noninvasive blood pressure monitoring issued april 2010
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Noninvasive Blood Pressure Noninvasive Blood Pressure MonitoringMonitoring
Issued April 2010Issued April 2010
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Expected Practice
Measure blood pressure (BP) in the upper arm using the oscillatory or auscultatory method.
Unable to measure in the upper armMeasure in forearmConsider thigh or calf measurement
Expected Practice
Use appropriate size BP cuff
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Expected Practice
Measure baseline BP bilaterally
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Expected Practice
Position patient the appropriate reference level for NIBP is
the heart.
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Patient Position—Seated 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) (Figure 1)
Figure 1
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Patient Position—Supine position patient supine
or
with head of bed at a comfortable level and with upper arm supported at heart level.
Figure 2
Figure 3
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Expected Practice
The patient and the caregiver should remain quiet throughout the procedure of taking a BP
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Scope and Impact of the Problem
Blood pressure is measured in virtually all patients
Accurate measurement of blood pressure is essential to guide management decisions
Inaccuracy may lead to over or under-treatment of the patient’s condition
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Supporting Evidence
Use oscillatory devices that meet the Association for the Advancement of Medical Instrumentation standards (mean difference + 5mm Hg and standard deviation < 8mm Hg) when compared to auscultatory method12 and the appropriate size cuff.
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Supporting Evidence Stiffness of the arteries, influences amplitude of the oscillations
and may cause underestimation MAP
Accuracy of the automated device may also be limited in patients with hypertension, hypotension, and cardiac dysrhythmia.
Some studies showed difference < 5mm Hg between BP measurement methods, other studies demonstrated that individual differences may be > 10mm Hg for some individuals.
Vasopressors show no significant effect on difference
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Supporting Evidence
Forearm and upper arm BP's are not interchangeable
Select the proper cuff size and positioning of forearm at heart level
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Supporting Evidence
Cuff Position
Forearm – position the cuff midway between the elbow and wrist
Thigh – position the cuff over the lower third of thigh ( lower edge of cuff approximately 2 to 3cm above popliteal fossa)
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Supporting Evidence
With all BP measurements select the proper size cuff
Calf BP measurements- place the patient in the supine position. Place the patient in the prone position for thigh BP measurements. If the patient cannot be place prone, position the patient supine with knee slightly bent.
Thigh pressures are normally higher than upper arm pressures
Calf pressures are not interchangeable with upper arm pressures
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Supporting Evidence
Calf BP measurement (referred to as an ankle BP) Korotkoff’s sounds are auscultated over either the dorsalis pedis or posterior tibial artery in calf BP or the popliteal artery in thigh BP
In adults, calf BP's should be used only if the upper arm is not accessible
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Supporting Evidence Reasons an extremity may not be suitable for BP
measurement.
BP cuffs should not be used on extremities with a deep vein thrombosis, grafts, ischemic changes, arteriovenous fistula, or arteriovenous graft
BP cuffs should not be applied over a PICC or midline catheter site
In extremities with peripheral IV while an infusion is running or any trauma/incision.
Patients that have had mastectomy or lumpectomy do not use the involved arm(s) for BP's if there is lymphedema.
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Supporting Evidence
Appropriate cuff size necessary for accurate measurement of BP in all extremitiesCuff too narrow = overestimation of BPCuff too wide = underestimation BP. Cuff is too small = falsely high reading may result Cuff is too large = falsely low reading may resultUse a cuff with a bladder capable of going around
80% of the arm
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Supporting Evidence Patients with aortic dissection, congenital heart disease,
coarctation of the aorta, peripheral vascular disease, and unilateral neurological and musculoskeletal abnormalities may demonstrate a difference in inter-arm BP
20% - 40% of individuals without the above conditions may have a measurable difference of 10 to 20mm Hg BP between left and right arms
One study showed higher mean differences in systolic and diastolic BP in older participants
When there is a consistent interarm difference, use the arm with higher pressure.
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Supporting Evidence
Body position and arm position influence the measurement of BP
With patient supine and arm placed at heart level the systolic BP is approximately 8mm Hg higher than in the sitting position
Studies show if arm is below heart level BP readings will be higher, conversely, if the arm is above heart level BP readings will be lower
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Supporting Evidence
Systolic and diastolic BP's in hypertensive and normotensive patients increase with talking
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Actions for Nursing Practice
Ensure that your facility has written procedures BP measurement
Ensure proper size cuffs are readily available
Ensure devices meet appropriate standards
Provide routine training healthcare providers in BP measurement
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For more information or further assistance, please contact a clinical practice specialist with the AACN Practice Resource Network.
Need More Information?
Email:practice@aacn.org
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