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

2. 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.

3. 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

4. Diastolic: 90 mm hg or >
BP Classification
Normal BP
Systolic: < 120 mmHg
Diastolic: < 80 mmHg
Prehypertension
(at risk)
Systolic: 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

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. Avoid:
Tourniquet Effect
Muffled Sounds
Artifactual Sounds

14. 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)

15. 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

16. 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

17. 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.

18. 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

19. Development of Statewide Algorithm

20. 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

21. 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

22. 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.

23. 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

24. 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.

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

26. 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.

27. 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

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