BLOOD PRESSURE TRAINING

Why manage BP if the patient feels fine? | Hypertension is often asymptomatic until damage is done. It causes end-organ damage: Heart (LVH, angina, MI, heart failure); Brain (CVA, TIA, dementia); Kidney (chronic renal failure); Eye (retinopathy, vision loss, blindness); Periphery (PAD)

How common is hypertension in the US? | More than 116 million adults; nearly half (48.1%) of US adults 18+ (measured HBP and/or taking antihypertensive medication)

Why is BP measurement an important skill for pharmacists? | Accessible healthcare professionals; monitor medication effectiveness; identify adverse effects; screen for undiagnosed hypertension

AMA BP Check Challenge: how many of 159 students were proficient on all 11 BP skills? | Only one. BP measurement is a SKILL that requires practice

What is blood pressure? | The force of blood pushing against the artery walls as blood moves through the body; reflects how well blood is delivered to tissues and organs

Systolic BP (top number) | Pressure when the heart contracts and pumps blood. Think: Squeeze. Heard as the FIRST Korotkoff sound

Diastolic BP (bottom number) | Pressure when the heart relaxes between beats. Think: Relax. Heard as the DISAPPEARANCE of Korotkoff sounds

Systolic and diastolic: where and how do you measure each? | Over the brachial artery of the upper arm using cuff and stethoscope. As the cuff deflates, the FIRST Korotkoff sound = systolic; the DISAPPEARANCE of sound = diastolic. (Automated devices use the oscillometric method and calculate both.)

What are Korotkoff sounds? | Swishing, thumping sounds caused by turbulence of blood in the artery (created artificially by the cuff)

Normal BP (ACC/AHA) | Less than 120 AND less than 80

Elevated BP (ACC/AHA) | 120-129 AND less than 80

Stage 1 hypertension (ACC/AHA) | 130-139 OR 80-89

Stage 2 hypertension (ACC/AHA) | 140 or higher OR 90 or higher

Hypertension vs hypotension | Hypertension = high BP (lecture: above 120/80). Hypotension = low BP (below 90/60)

Markedly elevated BP | Greater than 180/110. Assess the patient, not the number!

How would you approach a patient with markedly elevated BP? | Recheck correctly after rest and ask about symptoms (chest pain, shortness of breath, vision changes, altered mental status, severe headache). WITH symptoms = possible emergency, call 911/send to ED. WITHOUT symptoms = recheck, document, and refer to provider promptly

BP 186/98 with vision changes and altered mental status | Symptomatic markedly elevated BP: possible emergency, call 911/send to ED

BP 178/90 with no symptoms | Stage 2 HTN (just under the 180/110 cutoff): recheck correctly, document, refer to provider

BP 150/94 with chest pain and slight shortness of breath | Symptoms make this an emergency regardless of the number: call 911

Auscultatory method | Listening with a stethoscope; aneroid or mercury sphygmomanometer

Oscillometric method | Electronic or automatic machine

Other BP methods | Finger cuff of Penaz, ultrasound, tonometry

Upper arm monitor | Considered the most accurate location

Wrist cuff: what are the suggestions? | Convenient for those who have trouble placing a cuff on their arm. Keep the wrist at heart level, sit still and supported, use a validated device. Less accurate than upper arm, so confirm abnormal readings with an upper arm cuff

Finger cuff: what are the suggestions? | Least reliable (affected by cold fingers, position, circulation). Keep the hand at heart level. Not preferred for diagnosing or monitoring; confirm any abnormal reading with an upper arm cuff

Why should the arm be at heart level? | Arm below heart level reads falsely HIGH; arm above heart level reads falsely LOW (gravity changes the pressure at the cuff)

Mercury sphygmomanometer | "Gold standard," calibrated at factory. Parts: calibrated glass tube, measured mercury, gravity. Inspect for cracks, dirt, clear markings, meniscus at zero

Aneroid sphygmomanometer | Calibrate to a validated mercury monitor. Parts: bellows, baffles, springs, gears. Inspect when received, before sold, every 6 months to 1 year, and periodically

Before measuring: what to avoid | For 30 minutes before: no caffeine, smoking, exercise, or eating

Before measuring: bladder and rest | Empty bladder; seated rest for 3-5 minutes

Time between multiple readings | 1 minute

Patient positioning | Remove clothing interfering with cuff; back straight and supported; feet uncrossed and flat on the ground; arm resting on a firm surface at heart level, palm up, fingers relaxed

Talking or moving during measurement | No talking or moving while taking BP (even you)

Correct cuff size | Bladder = 75-100% around the bicep

Why is selecting the correct cuff size important? | Too small reads falsely HIGH; too big reads falsely LOW. Wrong size can misclassify the patient (unnecessary treatment or missed hypertension)

Cuff placement | On bare upper arm, bladder aligned with brachial artery, 2 fingers above the end of the elbow; stethoscope must not touch the cuff

Cuff tightness | Two fingers snugly inserted at top/bottom of cuff

Arm choice: initial visit | Measure BOTH arms

Arm choice: repeated measurements | Use the arm with the higher readings

Arm choice: screenings | Right arm / patient preference

Stethoscope tips | Make sure it is "on"; earpieces point toward nose; bell side preferred; place below the cuff to avoid noise

Thumb valve | "Righty tighty; lefty loosy." When it's closed, it's closed: don't over-tighten

What is the Maximum Inflation Level (MIL)? | A palpated estimate of systolic BP (no stethoscope needed) that gives a target SBP and decreases patient discomfort

Steps to find the MIL | 1) Find radial pulse (thumb side) 2) Place correct size cuff 3) Inflate and note when the pulse stops (pulse obliteration = estimated systolic) 4) Wait more than 30 seconds before taking the BP

Why find the MIL (pulse obliteration) before taking BP? | Gives a target systolic so you inflate to the right level: avoids under-inflating and missing the true systolic, avoids over-inflating and hurting the patient, and guards against an auscultatory gap (sounds temporarily disappear)

How high do you inflate to take the BP? | Pulse obliteration point + 20-30 mmHg

Inflation and deflation rate | Inflate rapidly; deflate at 2 mmHg/second

Deflating too slowly | Hurts the patient and makes sounds harder to hear

Deflating too fast | Underestimates SBP and overestimates DBP

How long do you keep listening after sounds disappear? | At least 5-10 seconds

Can't hear Korotkoff sounds? How do you intensify them? (more common in elderly and some women) | Sound intensification: wait 1 minute, raise arm ~30 seconds, have patient make several fists, return arm to heart level, repeat measurement

How to record numbers | EVEN numbers only; if between, round up

What to document with a BP | Units (mmHg), arm (RA/LA), patient position (seated/standing/supine), cuff size, method (aneroid/mercury/automated)

Example documentation | 134/86 mmHg; RA; Seated; Large Adult Cuff; Aneroid

Why do home BP testing (SMBP)? | Gives better data than a single office reading: catches white coat and masked hypertension, shows trends, checks medication effectiveness, and engages the patient

Home BP: usual procedure | Same technique as in the office: validated upper arm monitor, correct cuff size, seated and rested 3-5 min, no caffeine/smoking/exercise for 30 min, back supported, feet flat, arm at heart level, no talking. Twice daily (AM and PM), 2 readings 1 minute apart each time, ideally for 7 days. Record every reading

What do you do with home BP data at the office? | Review the log, average the readings (not just one number), compare with office readings, check the device and technique, then communicate next steps or refer per protocol

Automated BP: steps | Same prep and positioning as manual; select correct cuff size and place correctly; ensure single-reading mode; press start and repeat if error; record SBP/DBP correctly; explain next steps

Would you trust this reading enough to make a clinical decision? | Be ready to say yes or no and why (wrong cuff size, patient talked or moved, arm not at heart level, no rest period, caffeine/smoking recently, etc.)

Full manual procedure order | 1) Explain procedure; first visit or follow-up 2) Ask about eating/caffeine/smoking/exercise in last 30 min 3) Bladder empty, 3-5 min seated rest 4) Position patient 5) Ask patient to stay quiet and still 6) Select cuff, place on bare arm 7) Palpate radial pulse to find MIL 8) Wait over 30 sec, place stethoscope (bell, not touching cuff) 9) Inflate 20-30 above obliteration, deflate 2 mmHg/sec 10) Identify SBP/DBP 11) Document (position, arm, cuff, device) 12) Verbalize next steps per protocol