Measuring blood pressure lying/sitting and standing ...
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Page 1 of 4 140 160 180 200 220 240 260 280 300 120 100 80 60 40 20 0 140 160 180 200 220 240 260 280 300 120 100 80 60 40 20 0 Observations Adults Measuring blood pressure lying/sitting and standing (manual recording) Naomi Stetson, formerly Lead Nurse, Peart-Rose Clinic, Imperial College Healthcare NHS Trust, London ©2021 Clinical Skills Limited. All rights reserved In healthy people, there is little difference between lying (supine), sitting and standing blood pressure measurements. However, standing up from sitting or lying can lead to a significant fall in blood pressure if postural (orthostatic) hypotension is present: a systolic blood pressure drop of ≥20 mmHg is diagnostic (NICE, 2019). For seated-to-standing measurements, however, which are less sensitive than supine-to-standing, a drop of ≥15 mmHg may be significant (Shaw et al., 2017). Postural hypotension is more common in the elderly and in people taking hypotension-inducing medication such as angiotensin-converting enzyme (ACE) inhibitors, alpha-blockers, beta-blockers and tricyclic antidepressants. Accurate measurement of supine or sitting and standing blood pressure is advisable in anyone who reports episodes of dizziness, fainting and unexplained falls, as well as in pregnant women and people with diabetes. Individual readings are influenced by many factors such as age, ethnicity, disease, the time of day, posture, emotions, exercise, meals, medicines, fullness of bladder, pain, shock, dehydration, acute changes in temperature and changes in altitude (NICE, 2019). Such factors may therefore determine the timing of the procedure. For example, if a patient reports dizziness each morning after taking medication, it is advisable to carry out the procedure at this time. Blood pressure should be measured using a properly maintained, calibrated and validated device. Mercury sphygmomanometers have been the gold standard for blood pressure measurement for many years, but are being withdrawn for health and safety reasons. Aneroid devices may be less accurate than mercury sphygmomanometers and their alternatives, especially over time (NICE, 2019). The British and Irish Hypertension Society (BIHS) website lists validated electronic blood pressure devices (see https://bihsoc.org). Refer to clinicalskills.net for further guidance on blood pressure measurement. Equipment Stand-mounted manometers are recommended because they are mobile and can be easily adjusted for height. Use a suitably sized box to support the patient’s arm while they are standing. Clean the equipment according to local policy (NICE, 2020). Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person. Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution. Advise the patient to rest for at least 5 minutes to settle their blood pressure (NICE, 2019; BIHS, 2017). Decontaminate your hands. Explain the procedure to the patient and gain consent. Remove any tight or restrictive clothing from the patient’s arm that you will use to take the measurement. Place the blood pressure device near to the patient so that you can read the display easily. If using a desk sphygmomanometer, put the device on a firm and stable surface. Measure the blood pressure in both arms initially, and if the values differ, use the arm with the higher value for subsequent recordings (NICE, 2019). Decontaminate your hands and prepare the patient Position the blood pressure device Box for patient to rest their arm on Stand-mounted sphygmomanometer Stethoscope Electronic notes
Transcript of Measuring blood pressure lying/sitting and standing ...
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ObservationsAdults
Measuring blood pressurelying/sitting and standing (manual recording)
Naomi Stetson, formerly Lead Nurse, Peart-Rose Clinic, Imperial College Healthcare NHS Trust, London
©2021 Clinical Skills Limited. All rights reserved
In healthy people, there is little difference between lying (supine), sitting and standing blood pressure measurements. However, standing up from sitting or lying can lead to a significant fall in blood pressure if postural (orthostatic) hypotension is present: a systolic blood pressure drop of ≥20 mmHg is diagnostic (NICE, 2019). For seated-to-standing measurements, however, which are less sensitive than supine-to-standing, a drop of ≥15 mmHg may be significant (Shaw et al., 2017). Postural hypotension is more common in the elderly and in people taking hypotension-inducing medication such as angiotensin-converting enzyme (ACE) inhibitors, alpha-blockers, beta-blockers and tricyclic antidepressants.
Accurate measurement of supine or sitting and standing blood pressure is advisable in anyone who reports episodes of dizziness, fainting and unexplained falls, as well as in pregnant women and people with diabetes. Individual readings are influenced by many factors such as age, ethnicity, disease, the time of day, posture, emotions, exercise, meals, medicines, fullness of bladder, pain, shock, dehydration, acute changes in temperature and changes in altitude (NICE, 2019). Such factors may therefore determine the timing of the procedure. For example, if a patient reports dizziness each morning after taking medication, it is advisable to carry out the procedure at this time. Blood pressure should be measured using a properly maintained, calibrated and validated device. Mercury sphygmomanometers have been the gold standard for blood pressure measurement for many years, but are being withdrawn for health and safety reasons. Aneroid devices may be less accurate than mercury sphygmomanometers and their alternatives, especially over time (NICE, 2019). The British and Irish Hypertension Society (BIHS) website lists validated electronic blood pressure devices (see https://bihsoc.org). Refer to clinicalskills.net for further guidance on blood pressure measurement.
Equipment
Stand-mounted manometers are recommended because they are mobile and can be easily adjusted for height. Use a suitably sized box to support the patient’s arm while they are standing. Clean the equipment according to local policy (NICE, 2020).
Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Advise the patient to rest for at least 5 minutes to settle their blood pressure (NICE, 2019; BIHS, 2017). Decontaminate your hands. Explain the procedure to the patient and gain consent. Remove any tight or restrictive clothing from the patient’s arm that you will use to take the measurement.
Place the blood pressure device near to the patient so that you can read the display easily. If using a desk sphygmomanometer, put the device on a firm and stable surface. Measure the blood pressure in both arms initially, and if the values differ, use the arm with the higher value for subsequent recordings (NICE, 2019).
Decontaminate your hands and prepare the patient Position the blood pressure device
Change image so nurse has an iPad in her hand rather than notes
Box for patient to rest their arm on
Stand-mounted sphygmomanometer
Stethoscope
Electronic notes
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Observations
Adults
Measuring blood pressure lying/sitting and standing Page 2
Position the arm Arm should be at heart level
Select correct cuff and bladder size Apply the cuff (a)
(b) Estimate the systolic pressure
Position the patient’s arm so that it is horizontal at the level of the mid- sternum (NICE, 2019; Mancia et al., 2013). Use a pillow to support the arm because muscle tension can raise the blood pressure (Frese et al., 2011).
Positioning the arm below the level of the heart leads to an overestimation of systolic and diastolic pressures of about 10 mmHg (NICE, 2019; O’Brien et al., 2003). Raising the arm above heart level leads to underestimation of pressures (NICE, 2019).
Make sure you select a cuff with a bladder of an appropriate size for the patient’s arm (MHRA, 2021; BIHS, 2017). (See also part 1 of this series.)
The maximal pulsation of the brachial artery lies 2–3 cm (approximately two finger-widths) above the antecubital fossa. Apply the cuff to the upper arm.
The centre of the bladder must lie over the brachial artery. The cuff should fit firmly and comfortably and be well secured. To avoid artefactual sounds, do not allow the tubing of the cuff to cross the auscultatory area or make contact with the stethoscope.
Palpate the brachial pulse (or use the radial pulse if the brachial is hard to find). Rapidly inflate the cuff to 20 mmHg above the value where the pulse disappears. Deflate the cuff. Note the pressure where the pulse reappears; this is the approximate systolic pressure (NICE, 2019).
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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Brachial artery
Radial artery
Ulnar artery
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General Notes
1/8/21Mrs Dalloway’s lying blood pressure at rest on her left arm taken at 10:00 is 150/80 mmHg.
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Observations
Adults
Measuring blood pressure lying/sitting and standing Page 3
Use the stethoscope Inflate the cuff
Slowly deflate the cuff Document your findings
Ask the patient to stand Stand for 1 minute
Place the diaphragm of the stethoscope chest piece over the brachial artery. Use the thumb to secure the chest piece and support the patient’s elbow with your fingers. Apply gentle pressure to ensure full contact with the skin. The chest piece must not touch the cuff.
Inflate the cuff to 20–30 mmHg above the estimated systolic pressure (NICE, 2019). Deflate the cuff at a rate of 2 mmHg per second and listen carefully for the Korotkoff sounds (NICE, 2019).
Note the measurement when Korotkoff sounds first appear (systolic) and when they disappear (diastolic). Continue deflating for another 20 mmHg, ensuring sounds have disappeared, then open the valve fully, and rapidly deflate the cuff.
Record the blood pressure reading. When recording on an observation chart, label “lying” blood pressure according to local policy. This may be a colour-coding system or the insertion of “L” by the measurement. Record which arm you used to record the measurement.
Leave the cuff in position and disconnect the sphygmomanometer. Ask the patient to stand, providing assistance if necessary. Ideally, support the measured arm in a horizontal position as the patient stands, as letting the arm hang down may falsely elevate the blood pressure reading.
Ask the patient to stand for 1 minute prior to measurement (NICE, 2019). Maintain the patient’s safety by observing for signs of dizziness and taking the appropriate precautions.
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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
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Patient Notes ? X
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General Notes
1/8/21Mrs Dalloway’s standing blood pressure taken at 10:05 is 130/70 mmHg.Reported to the nurse in charge and waiting for follow up.Patient informed.Team informed to observe patient due to high risk of falls.
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Adults
Measuring blood pressure lying/sitting and standing Page 4
Position the arm
Ensure that the patient’s arm is horizontal at the level of the mid-sternum (NICE, 2019). Check that the arm is supported because muscle tension can affect the reading (Frese et al., 2011).
Observations
Take the reading
Decontaminate hands and document the reading Automatic blood pressure monitors: (a)
(b) (c)
Reconnect the device and repeat the procedure for measuring blood pressure. If the patient has had falls or feels faint on standing, or is at risk of falls for any other reason, then you should take a 3-minute reading as well, and take further readings every minute if the blood pressure continues to fall (RCP, 2017).
Remove the cuff, make the patient comfortable then decontaminate your hands. Document the reading according to local policy. Document symptoms of dizziness, light-headedness, feelings of weakness and palpitations, vagueness, pallor and visual disturbance (RCP, 2017). When completing an observation chart, insert an “S” by the measurement or use a colour coding system. Inform the nursing and medical team if there is a drop in systolic blood pressure of ≥20 mmHg, if systolic pressure falls below 90 mmHg or if diastolic pressure falls by ≥10 mmHg and symptoms are present (NICE, 2019; RCP, 2017).
Calibrate automatic blood pressure monitors according to the manufacturer’s instructions. Apply a cuff of appropriate size and operate the machine according to the manufacturer’s instructions. The cuff is automatically inflated and deflated, and the blood pressure and pulse are digitally displayed.
Make sure the patient does not use their measured arm to steady themselves as they stand, as the muscle tension may trigger the machine to take a reading. Take into account the machine inflation time to avoid missing the 1-minute measurement on standing. It is good practice to occasionally check the monitor against another validated device. The recorded blood pressure may differ slightly between devices.
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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.
Electronic automated devices may not measure blood pressure accurately if the patient has an irregular pulse (NICE, 2019). Always palpate the patient’s brachial or radial pulse before measuring blood pressure. Recording the pulse manually will ensure accuracy and allow you to assess the character, rhythm and strength of the pulse (see clinicalskills.net procedure on “Assessing the pulse”). If the pulse is irregular, take the blood pressure reading manually with auscultation over the brachial artery (NICE, 2019).
Brachial artery
Radial artery
Ulnar artery
