The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [472]
17 Once no further sounds can be heard, the cuff should be rapidly deflated (O’Brien et al. 2003). To prevent venous congestion to the arm (O’Brien et al. 2003, E).
18 If you need to recheck the blood pressure wait 1–2 min before proceeding (BHS 2006). Venous congestion may make the Korotkoff sounds less audible (Bickley and Szilagyi 2009, E).
Postprocedure
19 Inform patient that the procedure is now finished. To reassure the patient. E
20 Wash hands using bactericidal soap and water or bactericidal alcohol handrub, and dry. Clean bell of stethoscope and cuff with detergent wipe (no alcohol). To minimize the risk of infection (Fraise and Bradley 2009, E).
21 Document fully as soon as the measurement has been taken and compare with previous results (O’Brien et al. 2003). Any interruption in the process may result in the measurement being incorrectly remembered (O’Brien et al. 2003, E).
Problem-solving table 12.3 Prevention and resolution (Procedure guideline 12.3)
Postprocedural considerations
Immediate care
Notify medical staff of an abnormal blood pressure result. As the treatment will depend on what is causing the abnormality, and its severity, it is important that practitioners try to ascertain the possible cause for the physiological change in blood pressure (Kisiel and Perkins 2006). Hypovolaemia will require fluid replacement and, if persistent, then inotropes and other cardiovascular drugs may be necessary (Hinds and Watson 2009). If the hypertension is transient, for example related to anxiety or pain, then it is important to address that issue and monitor the blood pressure until it resolves. However, if the patient is diagnosed as having hypertension they will require drug therapy to control their condition (NICE 2006). To determine the cause of the altered blood pressure more information will be required, including:
gaining a comprehensive medical history from the patient (Steele and Hardin 2007)
gaining a full set of observations
an ECG (Steele and Hardin 2007)
urinalysis including protein, leucocytes, blood and the osmolality of the urine (Steele and Hardin 2007)
blood tests for full blood count, urea, creatinine and electrolytes (Steele and Hardin 2007) and fasting blood tests for glucose and lipids (Camm and Bunce 2009)
a chest Xray or further radiological investigations may be required (Camm and Bunce 2009)
a septic screen including blood cultures, sputum specimen, swabs of any wounds or potential sites of infection (Hinds and Watson 2009)
their current fluid balance (Kisiel and Perkins 2006).
Ongoing care
If the patient is hypertensive and in primary care, they will require at least monthly blood pressure measurement and more frequently if it is accelerated hypertension or there are any further concerns (NICE 2006). Additionally, it will be necessary to give lifestyle advice on, for example, eating healthily, smoking cessation (NICE 2006). If the hypotension is orthostatic then advise the patient to change position slowly so the baroreceptors and sympathetic nervous system have time to adapt the blood pressure to each stage (Marieb and Hoehn 2010).
Documentation
As well as the accurate recording of the blood pressure measurement it is also important to record:
the position the patient was in
the arm used, and if both arms were used initially, the pressure of each
arm circumference and the cuff size used
if there is an auscultatory gap or any difficulties in obtaining a reading, such as the absence of stage 5
the state of the patient, for example were they in pain, frightened, and so on
any medication they are on and when they last took it.
(O’Brien et al. 2003)
When documenting the medication the patient is on, it is important to include not only cardiovascular medication but also other medication which might affect their blood pressure, including tricyclic antidepressants, neuroleptic agents (O’Brien et al. 2003), contraceptives, decongestants,