blood products, increased intracranial pressure
  • Postoperative conditions, toxemia of pregnancy
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13
Q

What are signs/symptoms of high blood pressure?

A
  • Headache (usually occipital), flushing, nosebleed, fatigue
  • Often asymptomatic until very high
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14
Q

What are signs/symptoms of low blood pressure?

A
  • Dizziness, mental confusion, restlessness
  • Pale, dusky, cyanotic skin/mucous membranes
  • Cool, mottled skin over extremities
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15
Q

What sites should be avoided for BP cuff?

A
  • IV infusion site, arteriovenous shunt/fistula
  • Side of breast/axillary surgery
  • Traumatized, diseased extremity or requiring cast/bulky bandage
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16
Q

Why determine previous baseline BP?

A
  • Enables assessment of change in patient’s condition
  • Provides comparison for future measurements
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17
Q

What factors can interfere with accurate blood pressure measurement?

A
  • Acute anxiety, stress, pain
  • Caffeine and tobacco use within 30 minutes
  • Not resting quietly for 5 minutes beforehand
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18
Q

Why should exercise, smoking, and caffeine be avoided before measuring blood pressure?

A
  • Exercise and smoking cause false elevations
  • Smoking increases BP immediately, lasting up to 15 minutes
  • Caffeine increases BP for up to 3 hours
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19
Q

What preparations are needed before measuring blood pressure?

A
  • Explain procedure to patient
  • Have patient rest at least 5 mins (sitting/lying) or 1 min (standing)
  • Ask patient not to speak during measurement
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20
Q

Why are these preparations important?

A
  • Allows patient to relax
  • Avoids falsely elevated readings
  • Enables objective comparison to rested readings
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21
Q

Why is selecting the appropriate cuff size crucial?

A
  • Improper size results in inaccurate readings
  • Too small/loose cuff can cause falsely high readings
  • Too large cuff can cause falsely low readings
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22
Q

What should be checked regarding the cuff components?

A
  • Release valve is clean and moves freely
  • Inflation bulb and tubing are intact and leak-free
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23
Q

Why perform hand hygiene before measuring blood pressure?

A
  • Reduces transmission of microorganisms between patient and nurse
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24
Q

What factors ensure patient comfort during measurement?

A
  • Warm, quiet, relaxing environment
  • Patient in sitting or lying position
  • Reduces stress affecting the reading
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25
Q

What is the proper patient positioning for blood pressure measurement?

A
  • Sitting or lying position
  • Forearm at heart level, thigh flat (provide support)
  • For arm: palm up
  • For thigh: knee slightly flexed
  • If sitting: legs uncrossed, feet on floor
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26
Q

Why is proper positioning important?

A
  • Unsupported extremity can cause isometric exercise, increasing diastolic BP
  • Crossed legs can falsely elevate BP readings
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27
Q

What should be done before applying the cuff?

A
  • Expose the extremity by removing constricting clothing
  • Ensures proper cuff application
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28
Q

How should the cuff be positioned?

A
  • Palpate brachial (arm) or popliteal (leg) artery
  • Center deflated cuff bladder over artery
  • Position cuff 2.5cm above pulsation site
  • Wrap cuff evenly and snugly around extremity
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29
Q

Why is cuff positioning over artery important?

A
  • Ensures proper pressure is applied during inflation
  • Loose cuff causes falsely high readings
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30
Q

What should be avoided when applying the cuff?

A
  • Do not place cuff over clothing
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31
Q

How should the manometer gauge be positioned?

A
  • Position gauge no further than 1 meter away
  • Ensures gauge indicates correct readings
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32
Q

What is the purpose of the two-step method?

A
  • Provides estimate of systolic pressure
  • Assists in determining level of cuff inflation
  • Useful when baseline BP is unknown
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33
Q

What are the steps for the first part of the two-step method?

A
  • Relocate and palpate brachial/popliteal pulse
  • Inflate cuff rapidly to 30mmHg above pulse disappearance
  • Slowly deflate, note reading when pulse reappears
  • Fully deflate cuff, wait 1 minute
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34
Q

Why are these steps important for the 2 step method?

A
  • Relocating prevents false low readings
  • Palpation determines maximal inflation point
  • Deflating fully prevents venous congestion and false high readings
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35
Q

What should be done with the stethoscope?

A
  • Place earpieces in ears, ensure clear sounds
  • Earpieces should follow ear canal angle
  • Relocate pulse, place bell/diaphragm over it
  • Do not let bell touch cuff or clothing
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36
Q

Why is proper stethoscope placement crucial?

A
  • Ensures optimal sound reception
  • Improper placement causes muffled sounds
  • Can result in false low systolic, false high diastolic readings
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37
Q

What should be done with the pressure bulb valve?

A
  • Close valve clockwise until tight
  • Prevents air leak during inflation
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38
Q

How should the cuff be inflated?

A
  • Rapidly inflate to 30mmHg above previously palpated systolic pressure
  • Uses patient’s estimated systolic pressure
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39
Q

How should the cuff be deflated during the two-step method?

A
  • Slowly release pressure bulb valve
  • Allow needle to fall at 2-3 mmHg/second
  • Ensure no extraneous sounds are audible
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40
Q

Why is the rate of deflation and noise level important?

A
  • Too rapid or slow deflation causes inaccurate readings
  • Noise interferes with precise Korotkoff sound determination
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41
Q

What indicates the systolic pressure reading?

A
  • Note point when first clear Korotkoff sound is heard
  • The sound will gradually increase in intensity
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42
Q

How is diastolic pressure determined in children?

A
  • Continue deflating cuff
  • Note point when sound becomes muffled/dampened
  • The fourth Korotkoff sound indicates diastolic in children
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43
Q

How is diastolic pressure determined in adults?

A
  • Continue gradual deflation
  • Note point when sound disappears
  • Listen 10-20 mmHg after last sound, then quickly release remaining air
  • Beginning of fifth Korotkoff sound indicates diastolic in adults
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44
Q

When is the one-step method used?

A
  • For frequent measurements
  • When previous systolic inflation level is known
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45
Q

What are the initial steps for the one-step method?

A
  • Place stethoscope in ears, ensure clear sounds
  • Relocate brachial/popliteal artery
  • Place bell/diaphragm over artery, avoid touching cuff/clothing
  • Close bulb valve tightly
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46
Q

How should the cuff be inflated in the one-step method?

A
  • Quickly inflate to 30 mmHg above palpated systolic pressure
  • Prevents air leak and ensures accurate systolic measurement
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47
Q

How is diastolic pressure determined in children using the one-step method?

A
  • Continue deflating cuff
  • Note point when sound becomes muffled/dampened
  • The fourth Korotkoff sound indicates diastolic in children
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48
Q

How is diastolic pressure determined in adults using the one-step method?

A
  • Continue gradual deflation
  • Note point when sound disappears
  • Listen 10-20 mmHg after last sound, then quickly release remaining air
  • Beginning of fifth Korotkoff sound indicates diastolic in adults
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49
Q

What does Hypertension Canada recommend for auscultation?

A
  • Take at least 3 measurements in same arm/position
  • Discard first reading
  • Average the latter two readings
50
Q

Why take multiple readings?

A
  • Increases accuracy of blood pressure measurement
51
Q

When should you repeat on the other arm?

A
  • If assessing patient’s BP for the first time
  • Compares readings between extremities to detect circulation problems
52
Q

What is considered a normal difference between arm readings?

A
  • Difference of 5-10 mmHg between extremities is normal
53
Q

What should be done after measurement?

A
  • Assist patient to comfortable position
  • Cover arm if previously clothed
  • Promotes comfort and well-being
54
Q

How should the cuff be handled?

A
  • Wipe with disinfectant or dispose according to policy
  • Reduces transmission of microorganisms between patients
55
Q

Why discuss findings with the patient?

A
  • Promotes patient participation in care
  • Increases understanding of health status
56
Q

Why perform hand hygiene?

A
  • Reduces transmission of microorganisms between patient and nurse
57
Q

What should the reading be compared to?

A
  • Previous baseline value
  • Acceptable value for patient’s age
  • Evaluates change in condition and alterations
58
Q

In what situations is it necessary to compare blood pressure readings across multiple extremities?

A
  • Critically ill patients
  • Patients with peripheral vascular disease
59
Q

If using upper extremities, which arm should be used for subsequent assessments?

A
  • Use the arm with the higher blood pressure reading
  • Unless contraindicated
60
Q

Why correlate blood pressure with pulse assessment and cardiovascular signs/symptoms?

A
  • Blood pressure and heart rate are interrelated
61
Q

What should be done if unable to obtain a blood pressure reading?

A
  • Measure pulse and respiratory rate to check for crisis
  • Assess for decreased cardiac output signs (weak pulse, confusion, pallor, cyanosis)
  • Notify nurse/provider immediately if signs present
  • Use alternative sites (lower extremity) or methods (Doppler, palpation)
  • Repeat with sphygmomanometer, as electronic devices less accurate with low blood flow
62
Q

What interventions are needed if blood pressure is insufficient for tissue perfusion?

A
  • Compare to baseline value (systolic 90 mmHg may be acceptable)
  • Position patient supine to enhance circulation
  • Restrict activity if causing BP decrease
  • Assess for decreased cardiac output signs and notify if present
  • Increase IV rate or give vasoconstrictor medications if ordered
63
Q

What should be done if blood pressure is elevated above acceptable range?

A
  • Repeat measurement on other arm and compare
  • Verify correct cuff size and placement
  • Ask colleague to repeat in 2 minutes
  • Observe for symptoms like headache, confusion (may be asymptomatic)
  • Report elevated BP to nurse/provider immediately
  • Administer antihypertensive medications as ordered
64
Q

What should be done after obtaining a blood pressure reading?

A
  • Inform patient of the value
  • Explain need for periodic reassessment
65
Q

Where should blood pressure readings be documented?

A
  • Record in nurses’ notes or vital sign flowsheet
  • Document in narrative notes after specific therapies
66
Q

What should be reported regarding blood pressure readings?

A
  • Report any abnormal findings to the nurse in charge or provider
67
Q

What should be considered for home blood pressure monitoring?

A
  • Assess home noise level to find quietest room
  • Consider electronic cuff if patient has hearing difficulties, resources, and dexterity
68
Q

Why can’t blood pressure be taken on the arm after a mastectomy?

A
  • Lymph node removal can cause lymph fluid buildup in the arm (lymphedema)
  • Blood pressure cuff pressure on the arm could worsen or trigger lymphedema
69
Q

What are potential complications of lymphedema?

A
  • Swelling, puffiness, heaviness
  • Aching or burning sensation
  • Trouble moving affected limb joint
70
Q

What are the main components of a sphygmomanometer?

A
  • Pressure manometer
  • Inflatable cuff with bladder
  • Pressure bulb with release valve
71
Q

What is the ideal cuff bladder width?

A
  • 40% of the arm’s circumference
72
Q

Where should the cuff’s lower edge be positioned?

A
  • 3 cm above the antecubital fossa
  • To allow room for stethoscope
73
Q

What should the bladder length of a blood pressure cuff cover?

A
  • 80 to 100% of the arm’s circumference
74
Q

What should the bladder width be in relation to the arm’s circumference?

A

Close to 40% of the arm’s circumference

75
Q

What is the best environment for blood pressure measurement by auscultation?

A
  • Quiet room
  • Comfortable temperature
76
Q

What is the preferred patient position for blood pressure measurement?

A
  • Sitting position
  • Lying or standing are alternatives
77
Q

Why is consistent patient positioning important for routine measurements?

A
  • Enables meaningful comparison of blood pressure values
78
Q

What factors should be controlled before measuring blood pressure?

A
  • Pain
  • Anxiety
  • Exertion
79
Q

Why is it important to minimize perceptions of a stressful environment?

A
  • To reduce any effect on blood pressure measurement
80
Q

What should be done during the initial blood pressure assessment?

A
  • Measure and record blood pressure in both arms
  • Normally pressures differ by 5-10 mmHg between arms
81
Q

What should be done in subsequent assessments?

A
  • Measure blood pressure in the arm with higher reading
  • Report differences >10 mmHg to provider (indicates vascular problems)
82
Q

What should be done regarding the patient’s usual blood pressure?

A
  • Ask patient to state their usual blood pressure
  • If unknown, inform patient of reading after measurement
83
Q

What patient education is important?

A
  • Educate on optimal blood pressure values
  • Educate on risk factors for hypertension
  • Educate on dangers of hypertension
84
Q

How does indirect blood pressure measurement work?

A
  • Inflated cuff collapses artery, blocking blood flow
  • Systolic pressure is when blood flow/sound returns on deflation
85
Q

What are the Korotkoff sounds?

A
  • Described by Nikolai Korotkoff in 1905
  • Correspond to systolic onset, turbulence, and diastolic pressure
86
Q

How are systolic and diastolic pressures recorded?

A
  • Systolic - note first Korotkoff sound
  • Diastolic - note 5th sound (disappearance) in adults
87
Q

Why is obtaining an accurate blood pressure measurement essential?

A
  • Blood pressure findings prompt medical decisions
  • Blood pressure findings prompt nursing interventions
88
Q

What should be done when unsure of a blood pressure reading?

A
  • Ask a colleague to reassess the blood pressure
89
Q

How can preparing the child help with cooperation?

A
  • Explain the “tight hug” sensation of the cuff
90
Q

Why are Korotkoff sounds difficult to hear in children?

A
  • Low frequency and amplitude
  • Pediatric stethoscope bell can help
91
Q

Which Korotkoff sound represents diastolic pressure in infants/children?

A
  • The 4th sound, which is typically muffled
92
Q

When should an ultrasonic stethoscope be used?

A
  • When unable to auscultate sounds due to weakened arterial pulse
93
Q

What does an ultrasonic stethoscope enable?

A
  • Allows hearing of low-frequency systolic sounds
94
Q

For whom is an ultrasonic stethoscope commonly used?

A
  • Infants
  • Children
  • Adults with low blood pressure
95
Q

When is the indirect palpation technique useful?

A
  • For patients with arterial pulsations too weak for Korotkoff sounds
  • Conditions like severe blood loss or decreased heart contractility
96
Q

What can be assessed by palpation? What is difficult?

A
  • Systolic blood pressure can be assessed
  • Diastolic pressure is difficult to assess by palpation
97
Q

How should palpated blood pressure be recorded?

A
  • Record systolic value and note it was palpated (e.g. “RA 90/—, palpated, supine”)
98
Q

What is the auscultatory gap?

A
  • Temporary disappearance of sounds in hypertensive patients
  • Occurs between 1st and 2nd Korotkoff sounds
99
Q

Why is the auscultatory gap important?

A
  • May cause underestimating systolic or overestimating diastolic pressure
  • Inflate cuff high enough to hear true systolic before gap
100
Q

How can palpation help determine cuff inflation level?

A
  • Palpate radial artery
  • Inflate 30 mmHg above pressure when radial pulse disappeared
101
Q

How is the auscultatory gap range determined?

A
  • Note pressures when radial pulse disappeared and reappeared
  • Record this range (e.g. “gap 180 to 160”)
102
Q

What is the delegation consideration for palpating blood pressure?

A

The skill cannot be delegated to unregulated care providers

103
Q

When might lower extremity blood pressure measurement be needed?

A
  • Upper extremities inaccessible due to dressings, casts, IV catheters, etc.
  • Comparing upper and lower pressures for certain conditions
104
Q

Which artery is used for lower extremity blood pressure?

A
  • Popliteal artery behind the knee
105
Q

What type of cuff is required for lower extremity blood pressure?

A
  • Wide and long enough for larger thigh girth
106
Q

What patient position is best for measuring lower extremity blood pressure?

A
  • Prone position
107
Q

If prone is impossible, during lower extremity blood pressure what should be done?

A
  • Ask patient to flex knee slightly for artery access
108
Q

How should the cuff be positioned for lower extremity blood pressure?

A
  • 2.5 cm above popliteal artery
  • Bladder over posterior midthigh
109
Q

How does lower extremity blood pressure procedure differ from brachial artery?

A
  • Procedure is identical to brachial auscultation
110
Q

How does leg systolic pressure typically compare to brachial?

A
  • Usually 10-40 mmHg higher in legs
111
Q

How does leg diastolic pressure compare to brachial?

A
  • Should be the same as brachial
112
Q

How is AOBP measurement performed?

A
  • Multiple measurements at 1-2 minute intervals
  • First by nurse to verify cuff position/validity
  • Rest with patient alone in quiet room
113
Q

What should be recorded for AOBP?

A
  • Average BP displayed
  • Heart rate
  • Arm used
  • Patient position (supine, sitting, standing)
114
Q

What are advantages of AOBP over manual?

A
  • Reduces white coat and masked hypertension risk
  • Easy to use, no stethoscope knowledge needed
  • Enables BP assessment during interactions
  • Limits interaction to decrease error risk
115
Q

What types of portable home devices are recommended?

A
  • Electronic digital readout devices (no stethoscope needed)
  • Minimize auscultation-induced errors
116
Q

What can be evaluated by assessing blood pressure and pulse?

A
  • Patient’s general cardiovascular health state
  • Responses to other system imbalances
117
Q

What are defining characteristics of certain nursing diagnoses related to blood pressure?

A
  • Hypotension
  • Hypertension
  • Orthostatic hypotension
  • Narrow or wide pulse pressures
118
Q

List some nursing diagnoses related to BP/pulse abnormalities.

A
  • Activity intolerance
  • Anxiety
  • Decreased cardiac output
  • Deficient/excess fluid volume
  • Risk for injury
  • Acute pain
  • Ineffective tissue perfusion
119
Q

How are nursing interventions determined?

A
  • Based on the identified nursing diagnosis
  • And related factors like poor intake, heat exposure, valve disease history
120
Q

How does the nurse evaluate intervention outcomes?

A
  • By reassessing the patient’s blood pressure after each intervention

Nursing 20G - Vital Signs (19 decks)

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