Question

Skill name:: Two step BP method

what is the Description of this skill?

what are the indicators?

what are the nursing interventions (pre, intra, post)?

what are the outcomes/evaluation?

what is the client education for this skill?

what are the potential complications?

what are the nursing interventions?

Answer 1

In clinical practice the blood pressure monitoring is used as a routine assessment tool in every physical examination, including outpatient visits, at least daily when patients are hospitalized, and before most medical procedures. The main indications for blood pressure monitoring are :

• As a screening for hypertension
• Assessing the effect of anti-hypertensive treatments in a patient to optimize their management
• Monitoring a person’s suitability for a sport or certain occupations
• Measurement of cardiovascular risk
• Checking for the risk of various medical procedures
• Assessing for any signs of clinical deterioration.

For measuring blood pressure there are two methods, the direct and indirect method. The direct method is an invasive method using an intra-arterial catheter to obtain a measurement.

The indirect (noninvasive) method is the most commonly used one. It involves the collapsing the artery with an external cuff. It provides an inexpensive and easily reproducible way to measure blood pressure.

It can be performed by using a manual cuff and sphygmomanometer, a manual cuff and Doppler ultrasound, or with an automated oscillometric device.

In manual blood pressure measurements, errors like an observer and methodological errors can occur.

In the two-step method for taking a blood pressure is monitored by feeling the brachial artery and then using a stethoscope. So the nurse will be taking the blood pressure twice using the same arm but with two methods.

It is considered the most accurate noninvasive blood pressure monitoring and extremely useful in patients with blood pressure issues.

Steps:

1.     Maintain position of the patient in a sitting or lying position with an arm at heart level

2.     Expose the upper arm by turning the patient’s arm, so palms are up

3.     Step 1: Palpate for a brachial pulse and place the blood pressure cuff 1-2 inches above the brachial pulse.

4.     Wrap the blood pressure cuff around the upper arm, so it fits appropriately and as the nurse can get 2 fingers snuggly underneath it.

5.     Then while palpating the brachial pulse with the non-dominate hand and inflate the cuff using the rubber bulb with the dominant hand

6.     While inflating the cuff note the point where no longer feel the brachial pulse, this will be the systolic reading

7.     Then continue deflating the cough slowly by turning the valve counter-clockwise until no pulse is felt. Note the reading where the pulse stopped, this will be the diastolic reading.

8.     Deflate the cuff completely

9.     Step 2: Wait for 30 seconds. In it, a stethoscope is used to assess the pulse and in the same arm.

10.        Locate the brachial pulse with the diaphragm or bell of the stethoscope

11.        Inflate the cuff again

12.        Inflate the cuff 30 mm of Hg above the patient’s systolic pressure of the first reading

13.        Then, slowly deflate the cuff while letting the sphygmomanometer drop at a rate of 2-3 mm of Hg per second.

14.        Note the point at which the first sound is heard, this will be the systolic pressure

15.        Deflate until the sounds disappear, the point at which the sound disappears is the patient’s diastolic pressure

16.        Then deflate the cuff completely and tell the patient the reading and document

Standard Protocol

Check the chart for Blood pressure (BP) range or if the record is not available to ask the patient.

Perform hand hygiene.

Introduce yourself

Check patient ID

Explain the procedure to the patient and clarify any doubts.

Make the patient relax, keep the feet flat on the floor or in bed, with legs uncrossed.

Equipment:

Select the appropriately sized cuff based on the patient’s body size.

Select appropriate and convenient limb for measurement.

Expose the brachial site by pushing up or removing clothing from the arm and avoid any constrictive clothing.

Maintain comfort by supporting the arm in comfortable position on the flat surface, forearm at heart level, palm up.

Don't over tighten the cuff by inflating too much.

Special considerations:

Avoid obtaining a blood pressure in the same arm in which an arteriovenous fistula (such as used in hemodialysis) is present, or where lymphedema exists as in case of breast cancer patients.

Try to avoid checking blood pressure in the extremity with intravenous access.

If bilateral arteriovenous fistulas or lymphedema is present, obtain a lower extremity blood pressure.

Delay obtaining a blood pressure is if the patient has smoked, exercised, or had caffeinated products or other stimulants prior to the measurement.

Readings:

60-90 diastolic / 90-140 systolic is the normal rage of BP. Lower and higher values must be assessed and monitored carefully. Notify the concerned authority if any variation occurs.