Vital Signs
Obtaining Blood Pressure by the Two-Step Method
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- » Obtaining Blood Pressure by the Two-Step Method
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Take the Review Test:
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 a blood pressure cuff to an extremity in which 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 nurse in charge, and implement orders from the health care provider.
Equipment
(Roll cursor over items to see labels)
Aneroid sphygmomanometer
Pressure Cuff
Stethoscope
Alcohol Swab
PrintableDelegation
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 the patient has not exercised, ingested caffeine, or smoked in the past 30 minutes.
- Ask the patient not to move, talk, or cough during blood pressure measurement, because 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.
Review Questions
1. The nurse is preparing to assess a patient’s blood pressure. What would cause the blood pressure reading to be inaccurately high?
Blood pressure cuff is too wide
Blood pressure cuff is too loose around the arm- Taking the blood pressure in an arm into which intravenous fluids are infusing
- Arm is positioned above the level of the heart
INCORRECT. Using a blood pressure cuff that is too wide would cause the blood pressure to be inaccurately low.
CORRECT. Using a blood pressure cuff that is too loose would cause the blood pressure to be inaccurately high.
INCORRECT. Taking the blood pressure in an arm with intravenous fluids infusing would affect the infusion of fluids but would not necessarily cause a falsely low blood pressure reading.
INCORRECT. Placing the arm above heart level would cause the blood pressure to be inaccurately low. Placing the arm above heart level causes a falsely low reading of about 2 millimeters of mercury for each inch above heart level.
2. What would cause the nurse to delay the assessment of a patient’s blood pressure?
- Patient is resting in bed, reading a book
- Patient received medication within the last 10 minutes
- Patient is visiting with family
- Patient has just finished having a cigarette
INCORRECT. This would be an ideal time to measure the patient’s blood pressure.
INCORRECT. Although some medications can affect blood pressure, there is no need for the nurse to delay measuring the client’s blood pressure for medication administration within the last 10 minutes.
INCORRECT. This is not a reason to delay the assessment of the patient’s blood pressure.
CORRECT. Smoking causes vasoconstriction, the narrowing of blood vessels. Blood pressure rises acutely and returns to baseline about 15 minutes after stopping smoking. The nurse should wait at least 15 minutes before measuring the patient’s blood pressure after smoking.
3. The nurse has just measured a patient’s blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements?
- Minimize the effect of anxiety
- Distract the patient
- Listen for the second and third Korotkoff sounds
- Confirm that the cuff was applied correctly
CORRECT. Taking two sets of blood pressure measurements helps prevent falsely high readings caused by a patient’s sympathetic response. Averaging minimizes the effect of anxiety, which often causes the first reading to be higher than subsequent measures.
INCORRECT. Distracting the patient is not the purpose of taking a second blood pressure reading.
INCORRECT. Listening for the second and third Korotkoff sounds is not the purpose of taking a second blood pressure reading.
INCORRECT. Confirming correct cuff application is not the purpose of taking a second blood pressure reading.
4. The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?
- Follow your regular healthy diet.
- Limit physical activity.
- Ensure an adequate daily intake of sodium and fat.
- Ensure that your diet has an adequate daily intake of calcium.
INCORRECT. The patient should continue to follow a regular healthy diet to reduce the blood pressure.
INCORRECT. The patient should be encouraged to be physically active in order to reduce blood pressure.
INCORRECT. The patient should be instructed to reduce sodium and fat intake in the diet.
CORRECT. This is what the nurse should instruct the patient, since an adequate intake of calcium is needed in the diet to control blood pressure.
5. Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy?
- Use the left arm to take the blood pressure.
- Use the right arm to take the blood pressure.
- Do not take the blood pressure.
- Use a lower extremity to take the blood pressure.
INCORRECT. Avoid applying the blood pressure cuff to an extremity, breast, or axilla when surgery has been performed on that side.
CORRECT. Using the right arm to take the blood pressure is the correct response, because you should avoid applying the blood pressure cuff to an extremity, breast, or axilla when surgery has been performed on that side.
INCORRECT. There is no reason to avoid taking the patient’s blood pressure.
INCORRECT. It is not necessary to use a lower extremity. You should avoid applying the blood pressure cuff to an extremity, breast, or axilla when surgery has been performed on that side.
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