Safety

• If the patient has a latex allergy, verify that the stethoscope and blood pressure cuff are latex free.
• Routinely clean the earpieces and diaphragm of the stethoscope with alcohol before and after each use.
• Select the appropriate size blood pressure cuff for the patient.
• Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. Also, avoid applying the cuff to an extremity that has been traumatized, is diseased, or requires a cast or bulky bandage.
• If the patient’s blood pressure is high, repeat the measurement in the other extremity and compare measurements. Ask another nurse to measure the blood pressure in 1 to 2 minutes. If the blood pressure continues to be high, assess for related signs and symptoms, report the measurement to the nurse in charge, and implement orders from the health care provider.
• If the blood pressure is low, position the patient supine, restrict activity, assess for related signs and symptoms, report the measurement to the charge nurse, and implement orders from the health care provider.

Equipment

(Roll cursor over items to see labels)

Aneroid sphygmomanometer

Pressure Cuff

Stethoscope

Alcohol Swab

Delegation

The skill of blood pressure measurement may be delegated to nursing assistive personnel (NAP) unless the patient’s condition is considered unstable, such as if the patient has hypotension. Be sure to inform NAP of the following:

• The appropriate limb to be used for measurement and the blood pressure cuff size and equipment (manual or electronic) to be used
• The frequency of measurement and factors related to the patient’s history, such as risk for orthostatic hypotension
• The patient’s usual blood pressure values and significant changes or abnormalities to report to you

Preparation

• Determine the need to assess the patient’s blood pressure:
  • Note risk factors for blood pressure alteration, including history of cardiovascular disease, renal disease, diabetes mellitus, circulatory shock (hypovolemic, septic, cardiogenic, or neurogenic), acute or chronic pain, rapid intravenous infusion of fluids or blood products, increased intracranial pressure, postoperative status, or pregnancy-induced hypertension.
  • Assess for signs and symptoms of blood pressure alteration. Hypertension may cause none or may produce headache, facial flushing, nosebleed, and fatigue. Hypotension may cause dizziness; mental confusion; restlessness; pale, dusky, or cyanotic skin and mucous membranes; and cool, mottled skin over the extremities.
• Assess for factors that can affect blood pressure, such as age, gender, daily (diurnal) variation, position, exercise, weight, sympathetic stimulation, medications, smoking, and ethnicity.
• Determine the best site for blood pressure assessment. Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. Also, avoid applying the cuff to an extremity that has been traumatized, diseased, or requires a cast or bulky bandage. Use a lower extremity when brachial arteries are inaccessible.
• Determine the previous baseline blood pressure and site (if available) from the patient’s record.
• Assess for latex allergy.
• Have the patient rest at least 5 minutes before measuring blood pressure while lying or sitting and rest 1 minute before measuring pressure while standing. Ask the patient not to speak while you are measuring blood pressure. Eliminate extraneous noise.
• Ensure that patient has not exercised, ingested caffeine or smoked in the last 30 minutes.
• Ask the patient not to move, talk or cough during blood pressure measurement, since these activities can falsely elevate the reading.

Follow-up

• If the patient’s blood pressure was assessed for the first time and was within the acceptable range, establish this blood pressure as the baseline.
• If this was not the first blood pressure measurement, compare this measurement with the patient’s baseline and with the acceptable range for the patient’s age.
• Teach the patient about personal risk factors for—and methods to prevent—hypertension, such as daily exercise, weight loss, reduced sodium and saturated fat intake, adequate intake of dietary potassium and calcium, and smoking cessation.
• Report abnormal findings to the nurse in charge or to the health care provider.

Documentation

• Record the blood pressure and the site assessed.
• Document measurement of blood pressure after administration of specific therapies.
• Record any signs or symptoms of blood pressure alteration.
• Report abnormal findings to the nurse in charge or to the health care provider.