Open Resources for Nursing (Open RN)
Subjective Assessment
Before taking a person’s blood pressure, it is important to determine if they have a history of elevated blood pressure or if they are taking any blood pressure medication. It is helpful to establish a baseline by asking their usual blood pressure reading or reviewing previous records in their chart. It is also important to determine if there are any arm restrictions such as those due to a fistula, mastectomy, stroke, or IV line before measuring blood pressure. See Table 3.3a for sample interview questions associated with the subjective assessment of blood pressure.
Table 3.3a Interview Questions for Subjective Assessment of Blood Pressure
| Interview Questions |
|---|
Have you ever been diagnosed with an elevated blood pressure?
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Are you currently taking any medications, herbs, or supplements for your blood pressure?
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Do you have any restrictions on taking blood pressure in your arms such as those due to a fistula or mastectomy?
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| What is your usual blood pressure reading? |
Do you take your blood pressure at home?
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If applicable:
|
Objective Assessment
Inspection
Before obtaining a blood pressure reading, it is important to inspect and consider conditions that would prevent the use of a blood pressure cuff, such as a history of clots or presence of current clots, lymphedema, wounds, a fistula, or current IV access lines. If these conditions exist, obtain the blood pressure in an alternative extremity.
Life Span Considerations
Children
Blood pressure measurement is not routinely performed on children under the age of 3 unless there are cardiac concerns.
Older Adults
Blood pressure measurements are sometimes difficult to hear in older adults. For patients who are clinically stable and Korotkoff sound auscultation is difficult, doppler auscultation may be helpful.
Blood pressure assessment should be completed after the patient has rested for a minimum of five minutes. If the patient has ingested caffeine or nicotine within 30 minutes before measuring blood pressure, this should be documented with the reading.
There are times when it is difficult to auscultate Korotkoff sounds. As a result, the care team must decide what alternate measures could be performed to obtain accurate blood pressure results. For patients who are critically ill or hemodynamically unstable, an arterial line may be placed directly into an artery to measure blood pressure. This is an invasive procedure and is not used for routine monitoring.
See Table 3.3b for a comparison of expected versus unexpected findings when assessing blood pressure.
Table 3.3b Expected Versus Unexpected Findings on Blood Pressure Assessment
| Assessment | Expected Findings | Unexpected Findings (Document or notify provider if this is a new finding*) |
|---|---|---|
| Inspection | Not applicable | Evidence of fistula, lymphadenopathy, IVs, clots, deficits from a stroke, or other restrictions from using the arm for blood pressure readings should be documented and communicated in handoff reports for continuity of care. |
| Auscultation | Able to identify Korotkoff sounds and blood pressure reading within expected parameters | Unable to identify Korotkoff sounds or blood pressure readings are outside of expected parameters. |
| Palpation | Able to palpate pulse | Unable to palpate pulse. |
| *CRITICAL CONDITIONS to report immediately | Blood pressure readings are outside of expected parameters for this patient’s age or the patient has symptoms associated with a blood pressure that is out of range. |
