North East & Yorkshire Healthcare Service

Blood Pressure Taking

Taking & recording

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Aims & Objectives

 Understanding Blood Pressure

 What is Blood Pressure

 Taking Blood Pressure

 Recording Accurate Readings

 Importance of Consent

 What is Hi / Low Pressure

 By the end of this course you will have a full awareness and understanding
of the purpose of taking and recording blood pressure and be aware of
appropriate actions to take.

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What is blood pressure?

When your heart beats, it pumps blood round your

body to give it the energy and oxygen it needs.
As the blood moves, it pushes against the sides of the
blood vessels. The strength of this pushing is your
blood pressure.
If your blood pressure is too high, it puts extra strain
on your arteries (and your heart) and this may lead to
heart attacks and strokes

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Preparing Equipment

 The accuracy of the blood pressure reading obtained is highly dependent

upon proper use of the equipment provided

 Blood pressure monitoring equipment must be recalibrated annually It is

the responsibility of the nurse in charge / Care Home manager to have a
system in place to monitor and maintain quality assurance with this
standard.

 Clean blood pressure machine and cuff with an approved cleaning wipe.
Use a single patient use cuff cover when a patient has a multi resistant
organism

 The circumference of the upper arm must be measured at the widest point
in order to determine which size cuff be used. See table

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Arm Circumference Cuff Size

Less than 23cm Small Adult

23cm to 33cm Standard Adult

33cm to 50cm Large Adult

51 to 53cm Adult Thigh Cuff

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PROCEDURE FOR BLOOD PRESSURE

MONITORING
 Oscillometric blood pressure devices may not be accurate in those with
weak or thready pulse.
 Patients with Atrial Fibrillation should have blood pressure taken using
a aneroid sphygmomanometer
 In patients with heart beats below 50 beats/minutes, even if the
rhythm is regular, some of the semi-automatic devices are unable to
reduce their deflation rate sufficiently so that too rapid a fall in cuff
pressure results in underestimation of systolic blood pressure and
overestimation of diastolic blood pressure
 Patients who have had trauma to the upper arm, previous mastectomy,
Arteriovenous fistula or a forearm amputation should not have blood
pressure measured from the effected side or those at risk of
lymphedema

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Service user / Patient Consent

 Valid consent must be given voluntarily by an appropriately
informed person prior to any procedure or intervention.
 No one can give consent on behalf of another adult who is
deemed to lack capacity regardless of whether the impairment
is temporary or permanent.
 However such patients can be treated if it is deemed to be
within their best interest.
 This must be recorded within the patient’s health records Care
Plan with a clear rationale stated at all times. Refer to Care
Home Information and Consent Policy for further information
and guidance for Assessing Mental Capacity and Best Interests.
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Cont
 SAFEGUARDING
 In any situation where staff may consider the patient to be a vulnerable
adult, they need to follow the Trust Safeguarding Adult Policy and
discuss with their line manager and document outcomes.
 REFERRALS
 Any referrals to health professionals, therapists or other specialist
services must be followed up and all professional advice or guidance
documented in the patients health records.
 EQUALITY ASSESSMENT
 During the development of this procedure the Care home has
considered the clinical needs of Each protected characteristic (age,
disability, gender, gender reassignment, pregnancy and maternity, race,
religion or belief, sexual orientation). There is no evidence of exclusion
of these named groups.

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Procedure
Action Rational
Verbally confirm the identity To avoid mistaken identity
of the patient by asking for
their full name and date of
birth. If client unable to
confirm, check identity with
family/carers

Introduce yourself as a staff To promote mutual respect and put

member and any colleagues client at ease
involved at the contact

Ensure verbal consent for the Example, as the client has the choice
presence of any other third to refuse
party is obtained

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Procedure
Explain procedure to patient Enables patient to make an informed
including risks and benefits and gain decision to proceed with blood
valid consent pressure monitoring

Decontaminate hands To reduce the risk of transfer of

transient micro- organisms on the
healthcare workers hands

Ask patient to remove any tight arm Allows the cuff to be applied in the
clothing. Assist the patient if required, correct position thus reducing the
ensuring privacy and dignity at all potential for error.
times

Check skin condition of the upper If patients arm is:-

arm Swollen/oedematous or has any
breaks do not continue, seek advice.

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Procedure Con’t
Request the patient to empty their Can effect blood pressure
bladder if they need to. reading(NICE, 2006)

Support the patients arm out- If the arm is above or below heart
stretched at heart level and check the level and not relaxed the reading may
brachial pulse, rhythm and pace. be effected (NICE 2006) This is to
ensure that the most appropriate
equipment is used e.g. a patient with
arterial fibrillation should have blood
pressure taken with aneroid

Apply the cuff and measure blood To obtain an accurate blood pressure
pressure, following the procedure for measurement
the use of the monitoring device.
Patient should not talk during the
procedure

Record Reading To Maintain an Accurate reading

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What is Normal Blood pressure

 Ideally, we should all have a blood pressure below 120 over 80

(120/80). This is the ideal blood pressure for people wishing to
have good health. At this level, we have a much lower risk of
heart disease or stroke.
 Most adults in the UK have blood pressure readings in the
range from 120 over 80 (120/80) to 140 over 90 (140/90).
 The higher your blood pressure, the higher your risk of health
problems. For example, someone with a blood pressure level
of 135 over 85 (135/85) is twice as likely to have a heart attack
or stroke as someone with a reading of 115 over 75 (115/75).

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High Blood Pressure (Hypertension)

 High blood pressure (hypertension) if your blood pressure
readings are consistently 140 over 90, or higher, over a number
of weeks.
 You may also have high blood pressure if just one of the
numbers is higher than it should be over a number of weeks.
 High blood pressure: This higher pressure puts extra strain on
your heart and blood vessels. Over time, this extra strain
increases risk of a Heart Attack or a Stroke.
 High blood pressure can also cause heart and kidney disease,
and is closely linked to some forms of dementia.

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Signs & Symptoms of Hypertension

 High blood pressure usually has no signs or symptoms, so the only way to
know if you have high blood pressure is to have yours measured. However,
a single high reading does not necessarily mean you have high blood
pressure. Many things can affect your blood pressure through the day
 there may be no single cause for their high blood pressure. We do not
know exactly what causes high blood pressure. We do know that your
lifestyle can affect your risk of developing it. You are at a higher risk if:
 you eat too much salt;
 you don’t eat enough fruit and vegetables;
 you are not active enough;
 you are overweight; or
 you drink too much alcohol.

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Additional Causes of high Pressure

 There are some factors that increase your risk of developing high
blood pressure, which you cannot control. These include:

 Age: as you get older, the effects of an unhealthy

lifestyle can build up and your blood pressure can increase.

 Ethnic origin: people from African-Caribbean and South

Asian communities are at greater risk than other people of high
blood pressure.

 Family history: you are at greater risk if other members

of your family have, or have had, high blood pressure.

 Some people may have high blood pressure that is linked to another
medical condition, such as kidney problems.

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Low Blood Pressure (Hypotension)

 Some people have a blood pressure level that is lower than normal. In
general this may be good news - because the lower your blood pressure is,
the lower your risk of stroke or heart disease. However, in a few cases,
having low blood pressure can cause problems.

 A low blood pressure reading is having a level that is 90/60mmHg, or lower.

 Only one of the numbers has to be lower than it should be to count as low
blood pressure. In other words:

 if the top number is 90 or less (regardless of the bottom

number) this may be low blood pressure

 if the bottom number is 60 or less (regardless of the top

number) this may be low blood pressure.

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What Causes Low Blood Pressure?

 Some people have a blood pressure level that is naturally low. That
is, there is no specific cause or reason why.

 However, some health conditions or medicines can cause you to

develop low blood pressure.

Is low blood pressure dangerous?

 Usually, having low blood pressure is not a cause for concern.
However, sometimes your blood pressure can drop to a point where
you may feel faint or dizzy.

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Blood pressure chart

 blood pressure chart below to see what blood pressure means. The
blood pressure chart is suitable for adults of any age. (The level for
high blood pressure does not change with age.)

 Blood pressure readings have two numbers, for example

140/90mmHg.

 The top number is your systolic blood pressure. (The highest

pressure when your heart beats and pushes the blood round your
body.) The bottom one is your diastolic blood pressure. (The lowest
pressure when your heart relaxes between beats.)

 The blood pressure chart shows ranges of high, low and healthy
blood pressure readings.

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Blood Pressure Chart Adults

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What blood pressure readings mean

 As you can see from the blood pressure chart, only one of the
numbers has to be higher or lower than it should be to count as
either high blood pressure or low blood pressure:

 90 over 60 (90/60) or less: may have low blood pressure.

 More than 90 over 60 (90/60) and less than 120 over 80 (120/80):
blood pressure reading is ideal and healthy.

 More than 120 over 80 and less than 140 over 90 (120/80-140/90):
Normal blood pressure reading but it is a little higher than it should
be, and you should try to lower it.

 140 over 90 (140/90) or higher (over a number of weeks): may have

high blood pressure (hypertension).

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To Conclude!

 if your top number is 140 or more - then you may

have high blood pressure, regardless of your bottom number.
 if your bottom number is 90 or more - then you
may have high blood pressure, regardless your top number.
 if your top number is 90 or less - then you may
have low blood pressure, regardless of your bottom number.
 if your bottom number is 60 or less - then you may
have low blood pressure, regardless of your top number.
Remember Always Document Every Reading

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