Blood Pressure Measurement PDF

Blood Pressure Measurement NURS 1090  Blood Pressure  Denition: pressure exerted by the blood against as it ows through the arteries  Inuenced by :  Cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elastic...

Blood Pressure Measurement NURS 1090  Blood Pressure  Denition: pressure exerted by the blood against as it ows through the arteries  Inuenced by :  Cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity  Measured by  Sphygmomanometer  Aneroid  Stethoscope  Clean prior to use  May use bell or diaphragm Blood Pressure readings Based on American Heart Association and American College of Cardiology, 2017 Category Systolic Diastolic (mm Hg) (mm Hg) Normal 90-119 and Less than 80 Elevated 120-129 and Less than 80 Stage 1 130-139 or 80-89 hypertension Stage 2 140 or higher or 90 or higher hypertension Hypotension less than 90  Factors a8ecting BP  Age  Stress  Race  Obesity  Medications  Disease process  Blood Pressure  Systolic – ‘top number’  Reects maximum pressure exerted on the arterial wall at the peak of left ventricular contraction  Systole – ventricular contraction  Diastolic – ‘bottom number’  Reects minimum pressure exerted on the arterial wall during left ventricular relaxation.  Diastole – ventricular relaxation  Blood Pressure: Older Adults BP increases Susceptible to with orthostatic advancing age hypotension Rise in systolic pressure related to decreased arterial vessel elasticity Sites for BP measurement  Upper arm-- preferred and easiest  Forearm  Thigh  Lower leg  BP measurement sites  Usually upper arm  Take when patient is not eating, smoking, in pain  Arm at heart level  Both arms on admission  Rest between measurements  Use alternate site if:  Breast or axillary surgery  IV present  Cast or bulky bandage  Shoulder, arm or hand is injured  Arterio-venous shunt for dialysis Selecting the proper cu8 size  Select by size of arm (extremity)  Note size range on inside of cu  Bladder must be correct length and width for the arm (extremity)  How does the size of the cu# a#ect the BP reading?  Korotko8 Sounds  Sounds heard while auscultating BP  5 sounds  First sound  Is the systolic pressure  Clear, rhythmical tapping  Second – fourth  Di8erent types of sounds, (muBed, thumping)  Fifth Sound- last sound followed by silence  Is the Diastolic pressure  Obtaining the BP  Palpatory method  Palpate (feel) pulsation of artery  Use rst time you take the BP  Auscultatory method  Listen to blood ow through artery  Use for subsequent readings Obtaining the BP by PALPATION  Follow universal steps  Doctor’s order (may also be done as a nursing judgment), approach, etc.  Palpatory Reading 1. Palpate brachial artery and place cu8 on arm. Close valve on hand bulb 2. Palpate radial pulse 3. Inate cu8 slowly until pulse is no longer felt--this is the palpatory systolic reading Cannot determine diastolic reading with this method  Obtaining BP by AUSCULTATION Follow universal steps 1. Palpate brachial artery at bend of elbow, ulnar side 2. Place stethoscope over brachial pulse 3. Inate cu8 to 30 mm. higher than palpated value  Obtaining BP by auscultation, cont. 4. Deate cu8 slowly (2 mm Hg/second), listening for sound of pulsations to recur. This rst sound is systolic reading. 5. Continue to deate until sound is no longer heard. The last sound heard is the diastolic reading.  If you need to rein ate cu, you must wait at least 1 minute  Auscultatory Gap  Temporary disappearance of systolic sounds at high cu8 pressure  Then sound reoccurs at a lower pressure  Nurse may miss this higher sound if BP is not palpated rst resulting in an erroneously low systolic pressure  Often present in hypertensive patients  Assessing Trends  Trends  A general direction of change or development in something  Why are trends important?  Provide objective data for assessing changes in a patient’s condition  Baseline data  By assessing trends, changes in a patient’s condition can be addressed before problems occur  Obtaining a manual BP by assessing BP trends  Universal Steps  Review the patient’s previous BP readings from the previous 24-48 hours or the last 4-6 BP readings and assess the systolic BP values  Determine the consistent SBP readings and eliminate any that are abnormally too high or too low.  Place the BP cu8 on the patient’s upper arm  Pump the cu8 30 points higher than the average SBPs and auscultate the BP  Example  The patient record shows the following BPs from the last 48 hours:  142/80  136/74  118/68  130/78  158/82  138/88  How high should the nurse inate the cu8 to obtain a manual Blood Pressure?  Electronic Blood Pressure Devices (Dinemap)  Electronically inates & deates cu8  Gives digital read-out of BP  Stethoscope not needed  Needs to be recalibrated periodically  Also gives pulse reading  May also have electronic thermometer attached.  Orthostatic Hypotension  Can occur when patient changes position: either from lying to sitting or sitting to standing. The BP and pulse may change signicantly.  BP falls (orthostatic hypotension)  Pulse rises  Patient feels faint, lightheaded or dizzy  Types of patients at risk  Prolonged bedrest, dehydration, analgesics, older adults  **Must be completed by a RN Orthostatic Vital Signs  Measurement of pulse and BP upon position change. Measure in the following order (follow facility policy) 1. Supine – Place the patient in a supine position for at least 3-5 minutes, then take the BP and pulse. 2. Sitting – Assist the patient to sit. Within 1-3 minutes, take the BP and pulse again. 3. Standing – Assist the patient to stand for 1-3 minutes, then take the BP and pulse again.  Record your results.  Do not delegate this procedure   A rise in pulse of 15-30 Orthostati beats/min. c Vital  Systolic BP ↓ 20 mmHg Signs: Diastolic BP ↓ 10 mmHg Abnormal  Patient becomes results symptomatic  Dizzy, lightheaded, nauseous, color change, diaphoretic  If symptoms occur, STOP TEST IMMEDIATELY and sit the patient down.  Take care to avoid patient falls and subsequent injuries  Recording Vital Signs  Document in “TPR” order in the appropriate place in the EMR  First write the Temperature, then the Pulse, then the Respiratory rate, BP, sPO2  37.0 - 76 - 16 - 120/80 SpO2 98%  Be sure to indicate if the temperature was rectal or axillary  Ex. 38.0 (R) or 37.5 (Ax)  Be sure to indicate if the pulse was apical, document if pulse was regular or irregular  Ex. 92 (A), irreg.  Then document the BP in the appropriate place