AACN BP Guidelines - Importance of Accurate BP Readings
Non-invasive blood pressure readings? I mean how hard can this be? We all learned about it in Nursing 101. However, maybe a review is in order…
The American Association of Critical Care Nurses (AACN) has recently published a new guideline regarding the importance of obtaining accurate non-invasive blood pressure (NIBP) readings and problems that can ensue.
How to obtain accurate NIBP readings:
1. Measure BP in the upper arm (between the shoulder and the elbow) using the oscillatory or auscultatory method.
2. Use appropriate-size BP cuff and follow instructions for fit and placement per manufacturer’s guidelines.
a. If upper arms cannot be used for BP measurement or if the maximum size BP cuff does not fit the upper arm, BP may be measured in the forearm.
b. Consider use of thigh and calf for BP measurement if the upper arms and forearms cannot be used.
3. Measure baseline BP in both upper arms. For clinically significant differences
in BP (>10 mm Hg), use the arm with the higher pressure.
4. Positioning of patient: The appropriate reference level for NIBP measurement is the heart.
a. Patient should be seated with back and arms supported, feet on floor, and legs uncrossed with upper arm at heart level (phlebostatic axis: 4th intercostal space, halfway between the anterior and posterior diameter of the chest.
b. If patient cannot be seated, position patient supine or with head of bed at a comfortable level and with upper arm supported at heart level.
5. The patient and the caregiver should not speak while BP is being measured.
6. Minimize complications by using the maximum (least frequent) NIBP cycle time for the shortest time period and by ensuring proper cuff placement.
Patient conditions that affect NIBP readings:
Stiffness of the arteries, particularly in older patients can nfluence amplitude of the oscillations and may cause underestimation of mean arterial pressure. Accuracy of the automated device may also be limited if patients are hypertensive, hypotensive, and/or have cardiac dysrhythmia.
1. Do not place BP cuff over a bony prominence
2. Do not allow BP cuff to over-inflate - set the parameters of the BP cuff machine no higher than 200mm hg unless patient with known BP higher than this.
3. Set the BP machine interval to what is required by patient condition. If patient is stable, do they need a BP reading every 15 minutes or is every 30 minutes adequate.
4. Remove the BP cuff when not needed for serial readings.
5. Do not take BPs in the arm of a patient with a dialysis access or in the affected arm of a mastectomy patient.
Correlate the BP to the patient…
If you get a measurement of 60/30 and the patient is awake, alert and talking to you and the last BP was 130/80, consider repositioning the BP cuff and obtaining another reading.
For patients with known high BP, a reading of 220/110 is still cause for concern - again always assess your patient.
Complications of NIBP…
1. Skin irritation and possible skin breakdown due to frequent NIBP cuff inflation
2. Artificially inflated BP readings if cuff inflates, deflates and reinflates repeatedly
3. Patient discomfort if cuff inflates too high
Importance of accurate readings…
Hypertension is one of the leading causes of heart disease in the US. The American Heart Association recommends home blood pressure monitoring for patients with known hypertension. It is equally important that the nurse know how to teach patients to do home BP monitoring. Remind patients to take their BP at approximately the same time each day and take all their meds as prescribed. Also, keep a log of BPs and bring it with them to their next appointment.
Maintaining accurate BP readings allows providers to have knowledge that will guide them to prescribe the correct medications in order to control your patient’s blood pressure.
Maintaining good BP control decreases the risk of end-organ damage caused by hypertension and increases the likelihood of excellent BP control.
AACN Practice Alert, 2016
American Heart Association, Home Blood Pressure Monitoring, 2015
About traumaRUs, MSN, APRN Admin
Joined: Apr '00; Posts: 52,484; Likes: 25,161
allnurses Asst Community Manager, Advanced Practice Nurse; from IL , US
25+ year(s) of experience in Heart Failure, Nephrology, ER, ICUOct 24, '16It always amazes me when I have patients who have been on BP meds for years and they don't know they should take and track their BP at home. I always wonder if it's a case of they hear what they want to hear or if their PCP or whoever it is that prescribes their meds has never had that discussion with them. I always like to stress there is a reason they call hypertension the silent killer. I also point out I have my own parents check their BP daily due to their own health issues.
Adequate blood sugar monitoring at home is something I don't think people take seriously like taking their BP. I had a discussion with a patient and several family members just the other week about checking blood sugars as well. I don't think I got through to my patient (uncontrolled sugars, A1C over 9, horrible diabetic neuropathy- overall just noncompliant about everything regarding their health), but the patient's sister said she was going to check in with her doctor and start working on hers more (which made me feel some good came out of the discussion).Oct 24, '16Does anyone have any tips on taking accurate manual blood pressure readings in challenging situations? i.e. ROSC, or trauma patientsOct 25, '16@aceofhearts - so true. I see pts all the time and when I have a random blood sugar of 450 and ask how their BS have been running at home, they look at me as though I sprouted horns - lol. And then they wonder why they are sitting in a dialysis chair? Hmmm
@drollette - in ROSC cases invasive BP monitoring is usually the standard of care. For trauma pts, it depends - sometimes in the leg, wrist if noninvasive BP can be obtained otherwise art line.Oct 25, '16I literally had to teach a new grad how to take a manual BP. No biggie but it was a first for me.
Does every nurse here use an appropriate sized cuff?Oct 25, '16Quote from Libby1987That blows my mind that you had to teach them that. It was something we had to pass in skills check-off. I might not have been the most confident, but I certainly knew what I was doing. I then filled in at a doctors office for a several hours a couple of times and became more confident. Now when I have to take a manual BP it's not a big deal.I literally had to teach a new grad how to take a manual BP. No biggie but it was a first for me.
Does every nurse here use an appropriate sized cuff?
It drives me crazy when I get a patient and they've been in the hospital for a couple of shifts, but they have the wrong BP cuff size! I immediately replace it with the proper size. Or sometimes I'll have the aid tell me the reading and it's off, so I go back in and recheck it myself and get a normal reading. Proper placement of the cuff is so important too, as detailed in the original post.Last edit by AceOfHearts<3 on Oct 25, '16 : Reason: autocorrect was wrongOct 25, '16Quote from AceOfHearts<3I had to take the initiative to get a pedi cuff in everyone's bag. Not a single licensed staff requested one or voiced concern of not having one. All levels of experience, too.That blows my mind that you had to teach them that. It was something we had to pass in skills check-off. I might not have been the most confident, but I certainly knew what I was doing. I then filled in at a doctors office for a several hours a couple of times and became more confident. Now when I have to take a manual BP it's not a big deal.
It drives me crazy when I get a patient and they've been in the hospital for a couple of shifts, but they have the wrong BP cuff size! I immediately replace it with the proper size. Or sometimes I'll have the aid tell me the reading and it's off, so I go back in and recheck it myself and get a normal reading. Proper placement of the cuff is so important too, as detailed in the original post.
We're "educated professionals dammit" often lamented here, but then we're not.Oct 26, '16Hi @traumaRUs,
Thanks for the quick response.
Where I work if there is a Trauma Team activation for an incoming patient (penetrating chest trauma, significant MOI, geriatric fall on thinners, GCS<8, etc) one of the first things we do as EMS transfers the patient to our stretcher is to get a rapid manual blood pressure (or a palpated systolic).
Multiple times I have had to call out "unable to obtain" after two or three attempts.
So, I guess Im hunting for tips in order to be more successful in the future.
Thanks againOct 29, '16I have found those kind of situations to be kind of stressful; a literal room full of people waiting quietly (as possible) for you to listen and call out the number, then you're blowing it up again, and then again, then it's like "sorry, can't hear anything." Once I worked in an ICU that had dopplers in every room to check pedal pulses and the like, and it was great to have a doppler at arms length with difficult to hear blood pressures, and you could pick up SBP's in the 50's or 60's (or less) easy-breezy, even in fairly loud environments. So ask around and see if you can find one of those portable type dopplers. Some of them have attached stethoscopes which is nice. You can't get a diastolic pressure, but at least you can get a useful number. So, if unfamiliar, here's my make shift I apologize if they are ridiculously self explanatory directions: if not on, get the cuff on the pt's arm but don't pump it up yet. Get your doppler and squirt a little gel on where you are going to be listening. Turn it on, then use the doppler to find/listen for the brachial pulse, once you hear it, while keeping your doppler on the spot, blow your cuff up. Blow up the cuff until you can't hear anything anymore, and then keep pumping the cuff up about until you are about 30mmHG higher than when you stopped hearing anything. Then, keeping your doppler on the spot (usually the brachial pulse, but you can do this elsewhere obviously), slowly release the cuff until you hear the tones again. The first sounds you hear: that's your systolic blood pressure....So you use the doppler and listen just like you you would if you were using your stethoscope....If I worked in trauma I'd probably buy my own doppler if I couldn't find one at the hospital because I hate that "unable to obtain" thing. lol. If you can't hear a pressure with a doppler you can assume they don't have one to speak of.
As far as having to teach a new grad how to do a manual pressure, I am sure there are plenty of newer nurses (and older, for that matter) that are a little rusty at taking manual blood pressures. It's because nurses practice in skill lab a few times during school, then go to the hospital or where ever and everything is done by machines, where you generally only check one yourself when the machine gives you (or the tech) a crazy or questionable number. And obviously we are better at things we do everyday vs. things we do rather rarely. Doctor's office nurses generally take a lot more manual pressures than the people working in CVICU, for example. Anyone can fumble a bit more with things they don't do all the time. A suggestion for newer nurses: when you have the chance, take pressures manually when you can just to practice in a non stressful environment. Then when the code blue is called, you aren't freaking out trying to do a manual pressure when you are totally stressed out (it's the little things that can bring you down. lol). Anyway, hope the doppler suggestion is helpful to someone.
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