Featured Nurse - May 2009

Accurate Blood Pressure Measurement for the Obese Patient in the Ambulatory Setting

Nancy Dole, RN, BSN; Emily Griffin, MN, RN, FNP-C; Carol Flansburg, RN, BSN; Barb Happel, MSN, FNP-C; Todd Burstain, MD; Nicole Denning, RN; Maria Luna, MA; Chris Goerdt, MD

Accurate blood pressure monitoring for hypertension is essential (Jones, 2003). The purpose of this evidence-based practice project was to develop a protocol for blood pressure measurement for the obese patients in an outpatient setting in order to obtain the most accurate blood pressure readings. Several key recommendations were identified in the literature for accurate blood pressure measurement. First is having the patient sit for 5 minutes prior to taking the blood pressure and using the correct size cuff is essential (Jones, 2003; Pickering, 2005; Zdrojewski, 2005). Second, the arm should be supported at heart level (Beevers, 2001; Adiyaman, 2006). Third, the measurement should be taken only on the upper arm. Forearm measurements can overestimate blood pressure (Pierin, 2004; de Gusmao, 2007). Fourth the patient should be seated in a chair with their back supported and legs touching the ground (Adiyaman, 2006; Chobanian, 2003; Pickering; 2005).

A policy for blood pressure measurement for large arms was developed. Adding long blood pressure cuffs to fit the patient’s arm was an easy, inexpensive strategy to address correct cuff size. Updates of electronic documentation to include size of cuff used were then completed. We initiated this project by obtaining buy-in from key stakeholders and had a multidisciplinary team, which was very helpful when we needed to purchase additional supplies. Educational strategies included a power point in-service, pocket cards, a creative logo and dissemination by the staff nurse-project director.

Through the evaluation, staff reported that “the protocol for accurate BP monitoring in the obese patient provides information on the correct technique” (mean score of 3.5 on 1-4 Likert scale with 4 = strongly agree). A patient survey (n=88) identified that patients are satisfied with the blood pressure measurement procedure (3.44 mean). Both the nurses and patients have found the addition of the long cuffs quite helpful. The nurses also find the check in time is more efficient because using the correct size cuff means the blood pressure measurement needs to be done only once.

References
Adiyaman, A., Verhoeff, R., Lenders, J., Deinum, J., & Thien, T. (2006). The position of the arm during blood pressure measurement in sitting position. [Electronic version]. Blood pressure monitoring, 11(6), 309-313.

Beevers, G., Lip, G., & O'Brien, E. (2001). ABC of hypertension: Blood pressure measurement: Part II -- conventional sphygmomanometry: Technique of auscultatory blood pressure measurement. [Electronic version]. BMJ: British Medical Journal, 322(7293), 1043-1047.

Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J.,Jr., et al. (2003). The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. [Electronic version]. JAMA: Journal of the American Medical Association, 289(19), 2560-2572.

de Gusmao, J. L., & Mion, D.,Jr. (2007). Blood pressure measurement in obese patients with cone-shaped arms. [Electronic version]. Journal of clinical hypertension (Greenwich, Conn.), 9(2), 152-3; author reply 153.

Jones, D. W., Appel, L. J., Sheps, S. G., Roccella, E. J., & Lenfant, C. (2003). Measuring blood pressure accurately: New and persistent challenges. [Electronic version]. JAMA: Journal of the American Medical Association, 289(8), 1027-1030.

Pickering, T., Hall, J., Appel, L., Falkner, B., Graves, J., Hill, M., Jones, D., Kurtz, T., Sheps, S., & Roccella, E. (2005). Recommendations for blood pressure measurement in humans and experimental animals: Part I: blood pressure measurement in humans: A statement for professionals from the subcommittee of professional and public education of the American Heart Association council on high blood pressure research. Circulation, 111(5), 697-716.

Pierin, A., Alavarce, D. C., o, J. L., Halpern, A., & Mion, D.,Jr. (2004). Blood pressure measurement in obese patients: Comparison between upper arm and forearm measurements. [Electronic version]. Blood pressure monitoring, 9(3), 101-105.

Zdrojewski, T., Kozicka-Kakol, K., Chwojnicki, K., Szpakowski, P., Konarski, R., & Wyrzykowski, B. (2005). Arm circumference in adults in Poland as an important factor influencing the accuracy of blood pressure readings. [Electronic version]. Blood pressure monitoring, 10(2), 73-77.

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