The fundamental caring skill that was chosen to demonstrate knowledge and understanding within a reflective framework was recording blood pressure. Blood pressure was chosen because it is a critical physiological function and a fundamental indicator of well being (Fullbrook 1993). It is an important and vital observation, in that it allows early therapeutic intervention should a patient’s status change (Fullbrook 1993). This essay will also demonstrate an understanding of best practice for the theory of blood pressure measurement of the patient. The factors which can influence different results in the measuring of blood pressure. In a model of reflection to aid the reflective process Gibbs (1998) was chosen.
Before placement started we were given books for Nursing Midwifery Council (NMC 2004) code of professional conduct, and the NMC (2004) guide for students of nursing and midwifery. This gave me the guidelines and knowledge for my accountability and confidentiality.
Marieb (1998) suggests that Blood Pressure may be defined as the force exerted by the blood against the walls of the arteries in which it is contained. Differences in blood pressure between different areas of the circulation provide the driving force that keeps the blood moving through the body.
Blood pressure is measured for one of two reasons, firstly to determine the patients blood pressure as a baseline prior to admission and secondly to monitor fluctuations within the blood pressure. Blood flow is defined as a volume of blood flowing from the heart through a vessel at any given time. Blood flow is equivalent to cardiac output. Resistance to the cardiac output is the opposite to flow and is a measure of the friction the blood encounters as it passes through the differently sized vessels. (Marieb 1998).
There are three important sources of resistance, blood viscosity, vessel length and vessel diameter. Normal blood pressure is maintained by neural, chemicals and renal controls. Blood pressure varies from not only moment to moment but also between the distributions of the various organs of the body. It is at its lowest in neonates and increases with age, stress, and anxiety (Marieb1998). Hypertension (high blood pressure) is also hereditary, 50% of people with high blood pressure have an inherited predisposition (Marieb1998). Alcohol abuse is also linked to high blood pressure as well as renal disease for e.g. renal impairment (Marieb1998). Other factors also can include shock, myocardinal infartion, and haemorrhage factors that cause a fall in blood pressure as they reduce the cardiac output. Some patients who are taking the oral contraceptive pill can be at risk from hypertension, or anyone who’s health status is being assessed.
As suggested by Mallett and Dougherty (2000), Systolic pressure is the maximum pressure of the blood against the wall of the vessel following the ventricular contraction and is taken as an indication of the interity of the heart, arteries, and arterioles. Diastolic pressure is the minimum pressure of the blood against the wall of the vessel following the closure of the aortic valve and is taken as a direct indication of the blood vessel resistance. Normal blood pressure generally ranges from 100/60mmHg to 140/90mm Hg but can fluctuate within a wide range and can still be considered normal (Mallett and Dougherty 2000), Hypotension or low Blood Pressure is generally defined in adults as systolic blood pressure below 100mmHg . In many cases hypotension simply reflects individual variations e.g. postural changes that result in lack of normal reflex response leading to low blood pressure (Mallett and Dougherty 2000).
Ideally the patient should be allowed to sit down for 15 minutes before blood pressure is measured. Elevation of systolic blood pressure as suggested by Mallet and Dougherty 2000 may be a temporary response to fever, physical activity or pain, even emotional stress other factors may also include obesity, a full bladder, diet, and legs crossed . Persistent elevation is diagnosed in several days apart exceeds upper limits of what is considered as normal for the patient. Mercury will be phased out of clinical use as a result of environmental, health and safety concerns and is being replaced by aneroid devices ( http://www.bpmonitoring.com/pt/re/bpm/abstract ).
Two main ways of measuring blood pressure are, indirectly by use of electronic monitoring for example, a Doppler. This is a machine which is attached to a patients arm by means of a cuff. This is inflated automatically by the machine, which then reads the pressure in the artery. The result is displayed on the machine as two readings.
Mean arterial pressure (MAP) which is the mean blood pressure during the reading. Mean arterial pressure is the average pressure required to push blood through the circulatory system this can be determined electronically or mathematically. Arterial pressure = 1/3 systolic pressure + 2/3 diastolic pressure. A blood measure of 130/85mmHm gives a mean pressure of 100mmHg (Mallett and Dougherty 2000).
A conventional method of recording a blood pressure is carried out using a sphygmomanometer. Blood pressures were traditionally recorded this way. But in acute settings they are increasingly recorded electronically. However nurses need to learn how to record a blood pressure manually as electronic devices are not always available.
When taking a blood pressure I always gain consent of the patient as regulated by the NMC (2004). I washed my hands to prevent any cross infection. Whilst this was gained I explained why, as this will allay any fears the patient may have and always endeavour to make the procedure as private as possible. Allow the person to sit down and relax prior to the procedure. Allow them to sit comfortably with their arm supported, using a pillow if possible as suggested by Mallett and Dougherty 2000 remove any restrictive clothing such as dressing gowns as this can give a false reading. I chose the cuff size as my patient was of normal weight. I position the equipment so that I can see the column clearly. After positioning the patients arm in line with the heart, I located the Brachial pulse, if a communal stethoscope has been used, I always clean the ear with alcohol swab to reduce cross infection between staff. The cuff as suggested by Mallett and Dougherty 2000 should fit snugly to the arm 2.5 cm above the brachial pulse. Ensure the cuff fit’s snugly to the arm and is secure. It is suggested by Mallet and Dougherty the cuff bladder should cover 80% of the circumference of the upper arm. I always take this into consideration when choosing a cuff that you use in practice. The sizes are suggested as a guide, a standard bladder 12 by 26 cm is suitable for majority of adults. An obese bladder 12 by 40 cm for obese or oedema of the arms. A small bladder 10 by 18cm for lean adults and children. However there may be some instances where taking the blood pressure on the arm is not possible such as a cerebrovascular accident, trauma, amputation , pain, so the nurse will have to use another site to record the blood pressure . I checked that the stethoscope is in working order and placed correctly in the ears. I palpated the radial pulse, then I inflated the cuff and waited till the pulse disappeared I noted the level at which this occurred as this equates the systolic pressure. I Deflated the cuff and waited for one minute.
I placed the stethoscope over the brachial pulse, I inflated the cuff to 20 mmHg above the estimated systolic pressure. Then I started to deflate the cuff slowly, listening carefully for the first korotkoff sound. Korotkoff sounds were named after Nicola Korotkoff who first identified the audible sounds of blood pressure in 1905, (Korotkoff as cited by O’Brian 1977). The sounds of the Korotkoff have five phases, phase one a clear tapping sound , phase two a softening of the sound, phase three, return of the sharper sound, phase four , abrupt muffling , phase five disappearance of sound – diastolic. (Roper, Logan , Tierney, 1990).
I noted the measurement on the column in front of me . This is the systolic pressure- the top number. I continued listening whilst deflating the cuff I noted the change in the sounds when the sound disappears this is the Diastolic blood pressure the bottom number. I Recorded the results clearly the reading was 140/70 mmHg I informed my patient advising them if there is any change as generally patients are interested in the results and often know what their blood pressure is and can advise if it’s not the norm. I thanked the patient for their cooperation and ask if there is anything else they needed or that they are comfortable.
I Documented the result in a clear way as in the NMC (2004) guidelines for records and record keeping. Also is it good nursing practice to compare with the last recording, note any differences and report any abnormal findings. If the result of the blood pressure recording is abnormal I always consult a doctor or nurse in charge of the result. I Disposed of the equipment safely as with health and safety and to prolong the use of the equipment, and cleaned the stethoscope again to prevent any cross infection. Put the equipment back from where I had it from so other members of team can locate it when it is needed as there is nothing more frustrating trying to locate a piece of equipment when one is needed.
Whilst on my first placement in the endoscopy and treatment unit, there is a small but extremely busy ward. Patients went to the ward to recover from procedures. Following these procedures observations were routinely carried out, Temperature, blood pressure, pulse and respirations were routinely done.
When the patients procedure was over observations were carried out at 15 minute intervals for the first hour, they were taken at these intervals so that if any sudden change occurred there was a possibility something might have gone wrong as a sudden drop in blood pressure can mean internal bleeding. My first blood pressure recording was using a sphygmomanometer the patient was recovering after a procedure taken place and had been sitting comfortably for 15 minutes. I introduced my self that I was a student nurse and explained that I needed to take a recording of their blood pressure and could I do so I gained permission and asked if they had had this procedure done before to which Mrs Smith (a pseudonym) said yes she had. I washed my hands to prevent any cross infection.
I followed the protocol for taking a manual blood pressure as suggested by Mallett and Dougherty (2000). I washed my hands and I removed any restrictive clothing, my patient was wearing a dressing gown as this can cause a false reading. I got the equipment making sure it was clean, and cleaned the ear pieces to prevent any cross infection (Wilson. 2001). I ensured the air was removed from the cuff. I located the brachial artery listened for a pulse I found this. I placed the cuff securely then I palpated the radial pulse and inflated the cuff until the radial pulse disappeared I noted this. I waited a minute asking the patient if she was comfortable. I inflated the cuff to around 20mmHg above the expected pressure. I made sure that I could see the column in front of me to avoid any mistakes and putting the patient through the procedure again so soon. I deflated the cuff at around 2mm per second, I listened out for the systolic pressure the first korotkoff phase. These can have many varying sounds from a thud to a swishing, to a muffled sound. I noted the first sound and waited for the second phase, korotkoff phase 5 to disappear and noted the recording which was 140/70 mmHg I told the patient what the reading was and documented it on her care plan.
Throughout this procedure you have to really concentrate and make sure no interruptions can take place as you can miss the korotkoff sounds. I actually couldn’t get the first korotkoff sounds on my first attempt so I explained to the patient and gained permission again to take the recording. To which she agreed, I felt self-conscious and nervous as I had missed the first korotkoff sounds but very pleased when I did manage to get the recording a second time. Having an underpinning knowledge in the procedure for taking blood pressure helps to understand the theory behind the practice.
To conclude my essay the skill of recording blood pressure is a vital one for the nurse, as we can not always rely on having electronic equipment to hand. I also gained that if different circumstances can have an effect on the pressure reading. I feel I have gained a learning skill I was quite worried about this skill but practice makes easier. The more blood pressure recordings I took me soon realised that no two patients were the same. I also learned that different factors can affect blood pressure, from the patient rushing in late for his appointment which can lead to elevated blood pressure. It has also given me a lot of confidence in myself and confidence with the patients I care for.
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