Proper Blood Pressure Measurement

Steps:

• Use a validated blood pressure monitoring device

• There are many blood pressure measurement device options out there; however, using one that is validated will enhance your confidence that the readings are accurate. A validated device is one that has been through a clinical testing and review process by an independent review company made up of physician experts in the blood pressure monitoring field using standardized protocols. Not being validated doesn’t necessarily mean the device is providing incorrect data, but validation adds confidence in accuracy.

  To determine if your blood pressure device is validated, here are some things to consider:

  • Look for information provided by the manufacturer regarding the validation status of the device. This information may be available in the device's user manual, packaging, or on the manufacturer’s website. Look for statements indicating the device has been validated.
  • Go to https://www.validatebp.org and, using the website’s search function, verify that your device(s) are listed. Enter the device’s brand name, model, or other relevant details to see if it appears on the list of validated devices.

  Links:

  US Blood Pressure Validated Device Listing

• Getting an accurate reading

• The position of the patient, the environment, activity, and other factors during measurement can have a significant effect on the results. Follow this guidance to obtain an accurate blood pressure reading:

  • Choose a quiet and calm area where the patient can sit comfortably for the blood pressure measurement. Eliminate any distractions or loud noises that could interfere with the reading. Check that the patient is comfortable and properly supported in the seated position. Discomfort can lead to elevated blood pressure readings. Make sure the patient is at ease before proceeding.
  • Briefly explain the blood pressure measurement process to the patient and address any questions they may have to help them relax further. Do not have a conversation with the patient during the BP measurement because talking can negatively affect the measurement.
  • Ensure that the patient has emptied their bladder prior to measurement. Consider giving them time to use the bathroom when rooming.
  • Ask the patient how long it has been since they have ingested caffeine. It is recommended to wait at least 30-60 minutes following caffeine intake before measuring blood pressure. This waiting period allows time for the temporary increase in blood pressure caused by the caffeine to subside.
  • Have the patient sit in a sturdy chair with their back supported and their feet flat on the floor. Crossing arms, legs, or ankles can affect blood flow and lead to inaccurate readings. Encourage them to keep their arms and hands relaxed without tensing the muscles.
  • Ask the patient to remove any tight clothing (sleeves or accessories) that may interfere with the cuff placement or restrict blood flow. The patient’s arm should be bare or have clothing that can easily be rolled up to ensure a more accurate reading.
  • Instruct the patient to extend their arm and place it on a table or armrest so that it is fully supported at heart level. Ensure the patient’s arm is relaxed and positioned with the palm facing upward. The upper arm should be parallel to the body, and the elbow slightly bent. The cuff placement should be aligned with the brachial artery.
  • Depending on the patient’s body type, an extra small or extra-large cuff may be needed to get an accurate blood pressure measurement. Using a cuff that does not accurately fit the patient’s arm can affect the result of the reading. A cuff that is too small may indicate an inaccurate higher pressure, and one that is too large for the patient could indicate an incorrect lower reading. A wrist cuff may also be used, but is not recommended, and proper positioning is key to getting an accurate measurement.

• Repeat BP measurement to confirm the accuracy and diagnosis of hypertension

• It is important to remember that blood pressure can vary throughout the day, and a single elevated blood pressure may not indicate that the patient has hypertension. Repeat measurements and evaluation are essential to confirm a diagnosis and determine appropriate treatment strategies. To diagnose hypertension, two or more blood pressure readings at separate medical appointments are needed. After new measurement, diagnose or assess control and initiate treatment per your established protocol. Also, consider prescribing SMBP (Self-Measured Blood Pressure) monitoring to confirm diagnosis and aid in achieving BP control. Consider following these steps as guidance to repeating measurements:

  • Take two or more blood pressure measurements at separate appointments. This allows for any fluctuations to stabilize.
  • Ensure consistent measurement techniques throughout each reading. Use the same arm and maintain proper patient positioning. Refer back to the previous section as needed.
  • Record each blood pressure measurement accurately, including date, time, and patient's position. Document any specific circumstances (recent physical activity, caffeine intake or stress) which may affect the readings.
  • Compare the average blood pressure measurement to established diagnostic criteria for hypertension. The guidelines may differ depending on factors such as age, presence of comorbidities, and additional risk factors.

  Links:

  Target: BP; Selecting a cuff size

  Target: BP; Using a wrist cuff to measure blood pressure

  AMA MAP BP landing page

  AMA guide to blood pressure competency program

  Sample Hypertension Management Protocol (Sanford Health)

  American Heart Association Clinical Practice Guideline

• Implement a Blood Pressure Measurement competency program

• Implementing a blood pressure measurement competency program involves several key steps, which may vary depending on your organization's resources and training preferences. Adapting the program to suit the unique needs of your staff will enhance its effectiveness and ensure that all staff who measure blood pressure are doing it correctly. It is suggested that blood pressure training be completed bi-annually or annually for all staff as a refresher and upon hiring new staff. The following are things to consider when establishing a training program:

  • Determine the specific goals and objectives of the blood pressure measurement competency program. Clearly define what skills and knowledge participants will gain from the program.
  • Identify the audience for the program, such as Doctors, Nurses, and Medical Assistants (i.e., all clinic personnel who measure patient blood pressure). Consider their existing knowledge and skill levels to tailor the training accordingly.
  • Design a curriculum that covers the essential aspects of blood pressure measurement, including techniques, equipment, and interpretation of results. Consider including modules on related topics like hypertension management and patient education.
  • Choose appropriate training methods, options may include in-person workshops, online courses, hands-on practice sessions, or any combination of these.
  • Identify the necessary resources, including training materials and any technology required for online or virtual training.
  • Identify competent trainers who possess expertise in blood pressure measurement. They should be able to effectively deliver the training content, answer questions, and provide guidance throughout the training.
  • Plan the training sessions according to the curriculum. Ensure the trainers engage participants through interactive activities, discussions, and hands-on practice. Encourage questions and provide clarifications as needed.
  • Evaluate participants' progress and comprehension through assessments, such as observing participants perform blood pressure measurements correctly. Offer individual feedback regarding their performance, strengths, and areas for improvement. If any skill deficiencies are identified, offer remedial actions such as additional training, resources, or practice opportunities.
  • Offer certification or recognition to participants who successfully complete the blood pressure training competency program. This can help validate their newly acquired skills and knowledge.
  • Encourage participants to pursue ongoing education and provide opportunities for refresher training. Blood pressure measurement guidelines and techniques may evolve over time, and it’s important to keep participants updated with the latest information. Continuously assess the effectiveness of the training program through feedback, performance, and outcomes. Gather feedback on the training program’s strengths, weaknesses, and areas for improvement to refine future iterations.

  Links:

  Sample New Employee Competency Checklist

  American Medical Association BP Competency Checklist

  American Medical Association Staff Competency for Manual Blood Pressure Measurement

  Additional resources can be found at: https://www.ama-assn.org/delivering-care/hypertension

  National Institutes of Health (NIH) guide to hypertension diagnosis