Measuring and Reporting Vital Signs Discussion Paper

Measuring and Reporting Vital Signs Discussion Paper

1.0 Manual Blood Pressure Measurement

Nurses have a specific responsibility to accurately assess, screen, and monitor individuals, which includes measuring blood pressure (BP). Blood pressure measurement is the primary tool used to confirm the diagnosis of hypertension and classify individuals based on their blood pressure levels (Dai et al., 2021). It also helps identify the risks associated with high blood pressure and guides interventions for controlling it (Waguespack & Dwyer, 2019). Additionally, blood pressure measurement is crucial in evaluating the effectiveness of interventions and assessing the outcomes of these interventions.

Numerous studies conducted over several decades have shown variations in the practice of blood pressure measurement among healthcare professionals. These studies have also highlighted the lack of adherence to blood pressure measurement guidelines (Rana et al., 2022). These variations and lack of adherence compromise the accuracy of blood pressure readings, leading to reduced effectiveness in preventing, diagnosing, and controlling hypertension. Furthermore, this can result in poor disease outcomes, increased healthcare costs, and premature mortality. Nurses need to follow standardized guidelines for blood pressure measurement to ensure accurate readings and improve patient outcomes (John et al., 2021). By doing so, they can contribute to the effective prevention, diagnosis, and control of hypertension, leading to better overall public health. Measuring and Reporting Vital Signs Discussion Paper

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1.1 Course Objectives

By the end of this assessment training, the student will be able to:

1. Understand the cardiovascular system and its components and how they maintain overall health.
2. Explain the role of blood vessels, heart, and blood in regulating and sustaining blood pressure.
3. Understand important blood pressure terminology and how to interpret and assess cardiovascular health.
4. Understand the importance of precise blood pressure measurement in evaluating and monitoring cardiovascular health.
5. Master the technique of placing the blood pressure cuff and interpreting blood pressure sounds.
6. Interpret blood pressure readings accurately and document them in patient records.
7. Understand factors that can affect blood pressure readings and how to account for them during manual measurement

1.3 Defining Blood Pressure

Blood pressure is the force exerted by the blood against the walls of blood vessels. It can be categorized into arterial, capillary, venous, and heart pressure. Systole refers to the contraction of the heart muscle, while diastole refers to its relaxation. Both systolic and diastolic pressures are measured. Systolic Blood Pressure (SBP) is the force required to pump blood from the lungs into the arteries. It is determined by the first tapping sound heard during measurement (Korotkoff Phase 1). Diastolic Blood Pressure (DBP) is the pressure in the arteries when the heart is at rest. It is determined by the last tapping sound heard when the pressure cuff is deflated (Korotkoff Phase IV). SBP represents the higher pressure, while DBP represents the lower pressure. Monitoring blood pressure is essential for assessing cardiovascular health.

In this course, the focus will be on arterial blood pressure. This pertains to the force per unit area applied on an artery by the blood flowing through its lumen. The regulation of arterial blood pressure is influenced by several factors, including the volume of blood present in the artery, the intensity of the heart muscle’s contraction, the tension of the arterial wall, and the viscosity of the blood.

1.4 Sites for Blood Pressure Measurements

Measurement sites include the upper arm, thigh, forearm/leg, and intra-arterial. The upper arm is one of the commonest sites where measurements can be taken. Another site for measurement is the thigh. The forearm or leg can also be used as a site for measurement. Intra-arterial measurement is an invasive method of measuring certain parameters (van Helmond et al., 2020).

1.5 Requirements for Taking Manual BP Measurement

Manual BP measurement using the sphygmomanometer has been considered the gold standard for measuring accurate blood pressure despite being phased out in the US practice due to the use of mercury in the scales. To measure arterial blood pressure in the brachial artery, it is essential to have a functioning manual BP machine that is well-serviced. The machine should also have an appropriate cuff size, which is approximately 40% of the arm circumference, measured midway between the acromion and olecranon or 2/3 of the arm length. Measuring and Reporting Vital Signs Discussion Paper

• A stethoscope is another crucial tool required for this procedure. The stethoscope allows the healthcare professional to listen to the sounds of blood flow in the brachial artery, which helps determine blood pressure accurately.
• An appropriate observation chart is necessary to record the measured blood pressure readings. This chart helps in documenting the patient’s blood pressure over time, allowing for better monitoring and analysis of any changes or trends.
• It is also important to have paper or a recording device to document the findings for reporting purposes. This ensures that the measured blood pressure readings are accurately recorded and can be easily shared with other healthcare professionals or included in the patient’s medical records.

1.6 Steps in Manual BP Measurement

1. Step 1: Consent and Positioning: Begin by explaining the procedure to the patient, seeking their consent, and ensuring they are in a comfortable position with their forearm supported at heart level and their arm supinated. Ensure that the upper arm is completely exposed by removing any tight clothing. This step ensures cooperation. The influence of cooperation can be effectively appreciated by considering the impact of arm positioning on blood pressure. It has been observed that blood pressure tends to rise when the arm is positioned below the level of the heart, while it decreases when the arm is positioned above the heart level. By understanding and utilizing this knowledge, you can promote cooperation to reduce the impact of confounding positional factors.
2. Step 2: Positioning of the Sphygmomanometer: Place the sphygmomanometer on top of the patient’s bed or locker and ensure it is at the same level as the patient’s heart. This allows for correct reading by minimizing the impact of atmospheric and postural factors on blood pressure.
3. Step 3: Zeroing the cuff and measurement: Completely deflate the bladder cuff and check the zero point. Test the pump to ensure it is moving freely. This step affirms the equipment’s fitness for use and effectiveness in minimizing the risk of BP measurement errors.
4. Step 4: Palpation of the brachial artery and placement of the cuff: To take a blood pressure reading, first locate the brachial artery in the inner elbow area. Then, position the cuff so that the center of the inflatable part covers the pulsation of the artery. Wrap the cuff firmly and evenly around the upper arm, ensuring that the bottom edge is 2 cm above the medial elbow crease where the stethoscope will be placed. This step enables accurate identification of the artery. Positioning the bladder directly over the brachial artery guarantees efficient compression of the artery while inflating the cuff. This also ensures an even distribution of pressure, resulting in precise readings.
5. Step 5: Inflation of the cuff: Using your non-dominant hand, gently feel the brachial artery using your fingertips. Employ your dominant hand to close the valve on the pressure bulb and gradually inflate the cuff until the pulse is no longer detectable. Observe the level of mercury at which the brachial pulse disappears and proceed to inflate the cuff an additional 30mmHg beyond that point. The valve’s closure effectively stops any air leakage, allowing for an accurate estimation of the systolic blood pressure reading by observing the point at which the brachial pulse disappears. By inflating the blood pressure cuff with 30mmHg above the systolic blood pressure, one can identify an approximate baseline systolic blood pressure reading without the risk of underestimating it. Measuring and Reporting Vital Signs Discussion Paper
6. Step 6: Auscultation: Place the earpieces of the stethoscope on your ears and position the diaphragm over the brachial artery site.
7. Step 7: Deflation: Gradually release the pressure on the cuff by 2-3 mmHg by opening the valve while carefully monitoring the Korotkoff sounds. Take note of the pressure level at which the initial Korotkoff sound is detected. This pressure indicates the onset of phase V. As the cuff deflates, the artery gradually opens up, allowing blood to flow through. The first Korotkoff sound signifies systolic blood pressure, while the last sound indicates diastolic blood pressure. The artery permits an increased blood flow when the cuff is fully deflated, resulting in a reduction of pressure. As the flow becomes more laminar, the sounds become less distinct. The initiation of laminar flow is indicated by the final Korotkoff sound, which aligns with the diastolic pressure.
8. Step 8: Retake the blood pressure. After waiting at least 60 seconds, repeat steps 3 to 7. This particular action facilitates the restoration of the mechanisms responsible for regulating blood pressure to their usual state following the occlusion of the brachial artery.
9. Step 9: Conclusion of the process: Conclude the procedure by fully deflating the cuff and carefully removing it from the client’s arm while assisting the patient in assuming a comfortable position. This demonstrates the completion of the process and allows the patient to engage in other activities as desired. Ensure infection prevention and control measures by removing the stethoscope from the ears and thoroughly cleaning the earpiece with an antiseptic solution. This step helps to maintain a hygienic environment and minimize the risk of potential infections.
10. Step 10: Proper Equipment Storage and Documentation: Properly store equipment to ensure safety and preparedness for future use. By storing equipment appropriately, we can minimize the risk of accidents or damage and ensure that it is readily available when needed again. Document the patient’s blood pressure at first and second measurements, then the average of the two, and any abnormal findings to ensure continuity of care. By recording and noting any abnormalities, healthcare professionals can maintain a comprehensive and accurate record of a patient’s condition and ensure that the process is patient-focused and also aimed at acting on any abnormalities. This information is crucial for providing consistent and effective care, as it allows for proper monitoring and follow-up actions to be taken.

 

Part Two: Assessment of the Learner’s Skills and Application: Scoring guide

Skill: Manual Blood Pressure Measurement	Satisfactory (Yes/No)	Unsatisfactory (Yes/No)	Assessor’s comments on what the learner missed or performed excellently, also areas for future learning
The learner explains the procedure to the patient and seeks their consent.
Positions the patient’s arm and sphygmomanometer correctly
Deflates the  cuff and ensures the reading at baseline is zero
Locates the brachial artery correctly	Measuring and Reporting Vital Signs Discussion Paper
Places the cuff correctly
Inflates the cuff to a reading that exceeds the point of loss of brachial pulse
Auscultates over the brachial artery and notes Korotkoff sounds
Appreciates the patient and assists the patient in becoming comfortable
Removes the cuff and records the reading
Repeats the process or demonstrates the intention to retake the BP

 

Part Three Explanation of the Assessment

The learners demonstrated a satisfactory performance, achieving key objectives in different areas of the procedure. Notably, they effectively conveyed the procedure to the patient, obtained consent, and displayed empathy in ensuring the patient’s comfort. The learners exhibited proficiency in crucial skills such as correctly positioning the patient’s arm and the sphygmomanometer, accurately placing the cuff, and inflating it precisely beyond the point of pulse loss. However, after competently performing auscultation over the brachial artery, two learners used the bell instead of the diaphragm to auscultate the Korotkoff. The majority identifying Korotkoff sounds reflected a strong understanding of the fundamental concepts. Generally, the learners showcased their competence by successfully meeting the goals and requirements of the procedure.

I identified gaps and areas for future learning. The learners achieved a baseline reading of zero after cuff deflation, but there is room for improvement in obtaining consistent and precise readings. Techniques for cuff placement and locating the brachial artery could be refined to enhance the accuracy of blood pressure measurements. One learner forgot and tied the cuff too tight, while one made it too loose. These skills are important in ensuring BP accuracy. Some learners should continuously improve pressure control during cuff inflation for optimal results. I also identified the difference in the speed and precision in locating the brachial artery. Some took longer, but I finally achieved this step independently. Enhancing the speed and precision in locating the brachial artery could further enhance the overall accuracy of the blood pressure measurement process.

When it comes to engaging with patients, learners showcased empathy; however, there is room for improvement in their ability to build rapport and create a more comfortable environment for the patient. To achieve this, learners should focus on enhancing their techniques for establishing a strong connection with patients. Although learners generally maintained accuracy in their documentation practices, there is an opportunity to adopt a more comprehensive approach. This would ensure that blood pressure readings are recorded with utmost clarity and completeness. By implementing such an approach, learners can enhance the overall quality of their documentation. The manual only provided a rationale for documenting but did not reinforce the need for completeness, especially in including time and biodata in the documentation. Measuring and Reporting Vital Signs Discussion Paper

All learners demonstrated satisfactory commitment to quality assurance by expressing their intention to repeat the process when necessary. However, it would be beneficial for them to review the protocols that defend why the repeat measurement is warranted further. Filling this gap would provide learners with a more nuanced understanding of when and why repeat measurements are necessary, ultimately improving their ability to ensure accurate results.

Room for Improvement

The assessment conducted demonstrated the achievement of critical objectives on effective communication, technical proficiency, patient-centered care, and acute observational skills. Recognizing these accomplishments while addressing areas for improvement will contribute to the continuous growth of these nursing students as competent and compassionate healthcare practitioners. The evaluation of manual blood pressure measurement indicated that the learners effectively met several crucial objectives essential to mastering this critical nursing skill. One of the significant accomplishments was the successful communication of the procedure to the patient and obtaining their consent, showcasing the learners’ dedication to ethical and patient-centered care. This aligns to ensure that healthcare practitioners possess not only technical proficiency but also the ability to communicate and engage effectively with patients.

This demonstrates a strong comprehension of the anatomical and physiological aspects of blood pressure measurement, fulfilling the objective of mastering the fundamental principles of the procedure. The learners competently performed auscultation over the brachial artery and accurately identified Korotkoff sounds, highlighting their achievement in developing acute listening skills necessary for precise blood pressure assessment. The successful execution of these tasks underscores the goal of cultivating acute observational skills, which are vital for accurate blood pressure assessment. The learners’ proficiency in these areas reflects their commitment to continuous improvement and their dedication to providing high-quality healthcare. By acknowledging their achievements and addressing areas for improvement, these nursing students will continue to develop into skilled and compassionate healthcare practitioners.

 

 

References

Dai, H., Bragazzi, N. L., Younis, A., Zhong, W., Liu, X., Wu, J., & Grossman, E. (2021). Worldwide trends in prevalence, mortality, and disability-adjusted life years for hypertensive heart disease from 1990 to 2017. Hypertension, 77(4), 1223–1233. https://doi.org/10.1161/hypertensionaha.120.16483

John, O., Campbell, N. R. C., Brady, T. M., Farrell, M., Varghese, C., Velazquez Berumen, A., Velez Ruiz Gaitan, L. A., Toffelmire, N., Ameel, M., Mideksa, M., Jaffe, M. G., Schutte, A. E., Khan, T., & Lopez Meneses, L. P. (2021). The 2020 “WHO technical specifications for automated non-invasive blood pressure measuring devices with cuff.” Hypertension, 77(3), 806–812. https://doi.org/10.1161/HYPERTENSIONAHA.120.16625

Rana, S. R. L., Thapa, B., Budhathoki, L., Rajaure, Y. S., Shrestha, B. K., Mahat, B., Dhungel, S., & Amatya, T. M. (2022). Knowledge regarding blood pressure measurement among first and second-year undergraduate medical students: A descriptive cross-sectional study. JNMA; Journal of the Nepal Medical Association, 60(247), 299–302. https://doi.org/10.31729/jnma.7413

van Helmond, N., Day, W., Martin, S. S., & Plante, T. B. (2020). Cuff-less, personal, ambulatory blood pressure devices and disruption of existing blood pressure measurement paradigms. American Journal of Hypertension, 33(9), 813–815. https://doi.org/10.1093/ajh/hpaa090

Waguespack, D. R., & Dwyer, J. P. (2019). Assessment of blood pressure: Techniques and implications from clinical trials. Advances in Chronic Kidney Disease, 26(2), 87–91. https://doi.org/10.1053/j.ackd.2019.02.002 Measuring and Reporting Vital Signs Discussion Paper