Accurate Blood Pressure Measurement Saves Lives: Best Practices June 27, 2016

Objectives To list the 3 classifications of blood pressure. To use correct patient positioning for an accurate BP measurement. To be able to select the correct size BP cuff for accurate measurement. To identify at least 3 lifestyle modifications that you can discuss with patients who have prehypertension or hypertension.

What is Blood Pressure (BP)? The force of blood against the walls of the arteries BP is recorded as 2 numbers: Systolic: the force exerted when the heart contracts Diastolic: the force exerted when the heart relaxes Hypertension is persistently high BP

Diastolic: 90 mm hg or > BP Classification Normal BP Systolic: < 120 mmHg Diastolic: < 80 mmHg Prehypertension (at risk) Systolic: 120-139 mmHg Diastolic: 80 –89 mmHg Hypertension Systolic: 140 mmHg or > Diastolic: 90 mm hg or > BP Goals for People with Diabetes*: 140/80. Lower systolic targets, such as 130 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden. *Reference: Standards of Medical Care in Diabetes – 2014 Diabetes Care Volume 37, Supplement 1, January 2014  

Why is this Important? Hypertension increases one’s risk of heart disease, stroke, kidney disease, and early death. Hypertension caused or contributed to nearly 1,000 deaths per day in 2009 (Million Hearts). 1 in 3 US adults have high blood pressure and only half have their condition under control. Inaccurate Blood pressure measurement can lead to misdiagnosis of hypertension.

Why is this Important? Million Hearts Goal Prevent 1 million heart attacks and strokes by 2017. 72 million adults with HPT 48% are uncontrolled. North Dakota is part of a Million Hearts project to improve BP. (9 month grant). 2 projects CVHD and SW District Health.

Patient Positioning Feet flat, legs uncrossed Back supported Arm exposed & level with heart No talking during measurement Avoid smoking 30 minutes prior to measurement Avoid full bladder

Arm Selection Avoid taking BP on the side that has/had: Pain or injury Breast or axilla surgery including Mastectomy Lymphedema Dialysis Shunt/Fistula Subclavian Stenosis (narrowing/constriction) IV/arterial line

Check Equipment Calibrate according to manufacturer's directions Visually inspect before use The needle on the sphygmomanometer must be within the zero box prior to inflation or take out of service until fixed

Selecting the Correct Cuff Size For reading to be accurate, place BP cuff on the patient’s arm so that the index line falls within range

Cuff too Big – index line left of range reading will be inaccurately low Cuff too Small - index line right of range reading will be inaccurately high

Correct Cuff Size Correct Placement Index line within range Apply the cuff snugly around arm, 1 inch above antecubital fossa.

Avoid: Tourniquet Effect Muffled Sounds Artifactual Sounds

The Cost of Making Small Measurement Errors Small errors may result in either: undiagnosed cases of hypertension (undertreated) misdiagnosed cases of hypertension in patients who are really prehypertensive (overtreatment)

Factors Affecting Accuracy of Blood Pressure Measurements Magnitude of discrepancy Talking/active listening 10 mmHg Distended bladder 10 – 15 mmHg Cuff over clothing 5 – 50 mmHg Smoking within 30 mins. of measurement 6 – 20 mmHg Back unsupported 6 – 10 mmHg Legs crossed 2 – 8 mmHg Arm unsupported 1 – 11 mmHg

BP Procedure Estimate systolic pressure: Palpate radial artery, inflate cuff until radial pulse can no longer be felt Deflate cuff completely & wait 15 – 30 seconds

BP Procedure Obtain BP Reading: inflate cuff 30mmHg above estimated systolic pressure then deflation at 2 – 3 mmHg/sec. Note systolic pressure: 1st two or more consecutive faint tapping beats (Korotkoff sound, phase 1) Note diastolic pressure: last sound heard or disappearance of sound (2mmHg below the last sound) Both methods are recognized standards: refer to your agency’s policy & procedure Listen for another 10 – 20 mmHg beyond last sound heard, then quickly deflate cuff to zero.

Always follow your agency’s BP Policy & Procedure BP Procedure Recheck & Record: Record BP, rounding up to the nearest 2mmHg Wait at least 1 minute between BP readings Notify provider of all readings of concern (some agencies have a policy that an RN will recheck prior to this step) Always follow your agency’s BP Policy & Procedure

Development of Statewide Algorithm

What can you do to ensure accurate BP measurement? Develop a BP policy & procedure Provide staff training Competency testing Calibrate BP equipment Rearrange furniture in exam rooms to accurately take a BP Position patient properly

Promote Medication Compliance & Lifestyle Modifications Always take BP medication as prescribed – don’t stop or skip a dose without consulting with your provider Maintain normal body weight Eat a healthy diet: high in fruits/vegetables, low in fat, reduce salt intake Physical Activity: at least 30 minutes, most days Avoid tobacco Limit alcohol use Manage stress/diabetes Have BP checked regularly & consider self monitoring

Central Valley Health District BP Quality Improvement By December 31, 2014 determine if nursing staff at CVHD are accurately measuring blood pressure on clients and if readings are documented in CVHD EMR correctly.

Gather Data – First Screening Done at large employer in Jamestown This screening was part of their health insurance requirement – biometric screenings shift plant, we go early some people are just getting off work and some coming. People have appointments – every 10 minutes. 20 hypertensive 33 were prehypertensive 15 normal

Recheck blood pressures Asked if we could return to the site and recheck some of the BP’s that were abnormal during screening in November. Shows that BP readings were high but after recheck some dropped into the prehypertension category. 8 people agreed to come for rechecks of the blood pressures. This time we quiet room, correct fitting cuff, bare arm, and a first and second reading if the first reading was abnormal 1 of the 8 – had a normal reading and was dismissed. 6 had abnormal readings These individuals were referred. Second reading 1 had normal 4 were per hypertensive 2 were hypertensive.

Gather Data – community screenings These 2 slides break out is similar even after we made adjustments in technique Priviate setting, quiet.

Rechecked Blood Pressure This time we rechecked the blood pressures we asked 15 people to stay who were abnormal in the initial screening. Only 6 would wait. Rechecked blood pressure. 4 stayed hypertensive and 2 became pre.

Conclusions Increased confidence level of nurse improved by monitoring technique, changing practice, equipment, training and policy changes. Modified our technique in the field – quiet setting Target those needing provider referral vs. those who could benefit from lifestyle modifications – potential health care savings. Workplace or community screenings can identify those with elevated blood pressures. Confidence level – nurses have better understanding of our equipment and BP practice techniques Better triage plan for abnormal readings Look for ways to capture the best BP reading

Robin Iszler, RN, Unit Administrator Central Valley Health District riszler@nd.gov